COA Bulletin #119 - Spring 2018

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Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Spring Printemps 2018 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




NEW Offerings at the 2018 Annual Meeting.................. Page 6 NOUVEAUTÉS à la Réunion annuelle 2018......................................... Page 7 Repenser les soins de santé : Une perspective locale et mondiale sur l’orthopédie � � � � � � 4 Making Global Surgery Work as a Community Orthopaedic Surgeon � � � � � � � � � � � � � � � � � � � � 13 Paediatric Femur Fractures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 20 .Advancing Collection of Standardized Hip and Knee Arthroplasty Data in Canada � � � � � 39

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Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 119 - Spring / Printemps 2018 COA / ACO Kevin Orrell 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: Web site/Site internet: 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: 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® (, 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., 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.


Rethinking Health Care: A Local and Global Perspective on Orthopaedics Kevin Orrell, M.D., FRCSC President, Canadian Orthopaedic Association


ince becoming President of the COA, Anne and I have had the tremendous privilege of travelling with the Carousel Presidents to South Africa, the United Kingdom, Australia, New Zealand and the United States. We have made many friends and have met large numbers of orthopaedic surgeons who hold Canadian orthopaedics in high esteem. It has been an honour to participate in international symposia and address the inquiries these other countries have about our universal health-care system. Domestically however, we are all aware of the significant problems that are present as we struggle to care for our patients when provincial governments fail to provide the necessary resources to do so adequately. I am grateful to the large number of people with whom I have had contact, in both academic and community practices. There is a common denominator of increasing difficulty to care for our patients as we attempt to do more with less. These encounters identify that orthopaedic surgeons across the country have very significant concerns about the environment in which we work. Access to care remains a Canadian embarrassment. The wait times for consultation, investigation and surgery, in all subspecialties, is unacceptable for a country that prides itself on universal health care. The COA is in the process of updating our position paper on “Access to Care” and invites provincial governments to partner with us to improve musculoskeletal health for all Canadians. This situation is even more embarrassing for a developed nation that permits welleducated and highly-skilled young orthopaedic surgeons to be under-employed. Although there has been some recent improvement in the number of orthopaedic surgeons seeking full time positions, this still remains a major concern for the COA. In the long term, training fewer surgeons will significantly impact the future of musculoskeletal care in Canada. The COA is committed to establishing a stronger relationship with the provincial/ regional orthopaedic associations. Our concerns are similar and it is hoped that stronger ties will increase our ability to initiate change. Cynthia Vezina, our Executive 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:

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 :

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 2018

Your COA / Votre association


(continued from page 3)

Director, Strategic Initiatives, and I had the privilege of attending the Ontario Orthopaedic Association meeting in Toronto in November for this purpose. The COA is making efforts to address our common concerns. Each member has a role to play in making our organization stronger and more capable of challenging our policy makers on behalf of our patients. The COA Mid-winter Meeting focused on many of the struggles we face on a daily basis. I would encourage everyone to communicate with us, and invite those with time and energy, to volunteer for committee work in our organization. Throughout our travels, I have witnessed how Canadian orthopaedics is held in high regard. Many individuals have distinguished themselves internationally. Congratulations are extended to Dr. Paul Beaulé and his research colleagues who recently received the 2018 Kappa Delta Elizabeth Winston Lanier Award at the AAOS meeting in New Orleans. The only other Canadian to ever receive this award was Robert Salter many years ago. Thanks to all who joined us for the very lively COA reception at the AAOS meeting. The Local Arrangement Committee in Victoria is working hard on our behalf to host the 2018 COA Annual Meeting. A warm welcome is extended to all members to join together in Victoria for what promises to be a very educational and entertaining meeting.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 20 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 43 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 52 I am most grateful for the opportunity to serve as your President this year. It has been a privilege to represent the COA and to work on your behalf to improve our ability to care for Canadians with musculoskeletal disease. Anne and I look forward to seeing as many of you as possible in Victoria!

Repenser les soins de santé : Une perspective locale et mondiale sur l’orthopédie Kevin Orrell, MD, FRCSC Président de l’Association Canadienne d’Orthopédie


epuis que j’assume la présidence de l’ACO, Anne et moi avons eu l’immense privilège de voyager, avec les présidents du groupe Carousel, en Afrique du Sud, au Royaume-Uni, en Australie, en Nouvelle-Zélande et aux États-Unis. Nous nous sommes faits beaucoup d’amis et avons rencontré un grand nombre d’orthopédistes qui ont une haute opinion de ce qui se fait en orthopédie au Canada. Ce fut un honneur de prendre part à des symposiums internationaux et de répondre aux questions des orthopédistes de ces pays sur notre système de santé universel. Ici, nous sommes toutefois bien conscients des problèmes considérables qui se posent; nous nous démenons pour traiter nos patients alors que les gouvernements provinciaux ne parviennent pas à fournir les ressources nécessaires pour le faire adéquatement. Je suis heureux d’avoir pu échanger avec un si grand nombre de personnes issues tant des milieux universitaire que communautaire. Le dénominateur commun : il est de plus en plus difficile de traiter nos patients, car il faut s’efforcer de faire plus avec moins. Ces rencontres permettent de constater que les orthopédistes partout au pays sont extrêmement préoccupés par leur environnement de travail.

COA Bulletin ACO - Spring / Printemps 2018

L’accès aux soins demeure une source d’embarras au Canada. Les temps d’attente pour une consultation, une investigation et une chirurgie, peu importe la sous-spécialité, sont inacceptables dans un pays qui se targue d’avoir un système de santé universel. L’ACO procède actuellement à la mise à jour de son énoncé de position sur l’accès aux soins et invite les gouvernements provinciaux à travailler avec elle de sorte à améliorer la santé de l’appareil locomoteur de toute la population canadienne. La situation est encore plus embarrassante pour un pays développé où le sous-emploi est si répandu chez des jeunes orthopédistes dûment formés et compétents. Bien que le nombre d’orthopédistes à la recherche d’un poste à temps plein se soit récemment quelque peu amélioré, il s’agit toujours d’une préoccupation majeure pour l’ACO. À long terme, la formation de moins d’orthopédistes aura une incidence considérable sur les soins de l’appareil locomoteur au Canada. L’ACO s’est engagée à renforcer ses relations avec les associations d’orthopédie provinciales et régionales. Nous avons des préoccupations semblables et espérons que des liens plus étroits nous permettront d’être davantage un moteur de changement. En novembre, Cynthia Vezina, notre directrice générale, Initiatives stratégiques, et moi avons eu le privilège d’assister au congrès de l’Ontario Orthopaedic Association (OOA), à Toronto, à cette fin.

Your COA / Votre association


(suite de la page 4)

L’ACO s’efforce d’aborder nos préoccupations communes. Chaque membre a un rôle à jouer pour renforcer notre organisation et l’habiliter encore davantage à confronter nos décideurs au nom de nos patients. La Réunion d’hiver de l’ACO était axée sur bon nombre des difficultés que nous éprouvons au quotidien. Je vous invite tous et toutes à communiquer avec nous et, si vous en avez le temps et l’énergie, à donner du temps au sein des comités de notre association. Dans nos déplacements, j’ai pu constater à quel point le milieu canadien de l’orthopédie est tenu en grande estime. De nombreuses personnes se sont distinguées sur la scène internationale. Félicitations au Dr Paul Beaulé et à son équipe de recherche, à qui on a récemment remis le prix Kappa Delta Elizabeth Winston Lanier 2018 au congrès de l’American Academy of Orthopaedic Surgeons (AAOS), à la Nouvelle-Orléans. Le seul autre Canadien à avoir remporté cette distinction est Robert Salter, il y a bien des années. Merci à tous ceux et celles qui ont assisté à la réception très animée de l’ACO au congrès de l’AAOS. Le Comité organisateur de la Réunion annuelle 2018 de l’ACO, à Victoria, travaille avec ardeur aux derniers préparatifs. Tous les membres sont cordialement invités à être des nôtres à Victoria pour une réunion des plus informative et divertissante. Je suis très reconnaissant d’avoir pu vous servir à titre de président cette année. Ce fut un privilège de représenter l’ACO et

Private Tours of Victoria, Exclusive for COA Annual Meeting Delegates


ign up for two private tours that have been organized exclusively for participants of the COA’s upcoming Annual Meeting being held in Victoria, BC from June 20-23. A chartered boat will take you on a private whale watching tour on Thursday, June 21 and a coach bus will bring you for tastings and lunch at two of Victoria’s most prolific wineries on Saturday, June 23. Learn more about these two tours by clicking here. Space is limited and pre-registration is highly recommended. Sign up through your online Annual Meeting registration form.

de travailler en votre nom en vue d’améliorer notre capacité à traiter les Canadiens et Canadiennes atteints de troubles de l’appareil locomoteur. Anne et moi espérons rencontrer le plus grand nombre possible d’entre vous à Victoria!

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: 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

Visites privées à Victoria pour les participants à la Réunion annuelle de l’ACO


nscrivez-vous aux deux visites privées organisées pour les participants à la Réunion annuelle de l’ACO, qui aura lieu à Victoria, en Colombie-Britannique, du 20 au 23 juin. Le jeudi 21 juin, partez observer les baleines à bord d’un bateau privé nolisé, puis le samedi 23 juillet, un autocar vous mènera dans deux des établissements vinicoles les plus prolifiques de Victoria pour des dégustations et un dîner. Pour en savoir plus sur ces visites, cliquez ici. L’inscription préalable est fortement recommandée, car les places sont limitées. Pour vous inscrire, utilisez le formulaire d’inscription en ligne à la Réunion annuelle.

COA Bulletin ACO - Spring / Printemps 2018

Your COA / Votre association


NEW Offerings at the 2018 Annual Meeting

Poster tours, Lunch and Learn sessions, practice transition ICLs, a full specialty day and so much more!


eedback and suggestions provided through Annual Meeting evaluations each year are carefully reviewed and considered by the COA program committee and leadership, and result directly in improvements, developments and refinements to our education programs. Each year’s Annual Meeting adds a new feature, session type or topic that makes every educational program diverse as we strive to offer members an Annual Meeting that grows, develops and progresses with the needs and interests of its participants. Here are some of the new things that we are offering this year at the 2018 Annual Meeting. • Showcase Theatre sessions increase CMEearning potential Accredited sessions will be running during the breaks and lunch hours on Thursday and Friday in the Exhibit Hall. Look for the brand-new showcase theatre in the exhibit area where moderated e-poster sessions will take place as well as ‘Lunch and Learn’ sessions featuring a journal club review of this year’s most read papers on OrthoEvidence, and presentations from the visiting ABC fellows in their areas of expertise. Earn valuable CME even during breaks! • From residency to retirement – ICLs for every career stage ICLs will discuss transition from residency and fellowship training into active practice, as well as transitioning into retirement and strategies for tax management. All ICLs are on a first come, first served basis. • More presentations! We received a record number of abstract submissions this year which translates to more podium and poster presentations. • Full specialty day Saturday, June 23 is your full day of subspecialty programming where symposia, paper sessions, guest speakers and ICLs will be offered from each of the orthopaedic subspecialties. • Improved spine program We have collaborated with the Canadian Spine Society (CSS) to develop a comprehensive spine program made up of three symposia, two ICLs, a poster tour and three paper sessions supported by international guest faculty and Canadian leading spine specialists.

Collaborative symposium with Indian Orthopaedic Association (IOA) The current and past Presidents from the IOA will be leading a trauma symposium along with members of the Canadian Orthopaedic Trauma Society (COTS) in this first collaboration with our orthopaedic colleagues in India.

• Intimate Partner Violence (IPV) educational program training session The team behind the EDUCATE IPV educational program will be leading a champion training session developed for all staff who see patients in fracture clinics. IPV champions will be provided with specialized training from the EDUCATE team that focuses on how to identify and respond to IPV within the fracture clinic setting as well as the EDUCATE program curriculum. Preregistration for this session is recommended through the Annual Meeting online registration program. • Session features keynote addresses The guest lecturers are scheduled during unopposed session time that doesn’t compete with any other programming. The R.I. Harris Lecturer, Founders’ Award research update, presentation by this year’s J.E. Samson Award recipient and a special address by the first COA Global Surgery (COAGS) Norman Bethune fellow will take place during one afternoon session block without concurrent sessions. You now won’t miss out on these keynote addresses. • Workshop provides hands-on experience with the SIGN IM Nail Dr. Lew Zirkle and a team of experienced instructors will be guiding a hands-on workshop on the treatment of long bone fractures in austere environments using the SIGN Nail system. • Town hall session brings leadership & membership together The COA Business Meeting has been revamped into a town hall session where members can address the Executive and Board of Directors with any questions or suggestions. This open session gives all members the opportunity to learn about recent projects, programs and work carried out by the COA’s various committees while providing feedback, input, and the chance to direct any questions to the leadership. All members are invited to participate in the Your COA in Review session on Thursday, June 21. Complete program information can be found by visiting: If you have not yet registered, visit to get signed up. Already made your plans to attend? Encourage your colleagues to join you in Victoria.

COA Bulletin ACO - Spring / Printemps 2018

Your COA / Votre association


NOUVEAUTÉS à la Réunion annuelle 2018

Visites d’affiches, causeries, conférences d’enseignement sur les transitions professionnelles, journée complète consacrée aux sous-spécialités, et bien plus encore!


a rétroaction et les suggestions fournies chaque année dans les évaluations de la Réunion annuelle sont considérées attentivement par le Comité responsable du programme et la direction de l’ACO, et entraînent des améliorations petites et grandes au programme de formation. Chaque réunion annuelle propose de nouvelles activités ou de nouveaux types de séances ou sujets afin de diversifier le programme, car nous nous efforçons d’offrir aux membres une réunion annuelle qui prend de l’ampleur et évolue selon les besoins et intérêts de ses participants. Voici quelques-unes des nouveautés que nous vous proposons à la Réunion annuelle 2018 : • Séances à la vitrine promotionnelle pour plus de crédits d’éducation médicale continue Les jeudi et vendredi, des séances de formation agréées auront lieu pendant les pauses et le dîner dans la salle d’exposition. Ne manquez pas la toute nouvelle vitrine promotionnelle, dans la salle d’exposition; on y tiendra des séances de présentation d’affiches électroniques et des causeries où un club de lecture examinera les articles les plus lus dans OrthoEvidence cette année, et les lauréats de la Bourse de voyage américano-britanno-canadienne (ABC) en visite chez nous y feront des exposés liés à leur domaine de spécialisation. Cumulez des crédits d’éducation médicale continue (ÉMC) même pendant les pauses! • De la résidence à la retraite : Des conférences d’enseignement pour tous et toutes Les conférences d’enseignement traiteront de la transition de la résidence et de la spécialisation à l’exercice actif, de même que de la transition à la retraite et des stratégies de gestion fiscale. Toutes les conférences d’enseignement sont accessibles selon le principe du premier arrivé, premier servi. • Toujours plus de présentations! Nous avons reçu un nombre record de précis, et cet afflux se traduit par plus d’exposés et d’affiches. • Journée complète consacrée aux sous-spécialités Votre journée complète des sous-spécialités aura lieu le samedi 23 juin. Des symposiums, séances de présentation de précis, conférences d’invités et conférences d’enseignement seront offertes pour chacune des sousspécialités orthopédiques. • Programme bonifié sur le rachis En collaboration avec la Société canadienne du rachis (CSS), nous avons conçu un programme exhaustif sur le rachis, composé de trois symposiums, de deux conférences d’enseignement, d’une visite d’affiches et de trois séances de présentation de précis, le tout présenté par des professeurs invités de partout dans le monde et d’éminents spécialistes canadiens du rachis. • Symposium conjoint avec l’Indian Orthopaedic Association Le président et le président sortant de l’Indian Orthopaedic Association (IOA) animeront un symposium en traumatolo-

gie en compagnie de membres de la Société canadienne d’orthopédie traumatologique (COTS), une première collaboration avec nos collègues orthopédistes indiens. • Programme de formation sur la violence conjugale L’équipe derrière le programme de formation sur la violence conjugale EDUCATE animera une séance de formation des champions à l’intention de tout le personnel des cliniques de traitement des fractures qui interagit avec les patients. Les champions de la violence conjugale suivront une formation spécialisée offerte par l’équipe du programme EDUCATE et axée sur le repérage des victimes de violence conjugale et les interventions connexes dans le contexte d’une clinique de traitement des fractures, ainsi que sur le curriculum du programme EDUCATE. Il est recommandé de s’inscrire à l’avance à cette séance, par l’intermédiaire du système d’inscription en ligne à la Réunion annuelle. • Plage horaire réservée aux conférences principales Les conférenciers invités prononceront leur conférence alors qu’il n’y aura pas de séance simultanée au programme. En effet, la conférence R.I. Harris, la présentation sur les développements dans la recherche récompensée par la Médaille du fondateur de la Société de recherche orthopédique du Canada (SROC), la présentation du lauréat du Prix J.-ÉdouardSamson de cette année et une allocution spéciale du premier lauréat de la Bourse de voyage d’études en orthopédie Norman Bethune du comité Planète ortho de l’ACO auront lieu en après-midi, dans une plage horaire où il n’y aura aucune autre séance au programme. Ainsi, vous ne passerez pas à côté de ces conférences principales. • Atelier pratique sur les clous intramédullaires SIGN Le Dr Lew Zirkle et une équipe de formateurs chevronnés animeront un atelier pratique sur le traitement des fractures des os longs en milieu austère à l’aide des clous intramédullaires SIGN. • Séance de consultation réunissant la direction et les membres La Séance de travail de l’ACO a été transformée en séance de consultation où les membres peuvent poser des questions ou formuler des suggestions au Comité de direction et au conseil d’administration. Cette assemblée générale permet à tous les membres d’en savoir plus sur les projets, programmes et travaux récents des comités de l’ACO, tout en leur donnant l’occasion de formuler de la rétroaction, de partager leurs idées et de poser des questions à la direction. Tous les membres sont invités à assister à la séance « Coup d’œil sur l’ACO », le jeudi 21 juin. Vous trouverez ici tous les renseignements sur le programme : Pour s’inscrire, il suffit de se rendre à Vous avez déja planifié votre participation à la Réunion annuelle? Invitez vos collègues à vous y rejoindre à Victoria.

COA Bulletin ACO - Spring / Printemps 2018

Over double the number of Level 1, 2 and 3 clinical studies than all competitors combined.1

No other bone stimulator comes close. *



Controlled Clinical Studies2-17

15 fresh fracture studies2-16




16 Randomized



3 Cohort Studies

12 Case Controlled

2 fresh fracture studies18,19

1 fresh fracture study21

1 nonunion study20

11 nonunion studies22-32


1 nonunion study17


» Click here to learn more about EXOGEN.

Summary of Indications for Use: EXOGEN is indicated for the non-invasive treatment of all osseous defects (excluding vertebra and skull), including the treatment of delayed unions, nonunions,† stress fractures and joint fusion. EXOGEN is also indicated for the acceleration of fresh fracture heal time, repair following osteotomy, repair in bone transport procedures and repair in distraction osteogenesis procedures. There are no known contraindications for the EXOGEN device. Safety and effectiveness have not been established for individuals lacking skeletal maturity, pregnant or nursing women, patients with cardiac pacemakers, on fractures due to bone cancer, or on patients with poor blood circulation or clotting problems. Some patients may be sensitive to the ultrasound gel. Full prescribing information can be found in product labeling, at, or by calling customer service at 1-855-771-0606 (toll free). * These studies, which reflect the body of evidence of the bone stimulator EXOGEN, include evaluations of applications outside the approved label. Assignment of evidence levels was based on the updated level of evidence rating system in the Journal of Bone & Joint Surgery. 2015;97(1):1-2. †

Active Healing Through Orthobiologics

A nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing.

References: 1. Bioventus, LLC. EXOGEN studies and competitor studies analysis literature search, United States. Data on File, RPT-000557: 2016. 2. Dudda M, Hauser J, Muhr G, Esenwein SA. J Trauma. 2011;71:1376-80. PMID: 22071933. 3. El-Mowafi H, Mohsen M. Int Orthop. 2005;29(2):121-4. PMID: 15685456. 4. Emami A, Petrén-Mallmin M, Larsson S. J Orthop Trauma. 1999;13(4):252-57. PMID: 10342350. 5. Handolin L, Kiljunen V, Arnala l, at el. J Orthrop Sci. 2005;10(4):391-5. PMID: 16075172. 6. Handolin L, Kiljunen V, Arnala I, et al. Arch Orthop Trauma Surg. 2005; 125(5):317-21. PMID: 15821899. 7. Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF. J Bone Joint Surg Am. 1994;76(1):26-34. PMID: 8288661. 8. Kristiansen TK, Ryaby JP, McCabe J, Frey JJ, Roe LR. J Bone Joint Surg Am. 1997;79(7):961-73. PMID: 9234872. 9. Leung KS, Lee WS, Tsui HF, Liu PP, Cheung WH. Ultrasound Med Biol. 2004;30(3):389-95. PMID: 15063521. 10. Lubbert PH, van der Rijt RH, Hoorntje LE, van der Werken C. Injury. 2008;39(12):1444-52. PMID: 18656872. 11. Mayr E. Rudzki MM, Rudzki M, et al. Handchir Mikrochir Plast Chir. 2000;32(2):115-22. PMID: 10857066. 12. Rue JP, Armstrong DW 3rd, Frassica FJ, Deafenbaugh M, Wilckens JH. Orthopedics. 2004;27(11):1192-5. PMID: 15566133. 13. Salem KH, Schemlz A. Int Orthop. 2014;38(7):1477-82. PMID: 24390009. 14. Strauss E, Ryaby JP, McCabe J. J Ortho Trauma. 1999;13(4):310-21. 15. Tsumaki N, Kakiuchi M, Sasaki J, Ochi T, Yoshikawa H. J Bone Joint Surg Am. 2004;86-A(11):2399-405. PMID: 15523009. 16. Zacherl M, Gruber G, Radl R, Rehak PH, Windhager R. Ultrasound Med Biol. 2009;35(8):1290-7. PMID: 19540659. 17. Schofer MD, Block JE, Aigner J, Schmelz A. BMC Musculoskelet Disord. 2010; 11:229. PMID: 20932272. 18. Couglin MJ, Smith BW, Traughber P. Foot Ankle Int. 2008;29(1):970-7. PMID: 18851812. 19. Gold SM, Wasserman R. J Orthop Trauma. 2005;19(1):10-6. PMID: 15668578. 20. Romano C, Messina J, Meani E. Guarderni di infezione osteoarticolari. 1999;83–93. 21. Kinami Y, Noda T, Ozaki T. J Orthop Sci. 2013;18(3):410-8. PMID: 23463120. 22. Farkash U, Bain O, Gam A, Nyska M, Sagiv P. J Orthop Surg Res. 2015;10:72. PMID: 25986554. 23. Gebauer D, Mayr E, Orthner E, Ryaby JP. Ultrasound Med Biol. 2005;31(10):1291-402. PMID: 16223643. 24. Jingushi S, Mizuno K, Matsushita T, Itoman M. J Orthop Sci. 2007;12(1):35-41. PMID: 17260115. 25. Lerner A, Stein H, Soudry M. Ultrasonics. 2004;42(1-9):915-7. PMID: 15047406. 26. Mayr E, Mockl C, Lenich A, Ecker M, Rüter A. Unfallchirurg. 2002;105(2):108-15. PMID: 11968536. 27. Nolte PA, van der Krans A, Patka P et al. J Trauma. 2001;51(4):693-702. PMID: 11586161. 28. Pigozzi F, Moneta MR, Giombini A et al. J Sports Med Phys Fitness. 2004;44(2):173-8. PMID: 15470315. 29. Roussignol X, Currey C, Duparc F, Dujardin F. Orthop Traumatol Surg Res. 2012;98(2):206-13. PMID: 22424956. 30. Rutten S, Nolte PA, Guit GL, Bouman DE, Albers GH. J Trauma. 2007;62(4):902-8. PMID: 17426546. 31. Watanabe Y, Arai Y, Takenaka N, Kobayashi M, Matsushita T. J Orthop Sci. 2013;18(5):803-10. PMID: 23775464. 32. Zura R, Della Rocca GJ, Mehta S, et al. Injury. 2015;46(10):2036-41. PMID: 26052056. EXOGEN, Bioventus and the Bioventus logo are registered trademarks of Bioventus LLC.



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Extraordinary Line-up of Guest Speakers at the 2018 Annual Meeting in Victoria



Une brochette d’invités exceptionnelle à la Réunion annuelle 2018, à Victoria


t this year’s COA Annual Meeting three renowned specialists from across the globe will be participating as guest speakers in our educational program. Addressing a variety of specialized topics, each keynote speaker has extensive experience in their field of concentration and has prepared a talk to address a lesser explored area of orthopaedic practice, while situating it within the larger framework of global healthcare initiatives.

rois des conférenciers invités dans le cadre du programme de formation de la Réunion annuelle 2018 de l’ACO sont des spécialistes internationaux de renom. Ces éminents conférenciers traiteront d’un éventail de sujets spécialisés; chacun possède une vaste expérience dans son domaine et abordera un aspect plus obscur de la pratique orthopédique en le plaçant dans le contexte des initiatives mondiales en matière de santé.

Register for the Annual Meeting today to have the opportunity to participate and hear exciting talks from some of the biggest names in the field.

Inscrivez-vous à la Réunion annuelle dès aujourd’hui pour assister à ces allocutions fascinantes par certaines des sommités du domaine.

Presidential Guest Speaker Conférencier invité par le président Franklin H. Sim, MD Wednesday, June 20, 17:30: Opening Ceremonies Le mercredi 20 juin, 17 h 30 : Cérémonies d’ouverture Teamwork in Orthopaedic Oncology Le travail d’équipe en oncologie orthopédique

Macnab Lecturer Conférencier Ian Macnab Professor David Hunter, MBBS (Hons), MSc (Clin Epi), M SpMed, PhD, FRACP (Rheum) Thursday, June 21, 11:15 / Le jeudi 21 juin, à 11 h 15 Principles and Development of Biomarkers for the Musculoskeletal System Principes et développement de biomarqueurs pour l’appareil locomoteur

R.I. Harris Lecturer Conférencier R.I. Harris Stuart L. Weinstein, MD Thursday, June 21, 15:30 / Le jeudi 21 juin, 15 h 30 Health-care Reform USA; The Promise and the Reality Réforme de la santé aux États-Unis : Les promesses et la réalité

COA Bulletin ACO - Spring / Printemps 2018

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COA Bulletin – Online Reading Tip #2

Bulletin de l’ACO – Conseil de lecture en ligne no2

ike what you’ve read and want to share it with a colleague? Or e-mail it to yourself should you ever want to refer back to an article of interest? Here’s how to use the SHARE feature in the online COA Bulletin viewer.


ous avez aimé un article et souhaitez le partager avec un collègue? Ou encore vous l’envoyer par courriel afin de pouvoir y revenir plus tard? Voici la fonction « SHARE » du lecteur Web du Bulletin de l’ACO.

Reading the Bulletin on a Computer? (desktop or laptop) Follow these steps:

Lecture du Bulletin sur ordinateur (de bureau ou portable) – Suivre les étapes suivantes :

Using the ‘SHARE’ Feature

Utiliser la fonction « SHARE »


1) Click on SHARE and the upload icon in the bottom left corner of the viewer.

1) Cliquez sur « SHARE » et l’icône de téléchargement, dans le coin inférieur gauche du lecteur.

2) Once you click on SHARE, a popup window will open providing you with different options.

2) Après avoir cliqué sur « SHARE », une fenêtre proposant diverses options s’affiche.

- Share from cover gives you a sharable link that opens up the COA Bulletin from the very beginning (cover page). - Share from page provides a sharable link that opens up the journal from a specific page of your choice or the current page you’re reading. This is a great way of sending someone a specific article – once they click on the link you’ll provide, the COA Bulletin will open up to the exact page or article that you wanted to share. - Once you’ve chosen either Share from cover or Share from page, click on one of the MEDIA ICONS to share that COA Bulletin link. Facebook, Pinterest, Twitter and e-mail options are provided. COA Bulletin ACO - Spring / Printemps 2018

- La fonction « Share from cover » génère un lien vers la page couverture du Bulletin, tout au début. - La fonction « Share from page » génère un lien vers la page de votre choix, ou vers la page active. Il s’agit d’un excellent moyen d’envoyer un article précis à quelqu’un : en cliquant sur le lien fourni, le Bulletin s’ouvre à la page ou à l’article exact que vous vouliez partager. - Après avoir sélectionné « Share from cover » ou « Share from page », cliquez sur une des icônes des MÉDIAS SOCIAUX (Facebook, Pinterest ou Twitter) ou sur l’icône du courriel pour partager le lien vers le Bulletin.

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Reading the Bulletin on a phone or tablet? Follow these steps: 1) The SHARE process is the same, but you need to make sure you are in FULL SCREEN MODE in order to see the SHARE option. 2) Click on the full screen icon found in the bottom right corner of the viewer. 3) The SHARE option and icon will then appear in the top right corner once you’re in full screen mode. 4) Now, follow the same steps to SHARE an article.


Lecture du Bulletin sur téléphone ou tablette – Suivre les étapes suivantes : 1) La procédure d’utilisation de la fonction « SHARE » est la même que sur ordinateur, mais vous devez vous assurer d’être en MODE PLEIN ÉCRAN pour pouvoir voir l’option. 2) Cliquez sur l’icône du mode plein écran, dans le coin inférieur droit du lecteur. 3) La fonction « SHARE » apparaît dans le coin supérieur droit en mode plein écran. 4) Suivez les étapes précédentes pour partager l’article souhaité.

Look for more online reading tips in future editions of the COA Bulletin D’autres conseils de lecture en ligne seront publiés dans les prochains numéros du Bulletin de l’ACO. COA Bulletin ACO - Spring / Printemps 2018

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Arthroscopy Association of Canada (AAC): Past, Present and Future of Orthopaedic Sports Collaboration Ivan Wong, M.D., MACM, FRCSC, DipSportMed Associate Professor, Dalhousie University AAC President Halifax, NS AAC Executive Committee Members*

Getting Up and Running he inaugural meeting of the Arthroscopy Association of Canada (AAC) was held in 2012, initiated by a small group of committed orthopaedic surgeons. While there was interest in pursuing a formalized structure, the group did not fully materialize into a developed association at that time. The AAC was re-formed in 2017, and the current AAC Executive is grateful to the founding members, many of whom now form our Advisory Committee, and have been pivotal contributors to the early success of the Association.


The AAC encourages national collaboration and advancement of sports and arthroscopy research and education. The AAC will mobilize the knowledge gained through the Association’s research to contribute to the global advancement of arthroscopic surgery and improved patient outcomes. Members include orthopaedic surgeons, sports medicine physicians, researchers and allied health-care professionals. Early Priority: Position Statement Concerning Arthroscopy of the Knee Joint One of the first tasks set out for the AAC was the development of a position statement in response to increased attention in the media and amongst health authorities as to the role of arthroscopy in knees with and without X-ray evidence of osteoarthritis (OA). While recognizing that there is a gap between scientific evidence and clinical practice, the purpose of this statement is to outline current best practice guidelines, taking into consideration the available evidence as well as the clinical knowledge of experienced surgeons. It is meant to be a guideline for the practice of arthroscopy while allowing for individual decision making by the surgeon and the patient after considering all risks and benefits of any procedure. COA Bulletin ACO - Spring / Printemps 2018

The AAC Position Statement was approved for endorsement by the COA Board of Directors at the COA Midwinter Meeting in Toronto on January 13, 2018 and is now available as a co-branded document. Furthermore, the statement was published in the Orthopaedic Journal of Sports Medicine (OJSM) on February 26, 2018. Thank you to all members who contributed and voted. Join Us in Person at the AAC Subspecialty Day The 2018 COA Annual Meeting takes place from June 20-23 in Victoria, BC, featuring a sports subspecialty day on Saturday, June 23. Tentative sports programming during the COA Annual Meeting will include combined sessions with both upper extremity and foot and ankle, paper presentations, a guest speaker, tips and tricks, a case-based symposium, a debate, a poster tour, and an AAC Business and Research meeting.

Summary of AAC Position on Knee Scopes: Arthroscopic debridement, and/or lavage, of the knee joint, has not been shown to have any beneficial effect on the natural history of osteoarthritis, nor is it indicated as a primary treatment in the management of osteoarthritis of the knee. However, this does not preclude the judicious use of arthroscopic surgery when indicated to manage symptomatic coexisting pathologies, in the presence of osteoarthritis or degeneration. Click here to see the full 8-page position statement in English or French.

We hope to see you there and we look forward to expanding on our educational model at future meetings. Research Opportunities A formal AAC research program is in its early stages, and the Executive continues to discuss the potential for Canadian collaborative studies that are clinical or registry-based. We are also developing a research grant/award process for trainees and active surgeons, as well as an accreditation process for AAC fellowships.

AAC Executive discussing the Group’s objectives at June 2017 Business Meeting in Ottawa.

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(continued from page 12)

We look forward to sharing further details with members at the next Annual Meeting. Get in Touch If you consider sports medicine and/or arthroscopy to be a component of your practice, we invite you to join the AAC. Membership categories include: • Active (orthopaedic surgeons, sports medicine and other physicians) • Affiliate (allied health professionals, researchers) • Associate (residents, fellows) • Senior (retired from practice) Please visit the Memberships section of our web site for more information. The AAC would like to hear from potential or existing members with your ideas. For all inquiries or to reach any of member of the Executive, please contact Trinity Wittman at

*AAC Executive Members President: Ivan Wong; Halifax, NS Education/Clinical: Laurie Hiemstra, Banff, AB Research: Femi Ayeni, Hamilton, ON Treasurer: Cole Beavis, Saskatoon, SK Secretary/Membership: Monika Volesky, Montreal, QC Public Relations and Communications: Ross Outerbridge, Kamloops, BC Industry Relations: Al Getgood, London, ON AAC Advisory Committee Catherine Coady, Halifax, NS Robert Litchfield, London, ON Peter MacDonald, Winnipeg, MB Robert McCormack, New Westminster, BC Nicholas Mohtadi, Calgary, AB Christian Veillette, Toronto, ON Daniel Whelan, Toronto, ON

Making Global Surgery Work as a Community Orthopaedic Surgeon Stephen Croft, M.D., FRCSC Team Lead, Broken Earth Western Newfoundland Corner Brook, NL Andrew Furey, M.D., FRCSC Team Lead, CEO Team Broken Earth St. John’s, NL


mplementing global health initiatives from communitybased centres can be a challenging feat, however certainly not impossible. Global health missions encompass many hurdles, but once overcome, they not only have the potential to improve the health and well-being of the local communities, but they can also have an inspiring and lasting impact on individuals and groups upon return from abroad. With that in mind, in November of 2016, a group of nineteen health professionals from Western Newfoundland joined forces with Team Broken Earth (TBE), a non-profit volunteer task force committed to delivering and improving health care in Haiti1. TBE is continuing the medical relief effort in Port-au-Prince, Haiti following the devastating 2010 earthquake, and helping Haitians build capacity to shape their own future. Dr. Stephen Croft, a community-based orthopaedic surgeon working in Corner Brook, Newfoundland, led the team to a successful mission under the TBE umbrella. As suspected, there were multiple challenges encountered along the path to Portau-Prince, some of them very specific to our Canadian community practice setting. What follows is an account how our team was able to address some of the biggest hurdles.

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 for details. The initial challenge that arose was the very question that this article is attempting to address: Is it possible to embark on such a large mission coming from a rural environment? Corner Brook, Newfoundland is a city of approximately 19,000 people, and is a member of the Western Regional Health Authority, which has a catchment area of approximately 78,000 people2. The consideration for removing a group of nineteen health professionals for one week as a self-sustaining group to Haiti was not taken lightly. Two orthopaedic surgeons, one general surgeon, one anaesthesiologist, four emergency room physicians, one internist, one family physician, one physiotherapist and a full complement of nursing staff were needed as members of the travelling team, not an insignificant number of staff to be removed from call rotas, nursing shifts, and daily schedules. After great deliberation, and under guidance from TBE Leader and CEO, Dr. Andrew Furey, the decision was made that the mission would be feasible. COA Bulletin ACO - Spring / Printemps 2018

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(continued from page 13)

Forming the team required careful consideration. Two specific areas of concern included removing too many staff from one location which could leave Western Health underserviced, and secondly, forming a cohesive group that would work well together in a Dr. Tracey Wentzell, and a local Haitian foreign environment. In orthopaedic surgeon working side by side order to alleviate these concerns, health professionals were not only chosen from the primary hospital within the Western Regional Health Authority, but also from Health Centres in the periphery of the region. Additionally, staffing concerns could potentially be overcome with locum coverage if needed. We initially would have liked to bring two anesthesiologists along, and considered a locum replacement to fill the gap at home, but ultimately we decided we could manage with just one. Regarding formal selection of team members, interested applicants were encouraged to put their names forward, and in the case of having to decide between multiple capable applicants (which was the case with OR nursing staff), names were randomly drawn in order to alleviate selection bias and dissatisfaction. In addition to challenges with human resources, missions of this magnitude require substantial fundraising. Cost of travel, lodging, food, and insurance are significant, particularly when travelling from community environments. Once the mission was set in motion and a timeline was in place, an aggressive fundraising campaign was implemented in order to increase local awareness and enlist community support. The team shared plans and objectives with local individuals, businesses, and organizations, via mail, in-person visits and formal presentations. The efforts were met with the needed sponsorship dollars, often via well-attended fundraisers, such as a silent auction, ticket raffles, and barbeques, as well as an abundance of encouragement. We were very grateful to have Newfoundlanders and Labradorians rallying behind the mission. Lastly, not only is the monetary cost of travel high, but the time associated with travel from a community setting is of significant concern. Depending on proximity to international airports, extra travel time is required in order to make the trip

a success, with some of our team members needing to make time for an overnight in Toronto or Miami before a final flight to Port-au-Prince. Planning travel ahead is optimal, in our case, about nine to twelve months before departure. Overall, global health Initiatives are an excellent way of getting involved with international medicine. The benefits are invaluable for both the vulnerable populations in need of service, as well as the individuals, groups, and communities taking part in the provision of care. Our TBE teams provide patient care and resident teaching which would otherwise be inaccessible, and have a sustainable impact on local health care. Team members also get to know each other on a more personal level, which can translate to a more congenial working environment back at home. Although there is a time and energy commitment required for global health travel, groups such as TBE and others in Canada are dedicated to helping fellow orthopaedic surgeons and other health professionals get involved. Implementing these initiatives from a community orthopaedic surgeon’s perspective is not only possible, but encouraged. You just might get hooked!

Team Broken Earth Western Newfoundland

Questions? Feel free to contact Drs. Croft or Furey by e-mailing To view a list of orthopaedic global health opportunities, including TBE, please visit and click on ‘Get Involved’. References 1. Team Broken Earth (2017). Canadian medical teams helping out in Haiti. Retrieved from: 2. Western Health (2017). Our people, our communities – healthy together. Retrieved from:

Dr. Stephen Croft teaching Haitian orthopaedic residents in their classroom COA Bulletin ACO - Spring / Printemps 2018

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2019 ABC Fellowship Applications Due July 13


he COA is accepting applications for the 2019 ABC Travelling Fellowship until July 13, 2018. The tour will take place during the Spring of 2019 over approximately five weeks. This fellowship opportunity is open to candidates who are under 45 years of age as of December 31, 2018 and who are either Canadian citizens or permanent residents with full-time positions in Canadian hospitals. Guidelines, application forms and further information can be found here. Want to learn more about the ABC fellowship? Attend the Lunch and Learn session featuring presentations from the COA’s most recent ABC fellows who participated in the 2017 tour as well as the visiting ABC fellows being hosted in Canada and the US this spring. The “Education Through Exchange” session will held in the Showcase Theatre in the Exhibit Hall on Thursday, June 20 from 12:45-14:00.

2017 ABC Fellows


Date limite de soumission des candidatures pour la Bourse de voyage ABC 2019 : Le 13 juillet


’ACO accepte les candidatures pour la Bourse de voyage américano-britanno-canadienne (ABC) 2019 jusqu’au 13 juillet 2018. La tournée aura lieu au printemps 2019 et durera environ cinq semaines. Les candidats doivent être âgés de moins de 45 ans au 31 décembre 2018 et être citoyens canadiens ou résidents permanents, en plus d’occuper un poste à temps plein dans un hôpital canadien. Vous trouverez les lignes directrices, le formulaire de demande et de plus amples renseignements ici. Vous souhaitez en savoir plus sur la Bourse de voyage ABC? Assistez au dîner-causerie où les derniers lauréats de l’ACO à avoir pris part à la tournée, en 2017, de même que les lauréats 2018 en visite au Canada et aux États-Unis ce printemps, feront des présentations sur la Bourse de voyage ABC. La séance « La formation par l’échange » aura lieu à la vitrine promotionnelle, dans la salle d’exposition, le jeudi 20 juin, de 12 h 45 à 14 h.

Les lauréats 2015

From the COA Archives…A History of the Canadian Orthopaedic Association by R.I. Harris


eing a member of a medical specialty and professional association so rich in history and achievement, I can’t help but have considerable interest in where things started and how orthopaedics in Canada and the COA were shaped by our forefathers. The COA office is graced with a few relics and artefacts that provide us with insight into how and why our Association was founded, and how we’ve come to where and what we are today. One of these prized items is the book written by Dr. R.I. Harris, published in 1967

by University of Toronto press for the Canadian Orthopaedic Association titled, A History of the Canadian Orthopaedic Association. A limited number of hardcover bound editions reside on the shelves of the COA’s Montreal office and likely in some of our more senior members’ libraries. The book outlines the careers of the founding members, the first orders of business and the development of the COA. We will be reproducing excerpts from this notable book in editions of the COA Bulletin so that all of our membership could learn more about COA Bulletin ACO - Spring / Printemps 2018

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(continued from page 15)

the valuable history of our Association. In this edition, we are pleased to share the book’s foreword by Past President, Dr. F.P. Patterson (whose life and career are described in the History of Orthopaedics in British Columbia series featured in past COA Bulletin editions) as well as the preface by the author, Dr. R.I. Harris, himself. Enjoy. – Ed. FOREWORD No member of the Canadian Orthopaedic Association, from its creation to the present time, has exercised such a preponderant influence on the Association as the author of this history, the late Robert I. Harris. Born July 1, 1889, in Toronto, Robert Harris died in June 28, 1966, at Banff, Alberta, having been stricken with a heart attack while attending the Canadian Orthopaedic Association Meeting. It was, perhaps, fitting that when death came, it was in the line of duty to this Association which he loved so much. This book is an expanded account of an address to the 1963 Annual Meeting which was held near the author’s summer home at Honey Harbour, Ontario. It was a singular honour that Dr. Harris was at that meeting as the special guest speaker of the President, Ian Davidson, and he prepared the talk at the request of the President. In the history, the author has outlined the founding of the Association and prepared biographical sketches of the early leaders of orthopaedic surgery in Canada. With his unpretentious dignity and modesty, only a vague reference was made to himself. As an undergraduate medical student, Robert Harris was first in his class graduating from the University of Toronto in 1915. He served with distinction in the Royal Canadian Army Medical Corps, was awarded the Military Cross and Bar and was mentioned in dispatches. Returning from World War I, he became a member of the staff of the Hospital for Sick Children in Toronto and the Christie Street Hospital for Veterans. In 1930 Dr. Harris left the Sick Children’s Hospital to become a member of the staff of the Toronto General Hospital, where in 1940 he established the Orthopaedic Service that has been the instrument for the education and stimulation of so many Canadian orthopaedic surgeons. Shortly after this he again enlisted in the Royal Canadian Army Medical Corps to serve as a Consultant in the Armed Services at home and abroad. To list all of the achievements of R. I. Harris would require a book, not a foreward, but a few of them must be included. He was a Charter Fellow and Founder of the Royal College of Surgeons of Canada. He presented one of the three papers at its first scientific meeting in 1963 and delivered the first Gallie Memorial Lecture in 1966. He was the first orthopaedic surgeon to be a member of the Council of the Royal College, a post he occupied from 1945 to 1953. During this time, he was responsible to a large part for the program of certification of orthopaedic surgeons, for the Fellowship in Surgery, modified for orthopaedic surgery, and for the approval of hospitals for training in this specialty. Dr. Harris was Hunterian Lecturer to the Royal College of Surgeons of England (1949) and was the first Canadian appointed by that College to be a Sims Commonwealth Travelling Professor in 1955. He was an Honourary Fellow of COA Bulletin ACO - Spring / Printemps 2018

the Royal College of Surgeons of England, the Royal College of Surgeons of Edinburgh, and the Royal College of Surgeons of Australasia. Possibly one of his greatest honours was a position that enabled him to make an everlasting contribution to international orthopaedic surgery. This was his election to the presidency of the American Orthopaedic Association in 1948. He conceived the idea and was President of the American Orthopaedic Association at the time of the first combined meeting of the American, British, and Canadian Orthopaedic Associations held at Quebec City in 1948. It was at this meeting that he was responsible for arranging the first group of young British orthopaedic surgeons to North America, thus the beginning of the successful exchange fellowship program. It was also during his tenure as President of the American Orthopaedic Association that negotiations were completed for publication of the Journal of Bone and Joint Surgery in both British and American volumes. A Charter Member and Founder of the Canadian Orthopaedic Association, Dr. Harris was our President in 1949 and remained a member of the Executive Committee, where his services were no less great, until his death. His staunchness to high principles, his firmness, example, and dignity inspired his colleagues with much of his own wisdom. To read of the accomplishments of this great man is an inspiration in itself. To have known the man - a gentleman, with

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(continued from page 16)

an infinite capacity for mastering detail, but yet successful in major issues, possessed of great moral courage, a kind physician, an outstanding teacher and leader - has been a privilege for the members of the Canadian Orthopaedic Association. We shall be ever indebted to our historian for this work he was preparing until his death, and even more for the worldwide honours he brought to orthopaedic surgery in Canada. F. P. Patterson, M.D., FRCSC PREFACE In was in 1943 that the initial steps were taken to establish a Canadian Orthopaedic Association. The initiative came from the Montreal Orthopaedic Association led by their President, J. Edouard Samson, and by J. Appleton Nutter who had founded that association in 1934. In October 1943, the Montreal Orthopaedic Association called a meeting to discuss the prospect of founding of a Canadian Orthopaedic Association. To this meeting they invited the late Dr. Andrew MacKinnon of Winnipeg and myself. The outcome was the establishment of a committee composed of all the past presidents of the Montreal Orthopaedic Association. The committee was asked to draft plans for the founding of a Canadian Orthopaedic Association. On presentation of its report to a meeting of the Montreal Orthopaedic Association on February 19, 1944, a Provisional Founding Committee was appointed which was charged with the responsibility of founding a Canadian Orthopaedic Association. It was also to act as the Provisional Executive Committee until the Association was legally established. The personnel of this committee were: • • • • •

President: Dr. J. Appleton Nutter Vice-President: Col. R. I. Harris Vice-President: Dr. A. P. MacKinnon Vice-President: Dr. J. Edouard Samson General Secretary: Dr. J. C. Favreau

On May 24, 1944, the Provisional Executive Committee met in Toronto during the meeting of the Canadian Medical Association. A Committee on By-Laws was appointed under the chairmanship of Dr. Samson and other business conducted. Later in the day, a number of Canadian orthopaedic surgeons met with the committee to discuss progress. With minor revisions they approved the activities of the committee to that date. During this period of organization, steps were taken to inform all orthopaedic surgeons in Canada, and especially those Canadian orthopaedic surgeons who were overseas at that time, of the activities of the Provisional Executive Committee. The first formal meeting of the newly organized Association was held in Montreal in June 1945 on the occasion of the meeting of the Canadian Medical Association. The termination of the war that year in both Germany (May) and Japan (June) made the choices of this date singularly appropriate, for already some of the overseas orthopaedic surgeons had returned to Canada and were able to attend this meeting.

At this meeting, a draft of the by-laws was submitted, a report of the work of the Provisional Executive Committee was read by Dr. Favreau, a scientific session was presented, and the decision was reached to seek incorporation of the Association through a federal charter as a national bilingual organization with headquarters in Montreal. The requirement for founding membership was set as ten years of active practice of orthopaedic surgery. It was agreed that from that date, officers of the Association were to be elected and business conducted in accordance with the by-laws. We have held Annual Meetings regularly beginning with that in 1945. Letter patents incorporating the Association were issued by the Secretary of State of Canada in 1948. In the early years, much time was spent in compiling and revising the by-laws. These were finally completed and published in French and English in 1956. R. I. Harris, M.B., FRCSC

COA Bulletin ACO - Spring / Printemps 2018

Triathlon Revision Knee System Revision redefined ®

Stryker’s Triathlon Revision Knee System features Tritanium Cone Augments • Simplified preparation with reamer-based instrumentation1, 2, 3, 4 • Unique 3D printed Tritanium augments are designed to provide structural support and biologic fixation • Allows for metaphyseal fixation without constraining subsequent implant positioning1 • SOMA-designed to help meet reconstruction challenges and fit a broad range of patients5 References 1. Triathlon Revision Knee System Surgical Protocol (TRITS-SP-2 Rev-2). 2. Triathlon Tritanium Cone Augments Validation Report. Doc #A0004381. Project #195725. 3. Femoral Bone Prep Tolerance Analysis. Doc #A0004384. Project #195725. 4. Tibial Bone Prep Tolerance Analysis. Doc #A0004385. Project #195725. 5. Leibowitz E, Lipschutz D, Soliman M, Meneghini M. Virtual Bone Analysis Determines Metaphyseal Augment Fit. ORS 2015 Meeting Poster. 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’s product offerings. A surgeon must always refer to the package insert, product label and/ or instructions for use before using any of Stryker’s products. The products depicted are CE marked according to the Medical Device Directive 93/42/EEC. 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 sales representative if you have questions about the availability of products in your area. 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. TRITS-AD-2_Rev-3_12043 10/16

Your COA / Votre association


McAULEY, James Patrick, MD, FRCSC 1956-2017


assed away at home surrounded by his loving family on Thursday, December 28th, 2017, after a heroic and dignified battle against a brain tumour. Adoring husband to his wife Diane of 36 years. Loving father to Erin (Mark) and Alexander (Lauren). Proud grandfather of Patrick and Sebastian. Cherished friend of his patients and colleagues throughout the world. Jim was a singularly talented and dedicated orthopaedic surgeon who approached the care of his patients with the same love and kindness with which he treated all those he came across. Beyond being a world class surgeon, his family was everything to him and he never let them forget it. A true gentleman in the purest sense of the word, and a devout Catholic, he embodied the virtues of compassion and gentleness. May he rest in the peace he so richly deserves. For online condolences, please visit www.westviewfuneralchapel. com13239524

D. W. C. (Bill) JOHNSTON, MD, FRCSC 1950-2018


r. DWC Johnston, 67, of Edmonton, AB, passed away suddenly on Monday, February 19, 2018 at the University of Alberta Hospital, where he had dedicated much of his professional life to his love of orthopaedics and administration. Born in Edmonton to Cooper and Wanda Johnston, he lived most of his life in Edmonton. He followed in the footsteps of his father, working as a dedicated orthopaedic surgeon, including roles as the Director for the Division of Orthopaedic Surgery, the Chief of Surgery at the University of Alberta Hospital and Grey Nuns Community Hospital, and the Site Medical Director at the University Hospital. Bill loved to travel the world, but was happiest reading the paper in his sunroom or at his beloved cabin, River Run. He loved his Edmonton Eskimos, farmers markets, the Rolling Stones and cooking soups that could never be replicated. He will be forever remembered for his knife skills both in the operating room and in the kitchen. Bill loved his family and friends quietly and wholeheartedly. He loved his second wife Mary Ritchie very dearly and, in turn, will always be loved and adored by her. They shared many worldly adventures, quiet nights at home and enjoying gourmet meals with their large family. He is also survived by his 4 children, Susan Boissonneault (Grant), Laureen Partington (Jeremy), Ron (Sarah Ramsey) and Elizabeth Tyson (Shaun) and his 2 stepchildren Erik Arnold (Laura) and Kathleen Ritchie.

He was known as “Grumps” to his 5 grandchildren, Jessica and Valerie Partington; Adam and Nathan Boissonneault; and Baby Tyson. Bill was very fortunate to have had many life-long friends, including very close relationships with his younger sisters and their husbands: Susan Stratton (Bruce), Lynn Fraser (Tom Turner), Jill McLennan (Graham) and Margot Routhier (Steve). Bill was predeceased by his very beloved first wife of 30 years, Mary Johnston (nee Banister) who left him too early from Melanoma in 2004. Bill created the Mary Johnston Chair in Melanoma Research in memory of his first wife Mary. In lieu of flowers, please join him in supporting his cherished cause. Any donations made in Bill’s name will be directed to the Mary Johnston Chair in Melanoma Research at the Cross Cancer Institute.

COA Bulletin ACO - Spring / Printemps 2018


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

Paediatric Femur Fractures – Introduction Sukhdeep K. Dulai, M.D., MHSc, FRCSC Associate Professor, Paediatric Orthopaedic Surgery University of Alberta/Stollery Children’s Hospital Guest Editor, COA Bulletin Edmonton, AB

evidence-based medicine and fiscal responsibility in health care, the pendulum has swung to favour techniques that are less invasive, have lower complication rates, facilitate earlier discharge from hospital, and/or are associated with a faster or better return of function.


In younger patients, early hip spica casting is favoured and has had good success, capitalizing on the immense remodelling potential in this patient population. In school-aged children, flexible intramedullary nails are predominant but submuscular plating is a valuable alternative, particularly for length-unstable fracture patterns. In adolescent patients, the lateral entry femoral nail has virtually eliminated the risk of avascular necrosis and has allowed rigid intramedullary nailing to become a viable option in the skeletally immature patient. Each of these management strategies is discussed in the following articles with tips to help you choose the best option for your next paediatric femur fracture patient. Thank you to all of the authors for their contributions to this issue, and to the editors for the opportunity to guest edit this feature.

aediatric diaphyseal femur fractures are a common problem that present the orthopaedic surgeon with a management dilemma that involves a complicated decision tree. Within the cornucopia of treatment options available, each has its strengths and pitfalls. Individual therapeutic plans must consider fracture and patient characteristics as well as surgeon experience and the resources/facilities available. Historically, the mainstay of treatment included prolonged skeletal or skin traction. Surgical options included open plating or external fixation. These techniques are still sometimes used today in special circumstances (e.g. pathologic or open fractures). However, with an ever-increasing awareness of

Management of Paediatric Femur Fractures with Early Hip Spica Casting Kyle Stampe, M.D., FRCSC Clinical Fellow, Paediatric Orthopaedic Surgery University of British Columbia/BC Children’s Hospital Vancouver, BC

For infants less than six months of age, skin traction or a Pavlik harness is preferred due to quicker healing, smaller patient size, similar efficacy and the ability to employ treatment without anaesthesia4.

Sukhdeep K. Dulai, M.D., MHSc, FRCSC Associate Professor, Paediatric Orthopaedic Surgery University of Alberta/Stollery Children’s Hospital Edmonton, AB

Contraindications to hip spica application are uncommon but include active diarrhea, significant soft tissue injury (traumatic or dermatologic) in the area of the cast, impending or existing compartment syndrome of the lower limb, and polytrauma requiring access to the abdomen/back.


emur fractures account for approximately 1.5% of fractures in the paediatric population1. To manage them, the surgeon must consider patient age, size, functional demands, comorbidities and psychosocial factors, fracture characteristics, implant availability, and surgeon experience. Non-operative treatment has long been the cornerstone of paediatric femur fracture management. The current mainstay of non-operative care is immediate hip spica casting which eliminates lengthy hospitalizations previously associated with traction +/- delayed hip spica, but has similar outcomes with respect to malunion risk2. Careful patient selection and attention to technical details are key in reproducing these results. Patient Selection Although it can be used for virtually any extra-articular fracture pattern, hip spica casting is usually reserved for infants and children up to five years of age1. It is limited to younger children since the technique relies on remodeling (Figure 1) to resolve residual deformity at the fracture site, and because hip spica casts are cumbersome and impractical in older children. COA Bulletin ACO - Spring / Printemps 2018

Special Considerations With all femur fractures in children, especially those less than 18 months of age, the potential for non-accidental injury (NAI) must be considered3. Where clinical suspicion warrants, the orthopaedic surgeon should initiate thorough investigation with reporting to the appropriate regulatory body as required. Metabolic bone disease should also be considered in the differential for these injuries, although uncommon. Technical Considerations A hip spica cast should be applied by experienced personnel, usually in the operating room under general anaesthesia. However, satisfactory results have been reported with application in the emergency department under conscious sedation7. Under general anaesthesia, the patient is placed supine on a (radiolucent) hip spica table. With the assistance of fluoroscopic imaging, closed reduction is then performed. As this treatment strategy capitalizes on fracture remodeling capacity and self-correction of limb length discrepancy due to anticipated overgrowth,

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

Postoperatively, most patients have minimal analgesic requirements and can be discharged home within 24 hours. Prior to discharge, the child’s parent/caregiver should be advised regarding the potential need for an alternate car seat to accommodate the cast.






Figure 1 Remodelling in a paediatric femur fracture: (a) displaced spiral diaphyseal femur fracture in a 17-month-old boy, (b) intra-operative image from fluoroscopy (note limited field of view due to the radioopaque table- we have since switched to a radiolucent table), (c) initial postoperative films in cast demonstrate residual overlap (to compensate for anticipated overgrowth), (d) Six weeks postop (marked callus formation guided by periosteum), (e) One year postop (remodelling in progress)

anatomic reduction is not required. Acceptable alignment at the time of casting includes up to 30 degrees of deformity in the sagittal and coronal planes for children younger than 24 months and up to 15 degrees varus/valgus, and 20 degrees flexion/extension in children between two to six years of age5. An average of 0.92 cm of femoral overgrowth and 0.29 cm of ipsilateral tibial overgrowth can be expected in these patients6. This will accommodate more than 1.3 cm of shortening. Consequently, at the time of cast application, mild shortening (up to 2 cm) at the fracture site is acceptable and, in most cases, desirable.

The obvious advantages of early hip spica casting include no blood loss and no retained hardware. However, complications can be significant. As previously mentioned, duodenal compression is possible, resulting in body cast syndrome10. In addition, compartment syndrome can be a catastrophic complication. In the setting of a hip spica cast, signs and symptoms of compartment syndrome may be overlooked by health-care workers incorrectly attributing an infant or toddler’s cries to fracture pain or general discontent with the limitations of the cast. However, compartment syndrome risk can be minimized by careful attention to the technique of cast application. Several authors have identified specific sequences in hip spica casting that can increase the risk of compartment syndrome11,12. In particular, a combination of traction, elevation, and pressure should be avoided as this has been implicated as the cause of compartment syndrome and skin necrosis associated with initial below knee cast application followed by reduction and cast completion in a 90/90 position11. Skin breakdown is another risk of spica casts, with studies showing 28% of patients having skin complications during treatment14. To minimize skin issues, some surgeons are proponents of applying waterproof hip spica casts, replacing the felt/cotton padding with a waterproof liner or wrap, thereby facilitating skin care. In summary, immediate hip spica casting is an effective treatment option for paediatric femur fractures, particularly in patients aged six months to five years. The treating surgeon must be vigilant for the possibility of non-accidental trauma. Femur fractures treated in a spica cast go on to heal quickly in this age group, needing only four to six weeks of immobilization and have great remodeling potential. Patients treated by this method require prolonged follow-up to monitor for resolving or evolving limb length discrepancy due to overgrowth. As an unintended benefit, the spica cast also offers a great potential for orthopaedic surgeons and cast technicians to show off their artistic side! (Figure 2)

The surgeon or a qualified assistant maintains the lower limbs in their final position while the cast is applied. A spacer (e.g. folded huck towel) is placed directly over the trunk prior to application of the first layer of the cast. This ensures adequate room for expansion with inspiration and helps to avoid duodenal compression. (Remember to remove this spacer once the cast has set, before the patient leaves the operating room!) The cast is then applied to the trunk and lower limb(s), ensuring adequate padding for all bony prominences and plaster or fiberglass slab reinforcements for augmentation across the hip joint(s). At this point, provide a valgus mold to the femoral portion of the cast while it hardens. This helps to minimize progressive varus deformity (secondary to gravity) in unstable diaphyseal femur fractures treated by casting. Double, one-and-a-half, and single limb spica cast configurations have all been employed successfully. In comparison to double limb spicas, recent studies have shown equivalent maintenance of reduction but lower negative impact on the family with single limb casts8,9.



Figure 2 Examples of the art of paediatric orthopaedics: (a) Spiderman inspired (b) Halloween inspired (note: She has socks, not casts, on her feet.) COA Bulletin ACO - Spring / Printemps 2018


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


(continued from page 21)

References 1. Kocher, Mininder S., et al. Treatment of pediatric diaphyseal femur fractures. Journal of the American Academy of Orthopaedic Surgeons 17.11 (2009): 718-725. 2. Madhuri V et al. Interventions for treating femoral shaft fractures in children and adolescents. Cochrane Database of Systematic Reviews. 29 (7) Jul 2014:CD009076. 3. Pandya, Nirav K., et al. Child abuse and orthopaedic injury patterns: analysis at a level I pediatric trauma center. Journal of Pediatric Orthopaedics 29.6 (2009): 618-625. 4. Flynn, John M., and Richard M. Schwend. Management of pediatric femoral shaft fractures. Journal of the American Academy of Orthopaedic Surgeons12.5 (2004): 347-359. 5. Flynn, John M., et al. Femoral shaft fractures. Rockwood and Wilkins’ Fractures in children 7 (2009). 6. Shapiro, Frederic. Fractures of the femoral shaft in children: the overgrowth phenomenon. Acta orthopaedica Scandinavica 52.6 (1981): 649-655. 7. Mansour III, Alfred A., et al. Immediate spica casting of pediatric femoral fractures in the operating room versus the emergency department: comparison of reduction, complications, and hospital charges. Journal of Pediatric Orthopaedics 30.8 (2010): 813-817.

9. Flynn, John M., et al. The treatment of low-energy femoral shaft fractures: a prospective study comparing the walking spica with the traditional spica cast. JBJS 93.23 (2011): 21962202. 10. Reid, Robert L., and Robert S. Gamon Jr. The cast syndrome. Clinical orthopaedics and related research 79 (1971): 85-88. 11. Mubarak, Scott J., et al. Volkmann contracture and compartment syndromes after femur fractures in children treated with 90/90 spica casts. Journal of Pediatric Orthopaedics 26.5 (2006): 567-572. 12. Large, Thomas M., and Steven L. Frick. Compartment syndrome of the leg after treatment of a femoral fracture with an early sitting spica cast. JBJS Case Connector 11 (2003): 22072210. 13. Terzioglu, Ahmet, et al. Pressure sore from a fruit seed under a hip spica cast. Annals of plastic surgery 48.1 (2002): 103-104. 14. DiFazio, Rachel, et al. Incidence of skin complications and associated charges in children treated with hip spica casts for femur fractures. Journal of Pediatric Orthopaedics 31.1 (2011): 17-22.

8. Leu, Dirk, et al. Spica casting for pediatric femoral fractures: a prospective, randomized controlled study of single-leg versus double-leg spica casts. JBJS 94.14 (2012): 1259-1264.

Flexible Intramedullary Nailing in the Management of Paediatric Femoral Shaft Fractures Ryan Katchky, B. Eng, M.D., FRCSC Clinical Fellow, The Hospital for Sick Children Toronto, ON Mark Camp, M.D., MSc FRCSC The Hospital for Sick Children Toronto, ON


ntroduced by Metaizeau in the 1980’s, flexible intramedullary nailing was developed as an alternative to traction in the treatment of paediatric femur fractures1. As surgeons have gained experience and implant systems have evolved, flexible nailing has become increasingly popular in this setting2.

COA Bulletin ACO - Spring / Printemps 2018

Biomechanical Rational Flexible intramedullary nailing (FIN), also known as elastic intramedullary nailing, relies on the concept of elastic stability. This is achieved by overbending two titanium nails, and inserting them within the femoral canal to allow three-point contact. This provides stability to translational and rotational loading, as the nails will work within the elastic portion of their stressstrain curve to achieve their precontoured shape, thereby resisting deforming forces. This permits micromotion, allowing secondary bone healing via callous formation3. To achieve elastic stability, it is essential to use two nails of equal diameter. Furthermore, they must be bent symmetrically, with the apex of each nail’s curvature coinciding with the fracture site. The nails should be overbent, as this will allow the

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 22)

nails to be pretensioned as they are inserted into the femoral canal, increasing their elasticity. Finally, the nails must be applied at 180° to each other. These principles allow the nails to achieve a ‘double arc secant in equilibrium’, thereby working in tandem to resist applied forces and achieving maximum elastic stability1. The biomechanics of elastic stability do not apply to length unstable fractures. In long oblique or comminuted fractures, applied compressive loads will cause the nails to increase their radius of curvature, allowing fracture shortening3. Indications The ideal indications for FIN include patients aged 6-11, weighing <45 kg, with length-stable, mid-diaphyseal femur fractures4,5,6. However, these indications can be expanded, with specific considerations discussed below. Age: Most children below six years of age can be successfully treated with spica cast immobilization, thereby avoiding a surgical procedure2. However, if a spica cast is contraindicated, such as in the setting of polytrauma or local soft tissue injury, FIN remains a viable treatment option7. As patients approach the age of 12, the femoral canal becomes large enough to accommodate a rigid, lateralentry nail, and the risk of avascular necrosis and greater trochanter apophyseal injury decreases. However, differences in skeletal maturity between females and males must be considered. Additionally, FIN remains an option for femoral shaft fractures until skeletal maturity depending on surgeon preference8. Location: While FIN is biomechanically ideal for mid-diaphyseal fractures, the technique can be performed in more proximal and distal fractures9 (Figure 1). Fracture Pattern: While the biomechanics of elastic stability are most applicable to transverse or short oblique fractures, FIN is an option for long oblique or comminuted fractures if the surgeon is cognizant of the risk of shortening. Measures to limit shortening and collapse at the fracture site include the use of end caps, which are threaded over the insertion site of the nails and prevent them from backing out10.

Figure 1 Preoperative and postoperative radiographs of a subtrochanteric fracture treated with flexible nails. One nail was contoured to achieve fixation into the femoral neck

Technical Aspects Several variations in techniques have been described. Important technical considerations common to most techniques include: Operating Room Setup: Either a radiolucent flat-top table or fracture table may be used. However, it is essential that orthogonal fluoroscopic views of the entire femur can be obtained prior to draping. Entry site preparation: The distal physis is marked and two centimetre incisions are made on the medial and lateral aspects of the femur terminating at this level. Dissection is carried down to bone, the entry point on the metaphyseal flare is confirmed on fluoroscopy, and a drill and/or awl is used to enter the medullary canal. Nail selection and contouring: Two matching nails are chosen so that the diameter of each nail is approximately 40% of the narrowest canal diameter. These nails are overbent symmetrically so that the apex of each nail corresponds to the fracture site. To allow for easier manipulation of the nails, the nails should be bent in plane with the hook at its distal tip11. Fracture Reduction: The nails can be advanced in the distal fragment prior to fracture reduction. Placing T-handle chucks on each nail allows excellent control of the distal fragment. Using these T-handles, to apply traction and correct angulation and malrotation, facilitates fracture reduction and nail advancement12 (Figure 2). Additional reduction adjuncts include an ‘F-tool’, mallets and pushers. In rare cases, an open reduction of the fracture may be required. Final Nail Positioning: Using fluoroscopic guidance, the nails are rotated until the pre-applied bends are at 180° to each other. The nails are cut to the appropriate length and advanced with a hollow tamp, and should lie along the supracondylar flare of the femur without impinging on the physis13. Any soft tissue entrapment by the nail end is cleared to minimize postoperative pain.

Figure 2 Reduction is achieved by advancing both nails in the distal fragment to the level of the metaphysis, and using each nail as a joystick with a T-handle chuck. This allows sequential passage of the nails into the proximal fragment COA Bulletin ACO - Spring / Printemps 2018



Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 23)

Postoperative Protocol Most patients may begin immediate mobilization with partial weight bearing following FIN of femoral shaft fractures. However, in length-unstable fractures, heavier children or proximal or distal fractures, a period of immobilization or restricted weight bearing is preferred13. Patients are restricted from sports for at least three months. Some surgeons remove nails only in cases where the patient has hardware irritation but others remove nails routinely at approximately one year to avoid late complications associated with nail migration. Outcomes Several case series have shown excellent results following elastic nailing of femur fractures. Fractures usually unite within ten weeks, and nonunion or delayed union is rare13,14.

Figure 3 Preoperative, immediate postoperative, and 12-week postoperative images of an 11-yearold girl treated with flexible nails for a femoral shaft fracture. This malunion may have been avoided by optimizing nail diameter, placing the apex of the nail contour at the fracture site, and ensuring the nails were rotated at 180° to each other. The surgeon may also have alternatively used an Adolescent Lateral Femoral Nail

Loss of reduction or malunion has been reported in up to 10% of cases. This complication is associated with mismatched nails or fracture comminution, and can be mitigated by adhering to principles of elastic nailing13 (Figure 3). A risk of hardware prominence of up to 54% has been reported. This may be reduced by cutting the nail ends short, and advancing them with a hollow tamp13.

Overall, flexible nailing is an important treatment option for paediatric femoral shaft fractures. When used with careful attention to appropriate indications, biomechanical principles and proper technique, it allows expeditious union of these fractures with low risk of major complications and should be in the arsenal of every orthopaedic surgeon treating paediatric orthopaedic trauma. References 1. Ligier J.N., Metaizeau J.P., Prevot J. Closed flexible medullary nailing in paediatric traumatology. Chir Pediatr 1983;24:3835. 2. Barry M., Paterson J.M. A flexible intramedullary nails for fractures in children. J Bone Joint Surg Br. 2004 Sep;86(7):947-53. 3. Ligier J.N., Metaizeau J.P., Prévot J., Lascombes P. Elastic stable intramedullary nailing of femoral shaft fractures in children. J Bone Joint Surg Br. 1988 Jan;70(1):74-7. 4. Sink E.L., Gralla J., Repine M.: Complications of pediatric femur fractures treated with titanium elastic nails: a comparison of fracture types. J Pediatr Orthop. 2005, 25 (5): 577-80. 5. Weiss J.M., Choi P., Ghatan C., Skaggs D.L., Kay R.M. Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. J Child Orthop. 2009 Feb;3(1):53-8

COA Bulletin ACO - Spring / Printemps 2018

6. Luhmann S.J., Schootman M., Schoenecker P.L., Dobbs M.B., Gordon J.E. Complications of titanium elastic nails for pediatric femoral shaft fractures. J Pediatr Orthop. 2003 JulAug;23(4):443-7. 7. Bopst L., Reinberg O., Lutz N.: Femur fracture in preschool children: experience with flexible intramedullary nailing in 72 children. J Pediatr Orthop. 2007, 27 (3): 299-303. 8. Stans A.A., Morrissy RT, Renwick S.E.: Femoral shaft fractures treatment in patients aged 6 to 16 years. J Pediatr Orthop. 1999, 19: 222-38. 9. Parikh S.N., Nathan S.T., Priola M.J., Eismann E.A. Elastic Nailing for Pediatric Subtrochanteric and Supracondylar Femur Fractures. Clinical Orthopaedics and Related Research. 2014;472(9):2735-2744 10. Nectoux E., Giacomelli M.C., Karger C., Gicquel P., Clavert J.M.: Use of end caps in elastic stable intramedullary nailing of femoral and tibial unstable fractures in children: preliminary results in 11 fractures. J Child Orthop. 2008, 2 (4): 309-14. 11. Metaizeau J.P. Stable elastic intramedullary nailing for fractures of the femur in children. J Bone Joint Surg Br. 2004 Sep;86(7):954-7. 12. Wainwright A., Narayanan U. A New Technique for Reduction of Paediatric Femoral Fractures Using Elastic Stable Intramedullary Nails. Annals of The Royal College of Surgeons of England. 2007;89(4):432-434. doi:10.1308/003588407X183517b. 13. Narayanan U., Hyman J., Wainwright A., Rang M., Alman B. Complications of Elastic Stable Intramedullary Nail Fixation of Pediatric Femoral Fractures, and How to Avoid Them. J Pediatr Orthop. 2004, 24 (4): 363-369. 14. Flynn J.M., Hresko T., Reynolds R.A., Blasier R.D., Davidson R., Kasser J.: Titanium elastic nails for pediatric femur fractures: a multicenter study of early results with analysis of complications. J Pediatr Orthop. 2001, 21 (1): 4-8.

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

Paediatric Femoral Submuscular Plating: The Internal “External Fixator” Luke Gauthier, M.D., FRCSC IWK Health Centre Halifax, NS


ubmuscular plating (SMP) is taking on an increasing role in the management of paediatric femur fractures through the mid-childhood years. As an evolution from traditional open plating, its popularity grew in the 1990’s in adult surgery primarily to reduce blood loss in these cases1,2,5,6. In the mid 2000’s, it crept into paediatrics to deal with trickier fracture patterns in school-age children (5-11) and at some centres, is now employed as commonly in this age group as elastic intramedullary nails3,4. Indications The emergence of SMP in the treatment of paediatric femur fractures has provided an effective alternative option in scenarios where fixation with flexible intramedullary nails has been demonstrated to be inadequate, but the child is not skeletally mature enough to proceed with rigid intramedullary nailing. As such, the primary indication for the use of SMP in the paediatric population has been “unstable” fracture patterns in skeletally immature patients. These can be viewed in three categories. First, the drawbacks of flexible nailing with “length unstable” Figure 1 patterns (due to obliquity or Ten- year-old male, tackled comminution) require an alterwhile playing football with sub- native approach in this setting10. trochanteric femur fracture Second, while flexible nailing can remain in the toolbox for subtrochanteric and supracondylar fractures (Figure 1), these are associated with higher complication rates (38% and 22% respectively)11. Finally, flexible nails have a higher complication rate in bigger patients (> 49 kg and older than ten years)12.







Figure 2. (a-f, Left to Right) Technique of submuscular plating. (a) The plate is slid down a submuscular space. (b) Length and plate position maintained with K-wires. (c) With K-wires in place, screws are added. (d-f) the use of a reduction screw to reduce the bone to plate

is held provisionally with proximal and distal Kirschner wires (Figure 2b). The first screw is usually placed through the last plate hole at the primary incision, followed by minimally invasive reduction techniques to achieve satisfactory sagittal and coronal plane plate reduction (Figure 2 c-f). The use of non-locking screws is traditional but may be situation dependant15. The final construct aims for screws near both the fracture site and the end of the plate (Figure 3) inserted in a percutaneous fashion16. In an alternative technique, clusters of locking and non-locking screws are inserted under direct visualization through only two slightly larger incisions towards the ends of the plate13. Comparisons and Complications Bearing in mind that SMP is most commonly employed in the school-age child (age 5-11) with a femur fracture when factors are not ideal for elastic nailing, there is a growing body of litera-

Technique The procedure is performed with the patient supine on a radiolucent table. The plate should be pre-contoured to match the patient’s coronal anatomy, although anatomic reduction is not the goal, with fixation principles of relative stability being followed13,14. After a small incision, typically at the distal but sometimes proximal metaphysis, use blunt dissection to create space along the length of the bone. Then, with traction held, the plate is slid along the femur in an extraperiosteal position (Figure 2a), from metaphysis to metaphysis if possible4. Plate position

Figure 3 Submuscular plate, coronally contoured, from metaphysis to metaphysis, with a non-anatomic reduction

COA Bulletin ACO - Spring / Printemps 2018



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

ture comparing the results and usage of elastic nailing to SMP amongst other fixation options. Sink et al. demonstrated fewer complications when limiting flexible nail use to “length-stable” fractures, while substituting SMP for the others17. A direct comparison study of 54 children age 5-12 with subtrochanteric fractures, (25 elastic nails: 29 plating) had fewer complications such as painful implants and malalignment with plate fixation, but weight bearing was earlier with nails18. Increasing safety evidence is leading to some multi-armed studies tying in the option of rigid intramedullary nailing in comparison to SMP, and flexible intramedullary nailing19,20. Sutphen et al. compared SMP, flexible intramedullary and rigid intramedullary nailing in children > 8 years. Again, flexible nailing was associated with increased malunion and hardware irritation and contrasting with an aforementioned study, longer time to full weight bearing. Rigid nailing had the lowest malunion rate but increased incidence of limp and heterotopic ossification. SMP allowed for most rapid return to full weight bearing and fastest healing rate21. One study looked at four major fixation options (external fixation, flexible intramedullary nail, rigid intramedullary nail, or plate fixation) in adolescents and found external fixation was the only outlier with higher complication and malunion rates. Overall, it concluded “the choice of fixation will remain influenced by surgeon preference, based on expertise and experience, patient and fracture characteristics and patient and family preferences”22. In one of the largest overall studies on plate fixation involving 85 patients, five patients had complications requiring reoperation. Two patients had infection requiring irrigation and debridement, two required osteotomy for valgus overgrowth, and one epiphysiodesis for a three centimetre leg length discrepancy. The overall rate of major and minor complications was 6% and 7% respectively which compared favourably to the 10-62% in the flexible nail literature for similar fracture patterns23. Another large study reporting on SMP in 60 fractures showed only one implant failure and one deep infection (in open fracture)24. Valgus overgrowth, one rather specific late complication, has been noted in SMP that bears mentioning. This occurs not due to malreduction at the time of initial surgery, but is thought to be due either to some immediate injury if placing the plate too close to the distal physis, or to its effect on the longitudinal and appositional growth of the femur over time. This has prompted some to recommend prophylactic plate removal in younger children25,26,27. Summary Submuscular plating of the femur is a versatile procedure whose technical aspects should be familiar to almost all orthopaedic surgeons. A strategy to recall typical indications for SMP are fractures within the same usual age group for flexible nailing, but are more unstable due to being: 1. Really long fracture pattern or comminuted (length: >2x cortical diameter, comminution: Winquist II or greater28) 2. Really proximal or distal 3. Really big patient (heavier >49kg, older >10yo)

COA Bulletin ACO - Spring / Printemps 2018

In these “unstable fractures”, SMP leads to lower complications and improved outcomes when compared to open plating or flexible IM nailing. SMP is associated with some unique sequelae such as valgus overgrowth and therefore planned hardware removal is beneficial. Due to the overlap of indications with other methods of fixation of paediatric femur fractures, having this technique in the orthopaedic surgeon’s arsenal allows them to employ it in the appropriate patient after careful consideration of patient and fracture characteristics. References 1. Winda K., Runkel M., Degreif J., Rudig L. Minimally invasive plate fixation in femoral shaft fractures. Injury. 1997;28(suppl 1): A13–A19. 2. Chrisovitsinos J.P., Xenakis T., Papakostides K.G., Skaltsoyannis N., Grestas A., Soucacos P.N. Bridge plating osteosynthesis of 20 comminuted fractures of the femur. Acta Orthop Scand Suppl. 1997 Oct;275:72–76. 
 3. Kanlic E.M., Anglen J.O., Smith DG, Morgan S.J., Pesantez R.F. Advantages of submuscular bridge plating for complex pediatric femur fractures. Clin Orthop Relat Res. 2004 Sep;426:244–251. 4. Sink E.L., Hedequist D., Morgan S.J., Hresko T. Results and technique of unstable pediatric femoral fractures treated with submuscular bridge plating. J Pediatr Orthop. 2006 MarApr;26(2):177-181. 5. Caird M.S., Mueller K.A., Puryear A., Farley F.A. Compression plating of pediatric femoral shaft. J Pediatr Orthop. 2003 JulAug;23(4):448-52. 6. Abbott M.D., Loder R.T., Anglen J.O. Comparison of submuscular and open plating of pediatric femur fractures: a retrospective review. J Pediatr Orthop. 2013 Jul-Aug;33(5):519-23. 7. Kong H., Sabharwal S. External fixation for closed pediatric femoral shaft fractures: where are we now? Clin Orthop Rel Res. 2013 Sept;471(9):2797-807. 8. Caird M.S. Mueller K.A., Puryear A., Farley F.A. Compresssion plating of pediatric femoral shaft fractures. J Pediatr Orthop. 2003 Jul-Aug;23(4):448-52. 9. Mooney J.F. The use of ‘damage control orthopaedics’ techniques in children with segmental open femur fractures. J Ped Orthop B. 2012 Sep;21(5):400-3. 10. Sink E.L., Gralla J., Repine M. Complications of pediatric femur fractures treated with titanium elastic nails. A comparison of fracture types. J Pediatr Orthop. 2005 Sep-Oct;25(5):577-580. 11. Parikh S.N., Nathan S.T., Priola M.J., Eismann E.A. Elastic Nailing for Pediatric Subtrochanteric and Supracondylar Femur Fractures. Clin Orthop Rel Res. 2014 Sep;472(9):2735-44. 12. Moroz L.A., Launay F., Kocher M.S., Newton P.O., Frick S.L., Sponseller P.D., Flynn J.M. Titanium elastic nailing of fractures of the femur in children. Predictors of complications and poor outcome. J Bone Joint Surg Br. 2006 Oct;88(10):1361–1366.

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13. Samora W.P., Guerriero M., Willis L., Klingele K.E. Submuscular plating for Length-unstable, Pediatric Femur Fractures. J Pediatr Orthop. 2013 Dec;33(8):797-802 14. Eidelman M., Ghrayeb N., Katzman A., Keren Y. Submuscular plating of femoral fractures in children: the importance of anatomic plate precontouring. J Pediat Orthop B. 2010 Sep;19(5):424-7. 15. Hedequist D., Bishop J., Hresko T. Locking plate fixation for pediatric femur fractures. J Pediatr Orthop. 2008 JanFeb;28(1):6-9. 16. Li Y., Hedequist D.J. Submuscular plating of pediatric femur fracture. J Amer Acad Ortho Surg. 2012 Sep20(9):596-603. 17. Sink E.L., Faro F., Polousky J., Flynn K., Gralla J. Decreased complications of Pediatric Femur Fractures with a change in management. J Pediatr Orthop. 2010 Oct-Nov;30(7):633-7 18. Li Y., Heyworth B.E., Glotzbecker M., Seeley M., Suppan C.A., Gagnier J., Vanderhave K.L., Caird M.S., Farley F.A., Hedequist D. Comparison of titanium elastic nail and plate fixation of pediatric subtrochanteric femur fractures. J Pediatr Orthop. 2013 Apr-May;33(3):232-8. 19. Kocher M.S., Sink E.L., Blasier R.D., Luhmann S.J., Mehlmann C.T., Scher D.M., Matheney T., Sanders J.O., Watters III W.C., Goldberg M.J., Keith M.W., Haralson III R.H., Turkelson C.M, Wies J.L., Sluka P., McGowan R. American academy of orthopedic surgeons clinical practice guideline on the treatment of pediatric diaphyseal femur fracture. J Bone Joint Surg Am. 2010 Jan;92:1790-2 20. Kuremsky M.A., Frick S.L. Advances in the surgical management of pediatric femoral shaft fractures. Curr Opin Pediatr. 2007 Feb;19(1):51-7

21. Sutphen S.A., Mendoza J.D., Mundy A.C., Yang J.G., Beebe A.C., Samora WP 3rd, Klingele K.E. Pediatric diaphyseal femur fractures: submuscular plating compared with intramedullary nailing. Orthopedics. 2016 Nov 1;39(6):353-8. 22. Rameiser L.E., Janicki J.A., Weir S., Narayanan U. Femoral fractures in Adolescents: a comparison of four methods of fixation. J Bone Joint Surg Am. 2010 May;92(5):1122-9. 23. May C., Yen, Y.-M., Nasreddine A.Y., Hedequist D., Hresko M.T., Heyworth B.E. Complications of plate fixation of femoral shaft fractures in children and adolescents. J Child Orthop. 2013 Jun;7:235-243. 24. Abdelgawad A.A., Sieg R.N., Laughlin M.D., Shunla J., Kanlic E.M. Submuscular bridge plating for complex pediatric femur fracture is reliable. Clin Orthop Rel Res. 2013 Sep;471:27972807. 25. Heyworth B.E., Hedequist D.J., Nasreddine A.Y., Stamoulis C., Hresko M.T., Yen Y.M. Distal femoral valgus deformity following plate fixation of pediatric femoral shaft fractures. J Bone Joint Surg. 2013 Mar 20;95(6):526-33. 26. Kelly B., Heyworth B., Yen Y.-M., Hedequist D. Adverse Sequelae due to plate retention following submuscular plating for pediatric femur fractures. J Orthop Trauma. 2013 Dec;27(12):726-9. 27. Pate O., Hedequist D., Leong N., Hresko T. Implant removal after submuscular plating for pediatric femur fractures. J Pediatr Orthop. 2009 Oct-Nov;29(7):709-712. 28. Winquist R.A., Hansen Jr S.T. Comminuted fractures of the femoral shaft treated by intramedullary nailing. Orthop Clin N Am. 1980;11(3):633–48.

Paediatric/Adolescent Femoral Shaft Fracture Management: Rigid Nailing Alicia Kerrigan, M.D. Resident, Orthopaedic Surgery, Western University London, ON Debra Bartley, M.D., FRCSC Associate Professor of Surgery, Western University Paediatric Orthopaedic Surgeon, Children’s Hospital of Western Ontario London, ON


emoral shaft fractures in the paediatric and adolescent population present a unique management challenge due to their open physes, immature vasculature, and smaller size1. Rigid intramedullary (IM) nail fixation has long been widely accepted as the standard of care for adult femoral shaft fractures2. In paediatric cases, appropriate management requires

consideration of multiple factors including patient age, weight, degree of skeletal maturity, fracture pattern and location, and mechanism of injury. Further socioeconomic considerations include family factors and costs to the health-care system. The American Academy of Orthopaedic Surgeons (AAOS) released a clinical practice guideline in 2009 (reissued in 2015 with no changes in recommendations) for the treatment of paediatric diaphyseal femur fractures. This guideline states that rigid IM nailing is a treatment option for children over the age of 11 years, along with flexible IM nailing and submuscular plating3. Important considerations for selecting rigid IM nail fixation over other methods include the age and weight of the patient, fracture pattern and location, and the size of the intramedullary canal4.

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Advantages & Disadvantages The advantages of rigid IM nail fixation are well documented and validated in the adult and paediatric literature. The rigid nail offers maximum stability with length and rotational control, which is ideal for proximal and distal fractures, as well as unstable fracture patterns. These advantages make rigid nail fixation a good option for paediatric femur fracture patterns that are poorly controlled with more traditional fixation techniques, such as flexible elastic nailing. In addition, the nail is a load-sharing implant that allows earlier mobilization and weight bearing, resulting in a shorter hospital stay3. Rigid IM nail fixation has been shown to have minimal risk of nonunion, malunion, and hardware-related complications5. Weiss et al. demonstrated that patients weighing over 50 kg or with a body mass index (BMI) greater than the 95th percentile had up to double the increased risk of postoperative complications when treated with flexible elastic nailing for femur fractures6. This supports the use of more rigid fixation in larger patients. Finally, rigid IM nail fixation avoids complications associated with other treatment options including knee stiffness, femoral shortening, and leg-length discrepancy7. The biggest perceived disadvantage of rigid IM nail fixation in the paediatric population is the risk of avascular necrosis (AVN) of the femoral head. Although rare, AVN can be a devastating complication. The blood supply to the femoral head comes primarily from the deep branch of the medial femoral circumflex artery (MFCA), which runs in close proximity to the piriformis fossa8. It is hypothesized that with IM fixation, the entry point of the nail into the proximal femur plays a role in femoral head osteonecrosis. A systematic review in 2011 compared three starting points of IM nail fixation in the skeletally immature patient: the piriformis fossa (PF), tip of the greater trochanter (TGT), and lateral greater trochanter (LGT) (Figure 1). Based on 19 relevant articles, AVN rates were 2% for PF entry, 1.4% for TGT entry, and 0% for LGT entry9. As such, the use of piriformis fossa as an entry point for IM nailing in skeletally immature patients is not advised. In contrast, the lateral greater trochanter entry point allows safe placement of the nail while avoiding any disruption of femoral head vascularity.

Figure 1 Anatomy of the proximal femur demonstrating the alternative start points for intramedullary nail fixation and their relationship to the vasculature (white – piriformis fossa (PF), black/solid – tip of the greater trochanter (TGT), grey/dotted – lateral greater trochanter (LGT))11 COA Bulletin ACO - Spring / Printemps 2018

Other cited complications associated with rigid IM nail fixation include premature closure of the greater trochanteric physis, increased femoral neck valgus, and thinning of the femoral neck10. Keeler et al. demonstrated that the use of an LGT start point caused no clinically significant difference in neck-shaft angle or narrowing of the femoral neck as compared to the contralateral native hip11. Furthermore, Gage and Cary demonstrated that premature closure of the greater trochanteric physis was found to be clinically insignificant after the age of eight12. This further supports the use of rigid IM nailing. Techniques Surgical techniques for rigid IM nail fixation follow the same principles as adult fixation. Given the open physes and immature vasculature, determining the appropriate start point is arguably the most important step of the procedure. For lateral entry, the start point should be midposition on the lateral aspect of the greater trochanter (Figure 2). Care must be taken to minimize trauma to the physis and avoid disruption of the vasculature. So-called “blind” attempts at Figure 2 guide wire positioning should Anteroposterior intra-operative be avoided by making a small radiograph of the left hip demincision and palpating the lateral onstrating guide wire placement entry site. After the appropriate on the lateral greater trochanter (LGT) reduction maneuvers, the guide wire is then inserted under fluoroscopic guidance and passed across the fracture site. It is advanced one to three centimetres proximal to the distal femoral physis, and the length of the nail is selected. The canal is reamed without causing excessive thinning of the cortex, and the nail is inserted. Both proximal and distal interlocking is recommended for rotational stability. Post-operatively, patients are weight bearing as tolerated with crutches or a walker11,13. Conclusions Surgical decisionmaking in the setting of paediatric femoral shaft fractures requires consideration of multiple factors. Rigid IM nail fixation should be considered in patients older than age 11, in heavier children, or in length-unstable fractures (Figure 3). With the appropriate selection of patient, fracture pattern, and surgical technique, rigid IM nail fixation is a safe and effective treatment for paediatric femoral shaft fractures.

Figure 3 Preoperative and postoperative anteroposterior radiographs of the right femur in an 11-year-old girl treated with rigid intramedullary nail fixation for a lengthunstable diaphyseal femur fracture

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

References 1. Anglen, J. O., & Choi, L. (2005). Treatment Options in Pediatric Femoral Shaft Fractures. Journal of Orthopaedic Trauma, 19(10), 724–733. 2. Hansen S.T., Winquist R.A. (1979). Closed intramedullary nailing of the femur. Kuntscher technique with reaming. Clinical Orthopaedics and Related Research. 138, 56-61. 3. Kocher, M. S., Sink, E. L., Blasier, R. D., Luhmann, S. J., Mehlman, C. T., Scher, D. M., Hitchcock, K. (2009). Treatment of pediatric diaphyseal femur fractures. The Journal of the American Academy of Orthopaedic Surgeons, 17(11), 718– 25. 4. Reynolds, R. A. K., Legakis, J. E., Thomas, R., Slongo, T. F., Hunter, J. B., & Clavert, J. M. (2012). Intramedullary nails for pediatric diaphyseal femur fractures in older, heavier children: Early results. Journal of Children’s Orthopaedics, 6(3), 181–188. 5. Sutphen, S. A., Mendoza, J. D., Mundy, A. C., Yang, J. G., Beebe, A. C., Samora, W. P., & Klingele, K. E. (2016). Pediatric Diaphyseal Femur Fractures: Submuscular Plating Compared with Intramedullary Nailing. Orthopedics, 39(6), 353–358. 6. Weiss, J. M., Choi, P., Ghatan, C., Skaggs, D. L., & Kay, R. M. (2009). Complications with flexible nailing of femur fractures more than double with child obesity and weight >50 kg. Journal of Children’s Orthopaedics, 3(1), 53–58.

8. Gautier E., Ganz K., Krugel N., Gill T., Ganz R. (2000). Anatomy of the medial femoral circumflex artery and its surgical implications. The Journal of bone and Joint Surgery British volume. 82(5), 679-83. 9. Allen, J., Macneil, M., Francis, A., & El-hawary, R. (2011). A Systematic Review of Rigid, Locked, Intramedullary Nail Insertion Sites and Avascular Necrosis of the Femoral Head in the Skeletally Immature, 31(4), 2009–2012. 10. Gonzalez-Herranz P., Burgo-Flores J., Rapariz J.M. et al (1995) Intramedullary nailing of the femur in children; effects on its proximal end. J Bone Joint Surg Br. 77:262–266. 11. Keeler, K. a, Dart, B., Luhmann, S. J., Schoenecker, P. L., Ortman, M. R., Dobbs, M. B., & Gordon, J. E. (2009). Antegrade intramedullary nailing of pediatric femoral fractures using an interlocking pediatric femoral nail and a lateral trochanteric entry point. Journal of Pediatric Orthopedics, 29(4), 345–351. 12. Gage J.R., Cary J.M. (1980). The effects of trochanteric epiphysiodesis on growth of the proximal end of the femur following necrosis of the capital femoral epiphysis. J Bone Joint Surg Am. 62.785– 794. 13. Elgohary, H. S. A., & El Adl, W. A. (2014). Antegrade rigid nailing through the tip of the greater trochanter for pediatric femoral shaft fractures. European Journal of Orthopaedic Surgery and Traumatology, 24(7), 1229–1235.

7. Kirby R.M., Winquist R.A., Hansen S.T. Jr. (1981). Femoral shaft fractures in adolescents: A comparison between traction plus cast treatment and closed intramedullary nailing. J Pediatr Orthop. 1, 193–197.

Vancomycin Use in Orthopaedic Surgery Thomas J. Wood, M.D., FRCSCa Edward M. Vasarhelyi, M.D., MSc, FRCSCa,b Division of Orthopaedic Surgery, London Health Sciences Centre University Campus, Western University London, ON b Bone and Joint Institute, Western University London ON a


urgical site infections are a difficult complication encountered in orthopaedic surgery. Optimizing antibiotic utilization is an essential component of reducing the burden of this potentially devastating complication. Antibiotics are delivered a number of ways to prevent and treat surgical site infections. Perioperative intravenous antibiotics are administered as infection prophylaxis. Antibiotics can be delivered directly to surgical wounds through polymethylmethacrylate bone cement or other antibiotic delivering implants. Recently, direct application of antibiotic powder into surgical wounds has

Evidence-based Vignettes These vignettes are a series of articles led by experts and thought leaders who advise on how to manage clinical controversies or address emerging treatment trends while applying evidence-based principles. With these vignettes, we aim to help provide the best evidence-based strategies to enable clinicians to incorporate new treatment and diagnostic strategies into current practice. Although no patient or condition fits into the proverbial “box,” we often need to solve problems in “real time” and these comprehensive opinions will, hopefully, provide some useful and applicable insights. – Dr. Femi Ayeni, Scientific Editor, COA Bulletin been used for infection prevention. Vancomycin has proven to be an effective antibiotic in the treatment of infection caused by numerous organisms, in particular methicillin resistant staphylococcus aureus (MRSA) and multidrug-resistant staphylococcus epidermidis. The use of this agent in orthopaedic COA Bulletin ACO - Spring / Printemps 2018



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procedures continues to evolve. We will review the use of vancomycin for prevention and treatment of infection as it applies to orthopaedic procedures. The use of preoperative antibiotic prophylaxis is one of the most effective means to decrease periprosthetic joint infections1. Most commonly, a first generation cephalosporin is given1. However, in patients with an anaphylactic penicillin allergy, often first and second generation cephalosporins are avoided and alternative therapy is used1. Vancomycin is indicated for antibiotic prophylaxis in patients who are colonized with methicillin resistant staphylococcus aureus (MRSA) or who have an anaphylactic reaction to penicillin2. Patients who have a stated allergic reaction of skin rash are still able to receive a cephalosporin. Vancomycin is less effective for prophylaxis due to under dosing and increasing resistance of MRSA1. Vancomycin does not provide gram negative coverage and has been shown to have higher risks of surgical site infections compared to use of cephalosporins or dual antibiotic treatment3-4. According to the MSIS International Consensus on Periprosthetic Joint Infection, patients who do not have an anaphylactic reaction to penicillin should receive a first generation cephalosporin2,5. Taken together, vancomycin should not be used as a sole agent for preoperative antibiotic prophylaxis, and whenever possible, a first generation cephalosporin should be given1,3-4,6. If the patient has a documented anaphylactic reaction to penicillin, the patient should receive dual therapy with vancomycin and clindamycin. If the patient is colonized with MRSA, and decolonization (intranasal mupirocin nasal ointment or 4% chlorhexidine soap skin wash for five days) has not been successful, vancomycin should be administered in conjunction with routine prophylactic antibiotics1,3-4,6. Local antibiotic delivery systems were popularized in the 1960s and are emerging as an effective way to decrease surgical site infection both in trauma and spine surgery7-9. Local antibiotic delivery can be given at higher concentrations, thus more likely reaching the minimum inhibitory concentration of bacteria, with lower systemic side effects8. Local antibiotics in the form of antibiotic-impregnated polymethylmetharcrylate cement beads are often used in cases of open fractures with evidence of reduced local infection rates10. Similarly, antibiotic impregnated nails can be used for long bone infections and infected nonunions following tibial or femoral nailing procedures with a reported infection clearance over 70%11-12. Furthermore, in a multi-centre analysis of 2056 patients, intrawound vancomycin powder lowered the risk of surgical site infection and return to the operating room when using a posterior approach for spine surgery9. This result is similar to multiple meta-analyses showing a protective effect of vancomycin powder against surgical site infection when used in spine surgery13-14. Currently, a randomized controlled trial is under way evaluating vancomycin powder use in orthopaedic trauma, particularly in tibial plateau and pilon fractures8. One retrospective study of 93 patients evaluated vancomycin powder in tibial plateau and pilon fractures compared to standard intravenous antibiotics alone15. Although not statistically significant, the rate of deep infection was 16.7% in controls compared to 10% in the vancomycin powder group, suggesting a potential role in orthopaedic trauma procedures. Though this type of antibiotic prophylaxis shows promise in some orthopaedic procedures, current evidence does not support the use of routine vancomycin powder in total joint arthroplasty2. COA Bulletin ACO - Spring / Printemps 2018

Often antibiotics are added to polymethylmethacrylate bone cement for primary and revision total joint arthroplasty. This is especially true during revision surgery in the setting of active or prior infection. Adding vancomycin to bone cement has been studied both in vitro and in vivo and can be effective in treating and preventing periprosthetic joint infection16-17. In a metaanalysis of 36,053 patients, antibiotic impregnated cement lowered the infection rate in primary total hip arthroplasty by 50%18. When used as a cement spacer as part of a two-stage revision, vancomycin is as effective as other antibiotic cement mixtures when treating periprosthetic joint infections19. In a study of 501 reverse total shoulder arthroplasties, antibiotic impregnated cement (tobramycin and vancomycin) was effective in preventing deep infections20. Based on such evidence, as well as the international consensus statement and registry data, there is a role for antibiotic impregnated cement both in primary and revision joint arthroplasties5,20-22. However, controversy exists around the cost effectiveness and the emergence of antibiotic resistance with routine use of antibiotic impregnated bone cement in primary total joint arthroplasty, especially in low risk patients5, 23.

In summary: • Vancomycin should only be used in patients who are MRSA carriers or who have an anaphylactic reaction to penicillin. • If using vancomycin for antibiotic prophylaxis, a second antibiotic should be added due to poor gram negative coverage. • Current available literature supports the use of vancomycin powder in open spine surgery to prevent surgical site infections. • Vancomycin can be added to bone cement, especially in revision total joint arthroplasty, or in spacers for treatment, and/or prevention of periprosthetic joint infection. References 1. Kheir M.M., Tan T.L., Azboy I., Tan D.D., Parvizi J. Vancomycin prophylaxis for total joint arthroplasty: Incorrectly dosed and has a higher rate of periprosthetic infection than cefazolin. Clin Orthop Relat Res 2017; 474(7): 1767-1774. 2. Hansen E., Belden K., Silibovsky R., et al. Perioperative antibiotics. J Arthroplasty 2014; 29: 29-48. 3. Ponce B., Raines B.T., Reed R.D., Vick C., Richman J., Hawn M. Surgical site infection after arthroplasty: comparative effectiveness of prophylactic antibiotics: Do surgical care improvement project guidelines need to be updated? J Bone Joint Surg Am 2014; 96(12): 970-977. 4. Tan T.L., Springer B.D., Ruder J.A., Ruffolo M.R., Chen A.F. Is vancomycin-only prophylaxis for patients with penicillin allergy associated with increased risk of infection after arthroplasty? Clin Orthop Relat Res 2016; 474(7): 1601-6. 5. Parvizi J., Gehrke T. Proceedings of the international consensus meeting on periprosthetic joint infection. Brooklandville, Maryland. Data Trace Publishing company 2013.

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6. Tyllianakis M.E., Karageorgos A., Marangos M.N., Saridis A.G., Lambiris E.E. Antibiotic prophylaxis in primary hip and knee arthroplasty: comparison between cefuroxime and two specific antistaphylococcal agents. J Arthroplasty 2010; 25(7): 1078-82. 7. Fleischman A.N., Austin M.S. Local intra-wound administration of powdered antibiotics in orthopaedic surgery. J Bone Jt Infect 2017; 2(1): 23-28. 8. O’Toole R.V, Joshi M., Carlini A.R., et al. Local antibiotic therapy to reduce infection after operative treatment of fractures at high risk of infection: A multicenter, randomized, controlled trial (VANCO Study). J Orthop Trauma 2017; 31 Suppl 1: S18S24. 9. Devin C.J., Chotai S., McGirt M.J., et al. Intrawound vancomycin decreases the risk of surgical site infection after posterior spine surgery-A multicenter analysis. Spine (Phila Pa 1976) 2015; ahead of print. 10. Decoster T.A., Bozorgnia S. Antibiotic beads. J Am Acad Orthop Surg 2008; 16(11): 674—8. 11. Reilly R.M., Robertson T., O’Toole R.V., Manson T.T. Are antibiotic nails effective in the treatment of infected tibial fractureas? Injury 2016; 47(12): 2809-2815. 12. Thonse R., Conway J.D. Antibiotic cement-coated nails for the treatment of infected nonunions and segmental bone defects. J Bone Joint Surg Am 2008; 90(Suppl. 4): 163-74. 13. Chiang H.Y., Herwaldt L.A., Blevins A.E., Cho E., Schweizer M.L. Effectiveness of local vancomycin powder to decrease surgical site infections: a meta-analysis. Spine J 2014; 14(3): 397-407. 14. Khan N.R., Thompson C.J., DeCuypere M., et al. A meta-analysis of spinal surgical site infection and vancomycin powder. J Neurosurg Spine 2014; 21(6): 974-83.

16. Hsu Y.H., Hu C.C., Hsieh P.H., Shih H.N., Ueng S.W., Chang Y. Vancomycin and ceftazidime in bone cement as a potentially effective treatment for knee periprosthetic joint infection. J Bone Joint Surg Am 2017; 99(3): 223-231. 17. Amerstorfer F., Fischerauer S., Sadoghi P., Schwantzer G., Kuehn K.D., Leithner A., Glehr M. J Arthroplasty 2017; 32(5): 1618-1624. 18. Parvizi J., Saleh K.J., Ragland P.S., Pour A.E., Mont M.A. Efficacy of antibiotic-impregnated cement in total hip replacement. Acta Orthop 2008; 79(3): 335-41. 19. Drexler M., Dwyer T., Kuzyk P.R., et al. The results of two-stage revision TKA using Ceftazidime-vancomycin-impregnated cement articulating spacers in Tsukayama type II periprosthetic joint infections. Knee surg sports traumatol arthrosc 2016; 24(10): 3122-3130. 20. Nowinski R.J., Gillespie R.J., Shishani Y., Cohen B., Walch G., Gobezie R. Antibiotic-loaded bone cement reduces deep infection rates for primary reverse total shoulder arthroplasty: a retrospective, cohort study of 501 shoulders. J Shoulder Elbow Surg 2012; 21(3): 324-8. 21. Australian Orthopedic Association National Joint Replacement Registry. au/en/annual-reports-2012. Accessed October 2017. 22. Engesaeter L.B., Lie S.A., Espehaug B., Furnes O., Vollset S.E., Havelin L.I. Antibiotic prophylaxis in total hip arthroplasty: effects of antibiotic prophylaxis systemically and in bone cement on the revision rate of 22,170 primary hip replacements followed 0-14 years in the Norwegian arthroplasty register. Acta Orthop Scand 2003; 74(6): 644-51. 23. Namba R.S., Chen Y., Paxton E.W., Slipchenko T., Fithian D.C. Outcomes of routine use of antibiotic-loaded cement in primary total knee arthroplasty. J Arthroplasty 2009; 24(6 Suppl): 44-7.

15. Singh K., Bauer J.M., LaChaud G.Y., Bible J.E., Mir H.R. Surgical site infection in high-energy peri-articular tibia fractures with intra-wound vancomycin powder: a retrospective pilot study. J Orthop Traumatol 2015; 16(4): 287-91.

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:

Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : COA Bulletin ACO - Spring / Printemps 2018



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

Shoulder Arthroplasty, the Retroverted Glenoid, and Implant Loosening in determining the biomechanical parameters of the shoulder following TSA. Cadaveric shoulder studies report varying degrees of retroversion correlating with biomechanical instability. Nyffeler et al. showed an association between retroversion and posterior displacement and loading of the glenoid8. Farron et al. correlated retroverotal shoulder arthroplasty sion with increases in posterior (TSA), first introduced and displacement of the glenohumerlater revolutionized by Pean al contact point, bone and cement The practice of orthopaedic surgery continues to evolve. stress, and micromotion around and Neer, respectively, is typically considered when nonsurgiWe are faced with an explosion of information stemming the glenoid implant9. Shapiro et al. cal measures have failed in treatfrom published cutting-edge research (bench and clinical). have shown that a retrovering osteoarthritis (OA). Although Likewise, an increasingly informed public has rapid access to sion of 15 degrees decreased shoulder arthroplasty notably information about novel therapies and surgical techniques. the glenohumeral contact area, improves pain and function in Oftentimes the best way to integrate evidence-based practice increased contact pressure, and upward of 95%, complication posterior and innovative treatments is unknown or challenging. To decreased inferior and 10 rates associated with implant suradd some perspective on how to approach emerging and/or glenohumeral forces . In a clinivivorship necessitating revision controversial topics, we have developed this Horizons feature cal study, Walch et al. observed a arthroplasty remain prevalent1,2. direct correlation between preopin the COA Bulletin. Glenohumeral OA can lead to erative retroversion and postopaltered glenoid morphology and complications such as gleIn the Horizons articles, thought leaders from various erative instability of the joint, directly noid loosening and dislocation in subspecialties will provide insights based on their extensive patients with biconcave-type gleaffecting surgical intervention clinical experience and ongoing research. The goal of this noid morphology11. Additionally, success rates. Glenoid compofeature is to ÂŤshed some lightÂť on the best way forward. nent loosening represents the Ho et al. reported that when cormost common cause of TSA failrecting retroversion, if the polyFemi Ayeni, M.D., FRCSC ure associated with factors that ethylene implant remained in include: increases in glenoid retgreater than 15 degrees of retroroversion, posterior subluxation of the humeral head, and version, it was associated with a higher rate of radiolucent lines. glenoid bone loss3. For example, Walch et al. reported glenoid Therefore, the degree of retroversion has been established as a component loosening in approximately 30% of patients with key factor in predicting complication rates following TSA. primary OA following TSA, which the authors postulated to be correlated with the quality of preoperative bone stock4. Despite Surgical techniques to address glenoid retroversion include the fact that posterior glenoid bone loss is relatively common, eccentric reaming, bone grafting, use of augmented glenoid optimal surgical management of glenoid retroversion in glecomponents, and reverse shoulder arthroplasty. However, the nohumeral OA is controversial and unresolved. Recent techuse of a prosthetically modified or augmented glenoid comnological advancements in polyethelyne implant design have ponent to compensate for glenoid deficiencies during TSA has spawned renewed interest in addressing this challenge. garnered renewed interest recently. An earlier study looked at the use of a posteriorly augmented glenoid component A classification system exists which defines glenoid morpholin 17 patients followed for a two-year period12. Although the ogy in glenohumeral arthritis5. Type A glenoids are identified majority of patients reported excellent to satisfactory results as a centered humeral head, and a central erosion of the gle(86%), radiolucent lines were detected in greater than 50% noid cavity with a minor (A1) and major (A2) sub-classification. of patients and one third of patients had moderate to severe Type B presents with a posterior subluxation of the humeral posterior glenohumeral subluxation12. In contrast, Gunther head with either the narrowing of joint posteriorly (B1) or et al. showed success with the use of a custom inset glenoid asymmetric loading of the posterior glenoid leading to excesimplant13. Authors reported improvements in pain, range of sive retroversion and biconcavity (B2). A recently described motion, and glenoid implants classified as low risk to loosening B3 glenoid is monoconcave, with at least 15 degrees retroverby radiographic analysis in all patients. Wright et al. compared sion, 70 degrees posterior subluxation of the humeral head, or the clinical outcomes and radiographic imaging of patients both6, and Type C have large margins of retroversion (>25%). with posterior glenoid wear treated with an augmented glenoid component, and patients without glenoid wear treated In general, glenoid malversion is believed to be a major predicwith a standard glenoid component14. Authors reported no tor for TSA failure resulting from increases in glenohumeral differences between the groups in terms of clinical outcomes, stress forces along the joint, humeral head displacement, and revision rates, or humeral head subluxation. A recent study eccentric loading of the glenoid component3,7. A number of demonstrated significant improvements in clinical outcome studies have reported retroversion as an important factor scores with no signs of glenoid component loosening, dislocaPeter Lapner, M.D., FRCSC Division of Orthopedics, Ottawa Hospital Research Institute, University of Ottawa Ottawa, ON


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tion or increased revision rates in patients treated with an anteriorly augmented component for anterior glenoid deficiency15. A number of studies have utilized cadaveric specimens to analyze the effects of different types of augmented components on shoulder biomechanics. For example, Kirane et al. compared changes in glenoid load strains between poly-step prostheses installed in Type B2 glenoid deficient shoulders and standard components in normal shoulders16. Authors showed no difference in strains between the groups, suggesting both are a viable treatment option for posterior glenoid defects. Another cadaver study compared the mechanical liftoff values of shoulders treated with a stepped augmented glenoid component between shoulders implanted with augmented components of varying designs, and found the stepped glenoid component to have significantly lower liftoff values17. Computational models have also been used to study the various pathological outcomes of augmented components in the arthritic glenoid. Sabesan et al. compared medialization values in 29 patients who were treated with a standard or an augmented glenoid implant18. Authors reported a greater ability to correct retroversion with lower medialization values in shoulders with the augmented glenoid compared to a standard component. Similarly, Hermida et al. compared stresses and fatigue life of standard glenoid components implanted in neutral or retroversion, and wedge components implanted in retroversion19. Implant survival was determined to be lowest in the standard component in a retroversion model compared with the standard component implanted in neutral, and the wedged component implanted in retroversion. Lastly, Knowles et al. studied the bone preservation outcomes of a computational comparison of three different augmented components implanted in the type B2 glenoid shoulder20. Authors reported a decrease in glenoid bone loss and greater bone quality in the posterior wedge implanted glenoid compared with a full and posterior step wedge prosthetic. Although a number of different corrective techniques have been described within the literature to address complex shoulder cases, few studies have compared all of these techniques. A recent cadaver study looked at the biomechanical outcomes of a posterior glenoid wear model comparing the use of augmented glenoid components and standard glenoid components in addition to eccentric reaming21. Results revealed a greater rate of implant loosening in the augmented glenoid component group as compared with the eccentric reaming group demonstrated by implant edge displacement measurements. In the interest of improving patient functional outcomes and implant longevity, and in order to decrease associated costs associated with early revision, it is imperative to determine the appropriate approach to glenoid reconstruction in the arthritic shoulder. Well-designed clinical trials in this area will be critical to assist the clinician in the future.

References 1. Norris T.R., Iannotti J.P. Functional outcome after shoulder arthroplasty for primary osteoarthritis: a multicenter study. J Shoulder Elbow Surg. 2002 Mar-Apr;11(2):130-5. 2. Kim S.H., Wise B.L., Zhang Y., Szabo R.M. Increasing incidence of shoulder arthroplasty in the United States. J Bone Joint Surg Am. 2011 Dec 21;93(24):2249-54. 3. Stephens S.P., Paisley K.C., Jeng J., Dutta A.K., Wirth M.A. Shoulder arthroplasty in the presence of posterior glenoid bone loss. The Journal of bone and joint surgery American volume. 2015 Feb 4;97(3):251-9. 4. Walch G., Young A.A., Boileau P., Loew M., Gazielly D., Mole D. Patterns of loosening of polyethylene keeled glenoid components after shoulder arthroplasty for primary osteoarthritis: results of a multicenter study with more than five years of follow-up. The Journal of bone and joint surgery American volume. 2012 Jan 18;94(2):145-50. 5. Walch G., Badet R., Boulahia A., Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. J Arthroplasty. 1999 Sep;14(6):756-60. 6. Bercik M.J., Kruse K., 2nd, Yalizis M., Gauci M.O., Chaoui J., Walch G. A modification to the Walch classification of the glenoid in primary glenohumeral osteoarthritis using three-dimensional imaging. J Shoulder Elbow Surg. 2016 Oct;25(10):1601-6. 7. Sears B.W., Johnston P.S., Ramsey M.L., Williams G.R. Glenoid bone loss in primary total shoulder arthroplasty: evaluation and management. J Am Acad Orthop Surg. 2012 Sep;20(9):604-13. 8. Nyffeler R.W., Sheikh R., Atkinson T.S., Jacob H.A., Favre P., Gerber C. Effects of glenoid component version on humeral head displacement and joint reaction forces: an experimental study. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2006 SepOct;15(5):625-9. 9. Farron A., Terrier A., Buchler P. Risks of loosening of a prosthetic glenoid implanted in retroversion. J Shoulder Elbow Surg. 2006 Jul-Aug;15(4):521-6. 10. Shapiro T.A., McGarry M.H., Gupta R., Lee Y.S., Lee T.Q. Biomechanical effects of glenoid retroversion in total shoulder arthroplasty. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2007 MayJun;16(3 Suppl):S90-5. 11. Walch G., Moraga C., Young A., Castellanos-Rosas J. Results of anatomic nonconstrained prosthesis in primary osteoarthritis with biconcave glenoid. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2012 Nov;21(11):1526-33.

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(continued from page 33)

12. Rice R.S., Sperling J.W., Miletti J., Schleck C., Cofield R.H. Augmented glenoid component for bone deficiency in shoulder arthroplasty. Clinical orthopaedics and related research. 2008 Mar;466(3):579-83. 13. Gunther S.B., Lynch T.L. Total shoulder replacement surgery with custom glenoid implants for severe bone deficiency. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2012 May;21(5):675-84. 14. Wright T.W., Grey S.G., Roche C.P., Wright L., Flurin P.H., Zuckerman J.D. Preliminary Results of a Posterior Augmented Glenoid Compared to an all Polyethylene Standard Glenoid in Anatomic Total Shoulder Arthroplasty. Bulletin of the Hospital for Joint Disease. 2015 Dec;73(1):79-85. 15. Lenart B.A., Namdari S., Williams G.R. Total shoulder arthroplasty with an augmented component for anterior glenoid bone deficiency. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2016 Mar;25(3):398-405. 16. Kirane Y.M., Lewis G.S., Sharkey N.A., Armstrong A.D. Mechanical characteristics of a novel posterior-step prosthesis for biconcave glenoid defects. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2012 Jan;21(1):105-15.

17. Iannotti J.P., Lappin K.E., Klotz C.L., Reber E.W., Swope S.W. Liftoff resistance of augmented glenoid components during cyclic fatigue loading in the posterior-superior direction. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2013 Nov;22(11):1530-6. 18. Sabesan V., Callanan M., Sharma V., Iannotti J.P. Correction of acquired glenoid bone loss in osteoarthritis with a standard versus an augmented glenoid component. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2014 Jul;23(7):964-73. 19. Hermida J.C., Flores-Hernandez C., Hoenecke H.R., D’Lima D.D. Augmented wedge-shaped glenoid component for the correction of glenoid retroversion: a finite element analysis. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2014 Mar;23(3):347-54. 20. Knowles N.K., Ferreira L.M., Athwal G.S. Augmented glenoid component designs for type B2 erosions: a computational comparison by volume of bone removal and quality of remaining bone. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2015 Aug;24(8):121826. 21. Wang T., Abrams G.D., Behn A.W., Lindsey D., Giori N., Cheung E.V. Posterior glenoid wear in total shoulder arthroplasty: eccentric anterior reaming is superior to posterior augment. Clinical orthopaedics and related research. 2015 Dec;473(12):3928-36.

Anterolateral Ligament Reconstruction with Anterior Cruciate Ligament Reconstruction Introduction to this edition’s debate:


ust when you think we have finally figured out the anterior cruciate ligament (ACL) reconstruction, and its relationship with knee stability, here comes a twist to the narrative; the need for an anterolateral ligament (ALL) reconstruction. To some, this technique has the potential to revolutionize ACL surgery, and to others, it seems like another “gimmick” procedure with no additional functional efficacy. To evaluate the potential uses and pitfalls of the ALL reconstruction, reputable and experienced clinicians from high-volume centres at the University of Manitoba and Banff Sports Medicine take on this latest debate. Enjoy!

Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

COA Bulletin ACO - Spring / Printemps 2018

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

Reconstruction of the Anterolateral Ligament of the Knee: Do Not Go There! Mireille Marquis, M.D., FRCSC Laurie A Hiemstra, M.D., PhD, FRCSC Banff, AB


nterior cruciate ligament (ACL) tear is a common injury, with an estimated annual incidence of 68.6 per 100,000 person-years1. Even in the hands of the most experienced surgeon, a number of failures occur after ACL reconstruction, and residual rotational instability is present in up to 25% of patients2. The reported incidence of ACL graft rupture varies from 14 to 30%3. Overall, return to sport is reported at 82%, with only 63% of patients returning to their preinjury level of play4. More recently, modification of ACL surgical techniques such as anatomic single and double bundle approaches, have attempted to reduce the number of failures as well as residual rotational laxity. Despite these advancements in surgical techniques, there is no substantial body of evidence demonstrating a significant reduction in rates of graft failure and rotatory instability. In 2013, the anterolateral ligament (ALL) of the knee was reintroduced by Claes, which triggered a media blitz about ‘a new knee ligament’5. This structure had originally been described by Segond in 1879 as a ‘pearly, resistant fibrous band’ going from the lateral epicondyle of the femur to the tibia. Further, in 1976, Hughston described the structure as the ‘mid-third lateral capsular ligament’, a ligament responsible for rotatory stability of the knee6. Since 2013, multiple cadaveric studies have been performed, providing a more detailed description of the anatomy of the ALL, and clarifying its role in knee stability. The ALL contributes to knee joint stability in internal rotation and anterior tibial translation, thus reducing anterolateral rotatory instability7,8,9,10. The option of addressing ALL deficiency in conjunction with an ACL reconstruction, with a goal of improving rotary stability outcomes and reducing failure rates, is appealing. However, consideration must be given to whether the risks of this extra procedure are worth undertaking in order to provide these potential benefits. There are a number of approaches to surgically addressing the ALL, and consequently many controversies surrounding best practice11,6. An anatomic reconstruction has been described, but significant variation exists in the precise surgical technique. There are different types of grafts, methods of fixation, and attachment points, with no consensus regarding the optimal choice12. In addition, the indications for a lateral-sided procedure are variable, and include a high-grade pivot shift, radiologic evidence of rupture, hyper-laxity, young age, high-risk sports, meniscal deficiency, and revision procedures with no clearly identified cause of failure. A non-anatomic lateral extraarticular tenodesis (LET) has also been described to address rotatory instability13. To date, none of these techniques to address the ALL have demonstrated clear superiority.

Figure 1 Ligament staple pull-out three-months post LET (complication of LET)

Despite compelling biomechanical data, the addition of an ALL reconstruction or an LET procedure, in conjunction with an ACL reconstruction, has not proven to result in improved clinical outcomes. It is also important to note that an additional ALL procedure is not without risk. The most concerning complication reported to date is over-constraint of the lateral compartment of the knee, creating greater contact stresses and leading to premature osteoarthrosis14,15. Recent studies using a posterior/proximal femoral fixation point have reported over-constraint of internal rotation after ALL reconstruction16,10. Studies reporting the use of an anterior/distal fixation point did not demonstrate this concern, however these studies also did not show a significant improvement in rotational stability8,17. From a biomechanical point of view, it appears that none of the current ALL reconstruction techniques effectively restore anterolateral stability without producing an alteration of normal joint kinematics. For these reasons, it has been proposed that an ALL reconstruction should be avoided if the lateral meniscus or posterolateral corner (PLC) is incompetent. In the presence of a PLC injury, fixation of the ALL with external tibial rotation would result in malposition of the tibia18.. Another concern relating to the addition of a lateral procedure to an ACL reconstruction, are the increase in surgical time, leading to an increased risk of infection19. Considerable morbidity of the donor site is an issue for both the ALL reconstruction and LET procedures. Hardware complications are also common and can necessitate a second surgery for removal (Figure 1). A lateral procedure requires additional skin incisions, increasing the risk of complications including infection. Finally, ALL reconstruction raises the problem of ‘real estate’ requiring the creation of more tunnels in the femur and the risk of tunnel convergence, bone deficiency, fixation issues, the increased risk of condyle fractures and the potential for technically difficult revisions in the future20.

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 35)

In our Canadian system, attention to fiscal responsibility is essential. There are cost implications to adding an ALL reconstruction with fixation required on the tibia and the femur, and when an allograft is used, there may be further additional costs. An LET is more cost effective with regards to disposables, but still requires an increase in surgical time. Most convincingly however, is the fact that the effectiveness of a lateral-sided procedure for improving clinical outcomes is still in question. In a recent systematic review by SonneryCottet assessing 24 studies reporting on a combined ACL reconstruction/LET, he notes that “combined ACL reconstruction and LET results in a significant reduction in the prevalence of residual pivot shift, but the majority of the studies do not demonstrate any significant difference with respect to patientreported outcome measures and return to sport. Although several authors report a trend towards decreased graft rupture rates, significant differences were not demonstrated in most studies21.” This review reports on only one study that evaluates outcome after combined ACL and ALL reconstruction at 32-months postoperative. In this single study, the authors demonstrated reduced graft rupture rates compared to isolated ACL reconstruction, but a 16% complication or re-intervention rate was also noted2. In conclusion, although evidence is growing for the addition of a lateral-sided procedure in combination with an ACL reconstruction, there is still much to learn. Although the orthopaedic community now recognizes the existence of the ALL, there is still a lot of confusion around its anatomy and function, optimal surgical techniques and surgical indications. There are significant complications associated with the procedures, and further evidence of efficacy and improvement in clinical outcomes is required before including ALL reconstruction or LET into routine surgical practice. Hopefully, the results of the Canadian STABILTY trial will answer some of these important questions. As with all trendy procedures, caution must be taken before embracing it into your routine practice, and the benefits have yet to be proven to outweigh the risks. References

5. Claes S., Vereecke E., Maes M., Victor J., Verdonk P., Bellemans J. Anatomy of the anterolateral ligament of the knee. 2013:321-328. doi:10.1111/joa.12087. 6. Chahla J., Geeslin A.G., Cinque M.E., Laprade R.F. Biomechanical Proof for the Existence o f the Anterolateral Ligament Anterolateral Ligament Knee Biomechanics Rotational Instability. 2018;37:33-40. doi:10.1016/j. csm.2017.07.003. 7. Chahla J., Moatshe G., Geeslin A.G., Laprade R.F. Biomechanical Role of Lateral Structures in Controlling Anterolateral Rotatory Laxity : The Anterolateral Ligament. Oper Tech Orthop. 2017:1-5. doi:10.1053/j.oto.2017.02.004. 8. Tavlo M., Eljaja S., Jensen J.T., Siersma V.D., Krogsgaard M.R. The role of the anterolateral ligament in ACL insufficient and reconstructed knees on rotatory stability : A biomechanical study on human cadavers. 2016:960-966. doi:10.1111/ sms.12524. 9. Rasmussen M.T., Nitri M., Williams B.T., et al. An In Vitro Robotic Assessment of the Anterolateral Ligament , Part 1 Secondary Role of the Anterolateral Ligament in the Setting of an Anterior Cruciate Ligament Injury. 2015:1-8. doi:10.1177/0363546515618387. 10. Nitri M., Rasmussen M.T., Williams B.T., et al. An In Vitro Robotic Assessment of the Anterolateral Ligament , Part 2 Anterolateral Ligament Reconstruction Combined With Anterior Cruciate Ligament Reconstruction. 2016:1-9. doi:10.1177/0363546515620183. 11. Cerciello S., Batailler C. Extra - Articular Tenodesis in Combination with Anterior Cruciate Ligament Reconstruction : An Overview. 2018;37:87-100. doi:10.1016/j.csm.2017.07.006. 12. Chahla J., Ph D, Geeslin A.G., Laprade R.F., Ph D. Anterolateral Ligament Reconstruction Techniques, Biomechanics, and Clinical Outcomes: A Systematic Review. Arthrosc J Arthrosc Relat Surg. 2017:1-9. doi:10.1016/j.arthro.2017.03.009.

1. Study A.P., Sanders T.L., Kremers H.M., et al. Incidence of Anterior Cruciate Ligament Tears and Reconstruction. 2016:1502-1507. doi:10.1177/0363546516629944.

13. Mathew M., Dhollander A. Antero lateral Ligament Reconstruction or Extra- Articular Tenodesis : Why and When ? Clin Sports Med. 2018;37(1):75-86. doi:10.1016/j. csm.2017.07.011.

2. Sonnery-cottet B., Thaunat M., Freychet B., Mermoz J. Outcome of a Combined Anterior Cruciate Ligament and Anterolateral Ligament Reconstruction Technique With a Minimum 2-Year Follow-up. 2015:1598-1605. doi:10.1177/0363546515571571.

14. Kheir M.M., Turnbull T.L., Ph D, Laprade R.F., Ph D. Biomechanical Results of Lateral Extra-articular Tenodesis Procedures of the Knee : A Systematic Review. Arthrosc J Arthrosc Relat Surg. 2016;32(12):2592-2611. doi:10.1016/j. arthro.2016.04.028.

3. Schilaty N.D., Nagelli C., Bates N.A, et al. Incidence of Second Anterior Cruciate Ligament Tears and Identification of Associated Risk Factors From 2001 to 2010 Using a Geographic Database. 2017:1-8. doi:10.1177/2325967117724196.

15. Fu F.H. Preface Structures of the Anterolateral Knee : Why All the Confusion ? Clin Sports Med. 2018;37(1):xvii - xviii. doi:10.1016/j.csm.2017.10.001.

4. Ardern C.L., Webster K.E., Taylor N.F., Feller J.A., Victoria O. Return to sport following anterior cruciate ligament reconstruction surgery : a systematic review and meta-analysis of the state of play. 2011:596-606. doi:10.1136/bjsm.2010.076364. COA Bulletin ACO - Spring / Printemps 2018

16. Schon J.M., Moatshe G., Brady A.W., et al. Anatomic Anterolateral Ligament Reconstruction of the Knee Leads to Overconstraint at Any Fixation Angle. 2016:1-11. doi:10.1177/0363546516652607.

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

17. Spencer L., Orth F., Burkhart T.A., et al. Biomechanical Analysis of Simulated Clinical Testing and Reconstruction of the Anterolateral Ligament of the Knee.:2189-2197. doi:10.1177/0363546515589166. 18. Miller T.K. The Role of an Extra-Articular Tenodesis in Revision of Anterior Cruciate Ligament Reconstruction. Clin Sports Med. 2018;37(1):101-113. doi:10.1016/j.csm.2017.07.010.

20. Kamath G.V., Redfern J.C., Greis P.E., Burks R.T. Revision Anterior Cruciate Ligament Reconstruction. 2011;39(1). doi:10.1177/0363546510370929. 21. Sonnery B., Nuno C., Barbosa C., Dutra T. Clinical outcomes of extra ‑ articular tenodesis / anterolateral reconstruction in the ACL injured knee. Knee Surgery, Sport Traumatol Arthrosc. 2017. doi:10.1007/s00167-017-4596-5.

19. Sonnery-cottet B., Archbold P., Zayni R. Prevalence of Septic Arthritis After Anterior Cruciate Ligament Reconstruction Among Professional Athletes Investigation performed at The Centre Orthope. 2008;(January 2003):2371-2376. doi:10.1177/0363546511417567.

Anterolateral Ligament Reconstruction with Anterior Cruciate Ligament Reconstruction: Worth a Consideration Peter B. MacDonald, M.D., FRCSC Medical Director, Department of Surgery, Pan Am Clinic Head, Section of Orthopaedic Surgery, University of Manitoba Winnipeg, MB


he anterolateral ligament (ALL) of the knee is poorly understood. Contrary to the belief of some, this is not a new ligament. In 1879, the French surgeon, Segond, described a “pearly resistant fibrous band” in the region of the anterolateral aspect of the knee. This structure was noted to be attached to the subsequently named, ‘Segond Fracture’. Many names have been attached to this structure including the ‘lateral capsular ligament’, ‘capsulo-osseous layer of the iliotibial band’ or ‘anterolateral ligament’. Claes1 went on to describe this structure in more detail in his 2013 publication. Throughout recent years, surgeons have been looking for ways to improve ACL reconstruction results. Much of this search relates to the belief that an ACL tear is not an isolated event, but associated with capsular disruption contributing to more of a rotational pattern of instability. Like many things in orthopaedics, trends come and go, like clothing styles. Cycles tend to relate to key articles of the teaching of prominent surgeons, who propagate philosophies to their fellows and those who closely follow the literature of their work. In the late 1960’s, Slocum and Larson2 were among the first to describe this rotational laxity along with Ellison who promoted an extra-articular reconstruction to prevent the rotational instability. Although these types of reconstructions are no longer used, the debate over whether structures like the anterolateral ligament need to be addressed continues, especially in the high-risk young, female, hyperlax athlete who is known to have a risk of recurrent instability in some series that exceeds 20 per cent. The current clinical body of literature for ALL reconstruction is lacking, limited mostly to level 4 and 5 evidence. This will

soon change with the pending completion of randomized trials. Biomechanical studies of this structure are generally of good quality but come with the inherent limitations when drawing conclusions from these papers. The ALL has been shown to resist internal rotation at high angles of flexion greater than 35 degrees and will not resist anterior drawer forces. Therefore, if the problem is related to rotatory instability in the pivot shift position of 15 to 20 Figure 1 degrees, a pure ALL Anatomy of the ALL reconstruction would not make sense in protection of the ACL graft in this position6. However, Sonnery-Cottret7 cautions us that cadaver studies have limitations and that the ACL ALL and ITB do not act as isolated structures, but rather in combination in their resistance of the pivot shift. He advocates clinical trials as opposed to further cadaveric studies. In a prospective comparative study of 502 patients8, who were high-risk athletes participating in pivoting activity, he found that ALL significantly decreased the risk of subsequent graft failure when compared to both the BTB and a 4-stranded hamstring technique.

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 37)

Getgood has advocated a different angle of reconstruction such as the one used in the lateral extra-articular transfer (modified Lemaire procedure which was originally described in 1967)5 where a strip of iliotibial band is transferred under the lateral collateral ligament, secured by staple to the posterior aspect of the lateral femoral condyle, and then sutured back onto itself. This vector is more in line with supporting the knee at a lower angle of flexion during the range of motion that the pivot shift occurs. A multi-centered randomized controlled study led by Getgood3 with more than 600 enrolled patients has been completed, and pending follow-up data will be highly anticipated in its results. Until such a time as a trial of this magnitude demonstrates clearly positive results, we can only postulate as to the role and the indication for ALL or LET in the augmentation of a traditional ACL reconstruction. It makes sense that, at least in some patients, there is a “missing link” and ACL reconstruction alone is not enough to completely fix this complex injury. However, the routine use of the LET in combination with ACL reconstruction may not be advisable. Herbst et al.2 from Pittsburgh performed a cadaveric study and looked at the biomechanical effect of adding the LET to an ACL reconstruction in isolated ACL insufficiency. Their group showed no difference and, in fact, a potential over-constraint situation when the LET is added2. My own opinion is that there is enough evidence so far which will be further substantiated supporting the judicious use of the LET procedure in athletes with hyperlaxity, in combined ACL and lateral capsular injuries, or in revision situations. References 1. Claes, S., Vereecke, E., Maes, M., Victor, J., Verdonk, P. and Bellemans, J. (2013), Anatomy of the anterolateral ligament of the knee. Journal of Anatomy, 223: 321–328. doi: 10.1111/ joa.12087. 2. Herbst, E., Arilla, F., Guenther, D., Yacuzzi, C., RahnemaiAzar, A., Fu, F., Debski, R., and Musahl, V. Lateral Extraarticular Tenodesis Has No Effect in Knees with Isolated Anterior Cruciate Ligament Injury. Arthroscopy: The Journal of Arthroscopic and Related Surgery. In press. 3. Getgood, A. Personal communication 4. Larson, R. Physical Examination in the Diagnosis of Rotatory Instability. Clinical Orthopaedics and Related Research 172;38-42 January/February 1983 5. Lemaire, M. (1975) Chronic Knee Instability. Technics and results of a ligament plasty in sports injuries. J Chir (Paris) 110:281-294.

COA Bulletin ACO - Spring / Printemps 2018

Figure 2 Modified Lemaire procedure

6. Parsons, E., Gee, A.O, Spiekerman, C., Cavanagh, P.R. The Biomechanical Function of the Anterolateral Ligament of the Knee. Am J Sports Med 43; 669-674 2015. 7. Sonnery-Cottet, B. Editorial Commentary: Studying the Anterolateral Ligament of the Knee. Have We Lost Track Our Main Focus? Arthroscopy: The Journal of Arthroscopic and Related Surgery, Vol 33, No 3 (March), 2017: pp 605-607 8. Sonnery-Cottet, B. et al. Anterolateral Ligament Reconstruction Is Associated With Significantly Reduced ACL Graft Rupture Rates
at a Minimum Follow-up of 2 Years. The American Journal of Sports Medicine, Vol. 45, No. 7. 15471557 2017 9. Spencer, L., Burkhart, T.A., Tran, M.N., Rezansoff, A.J., Deo, S., Caterine, S., Getgood, A.M. Biomechanical Analysis of Simulated Clinical Testing and Reconstruction of the Anterolateral Ligament of the Knee. Am J Sports Med. 43; 2189-2197. 2015.

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

Advancing Collection of Standardized Hip and Knee Arthroplasty Data in Canada The Canadian Joint Replacement Registry (CJRR) is Canada’s only panCanadian medical device registry. It was launched in 2001 in collaboration with the Canadian Orthopaedic Association, and is managed by the Canadian Institute for Health Information (CIHI). CIHI also has a national program on patient-reported outcome measures (PROMs), which includes focused work on hip and knee arthroplasty. Information on the CJRR and the PROMs programs can be found at and

CJRR Coverage IHI captures all acute, inpatient hip and knee replacement procedures across Canada through the Discharge Abstract Database (DAD), and the Hospital Morbidity Database (HMDB). Some provinces also send data on day surgery procedures to CIHI. CJRR captures other clinical information, as well as prosthesis information that is not available in DAD or HMDB. In fiscal year 2016-2017, CJRR data for almost 89,000 hip and knee arthroplasties were submitted to CIHI. This represented 71% of all hip and knee arthroplasties performed in hospitals in Canada.


As shown in Figure 1, coverage varied by province as some provinces have mandated reporting to the registry. Mandatory submissions from all jurisdictions is the most effective way to ensure a comprehensive capture of prosthesis and other clinical information, in order to inform device surveillance, procurement functions, and improve patient outcomes. Our goal is to reach greater than 90% coverage across Canada. Provincial initiatives are underway in Alberta and Nova Scotia that will lead to higher coverage in the coming years.

PROMs Update National Hip & Knee PROMs Program CIHI continues to coordinate efforts to advance a common approach for routine collection and reporting of PROMs, which includes support and leadership from the CJRR Advisory Committee, chaired by Drs. Eric Bohm and Michael Dunbar, and CIHI’s PROMs Hip and Knee Replacements Working Group, chaired by Dr. Eric Bohm. In November 2017, national PROMs data collection standards for hip and knee arthroplasty have been finalized. The national PROMs standards include guidelines for survey time points, a minimum data set (MDS) and recommended PROMs instruments (EQ-5D-5L, Oxford Hip Score and Oxford Knee Score). These standards are endorsed by the CJRR Advisory Committee and CIHI’s PROMs Hip and Knee Replacements Working Group. The PROMs data collection standards will be published in the PROMs Data Collection Manual – Hip and Knee Arthroplasty which will be released by summer 2018. In the interim, please contact if you have questions about the PROMs standards. Ontario Hip and Knee PROMs Pilot Project Ontario is the first province in Canada to adopt the national PROMs standards for hip and knee arthroplasty. In 2017, the Ontario Ministry of Health and Long-term Care (MOHLTC) approached CIHI and Cancer Care Ontario (CCO) to jointly execute a new project for PROMs in hip and knee replacement patients. CIHI is leading on data collection, submission and reporting standards and will also provide comparative report-

What’s Ahead for CJRR CIHI is implementing a number of changes to the CJRR data submission process. The CJRR Web-Based Data Submission and Reports Tool will be retired in summer 2018, once the 2017–2018 data has been processed. As of April 1, 2018, hip and knee replacement prosthesis information can be submitted via CIHI’s main hospitalization database, the DAD. This means that the prosthesis information for these provinces are a part of the patient’s hospitalization record that is submitted to CIHI.

Figure 1 CJRR Coverage, 2016-2017 COA Bulletin ACO - Spring / Printemps 2018



Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 39)

ing for the province while Cancer Care Ontario is leading on implementation of data collection across sites. Pilot data collection was initiated in April 2018 and the intent is to scale-up to full provincial implementation by April 2020. The project is intended to inform provincial priorities, such as Quality-Based Procedures and the Patients First Action Plan for Health Care, and support a value-based health-care delivery. OECD PROMs Project The Organisation for Economic Co-operation and Development (OECD) has launched the Patient Reported Outcomes Indicators Survey (PaRIS) initiative ( which is aimed at facilitating common reporting of internationally comparable PROMs and patient-reported experience measures (PREMs). PROMs for hip and knee arthroplasties are one of the areas of focus for the OECD PaRIS initiative. At the request of the OECD, in spring 2017, CIHI prepared a discussion paper to share Canada’s experience with PROMs in hip and knee arthroplasty and provide a proposed roadmap for standardizing collection and reporting internationally. As a result, the OECD invited CIHI to co-lead an international working group for PROMs in hip and knee, and CIHI accepted this role on behalf of Canada.

COA Launches New Choosing Wisely Canada Recommendations


he COA has partnered with Choosing Wisely Canada to launch five new orthopaedic recommendations concerning knee arthroscopy, ordering of MRIs, pain management, and pathological examination of tissues. The new guidelines have been added to the existing list launched in 2014, for a total of 10 orthopaedic recommendations. Click here to view the new Choosing Wisely Orthopaedic Recommendations. Thank you to members of the COA Standards Committee, the Arthroscopy Association of Canada and the Canadian Arthroplasty Society for their dedicated work on this initiative.

COA Bulletin ACO - Spring / Printemps 2018

This OECD PaRIS Working Group on Hip and Knee Replacement Surgery was launched in December 2017. Members of the working group include clinicians; national arthroplasty registries; the International Society of Arthroplasty Registries; the International Consortium of Health Outcome Measurement (ICHOM); and government and patient representatives from volunteer OECD member countries. The priorities of the PaRIS Hip and Knee Working Group are to: 1) Use existing PROMs programs to pilot international comparable reporting in OECD’s Health at a Glance 2019 report. 2) Advance new PROMs standards and data collection to maximize comparable reporting beyond Health at a Glance 2019 for an expanded suite of countries. Stay tuned for updates in future COA Bulletins on these national and international initiatives!

L’ACO lance sa nouvelle liste d’énoncés pour la campagne nationale Choisir avec soin


’ACO s’associe à la campagne nationale Choisir avec soin en vue de lancer cinq nouveaux énoncés liés à l’orthopédie. Ils portent sur l’arthroscopie du genou, la demande d’IRM, la gestion de la douleur et l’anatomopathologie. Ces nouvelles recommandations s’ajoutent aux énoncés publiés en 2014, pour un total de dix recommandations en orthopédie. Cliquez ici afin de lire la nouvelle liste d’énoncés pour la campagne Choisir avec soin. Merci aux membres du Comité sur les normes nationales de l’ACO, de l’Arthroscopy Association of Canada et de la Société canadienne d’arthroplastie pour leur immense travail dans le cadre de cette initiative.

More possibilities

1) AXSOS-PO-1 Petersik A, Virkus WW, Burgkart R, von Oldenburg G. Evidence-based �it assessment of anatomic distal medial tibia plates. Poster session presented at: OTA 2014. 29th Annual Meeting of the OTA; 2014 Oct 15-18; Tampa, FL.

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 su 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 uc Stryker representative if you have questions about the availability of Stryker products in your area. Stryker Corporation or its divisions or other corporate af�iliated entities own, use or have applied for the following trademarks or service marks: AxSOS 3, SOMA, Stryker. All other trademarks are trademarks of their respective owners or holders. AXSOS-FL-2 Rev. 1, 11-2015 Copyright © 2015 Stryker

Canadian Orthopaedic Association (COA) 2018 Annual Meeting Program Features Spine! Spine is the featured subspecialty at the 2018 Canadian Orthopaedic Association’s Annual Meeting, from June 20-23 in Victoria, BC. We are pleased to highlight some of the spine programming offered at this year’s event: • Guest faculty includes: Drs. Stuart Weinstein (University of Iowa), Sean Christie (Dalhousie University, CSS President), Pradeep Maken (President, South Africa Orthopaedic Association) along with Canada’s leading spine specialists. • 3 spine paper sessions, featuring recipients of the 2018 Canadian Spine Society’s top paper awards. • Spine poster tour during Thursday evening’s casual Poster Pub session. • 3 symposia, discussing advances in degenerative spine surgery treatment, the importance of considering concurrent spine/hip disease when planning surgery, and emerging, promising biologic/biomaterial approaches. • 2 Instructional Course Lectures covering modern approaches to complex spinal surgery, as well as the economic and ember? m A O C clinical value of timely surgery. Not yet a ned up! • Full specialty day featuring an entire day of spine programming. Get sig .org


no info@ca


Innovations, new technologies, evidence-based presentations throughout both the Canadian Orthopaedic Research Society (CORS) and COA scientific programs


Earn valuable CME - even during breaks at the poster tours and lunch and learn sessions


Catch up with colleagues from across the country and abroad


A special address by CSS President, Dr. Sean Christie, during the Opening Ceremonies & CSS exhibit booth


Experience the beauty of the West Coast in this incredible host city


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

Gain Practice-Changing Skills in Just 1 Hour: Intimate Partner Violence (IPV) Educational Program for Fracture Clinics What is the EDUCATE Program? The EDUCATE program was developed by Drs. Sheila Sprague and Mohit Bhandari and their team of investigators, and is an IPV educational program for all fracture clinic staff who see patients (i.e. orthopaedic surgeons, residents, non-physician HCPs, and non-HCP staff). The program takes approximately one hour to complete and includes a brief introductory video discussing the importance of optimizing fracture clinics to identify and assist women experiencing IPV. This is followed by an in-person presentation delivered by “local IPV champions” (please see below sections) in which participants are taught how to successfully identify and assist patients experiencing IPV through video demonstrations, case studies, and group discussions. How Will the EDUCATE Program Benefit Fracture Clinics? Previous research has found that one out of every six female fracture clinic patients has experienced IPV within the previous 12 months (this is commonly referred to as current IPV). The COA has a position statement recognizing IPV as a significant social determinant of morbidity and mortality. This position statement encourages members to educate themselves further about IPV and take steps to incorporate IPV identification and assistance into practice. However, orthopaedic surgeons and other HCPs often report challenges identifying and assisting women experiencing IPV. Recent research suggests that these challenges can be overcome with clinical educational programs.

Drs. Sheila Sprague and Mohit Bhandari, developers of the EDUCATE program, from McMaster University’s Centre for Evidence-Based Orthopaedics

Bring the EDUCATE Program to Your Fracture Clinic!

EDUCATE program participants will learn the knowledge and skills necessary to successfully identify and assist victims of IPV within their practice. This will allow fracture clinics to provide a high-quality of care to the one in six female patients experiencing current IPV and contribute to improving health care equity for women.

The COA and the EDUCATE team are looking for Champions across Canada to bring the EDUCATE program to their fracture clinic. Champions will receive specialized training about IPV in the orthopaedic context as well as the EDUCATE program curriculum.

• Contribute to a growing movement focused on breaking the silence around gender-based violence and abuse. What are the Requirements to be a Local IPV Champion? Any orthopaedic surgeon, resident, allied HCP, or non-HCP staff who sees patients in the fracture clinic can become a local IPV champion. Champions should however, be individuals who have: • An interest in supporting women experiencing abuse. • Adequate time to devote to the role. • The ability to engage fracture clinic team members to participate in the training.

Champion training will take place at What are the Benefits of Serving the COA 2018 Annual Meeting: as a Local IPV Champion? Friday June 22 from 13:45 – 15:30 • Gain an opportunity to take on a leadership role within the fracture clinic. What are the Responsibilities of • Learn new knowledge and clinical a Local IPV Champion? skills that will contribute to improved Local IPV champions will be providE R E patient care. CK H I L ed with specialized training from the C a • Develop and refine medical education come e b EDUCATE team that focuses on how to ideno t p u skills. igns o tify and respond to IPV within the fract • Obtain CME credit for participating in the ampion h ture clinic setting as well as the EDUCATE C local IPV champion training. program curriculum. This training takes 1.5 • Become an advocate for women who are hours to complete and will be taking place at the COA 2018 living in vulnerable and dangerous Annual Meeting in Victoria British Columbia and is scheduled situations. for Friday June 22 from 13:45 to 15:30. See final program COA Bulletin ACO - Spring / Printemps 2018



Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 43)

for room location and details. Once local IPV champions have received training, they will be responsible for delivering the EDUCATE program at their fracture clinic. If you are interested in becoming a champion, but cannot attend the champion training at the COA 2018 Annual Meeting, please contact us for future training opportunities.

How Can Fracture Clinics Obtain Access to the EDUCATE Program? The EDUCATE program is delivered to fracture clinics by local IPV champions. To bring the EDUCATE program to a fracture clinic, one or more individuals from the fracture clinic must volunteer to serve as a champion.

What Are Current Champions Saying about the EDUCATE Program? “The EDUCATE program has helped our team to better identify and address the needs of IPV victims in our fracture clinic. As a result, we have become better informed about the many local IPV resources, and have comprehensive resource materials available for patients in our clinic. The feedback I have received from my colleagues who completed the program was overwhelmingly positive, and I strongly encourage others to serve as Champions and bring the EDUCATE program to their fracture clinics.” - Prism Schneider, MD, PhD, FRCSC “This program has helped our team become much more comfortable asking patients about intimate partner violence and providing essential lines of communication with community and hospital services as well as immediate help if necessary.” - Brad Petrisor, MD, MSc, FRCSC

“Like many surgeons, I was unaware of how we could be point of initial contact with this issue for patients, and felt ill-equipped to deal with the issue should it arise. Having implemented the EDUCATE program at my fracture clinic, our staff have become more familiar with signs and symptoms, and more aware of resources available.” - Andrew Furey, MD, MSc, FRCSC “A lack of education can lead to lost opportunities to make a difference. EDUCATE teaches essential clinical skills for any health-care provider who sees patients in the fracture clinic. I have rarely seen an educational program that has the potential to make such a difference.” - Emil Schemitsch, MD, FRCSC

“Teaching the residents in our training program about domestic violence, and how they can make a huge difference in the lives of their patients by being prepared to recognize and address this issue, has been especially fulfilling.” - Aaron Nauth, MD, MSc, FRCSC

COA Bulletin ACO - Spring / Printemps 2018

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

“As physicians, we spend our lives learning how best to “treat the patient” and not simply the disease. The training to become a champion was not onerous at all, and it quickly provided me with the tools and confidence to identify and help patients who suffer from IPV.” - Anthony Adili, MD, FRCSC

“Serving as Champion for the EDUCATE program was a great experience. The program was enthusiastically received and the feedback provided to me by front line health-care providers was overwhelmingly positive.” - Lynn Vicente, RN, CCRP

If you are interested in serving as a local IPV champion and bringing the EDUCATE program to your fracture clinic, please complete our brief (one minute) sign-up form by visiting

The EDUCATE program was made possible by the following individuals: Sheila Sprague, Mohit Bhandari, Gina Agarwal, Deborah J. Cook, Vanina Dal Bello–Haas, Samir Faidi, Diane Heels-Ansdell, Norma MacIntyre, Paula McKay, Angela Reitsma, Patricia Schneider, Taryn Scott, Patricia Solomon, Lehana Thabane, Andrew Worster (McMaster University, Hamilton ON), Diana Tikasz (Hamilton Health Sciences, Hamilton ON), Gerard P. Slobogean (University of Maryland, Baltimore MD), Prism S. Schneider, Richard E. Buckley, Leah Schultz, Tanja Harrison (University of Calgary, Calgary AB), Brad A. Petrisor (Hamilton Health Sciences, Hamilton ON), Andrew Furey, Kayla Cyr, Erin Baker (Memorial University of Newfoundland, St. John’s NL), Jeremy A. Hall, Aaron Nauth, Milena Vicente (St. Michael’s Hospital, Toronto ON), Debra L. Sietsema (The CORE Institute, Phoenix AZ), Emil H. Schemitsch, Melanie MacNevin (London Health Sciences Centre, London ON), Anthony Adili (St. Joseph’s Healthcare, Hamilton ON), Douglas Thomson, Trinity Wittman (Canadian Orthopaedic Association, Montreal QC), Aparna Swaminathan (University of Toronto, Toronto ON), Ari Collerman (Hamilton Health Sciences, Hamilton ON), Nneka MacGregor (Women’s Centre for Social Justice, Toronto ON), Sarah Resendes Gilbert (Domestic Assault Review Team, Waterloo ON)

Who Can I Contact for Additional Information? If you have questions about the EDUCATE program or becoming a champion, please contact Taryn Scott by email at

Did You Know? • 1 in 3 women presenting to fracture clinics have experienced IPV at some point in their lives. • IPV is the most common cause of non-fatal injury to women. • Every 6 days, a woman in Canada is killed by her intimate partner. • 45% of women who are killed by their intimate partner have attended a hospital for treatment of injuries related to IPV within the past 2 years.

Evaluating Shoulder Care in Alberta: Team-based Care at the Glen Sather Sports Medicine Clinic Breda H. Eubank, PhD(c), CAT(C) Assistant Professor Department of Health and Physical Education Faculty of Health, Community, and Education Mount Royal University Calgary, AB David M. Sheps, M.D., MSc, MBA, FRCSC Assistant Clinical Professor Division of Orthopaedics Department of Surgery University of Alberta Edmonton, AB


anagement of rotator cuff pathology is complex, with a multitude of existing treatment options1. Rotator cuff pathology has attracted recent attention due to

commonality and burden of this disease2,3. Quality of care for patients with rotator cuff pathology must be responsive to clearly identified needs of the population based on available evidence-based research. Quality improvements in caring for Albertans presenting with rotator cuff pathology are necessary and can result in considerable savings of resources or expansion of services for the community4. The Health Quality Council of Alberta (HQCA) created a framework that can be used to measure quality in health care5. This framework consists of six dimensions of quality that measure patient experience and system performance: appropriateness, acceptability, accessibility, effectiveness, efficiency, and safety5. In 2015, the Glen Sather Sports Medicine Clinic (GSSMC) at the University of Alberta participated in a joint initiative with the University of Calgary Sports Medicine Centre (UCSMC). The goal of the project was to measure and evaluate the current COA Bulletin ACO - Spring / Printemps 2018



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

quality of care for patients presenting with rotator cuff pathology in Alberta using the HQCA’s framework. Quality improvements occurred in three stages: • Stage 1) Development of clinical pathway algorithms and clinical practice guidelines for the diagnosis and treatment of rotator cuff pathology presenting to primary, secondary, and tertiary health-care settings6; • Stage 2) Measuring the current standard of care for patients presenting to primary, secondary, and tertiary health-care settings in Alberta7-9; • Stage 3) Comparing quality measures (i.e., appropriateness, acceptability, accessibility, effectiveness, efficiency, and safety) in the current state with ideal pathway and practice guidelines to identify gaps in care7. Summary of Results Stage 1) A modified Delphi method was used to build consensus around improving the current standard of care for patients presenting with rotator cuff pathology6. Clinical pathway algorithms were developed by an expert panel for three types of rotator cuff pathology: acute, chronic, and acute-onchronic. Consensus was also reached for 59 statements representing five domains (screening, diagnosis, physical examination, investigation, and treatment) used to guide clinical practice.

The ideal waiting for surgery is between 12 and 22 weeks for an acute rotator cuff tear, and between 30 and 38 weeks for a chronic tear6. Only 40% of patients requiring surgery received surgery within the ideal timeframe. Application: Team-based Care at the Glen Sather Sports Medicine Clinic Ultimately, the current model of care for patients presenting with disorders of the rotator cuff in Alberta is plagued with lengthy waiting times, low levels of patient satisfaction, inappropriate use of health-care resources, and inefficient clinical pathways. The current model of care requires a paradigm shift and shuffling of health-care resources. Team-based models of care are a potential solution to these challenges.

The COA will regularly be inviting members to feature innovative orthopaedic care pathways from across the country. If you would like to submit your model of care for publication in the Bulletin, please contact Trinity Wittman at

Stage 2) A convenience sample of patients from both the GSSMC and UCSMC were recruited and asked to complete two online questionnaires: The Health-care Access and Patient Satisfaction Questionnaire (HAPSQ) and the Rotator Cuff Quality-of-Life Index (RC-QOL). The HAPSQ was used to collect information regarding appropriateness, acceptability, accessibility, efficiency, and safety10,11. The RC-QOL was used to evaluate effectiveness12. Results from the surveys found that patients experienced long waiting times. The longest times were waiting to see an orthopaedic surgeon (mean: 172 days, SD: 191) and waiting for MRI (mean: 103 days; SD: 100). Patient satisfaction was high with respect to quality of care received by orthopaedic surgeons, but low with respect to time spent waiting for care. The two main cost drivers to the public healthcare system were from diagnostic imaging and physician visits. Stage 3) A comparison between current and ideal clinical standards of care found that magnetic resonance imaging (MRI) was over-prescribed (i.e., 56% of patients received an MRI) and redundant (i.e., 33% of patients received both ultrasound and MRI). Twenty-two percent of patients experienced indirect clinical pathways, where patient care was fragmented and care was received from too many health-care professionals. The ideal standard of care for patients treated conservatively should include a trial of non-operative treatment started at the time of the initial clinical presentation, and that MRI and referral to a surgeon be reserved for non-responders to conservative treatment6. The recommended standard of care includes a 12-week home or supervised physical therapy program, with COA Bulletin ACO - Spring / Printemps 2018

pain control methods (i.e. cortisone injection) at the six-week mark if patients are not able to achieve pain-free status at that point in time6. Only a third of non-operative patients met the ideal standard of care and successfully completed 12 weeks of physical therapy.

In Canada, there are pockets of innovation that use non-physicians to help musculoskeletal patients navigate through the medical system. Non-physician models of care (NPMC) engage a team-based approach to evaluating, managing, and treating patients with musculoskeletal disorders13. NPMC help to eliminate silos of health-care delivery and allow for a more integrated approach to care. These models lead to better coordination of appropriate healthcare resources and services, which lead to better health outcomes. NPMC utilize current health human resources such as physiotherapists, physician assistants, or athletic therapists, who are trained at a specialist’s competency level with minimal re-training. These allied health-care professionals are able to provide a high standard of care within a narrow field in an interprofessional team with a supervising physician. The GSSMC has currently adopted an innovative care delivery model that utilizes physiotherapists, with a supervising orthopaedic surgeon, to help triage, manage, and treat patients presenting with shoulder pain. Combined with the aforementioned consensus guideline for the diagnosis and treatment of rotator cuff pathology, the GSSMC has developed two shoulder intake clinics to manage the pooled referrals received by the both the clinic and the offices of the participating orthopaedic surgeons. The surgeons evaluate incoming referrals to determine their appropriateness for either a surgical or non-surgical pathway. As part of the initial assessment, patient records are assessed to determine what investigations have been performed, so as to reduce the number of repeat investigations. A standard series of X-rays is obtained at the initial assessment (if not already completed) based on the patient’s presenting complaint. Community physicians and physiotherapists are encouraged to refer patients without tertiary imaging, particularly in the

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

setting of an acute injury, such as a dislocation or acute rotator cuff tear. This allows those patients requiring more urgent assessment to be evaluated within an appropriate timeframe.

deducted from physician billings required to cover the administrative support necessary to operate both the surgical and non-surgical shoulder clinics.

Patients who are deemed to require a course of non-operative treatment are offered an appointment in the non-operative shoulder clinic staffed by primary care sports medicine and physiotherapy. This reduces the wait time to see a care provider, and initiates a course of non-operative treatment or investigations (if indicated). The physiotherapist assigns the initial rehabilitation program and reviews it with the patient. Further rehabilitation is then offered through the clinic to allow for greater continuity of care. Appropriate follow-up is also arranged with primary care sports medicine. Should a surgical referral be deemed appropriate, this is arranged with the first available shoulder surgeon in a timely manner.

In addition to the aforementioned shoulder clinics, the GSSMC has established clinics for both knees and concussions that follow similar principles with the goal of creating a comprehensive care environment for these disorders. As with the shoulder clinics, the goal is to ensure that an appropriate assessment of each patient is performed by both a physician and non-physician expert, that appropriate and cost-effective investigations are performed, and that rehabilitation is initiated immediately following the first assessment. Continuity of care is provided through ongoing rehabilitation at the GSSMC, also utilizing evidence-based principles, with appropriate follow-up and surgical intervention as required.

Patients triaged to the surgical clinic are assessed in a similar fashion to patients in the non-operative pathway. Those deemed immediately surgical are offered an operation. This is coordinated with a course of rehabilitation assigned by the therapist to be undertaken by the patient prior to surgery. Those patients deemed non-operative after assessment in the surgical clinic follow a similar pathway to patients in the non-operative shoulder clinic with the option of further rehabilitation at the GSSMC to ensure continuity of care. Follow-up is also arranged with the treating surgeon to ensure that the outcome of rehabilitation is assessed, and if not found to be successful, further treatment options, including potential surgery, are pursued.

Conclusions The introduction of a collaborative NPMC system at the GSSMC has allowed the clinic to begin to address the shortfalls in the health-care system in Alberta for managing shoulder issues. The goal of the team is to complete an appropriate assessment of the patient’s shoulder issues by both a physiotherapist and a physician, establish an appropriate diagnosis, and initiate an appropriate course of rehabilitation at the initial visit that can be started immediately by the patient. Secondary goals include a determination of the most appropriate imaging (if required), and arrangements for surgery (if deemed appropriate). This addresses, to a large degree, the fragmentation of care delivery seen in the work evaluating the present standard of care, and also addresses the need for appropriate rehabilitation, which is the correct first line treatment for the majority of patients with shoulder disorders. In the future, the model of care offered at the GSSMC will continue to be evaluated from both a qualitative and quantitative perspective. Our goal is to continue to offer the highest quality, evidence-based care to our patients that is both timely and cost-effective, including reducing the waste that occurs in the present system due to unnecessary physician visits, imaging, and inappropriate and ineffective rehabilitation.

The principles employed by the therapists at the GSSMC are almost exclusively exercise-based, with minimal use of passive modalities. Respect for the kinetic chain and a thorough understanding of scapular function as part of the overarching principle of shoulder rehabilitation is key to the successful outcomes achieved for patients treated in the GSSMC environment. This includes patients in both the non-operative and operative treatment pathways. Patients are generally seen on a weekly or biweekly basis and provided a daily home exercise program that aligns with the consensus rehabilitation protocols created by the Shoulder and Upper extremity Research Group of Edmonton (SURGE). This reduces the number of therapy visits required by the patient, and lessens the financial burden of rehabilitation. It also allows the therapists at the GSSMC to see a greater number of patients in a one-on-one fashion so as to improve the quality of the therapists’ time with each patient. Finally, the communication between the physician and therapist regarding the progress of each patient occurs regularly, further ensuring that adjustments to care can be made in a timely fashion. The development of a team-based model of care for the GSSMC at the University of Alberta required the adoption of a sessional rate for the physiotherapists working in either the surgical or non-surgical shoulder clinics. The financial sustainability of the model is predicated on a minimum number of new consultations being performed per half day. Utilizing the team conference fee code from the Alberta Health Care Insurance Plan Schedule of Medical Benefits, funding could be sustained by directing the team conference fee code toward the sessional rate. This occurred over and above the overhead

For more information, please visit our web site at https://www. or contact Dr. David M. Sheps at References 1. Yamaguchi K. New guideline on rotator cuff problems. American Academy of Orthopaedic Surgeons Now 2011; 5(1):1-4. 2. Merolla G., Paladini P., Saporito M., Porcellini G. Conservative management of rotator cuff tears: literature review and proposal for a prognostic. Prediction Score. Muscles Ligaments Tendons J 2011; 1(1):12-19. 3. Yamamoto A., Takagishi K., Osawa T., Yanagawa T., Nakajima D., Shitara H. et al. Prevalence and risk factors of a rotator cuff tear in the general population. J Shoulder Elbow Surg 2010; 19(1):116-120.

COA Bulletin ACO - Spring / Printemps 2018


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


(continued from page 47)

4. Peacock S., Chan C., Mangolini M., Johansen D. Tehcniques for measuring efficiency in health services. Staff Working Paper. Productivity Commission. Retrieved from http:// 2001. Ref Type: Report 5. Health Quality Council of Alberta. Alberta quality matrix for health user guide. Health Quality Council of Alberta. Accessed 5 May 2017. 2003. Ref Type: Report

9. .Eubank B.H., Mohtadi N.G., Lafave M.R., Wiley J.P., Emery J.C. Further validation and reliability testing of the Rotator Cuff Quality of Life Index (RC-QOL) according to the ConsensusBased Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines. J Shoulder Elbow Surg 2017; 26(2):314-322. 10. Lau B, Lafave M, Mohtadi N, Butterwick D. Utilization and cost of a new model of care for managing acute knee injuries: the Calgary Acute Knee Injury Clinic. BMC Health Services Research 2012; 12(145):doi:10.1186/1472-6963-12-445.

6. Eubank B.H., Mohtadi N.G., Lafave M.R., Wiley J.P., Bois A.J., Boorman R.S. et al. Using the modified Delphi method to establish clinical consensus for the diagnosis and treatment of patients with rotator cuff pathology. BMC Med Res Methodol 2016; 16:56.

11. Mohtadi N., Chan D., Lau B., Lafave M. An innovative Canadian solution for improved access to care for knee injuries using “Non-Physician Experts”: the Calgary Acute Knee Injury Clinic. Rheumatology 2012; S2(002):doi:10.4172/2161-1149. S2-002.

7. Eubank B., Lafave M., Wiley J.P., Sheps D., Bois A., Mohtadi N. Evaluating quality of care for patients with rotator cuff disorders. Part 2: Assessing accessibility, acceptability, efficiency, effectiveness, appropriateness, and safety. BMC Health Services Research 2017; Submitted.

12. Hollinshead R.M., Mohtadi N.G., Vande Guchte R.A., Wadey V.M. Two 6-year follow-up studies of large and massive rotator cuff tears: comparison of outcome measures. J Shoulder Elbow Surg 2000; 9(5):373-381.

8. Eubank B., Lafave M., Mohtadi N., Sheps D., Wiley J.P. Evaluating quality of care for patients with rotator cuff disorders. Part 1: Validation and reliability testing of the Healthcare Access and Patient Satisfaction Questionnaire (HAPSQ). BMC Health Services Research 2017; Submitted.

13. Naylor D., Girard F., Mintz J., Fraser N., Jenkins T., Power C. Unleashing innovation: Excellent healthcare for Canada. Government of Canada: Report of the Advisory Panel on Healthcare Innovation. 2015. http:// tem-systeme-sante/report-healthcare-innovationrapport-soins/alt/report-healthcare-innovation-rapport-soins-eng.pdf. Accessed 10 October 2017. 2015. Ref Type: Report

First Combined Symposium Premier symposium with Indian Orthopaedic conjoint avec l’Indian Association Orthopaedic Association


he COA has partnered with the Indian Orthopaedic Association (IOA) on a trauma symposium that will be offered at the upcoming Annual Meeting in Victoria on Friday, June 22 at 13:45. Join us in welcoming IOA President and Past President, Drs. Mandeep Dhillon and Ram Prabhoo, along with Canadian trauma faculty as they discuss whether fracture surgery makes a difference. See the final program for full details and make sure to add this exciting session to your Annual Meeting itinerary.

COA Bulletin ACO - Spring / Printemps 2018


’ACO, en partenariat avec l’Indian Orthopaedic Association (IOA), offrira un symposium en traumatologie à la Réunion annuelle à Victoria le vendredi 22 juin, à 13 h 45. Venez accueillir les Drs Mandeep Dhillon et Ram Prabhoo, respectivement président et ancien président de l’IOA, et les spécialistes en traumatologie canadiens invités, qui discuteront de l’incidence du traitement chirurgical d’une fracture. Consultez le programme final de la Réunion annuelle pour les détails, et n’oubliez pas d’ajouter cette séance des plus intéressante à votre programme.

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Foundation / Fondation


Canadian Orthopaedic Foundation Announces First Community Innovation Awards


n 2017, the Canadian Orthopaedic Foundation (COF) instituted a new research awards competition for community researchers. In November, the first two awards were presented. The Community Innovation Awards celebrate community-based surgeons and research studies dedicated to improving patient care or musculoskeletal health. There are many Canadian orthopaedic surgeons interested in research working in the community, but these skilled

surgeons may find it difficult to obtain funding for their innovative research ideas. This program fills a gap in the research landscape in Canada, encouraging community orthopaedic researchers to bring their research ideas to fruition. The first two awards of $15,000 each were granted to Dr. Olivia Cheng and Dr. Kevin Koo. Here, they share information on their research projects:

Dr. Olivia Cheng, Collingwood General and Marine Hospital, Collingwood, Ontario: “Telemedicine is effective in the reduction of patient-care costs for hip fracture patients”

Dr. Kevin Koo, Markham Stouffville Hospital, Markham, Ontario: “Impact of an orthogeriatric collaborative care model for older adults with hip fracture in a community hospital setting”

An increase in the use of telemedicine for routine and uneventful postoperative appointments could translate into cost savings for local health-care systems. Future use of telemedicine for routine postoperative follow up appointments could potentially extend to other orthopaedic cases such as shoulder and knee joint replacement surgeries. A use of telemedicine by more orthopaedic surgeons and additional specialties may result in a significant decrease in local health system patient transfer cost expenditure.

Hip fractures often occur in older individuals with pre-existing frailty. The Quality-Based Procedures Clinical Handbook for Hip Fracture from Health Quality Ontario (HQO) recommends, based on the best available evidence, that care should be provided by a multidisciplinary team in accordance with principles of appropriate geriatric care.

The evidence for orthogeriatric care mostly comes from academic settings from other countries. In Canada, an academic centre in Toronto demonstrated reduced length of stay, costs, With the results of this study, the researchers intend to propose time to surgery, and increased initiation of appropriate osteothe use of telemedicine for uneventful orthopaedic follow up porosis treatment after implementation of an integrated hip appointments amongst local orthopaedic surgeons and local fracture co-management model. It is unclear whether the hospitals to decrease the cost associated with travel. outcomes in these studies are generalizable to or feasible in the community hospital setting. In July 2016, an orthogeriatric collaboration was established at Markham-Stouffville whereDr. Rick Buckley, Chair of the COF Research Committee, says, “The by older adults admitted with a hip fracture Research Committee was pleased with the proposals we received are seen by a geriatrician for a proactive comprehensive geriatric assessment. to this program. We suspected that there are surgeons out there in

the community with good research ideas, just lacking the funding to bring them to life. Now, we know this is true. This is a previously untapped research potential. The two projects we selected for funding will have a direct impact on the orthopaedic community.”

The Community Innovation Awards competition is made possible by COF donors. The COF is particularly grateful to Zimmer Biomet and to other supports of the Powering Pain Free Movement Campaign for funding which enabled the expansion of the research program. COA Bulletin ACO - Spring / Printemps 2018

The research team hypothesizes that the systematic implementation of principles of geriatric care through an orthogeriatric collaboration model improves process and outcome measures in hip fracture care in a community hospital setting.

Foundation / Fondation


La Fondation Canadienne d’Orthopédie annonce les premiers lauréats du Prix d’innovation communautaire


n 2017, la Fondation Canadienne d’Orthopédie instaurait un nouveau prix à l’intention des chercheurs en milieu communautaire. En novembre, elle a récompensé ses deux premiers lauréats. Le Prix d’innovation communautaire récompense les orthopédistes en milieu communautaire et les projets de recherche visant à améliorer les soins ou la santé de l’appareil locomoteur. De nombreux orthopédistes canadiens en milieu communautaire s’intéressent à la La Dre Olivia Cheng, de l’Hôpital General And Marine de Collingwood (Ontario), pour son projet de recherche intitulé : Telemedicine is effective in the reduction of patient-care costs for hip fracture patients Une utilisation accrue de la télémédecine pour les rendezvous de suivi postopératoire en l’absence de complications pourrait entraîner des économies au sein des systèmes de santé locaux. Éventuellement, l’utilisation de la télémédecine pourrait s’étendre à d’autres interventions orthopédiques, comme les arthroplasties de l’épaule et du genou. L’utilisation de la télémédecine par davantage d’orthopédistes et d’autres spécialistes pourrait entraîner une baisse considérable des coûts de transfert des patients pour les systèmes de santé locaux.

recherche, mais ont de la difficulté à obtenir du financement pour leurs projets de recherche novateurs malgré leurs compétences. Ce prix comble une lacune dans le paysage de la recherche au Canada et incite les orthopédistes en milieu communautaire à concrétiser leurs projets de recherche. Les 2 premiers prix, de 15 000 $ chacun, ont été remis aux Drs Kevin Koo et Olivia Cheng. Voici un sommaire de leur projet de recherche : Le Dr Kevin Koo, de l’Hôpital de Markham-Stouffville, à Markham (Ontario), pour son projet de recherche intitulé : Impact of an orthogeriatric collaborative care model for older adults with hip fracture in a community hospital setting Les fractures de la hanche sont fréquentes chez les personnes âgées déjà fragilisées. Le Quality-Based Procedures Clinical Handbook for Hip Fracture, de Qualité des services de santé Ontario (QSSO), recommande, en fonction des meilleures données probantes sur les fractures de la hanche, que les soins soient prodigués par une équipe multidisciplinaire selon les principes des soins gériatriques appropriés.

Les données probantes en soins orthogériatriques sont principalement issues de milieux universitaires à l’étranger. Au Grâce aux résultats de cette étude, les chercheurs comptent Canada, un centre universitaire torontois a constaté une réducproposer l’utilisation de la télémédicine par les orthopédistes tion de l’hospitalisation, des coûts et des délais avant la chiruret les hôpitaux de la région pour le suivi orthopédique en gie, ainsi qu’une augmentation des traitements de l’ostéol’absence de complications afin de réduire les frais de déplaceporose appropriés, après la mise en œuvre d’un modèle de ment. cogestion intégrée des cas de fracture de la hanche. On ne sait pas trop si les résultats de ces études sont généralisables ou applicables dans les Le Dr Rick Buckley, président du Comité de la recherche de la Fondation, raconte : hôpitaux communautaires. En juillet 2016, « Le Comité de la recherche est heureux des soumissions reçues pour ce prix. Nous une initiative de collaboration orthogériatrique a été lancée à l’Hôpital de Markhamnous doutions que les orthopédistes en milieu communautaire avaient de bonnes Stouffville : les personnes âgées admises idées de recherche, mais qu’ils manquaient de financement pour les concrétiser. en raison d’une fracture de la hanche sont Nous savons maintenant que c’est vrai. Il s’agit d’un potentiel de recherche vues par un gériatre pour une évaluation inexploité jusqu’ici. Les deux projets que nous avons choisi de financer auront une gériatrique globale et proactive.

incidence directe sur le milieu orthopédique. »

Le Prix d’innovation communautaire a été rendu possible par les donateurs de la Fondation. La Fondation remercie particulièrement Zimmer Biomet et les autres participants à la campagne Misons sur une vie sans douleur pour avoir permis, par leur contribution financière, l’expansion de ses programmes de financement de la recherche.

L’équipe de recherche part de l’hypothèse que l’application systématique de principes des soins gériatriques à l’aide d’un modèle de collaboration orthogériatrique améliore les processus et résultats liés au traitement des fractures de la hanche dans les hôpitaux communautaires. COA Bulletin ACO - Spring / Printemps 2018

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


Using the CanMEDS Roles in Your Practice Professional

of commitment to excellence in clinical practice and mastery of the discipline. This allows us to deliver on those patient needs as medical experts in our field. What we often overlook however, is our own well-being. Physicians spend countless hours training in medical school, residency and fellowship, then enter a busy career dominated by long work hours, which often The CanMEDS framework is a tool used for teaching and for our stretches late into life. It is easy continuing medical education. It is well established, benefits our to understand why burnout profession and has been integrated into the Royal College’s programs is not uncommon. Physicians including Maintenance of Certification. The seven roles of the are more likely to burnout CanMEDS are: than other professionals4.5. Physician burnout, in turn, is an independent predictor of • Medical Expert (the integrating role) higher incidence of medical • Communicator errors and major malpractice • Collaborator suits6.7. It seems selfish, but it is • Leader necessary for us to be in good • Health Advocate physical and mental health to • Scholar deliver the best care for our • Professional patients. Determining exactly where the balance lies is difOver the next few editions of the COA Bulletin, I will be asking ficult for us all, but for the sake various members of the COA to define each of the roles and how of our patients and our own they can be used in day to day practice and education. This series well-being, we must all take will provide guidelines on how to use the CanMEDS roles to their full time to reflect on this.

Ted Tufescu, M.D., FRCSC Program Director, University of Manitoba Winnipeg, MB


hat defines a professional, and who falls just short of that mark? We would all agree that an amateur is definitely not a professional, so perhaps this is a good place to begin. The word amateur refers to someone who has a love for an activity. Amateurs engage in a pursuit on an unpaid basis, while professionals derive their income from it. But it is not enough to be remunerated for a service to be considered professional? A professional’s performance needs to meet a higher standard, regardless of remuneration, when compared to an amateur. - “A professional is someone who can do his best work when he doesn’t feel like it.” - Alistair Cooke, American journalist (19082004)

advantage in your orthopaedic practice. Dr. Ted Tufescu has kindly agreed to examine the role of Professional in this edition’s feature. Enjoy! – Ed.

Setting high standards is an important pillar of professionalism. For the medical professional, this can be deconstructed into a commitment to patients, to society, to one-self, and to the profession1. Commitment to individual patients comes naturally to us. Simply put, it means doing the best we can, each time, and for each individual patient, with their particular circumstances. However, putting individual patient care first, at all times, can lead to physician burnout. Striking the right balance between patient care and self-care, is an important consideration for a successful professional. Similarly, commitment to our society and to our profession are linked, and best discussed together. Our professional relationship with society is a social contract. On our end, we regulate our profession to best serve society, and in return, we expect society to put trust in us and to deliver the necessary resources we require to function. Commitment to Patients and to One-Self Commitment to the patient is best defined by the ethic of care2,3. The Royal College of Physicians and Surgeons of Canada (RCPSC) asks that we be attentive to the concepts of altruism, compassion and caring, moral and ethical behavior, integrity and honesty, and respect for diversity1. In other words, we need to put the patient first, be considerate of his or her circumstances, and manage our conflicts of interest. The RCPSC also speaks COA Bulletin ACO - Spring / Printemps 2018

Commitment to Society and the Profession Commitment to our patients and to our own well-being, is about balance. Similarly, making a strong commitment to society and to our profession is a two-way street. Government, taxpayers, stakeholder organizations, the media and others, all have expectations that influence our profession. In return, our profession provides services that impact not only individual patients, but also promote public health8. Health promotion is the process of enabling people to increase control over determinants of health, and thereby to improve their health9. Our professional association, the COA, has focused orthopaedic surgeons on countless important societal missions. A current example is the EDUCATE program, which empowers surgeons and allied health-care workers to deal with interpersonal violence, a problem that affects one in six women in our fracture clinics10. As we work toward licensure, we commit to professional standards. There are multiple exams throughout our training that test our ability, and along our career we are expected to continue to develop as medical experts and keep up to date by accessing regular educational opportunities. For example, the RCPSC has a Maintenance of Certification (MOC) program which all Fellows must both adhere to and comply with, in accordance with Article 6 of Royal College Bylaw No. 19. Fellows follow a five-year MOC cycle. To adhere to the MOC program, fellows must accumulate forty credits in each year of the cycle. To comply with the MOC program, fellows must accumulate

Training & Practice Management / Formation et gestion d’une pratique (continued from page 52)

400 credits in the entire five-year cycle, with 25 credits from each section. Failure to adhere to or comply with these requirements results in loss of the FRCSC designation. Without this kind of rigor within the profession, the delivery of health care suffers, and, in turn, society suffers.

5. Shanafelt T.D, Hasan O, Dyrbye L., et al. Changes in burnout and satisfaction with worklife balance in physicians and the general US working population between 2011 and 2014. Mayo Clin Proc 2015;90:1600-13.

6. Shanafelt T.D., Balch C.M., Bechamps The Social Contract and Society’s G., et al. Burnout and medical errors Responsibility among American surgeons. Ann Surg Our profession is linked to society 2010;251:995-1000. through a social contract. Our part is to maintain high professional standards, and 7. Balch C.M., Oreskovich M.R., Dyrbye L.N, to pursue strategies that improve health care et al. Personal consequences of malpractice lawfor our entire community. But, as we strive to suits on American surgeons. J Am Coll Surg remain accountable to our community, and 2011;213:657-67. to the profession, we can expect certain deliverables in return from society. We should be 8. Royal College of Pysicians and Surgeons of permitted to self-regulate our profession, a priviCanada. canMEDS Role: Professional. royalcollege. lege that has been bestowed on us thus far. This ca. Enabling Competencies 2.1,2.2. includes control over entrance into the proCopyright © 2015 fession, licensing, and standards for mainte9. The World Health Organization. Ottawa The Royal College of Physicians nance of licensure. Furthermore, we should Charter for Health Promotion. WHO, and Surgeons of Canada. be entrusted with clinical independence. Geneva,1986. This means that, as medical experts, we Reproduced with permission provide appropriate care, without influence 10. Intimate Partner Violence: What Canadian from bureaucratic or corporate bodies in our Orthopaedic Surgeons Need to Know!’ clinical decision making. Decreasing resources and increasingly (COA Spring Bulletin, 2017). complex management systems built for efficient delivery of health care, sometimes pose a threat to our clinical autonomy. This is a threat to the integrity of our profession and should Upcoming COA/CORS/CORA prompt us to remain vigilant. We must ask ourselves what Annual Meeting Dates more we can do to deliver appropriate care, but also what our government, and relevant stakeholders acting on behalf of Dates de la prochaine Réunion annuelle society, must do to help us sustain the high standards that we, as medical experts, have set. de l’ACO, de la SROC et de l’ACRO Conclusion In summary, the successful medical professional attends to patients first and foremost, while investing in her own wellbeing and longevity in the profession. Within our professional organizations, we must work to maintain high standards and foster strategies to promote the well-being of society. In return, we must maintain control over our profession and receive adequate resources to continue our mission. References 1. Royal College of Physicians and Surgeons of Canada. CanMEDS Role: Professional. 2. Canadian Medical Association Professionalism. 2005.



3. Royal College of Physicians and Surgeons of Canada. CanMEDS Role: Professional. Enabling Competencies 1.1-1.5. 4. Shanafelt T.D., Boone S., Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012;172:1377-85.


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


Combined with the 2nd ICORS Meeting June 19-22 juin CORA Meeting/Réunion de l’ACRO June 19 juin Montréal, QC COA Bulletin ACO - Spring / Printemps 2018


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


Online Videos: The Next Step in Surgical Education… or More Useless Videos on the Internet? William M. Weiss, M.D., MSc, FRCSC Associate Director of Research & Assistant Professor Texas Tech University HSC & William Beaumont US Army Medical Program El Paso, TX

What is Vumedi? umedi ( is an online educational platform intended for physicians and allied health professionals. It is essentially a video archive submitted by members, organized by subspecialty. The verification process for joining requires submission of a curriculum vitae which is used to verify that the potential member is indeed a practicing physician. It is free to join and there are no membership fees.


The goal of Vumedi is to provide an educational platform for physicians. Every subspecialty in orthopaedic surgery is represented, but content varies. There is also education on billing, legal, and business aspects of practice - but these are largely relevant to practicing in the United States. Other medical specialties are also represented. Vumedi occasionally hosts live events that members can attend online, and annually hosts “The Event” which provides an additional forum for small group discussions. There are no lectures or podium presentations at The Event, as the format is case discussions led by faculty that highlight learning objectives. CME credits can be obtained for attending live webinars and The Event. What Are the Benefits? Vumedi provides a virtual venue for physicians to learn from other physicians. Videos are not limited to surgical techniques, but also pertain to clinical presentation, physical examination, and advanced imaging. It allows exposure to rare pathology, complications, and advanced techniques not commonly encountered, facilitating discussion and insight on challenging diagnoses and techniques. Vumedi promotes physician discussion, both by public posts and private messages within the web site. Many prominent surgeons post lectures and surgical techniques for the purpose of education, making their expertise available to those who may not otherwise have access. Are There Potential Limitations? Any time case studies, clinical cohorts, or surgical images are shared, there is potential and concern for violation of the Health Insurance Portability and Accountability Act (HIPAA). Vumedi states that, according to HIPAA, surgical videos or images in which the patient cannot be identified can be shared. If the patient is identifiable, then patient permission must be obtained. The FAQ section of the Vumedi web site contains a link to the relevant portions of HIPAA for review. While Vumedi is compliant with HIPAA, this may not be in accordance with individual hospital or corporation policy. COA Bulletin ACO - Spring / Printemps 2018

The rights to videos posted on Vumedi are maintained by the individual who posts the content, and can be removed at any time. The primary limitation of Vumedi is that the content diversity and quality are entirely dependent on the community of users. There is potential bias in what is presented based on the opinions of those posting, and there are subspecialty areas where limited content is available. Who Uses It? Vumedi states there are more than 200 000 physician members worldwide. My Thoughts? Vumedi is a useful tool for review, particularly for exposure to new surgical techniques. Many prominent surgeons have posted operative cases providing instruction for those who may not have the opportunity to learn from them directly. This is obviously not as effective as “one on one” or hands-on teaching, but does provide exposure and instruction that may not be otherwise possible. Notable limitations of Vumedi include: content is limited by what is uploaded to the platform, and the opinions of those posting may bias the presentation of controversial topics. It remains up to the individual physician to critically evaluate the quality and safety of the information presented. Concerns for violation of patient privacy remain. Although Vumedi is compliant with HIPPA, posting physicians should ensure that it is also in line with the policies of their hospital or corporation.

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

Hip Conditions in the Young Adult: A Practical Course May 26, 2018

Course Chair

Dr. Olufemi Ayeni MD, PhD, FRCSC Director of Sports Medicine Research Program Associate Professor McMaster University


White Oaks Conference Centre Niagara on the Lake Ontario, Canada

Keynote Speaker

Dr. Paul Beaulé MD, FRCSC

Course Fees Physician - $250

(Includes chiropractors, naturopaths, etc.)

Allied Health Professional – $150 (Includes physiotherapists, occupational therapists, etc.)

Trainee - $125 (Includes fellows, residents, medical students, etc.)

Learning Objectives By the end of the program, registrants will: • Have a comprehensive understanding of hip imaging and diagnostic techniques • Familiarize themselves with strategies that enable thedevelopment of clinical practice that involves the management of hip conditions • Develop an understanding of appropriate use of non-operative interventions and strategies from allied health professionals • Acquire an understanding of how to formulate a management plan for hip disorders and further their knowledge in hip arthroscopy and other surgical procedures • Acquire an understanding of current research initiatives in the field of hip arthroscopy and possibilities for collaboration

Current Trends in Orthopaedics Loire Valley France, May 20-26, 2018 www. COA Bulletin ACO - Spring / Printemps 2018


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