COA Bulletin #107 Winter 2014 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Winter / Hiver 2014 Publication Mail Envoi Poste-publication Convention #40026541 4150 O. Ste-Catherine W., Suite 450 Westmount QC H3Z 2Y5

BULLETIN

107

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

Are We Ready to Share Resources?

locums aren’t the solution to underemployment...... 6

Sommes-nous prêts à partager les ressources?

Les suppléances ne sont pas la solution au sous-emploi........... 8

Critical Appraisal of the Literature: Systematic Reviews and Meta-Analyses ��9 The Impact of Osteoporosis Initiatives Over the Past Decade ��17 Prix J.-Édouard-Samson 2014 - Reconnaissance des travaux sur le rachis du Dr Brian Kwon ��27

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For more information or to contact a Sanofi representative please call 1-888-333-0506 Important Treatment Considerations Synvisc®/Synvisc-One® (hylan G-F 20) is for intra-articular injection to treat pain associated with osteoarthritis of the knee. Synvisc®/Synvisc-One® contains small amounts of avian protein and should not be used in patients with related hypersensitivities. Adverse events involving the injected knee after intra-articular injections of Synvisc®/Synvisc-One® may include: transient pain and/or swelling and/or effusion. The post marketing experience has identified the following systemic events to occur rarely with Synvisc®/Synvisc-One® administration: rash, hives, itching, fever, nausea, headache, dizziness, chills, muscle cramps, paresthesia, peripheral oedema, malaise, respiratory difficulties, flushing and facial swelling. If venous or lymphatic stasis is present, Synvisc®/Synvisc-One® should not be injected into the knee. Synvisc®/Synvisc-One® should not be used in infected or inflamed knees or in patients having skin diseases or infections in the area of the injection site. References: 1. Synvisc/Synvisc One Product Monographs, Genzyme Canada Inc., July 18, 2008/March 2, 2009. 2. Wobig M, et al. Viscosupplementation with Hylan G-F 20: A 26-Week Controlled Trial of Efficacy and Safety in the Osteoarthritic Knee. Clinical Therapeutics.1998; 20:410-423. 3. Chevalier X, Jerosch J, Goupille P, et al. Single, intra-articular treatment with 6 ml hylan G-F 20 in patients with symptomatic primary osteoarthritis of the knee: a randomised, multicentre, double-blind, placebo controlled trial. Ann Rheum Dis. 2010; 69:113-119. 4. Raynauld JP, et al. Effectiveness and safety of repeat courses of hylan G-F 20 in patients with knee osteoarthritis. OsteoArthritis and Cartilage. 2005; 13:111-119. 5. Huskin JP, et al. Multicentre, prospective, open study to evaluate the safety and efficacy of hylan G-F 20 in knee osteoarthritis subjects presenting with pain following arthroscopic meniscectomy. Knee Surg Sports Traumatol. 2008; 16:747-752. 6. Waddell DD, et al. Total Knee Replacement Delayed With Hylan G-F 20 Use in Patients With Grade IV Osteoarthritis. Journal of Managed Care Pharmacy. 2007; 2(13):113-121. 7. Marshall KW, et al. Amelioration of Disease Severity by Intra-articular Hylan Therapy in Bilateral Canine Osteoarthritis. Journal of Orthopaedic Research. 2000; 18:416-425. 8. Li P, et al. Osteoarthritis Cartilage. 2012; 20(11):1336-1346. 9. Wang Y, et al. BMC Musculoskelet Disord. 2001; 12 :195.

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Message Bulletin Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 107 Winter / Hiver 2014 COA / ACO Dr. Bas Masri President / Président Dr. John Antoniou Secretary / Secrétaire Mr. Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4150 Ouest, rue Sainte-Catherine West Suite 450, Westmount, QC H3Z 2Y5 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Dr. Marc Isler Editor-in-Chief / Rédacteur en chef Dr. Peter Lapner Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Dr. Nicholas Newman Proof reader / Correcteur d’épreuves Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page CL Graphique Inc. Printer / Imprimeur Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www.orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

COA Bulletin ACO, Winter / Hiver 2014

The President’s message and, occasionally, other important news for the COA membership will be carried beneath.

Le mot du président, et parfois d’autres nouvelles importantes pour les membres de l’ACO, apparaîtront ci-dessous.

Are We Ready to Share Resources?

locums aren’t the solution to underemployment Bas A. Masri, M.D., FRCSC President, Canadian Orthopaedic Association

anada faces an unprecedented oversupply of orthopaedic graduates, many of whom can only find precarious work as locum tenens or are forced to look for work offshore. Many factors contribute to the situation. Chief among them, though, are austerity measures initiated by provincial health ministries that have effectively cancelled a projected expansion of orthopaedic resources in particular, and human health resources in general. It’s not as if Canada does not need these new surgeons. Demand is greater than ever. Indeed, early in the last decade, governments and universities went to a great deal of trouble and expense to increase orthopaedic residency positions by about 90%. The talented young men and women recruited to fill those spaces are now for the most part facing very real struggles, often working as itinerant contract trauma surgeons covering call for established surgeons or doing serial fellowships until conditions change. Eventually, a number of these young surgeons find their niche, often by chance, because generational turnover opens up existing positions at just the right moment. Such underemployment; however, is a systemic problem that will take years to resolve after many rounds of delicate negotiations to reduce the number of residencies to sustainable levels. It’s a painful predicament. These long-term market forces may be mostly beyond the Canadian Orthopaedic Association’s control, but how our profession responds in the meantime to this difficult situation is. I propose a return to an old-fashioned virtue: teamwork. By this, I don’t mean a group of individual surgeons who like to work together because their personalities are compatible and their skills are complementary — although that seems a minimum for team-building. I believe something more formal is needed, where the team practice is delineated in detail so that roles and responsibilities are clear and transparent, where there is a forward-looking strategic plan to nurture the practice and the profession, and where patient-centred care trumps all other considerations. Locums have become a type of “grey market” for unemployed orthopaedic surgeons, allowing some established surgeons to divest themselves of their emergency call obligaThe Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450, Westmount, Quebec, H3Z 2Y5. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450 Westmount, Quebec, H3Z 2Y5 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

Le Bulletin de l’Association Canadienne d’Orthopédie est publié au printemps, été, automne, hiver par l’Association Canadienne d’Orthopédie, 4150, rue Ste-Catherine Ouest, Suite 450, Westmount, Québec H3Z 2Y5. Le Bulletin est distribué aux memb res 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 : l’Association Canadienne d’Orthopédie, 4150, rue Ste-Catherine Ouest, Bureau 450, Westmount, Québec H3Z 2Y5 À moins que le contraire ne soit spécifié, les opinions exprimées dans cette revue sont celles de leur auteur et ne reflètent aucune ment un endossement ni une position de l’Association Canadienne d’Orthopédie. Dépot légal : Bibliothèque nationale du Canada ISSN 0832-0128

(continued from page 6)

Contents / Sommaire Message . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Info . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9 Forum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 14 Themes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17 Foundation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 25 In Futurum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29 Advertisers Sanofi . . . . . . . . . . . . . . . . . . . . . . . . . . . . Cov./Couv. 2 Wright Medical . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Stryker . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4, 32 MicroPort . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Exactech . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Vitality Depot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28 Smith & Nephew . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Biomet Canada Inc. . . . . . . . . . . . . . . . . . Cov./Couv. 4

tions. One can argue that trauma call is the only regular work available and graduates should count their blessings, but there are some serious flaws in this line of thinking. Never mind the loss of subspecialty skills, the potential for abuse is obvious, since contract workers have no say in how the work is meted out. Also, their careers can be at risk if something should go wrong and patient hand-over protocols are not as rigorous as they should be. Even more concerning, does “remote management” of an emergency trauma patient by an established surgeon through a contract worker compromise optimal outcomes? It’s hard to imagine how these types of locums are an example of best practices. I believe we need to return to the traditional locum tenens, where the “placeholder” substitutes for a brief amount of time, covering both elective and call work. If a practice has real concerns about the amount of trauma call obligation they need to fulfill, then the team should consider hiring an orthopaedic surgeon with an interest in trauma. Let’s give some real work to these young surgeons who have had a steady diet of trauma, and while we are at it, let’s argue for resources to look after injured patients during day-time hours, which will positively impact the surgeons delivering trauma care, and will improve outcomes for patients. At the heart of the underemployment/unemployment crisis lies an existential question: Are surgeons willing to share some of their closely guarded resources with a new generation of surgeons who have no access to new resources? Can we change the models of practice to allow intergenerational practice integration in a manner different from what we have done for decades? I personally see these challenges as an opportunity for a positive change and ultimately for the continued growth and success of the profession.

Right from the Start. C E L E B R AT I N G

YEARS

n SCAPULAR NOTCHING We knew scapular notching was a design problem—but it didn’t have to be. That’s why we developed the Equinoxe® system. An eight center study found a notching rate of just 13.2%, with 0 notches with grades >2, using the Equinoxe reverse shoulder prosthesis.1 These are the results of the cited study. Individual results may vary.

Nine years of clinical use and 34 peer-reviewed studies prove we had it right from the start. view the research www.exac.com/equinoxestudies

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COA Bulletin ACO, Winter / Hiver 2014

Sommes-nous prêts à partager les ressources? Les suppléances ne sont pas la solution au sous-emploi Bas A. Masri, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

e Canada est confronté à un surplus sans précédent de jeunes orthopédistes, dont bon nombre doivent se contenter d’un travail précaire comme suppléant ou chercher du travail à l’étranger. De nombreux facteurs contribuent à la situation, principalement les mesures d’austérité imposées par les ministères provinciaux de la Santé, qui sont venues annuler l’expansion prévue des ressources en orthopédie, mais aussi en santé en général. Ce n’est pas que le Canada peut se passer de ces nouveaux orthopédistes : la demande est plus forte que jamais. En effet, au début de la dernière décennie, les gouvernements et universités ont investi énormément de temps et d’argent afin d’augmenter le nombre de résidences d’environ 90 %. Et la plupart des jeunes hommes et femmes de talent recrutés dans la foulée de ces efforts sont aujourd’hui confrontés à des difficultés bien réelles : ils doivent souvent passer d’un contrat en traumatologie à l’autre, effectuer le temps de garde d’orthopédistes établis ou enchaîner les formations spécialisées en attendant que les choses changent. Éventuellement, une partie de ces jeunes orthopédistes trouvent leur place, souvent à la suite d’un coup de chance, lorsque des postes se libèrent juste au bon moment en raison des départs à la retraite. Un tel taux de sous-emploi constitue cependant un problème systémique qu’on mettra des années à régler, après de nombreuses séances de négociations épineuses en vue de ramener le nombre de résidences à un niveau viable. La situation est vraiment malencontreuse.

« Il nous faut, je crois, quelque chose de plus officiel : les activités de l’équipe devraient être détaillées, de sorte que les rôles et responsabilités soient clairs et transparents; un plan stratégique tourné vers l’avenir devrait nourrir l’exercice et la profession; et les soins axés sur le patient devraient prévaloir sur toutes les autres considérations. »

L’Association Canadienne d’Orthopédie n’a généralement aucun contrôle sur l’offre et la demande à long terme; elle en a toutefois sur la réaction de la communauté orthopédique à ces circonstances difficiles. Je propose que l’on revienne à une de nos bonnes vieilles vertus : l’esprit d’équipe. Et je ne parle pas d’un groupe d’orthopédistes qui aiment travailler ensemble parce qu’ils ont des personnalités compatibles et des compétences complémentaires, même si cela semble un minimum pour favoriser l’esprit d’équipe. 8

COA Bulletin ACO, Winter / Hiver 2014

Les suppléances sont en quelque sorte devenues un « marché gris » pour les orthopédistes au chômage, permettant à certains orthopédistes établis de se décharger de leurs obligations en matière de temps de garde. On peut arguer que le temps de garde en traumatologie est le seul travail régulier disponible et que les jeunes orthopédistes devraient s’estimer heureux d’en faire, mais ce raisonnement présente de grandes failles. Au-delà de la perte des compétences spécialisées, les risques d’abus sont évidents, puisque les travailleurs contractuels n’ont pas leur mot à dire sur la répartition du travail. De plus, leur carrière peut être compromise si quelque chose tourne mal et si les protocoles de transfert des soins ne sont pas aussi stricts qu’ils le devraient. Plus préoccupant encore, la gestion « à distance » d’un patient en traumatologie par un orthopédiste établi, en passant par un travailleur contractuel, peutelle compromettre les résultats pour le patient? On peine à s’imaginer en quoi ces suppléances pourraient constituer des pratiques exemplaires. Je crois qu’il faut revenir à la notion traditionnelle de suppléance, c’est-à-dire un remplacement de courte durée, tant pour le temps de garde que pour les soins électifs. Et si une équipe a vraiment du mal à remplir ses obligations relatives au temps de garde en traumatologie, elle devrait envisager l’embauche d’un orthopédiste qui s’intéresse à la traumatologie. Donnons du vrai travail à ces jeunes orthopédistes abonnés à la traumatologie et, tant qu’à y être, demandons des ressources pour veiller sur les blessés le jour, ce qui aurait une incidence positive sur les orthopédistes assurant la prestation des soins traumatologiques, en plus d’améliorer les résultats pour les patients. Une question existentielle est au cœur de cette crise du sous-emploi et du chômage : les orthopédistes sont-ils prêts à partager une part de leurs précieuses ressources avec une nouvelle génération d’orthopédistes pour qui on n’en débloque pas de nouvelles? Pouvons-nous changer les modèles d’exercice de sorte à intégrer les générations autrement que nous le faisons depuis des décennies?

Personnellement, je vois ces défis comme une occasion d’instaurer des changements positifs et, au bout du compte, d’assurer la croissance et la réussite au sein de notre profession.

Info Facts, figures, finance and other general themes.

Section des faits et chiffres intéressants ainsi que d’autres thèmes généraux.

Critical Appraisal of the Literature: Systematic Reviews and Meta-analyses Akshay Seth M.D., MScPT Darren M. Roffey PhD 1,2 Eugene K. Wai M.D., MSc, FRCSC, Associate Professor 1 2

Division of Orthopedic Surgery, Faculty of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON 2 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON 1

The ‘why’ and ‘what’ of systematic reviews s the volume of orthopaedic literature expands, surgeons are challenged to remain at the forefront of their fields. Interpreting the data required to stay up-to-date is complicated by studies with conflicting results or flawed methodologies. Systematic reviews and meta-analyses make interpreting the influx of new information more user-friendly by summarizing relevant individual studies while aiming to limit bias and random error1,2.

A systematic review uses an explicit, pre-determined scientific methodology to review, appraise and summarize the literature on a specific clinical question1. A meta-analysis can be thought of as a quantitative systematic review, in which statistical techniques are used to synthesize the results of multiple primary investigations2. High-quality systematic reviews are considered to be Level I evidence and can play a significant role in developing policy, clinical decision-making and guiding further research3. However, poor-quality systematic reviews can be misleading and cause confusion in making patientcare decisions.

based on expert opinion is unlikely to follow an evidence-based methodology, and may actually be representative of a narrative literature review that is at an increased risk of bias4. Other sources of bias can also be introduced through poor-quality trials (i.e. the “garbage in, garbage out” concept), heterogeneity of the primary investigations, or publication bias4. In a well-designed systematic review, each respective source of bias can be identified and minimized through critical appraisal, appropriate subgroup analysis and a well-designed literature search. By being aware of the potential sources of bias, surgeons can more easily differentiate between high and low-quality reviews. How are high-quality systematic reviews designed? Reporting checklists are designed to help authors produce highquality systematic reviews and meta-analyses. These checklists ensure a combination of methodological rigour and complete and transparent reporting. PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) is a reporting checklist designed for systematic reviews and meta-analyses of RCTs. It consists of a 27-item checklist and flow diagram that ensures the reader has access to structured information about the reviewed articles and the flow of information throughout the review process5. MOOSE (Meta-analysis of Observational Studies in Epidemiology) is a similar checklist designed for systematic reviews and meta-analyses of observational studies6. With many journals now endorsing (and even requiring) the utilization of such checklists, surgeons should look for reviews that follow these structured approaches and likely contain more reliable results.

Systematic reviews and meta-analyses make interpreting the influx of new information more user-friendly by summarizing relevant individual studies while aiming to limit bias and random error.

Although randomized, allocation-concealed, double-blind placebo-controlled trials (RCTs) are the gold standard in research and guide the outcomes of many systematic reviews, they are generally not applicable in surgical-based studies. Interpretation of a systematic review in the orthopaedic field needs to take this into consideration. In this article we hope to provide surgeons with an understanding of how to identify high-quality systematic reviews and meta-analyses that can influence clinical practice.

Pitfalls and perils of systematic reviews Despite their esteemed status, systematic reviews and metaanalyses are susceptible to bias that can impact the validity of the results. A review with a broad clinical question or conclusions

Evaluating the quality of a systematic review Critical appraisal checklists such as the AMSTAR (A MeaSurement Tool to Assess systematic Reviews) are available to evaluate the validity of the results presented in systematic reviews. AMSTAR is an 11-item checklist that assesses the methodological quality of systematic reviews and meta-analyses which include RCTs7. The AMSTAR checklist focuses on whether the research question was addressed through the appropriate identification, appraisal, synthesis and reporting of primary investigations – including an assessment of the heterogeneity of the results, which is important in orthopaedic studies where various outcome measures, surgical techniques and diagnoses are pooled to increase the data in the review. When heterogeneity is reported, the reader should look for the inclusion of subgroup analyses; consistency COA Bulletin ACO, Winter / Hiver 2014

(continued from page 9)

of results across subgroup analyses and multiple studies should be prioritized.

4. Yuan Y., Hunt R. Systematic reviews: The good, the bad and the ugly. Am J Gastroenterol 2009;104:1086-1092.

Furthermore, the GRADE (Grading of Recommendations Assessment, Development and Evaluation) framework is designed to present evidence summary tables for systematic reviews so that the estimate of effect or association can be scrutinized in relation to the quantity of specific interest8. GRADE is now widely implemented by organizations such as the World Health Organization, Agency for Healthcare Research and Quality, and National Institute of Health and Care Excellence.

5. Moher D., Liberati A., Tetzlaff J., Altman D.G., The PRISMA Group (2009). Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. BMJ 2009;339:b2535.

In conjunction with the AMSTAR checklist and the GRADE framework, surgeons can effectively and efficiently identify the strengths and weaknesses of a systematic review, which is necessary for evaluating the validity of the results and the overall outcomes, and whether they are applicable to clinical decisionmaking. The influence of systematic reviews The Cochrane Collaboration produces systematic reviews and meta-analyses that reliably assemble large volumes of information to answer specific clinical questions or estimate effect sizes more precisely than individual investigations. As a result, Cochrane systematic reviews often play an integral role in designing future studies, applying for research funding or establishing clinical practice guidelines. For example: the Cochrane Review on the prevention of falls, first published in 19979 and last updated in 201210, has been used to inform the UK’s National Institute for Clinical Excellence 2004 guideline on the prevention of falls in older people11, the Australian Commission on Safety and Quality in Health Care’s 2009 fall prevention guidelines for the community, hospitals, and residential aged care facilities12, and the American Geriatrics Society/British Geriatrics Society 2010 guideline for prevention of falls in older persons13. As the quantity and quality of primary research in orthopaedics increases, the need for systematic reviews and meta-analyses will similarly grow. Being able to critically appraise systematic reviews and appropriately apply their results to individual clinical practice will become increasingly important for orthopaedic surgeons. References 1. Systematic Reviews: CRD’s guidance for undertaking reviews in health care. Centre for Reviews and Dissemination, University of York, 2008. 2. Bhandari M., Robioneck B. Advanced concepts in surgical research. New York: Thieme Publishing Group, 2009. 3. OCEBM Levels of Evidence Working Group. The Oxford 2011 Levels of Evidence. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o=5653 [Last accessed 3 January 2015].

COA Bulletin ACO, Winter / Hiver 2014

6. Stroup D.F., Berlin J.A., Morton S.C., Olkin I., Williamson G.D., Rennie D., Moher D., Becker B.J., Sipe T.A., Thacker S.B. Meta-analysis of observational studies in epidemiology: a proposal for reporting. Meta-analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000;283(15):200812. 7. Shea B.J., Grimshaw J.M., Wells G.A., Boers M., Andersson N., Hamel C., Porter A.C., Tugwell P., Moher D., Bouter L.M. Development of AMSTAR: a measurement tool to assess the methodological quality of systematic reviews. BMC Med Res Methodol 2007;7:10-16. 8. Guyatt G.H., Oxman A.D., Schünemann H.J., Tugwell P., Knotterus A. GRADE guidelines: a new series of articles in the Journal of Clinical Epidemiology. J Clin Epidemiol 2011;64:380382. 9. Gillespie L.D., Gillespie W.J., Cumming R., Lamb S., Rowe B.H. Interventions for preventing falls in the elderly (Cochrane Review). The Cochrane Library 1997, Issue 4. Oxford: Updated Software. 10. Gillespie L.D., Robertson M.C., Gillespie W.J., Sherrington C., Gates S., Clemson L.M., Lamb S.E. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;9:CD007146. 11. National Collaborating Centre for Nursing and Supportive Care (UK). Clinical Practice Guideline for the Assessment and Prevention of Falls in Older People. London: Royal College of Nursing (UK); 2004 Nov. (NICE Clinical Guidelines, No. 21.) 12. Australian Commission on Safety and Quality in Health Care. Falls prevention guidelines. www.safetyandquality.gov. au/our-work/falls-prevention/. [Last accessed 3 January 2015]. 13. Panel on Prevention of Falls in Older Persons, American Geriatrics Society, British Geriatrics Society. Summary of the updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc 2011;59(1):148-57.

Between Carrot and Stick the soft power of a nudge Doug Thomson CEO, Canadian Orthopaedic Association

principle to guide that individual: libertarian paternalism.

This latter concept may at first seem paradoxical, but it resonated for me as a way of describing the governing ethos underlying the COA and other professional associations. Here’s what the authors have to say: “The libertarian aspect of our strategies lies in the straightforward insistence that, in general, people should be free to opt out of undesirable arrangements if they want to do so.…The paternalistic aspect lies in the claim that it is legitimate for choice architects to try to influence people’s behaviour in order to make their lives longer, healthier, and better.… Libertarian paternalism is a relatively weak, soft, and non-intrusive type of paternalism because choices are not blocked, fenced off, or significantly burdened.” Similarly, it could be said, the COA can develop policies and positions that can inform and influence our members, but we cannot compel them to conform. The decision is theirs, which brings us to the notion of a choice architect.

ehavioural research seems to confirm what we intuitively already know – that we, humans, are a contrarian and fickle bunch. We resist change because we’re averse to losing what we already have. The hurt of loss, even if there’s a net benefit to a transaction, is greater than the pleasure of acquisition. Yet, despite this native resistance, we are easily influenced by the words and actions of others, especially if framed in a forceful and consistent manner. Recent events, if not rhetoric, can often greatly affect our judgement and subsequent actions. And lest we think our judgement is above reproach. Studies regularly find that up to 90% of drivers consider their performance behind the wheel to be well above-average. We’re also unrealistically optimistic about the future. How else to explain why a Leaf fan like myself still earnestly hopes for a Stanley Cup win this year? And while we may all think of ourselves as rugged individualists, we are more likely to conform to the perceived group consensus if we know that our comments will be attributed. Given these and many other foibles of human nature, it’s a wonder we can convince anybody to do anything. Carrot and stick seem to be the universally accepted modes of moving things forward, as exemplified by the black arts of marketing and politics. But surely there must be a middle way between reward and punishment, security and fear – a type of soft power that’s less coercive. And it seems there might be. In 2008, “Nudge – Improving Decisions About Health, Wealth, and Happiness,” became a global publishing phenomenon, enjoyed its moment of fame as a social-policy prescriptive, and continues today as a field of inquiry through academic research, a web site and blogs. But I confess it wasn’t until last summer, at the Montreal Annual Meeting, that I became aware of “Nudge” and its ideas. On my way to a meeting, I briefly stopped in for a presentation by Prof. Boaz Keysar of the University of Chicago, called “Small Change, Big Impact: The Science of Influence.” I stayed long enough to be intrigued by what he had to say, since it was such a fresh perspective, and jotted down a title, “Nudge,” and its co-authors, Profs. Richard H. Thaler and Cass R. Sunstein. Then I had to go. It turns out that Thaler is the director of the Centre for Decision Research at the University of Chicago’s Booth School of Business, and the co-director of the Behavioural Economics Project at the federal National Bureau of Economic Research. While Sunstein is the founder and director of the Program on Behavioural Economics and Public Policy at Harvard Law School, and served between 2009 and 2012 as the Administrator of the White House Office of Information and Regulatory Affairs. Now, months later, I’ve read the book, and I’m a believer of sorts. Among much else, Thaler and Sunstein have come up with a novel agent of change – the choice architect – and an ethical

Thaler and Sunstein note that much of their approach is based on four decades of research in the emerging science of choice, which “has raised serious questions about the rationality of many judgments and decisions that people make.” It’s not so much the decision-makers’ fault, many times it’s the sloppy or devious way the choices are presented. Indeed, if we are to accord individuals the freedom to voluntarily opt out, even when it’s not in their best interests to do so, then we need to be much more meticulous – not to mention, ethical – in crafting the choices presented to decision-makers. It’s up to the choice architect, say the authors, to create an environment for decision-making that moves people in directions that will improve their lives. That’s a fairly tall order, and a choice architect’s lot is not an easy one. Thaler and Sunstein devote a good number of pages outlining how our behavioural tendencies and innate preference for not making hard decisions lead us to a comfortable do-nothing default position or to sound-bites rather than complicated reasoning. We are all too human, it seems, but choice architects must take this in their stride: “Choosers are human, so designers should make life as easy as possible. Send reminders, and then try to minimize the costs imposed on those who, despite your (and their) best efforts, space out.” So what qualifies as a nudge? A nudge is any facet of choice architecture that changes, in a desired fashion, how people behave – and it must do so while being easy and cheap to avoid. No carrot. No stick. No power to command. For example, in the battle to promote healthy eating, displaying fruit at eye-level counts as a nudge; banning junk food doesn’t.

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There are many ideas and case histories in the book, and more available at the Nudge web site (www.nudges.org). My favourite idea from the book is also the authors’ favorite, a software utility (alas, yet to be invented) that acts as a civility check on e-mails. In these parlous times, it’s all too easy to send an angry e-mail in the heat of the moment and then in very short order come to deeply regret clicking “send.” The Civility Check utility would scan a person’s outgoing e-mail for words and phrases that could cause offense and then post a warning if it detects heated language: “This appears to be an uncivil e-mail. This will not be sent unless you ask to resend in 24 hours.” It wouldn’t be a “retrieve” button, but the next best thing. And perhaps being shamed by a computer would lead to more tempered outlook on life.

cates, was to turn the steps into a piano keyboard, complete with minor keys. Stair use increased by 66%, and as the video attests, fun was had by all. The escalator is noticeably empty.

Another great idea is RECAP (Record, Evaluate, and Compare Alternative Prices), which would impose a mild form of government regulation on complex pricing schemes such as credit cards, mortgages and cell-phone plans. The government wouldn’t regulate how much institutions and corporations could charge for services, but it would regulate their disclosure practices and provide information to customers on all the different existing fees. Along with fee disclosure, service providers would be required to send to their customers’ annual usage disclosures on all the different fees incurred. Thaler and Sunstein say the best way to help people “improve their performance is to provide feedback. Well-designed systems tell people when they are doing well and when they are making mistakes.”

Bookstore shelves are crammed with business titles, telling you how to get to ‘yes’, or to lean in, or to use naked statistics or to focus, because it’s the hidden driver of excellence. And there are more than a few books on decision theory. What sets “Nudge” apart is the authors’ evident fondness for the human species, with all our quirky impulses and rationalized beliefs. Part of the fun is that we can recognize ourselves. And when you get into their chapters on wealth, health and happiness, many of the ideas are imaginative and inspiring. There’s a real sense of the “Yes, we can” optimism that was briefly the prevailing mood in 2008.

For a real-life example of a playful nudge, check out the “Piano Stairs” on YouTube. At the Odenplan subway station in Stockholm, commuters were creating a traffic bottleneck by choosing a long escalator instead of a neighboring flight of stairs. The choice architects on this project worked from the premise that the easiest way to change people’s behaviour for the better is by making it fun to do (www.thefuntheory.com). Their solution, as the video title indi-

All this may seem quite removed from our circumscribed world of orthopaedics, but making difficult decisions with far-reaching consequences for the profession is the essence of the Association’s mandate. Thaler and Sunstein note that “people may most need a good nudge for choices that have delayed effects; those that are difficult, infrequent, and offer poor feedback; and those for which the relation between choice and experience is ambiguous.” This sounds eerily like some of the complex issues that the COA must face.

Simple decisions are so much a part of our daily lives, we barely notice the choice architecture underneath that guides us along. That may work for going to Timmies, but the more complicated issues of professional life probably could do with the skills of a choice architect. The answers to seemingly intractable problems usually come from innovation, and choice architecture seems to improve the odds for inventiveness. When push comes to shove, maybe a nudge will do.

Implementing an injury prevention program in youth soccer using the FIFA 11+ program Matt Greenwood, Ontario Soccer Association Rhona McGlasson, Executive Director, Bone & Joint Canada

n April 2014, Bone and Joint Canada in conjunction with the Ontario Soccer Association, received funding through the Ontario Trillium Foundation to implement the FIFA 11+ injury prevention program. This program is a warm-up dynamic exercise program that has been shown to reduce knee and ankle injuries in youth soccer by up to 46% in soccer clubs. The program is being implemented across Ontario as a pilot program to assist in the creation of an appropriate national strategy. Participation in sports has been shown to have many health benefits. However, for many athletes there is also a downside: injury. In health care, emergency departments, physician’s offices and clinics see the influx of athletes that have sustained a musculoskeletal injury through participation in sport that requires consul12

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tation and treatment. Soccer is one of the leading sports contributing to injury rates in Canadian youth (ages 11-18), and it accounts for greater than 10% of all sport injuries requiring medical attention1. Injuries are in the lower extremity, with ankle injuries the most common, followed by knee and groin/thigh injuries3,4. On a short-term basis the consequences for injured athletes is pain and a period of disability which leads to a reduction in participation in sport. For some less fortunate athletes, injury can also lead to long-term consequences such as osteoarthritis. These athletes will need additional interventions within the health-care sector including the potential need of a future joint replacement. With such significant lifelong consequences, injury prevention in soccer is critical.

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Athlete development and injury prevention Within soccer, FIFA have developed an injury prevention program that has been shown to reduce injury rates by up to 46%. It is a 20-minute warm-up program that includes 15 exercises and is completed twice a week. These exercises are all provided on the FIFA web site at http://f-marc.com/11plus/home/. They are divided into three sets of exercises: Part 1: Running Part 2 Strength and plyometrics Part 3: Running

Implementing the FIFA 11+ The Ontario strategy was developed to address the findings of a survey which was completed by coaches in Ontario in the spring of 2014 and identified that 55% were unaware of the FIFA 11+ program. The pilot project was therefore established using a grass roots marketing strategy to build awareness and interest in the soccer community and to assist clubs in adoption of the program. This program was launched in April 2014 and has undertaken coordinated communication and training activities focused on educating grassroots soccer coaches on the exercises so they are familiar and

Coaches are extremely familiar with the running exercises; however, they often have less experience with the strengthening and plyometric program in Part 2. These exercises establish the fundamental strength and agility for the players to be successful with the physical activity required in soccer. There are four components to these exercises: 1) core strength, which is foundational to all physical activity; 2) eccentric hamstring strength; 3) jumping and landing with good technique and 4) keeping the knee over the toes in all movement especially when changing direction. Across Canada, there is growing interest in implementing the FIFA 11+ as part of a long-term athlete development model. The long-term player development philosophy is a new approach to providing training for athletes which offers a framework for training children and youth that includes: Active Start (3-6 years), FUNdamentals (6–8/9), Learning to Train (girls 8–11, boys 9–12), Training to Train (girls 11–15, boys 12–16), Training to Compete (girls 15–21, boys 16–23), Training to Win (girls 18+, boys 19+). This model was developed by Sport Canada, Canadian Sport 4 Life and all sports in Canada are making changes with their respective coaching programs to align. While there are many components to this model, the Ontario Soccer Association has gained a reputation for its dynamic progress including the creation of a high-performance league (Ontario Player Development League) which was introduced in 2014. This has been implemented in 18 clubs and has changed the way that clubs function including both how coaching is provided as well as increasing the programming in physical conditioning including injury prevention and return to sports.

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comfortable in the supervision of their athletes. Training sessions have been held across Ontario that have included both the soccer coaches as well as health-care professionals including physiotherapists, chiropractors, athletic therapists and kinesiologists who work directly with the teams on the field or in the management of injured athletes. Players and parents are key stakeholders and need to be familiar with the program so that they understand the importance of injury prevention for lifelong participation in sport and recreation. The selling point to club technical staff is obvious – better prepared athletes mean less time in hospital and doctors’ waiting rooms and more time on the field participating in the sport they love. By January 2015, 38 clubs across the province had undertaken activities to implement the FIFA 11+ program demonstrating the commitment of soccer professionals to reducing injury rates. Reinforcing injury prevention to athletes is also a key component of this strategy. Injured athletes provide a reality to coaches and their teammates on the impact of injuries to both the athlete and team morale. The FIFA 11+ program, including the exercises and the manual are available on the web site http://f-marc.com/11plus/home/. Promotion tools including posters and tear off pads are available for free through the Canadian Orthopaedic Foundation by e-mailing soccer–injury@canorth.org. All health-care professionals including emergency departments, surgeons, clinics and rehabilitation setting are encouraged to use these materials to support the awareness and implementation of the program. The overall goal of the implementation of the FIFA 11+ program is to reduce the injury rates in Ontario and eventually across Canada. This can be achieved through a coordinated approach where health-care and soccer professionals align with a focus on reducing the injury rates and stopping our youth from suffering through the pain and disability of injury.

Forum

In this section, we introduce subjects for reflection and debate by asking orthopaedic surgeons, researchers and other professionals to express their opinions on topics of which they are particularly knowledgeable.

For further information about the FIFA 11+ program or ongoing strategies to promote program implementation, please contact Rhona McGlasson at Rhona.McGlasson@bell.net References 1. Emery C.A., Meeuwisse W.H., McAllister J.R. Survey of sport participation and sport injury in Calgary and area high schools. Clin J Sport Med 2006;16:20-26. 2. Emery C.A., Tyreman H. Sport Participation, Sport Injury, Risk Factors and Sport Safety Practices in Calgary and area Junior High Schools. Paediatric and Child Health 2009 14(7) 439444. 3. Emery C.A., Meeuwisse W.H. A comparison of risk factors for injury in indoor and outdoor soccer. Am J Sport Med 2006;34:1636-1642 4. Emery C.A., Meeuwisse W.H. Risk factors for injury in indoor compared with outdoor adolescent soccer. Am J Sports Med 2006;34:1636-1642.

Vous trouverez sous cette rubrique des sujets de discussions et de débats écrits par des orthopédistes, des personnes impliquées dans la recherche et d’autres professionnels sur des sujets qui leur sont connus et dont ils sont les experts.

Introduction to this edition’s debate on intertrochanteric hip fractures

oth intramedullary and extramedullary devices are currently used for the treatment of intertrochanteric and subtrochanteric hip fractures. Given that the sliding hip screw was introduced much earlier, treatment outcomes have been more thoroughly documented. This implant also has a significant cost advantage over newer intramedullary hip screw designs. Although the latter has the theoretical advantage of being a load-sharing device, evidence to support its use is lacking 14

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and the factors that should be included in the surgical decisionmaking algorithm are controversial. I hope that you enjoy and learn from this debate. Thanks are extended to Drs. Leighton and Reindl along with their co-authors for these contributions. Peter Lapner, M.D., FRCSC Scientific Editor, COA Bulletin

The Compression Hip Screw is the Favoured Device for Most Intertrochanteric Hip Fractures in 2015 Ross K. Leighton, M.D., FRCSC Professor of Surgery Dalhousie University Blair Ogle, M.D., FRCSC Halifax, NS

ntertrochanteric hip fractures are occurring with increasing frequency and will continue to increase as the Baby Boomers age. The Boomers, as of 2015, are officially “old”. These fractures will take up more and more resources, and by 2030 could occupy >50% of the available orthopaedic beds in all hospitals. It is therefore in our best interest to treat Figure 1 them efficiently with early post-op mobilization to obtain the best possible outcomes and to secondarily to optimize the use of hospital resources. Intertrochanteric hip fractures are extra-capsular fractures and occur between the femoral neck and the inferior border of the lesser trochanter (Figure 1). Over 300,000 hip fractures occur in North America each year and this figure will double by 2040. Over 50% of these fractures are intertrochanteric and 95% occur in people over age 65. Diagnosis is made on plain X-rays, AP and lateral shoot through (Anderson view), although a very few require a bone scan or MRI if an occult fracture is suspected and not seen on plain X-rays. Many classifications exist but most of the literature is very comfortable in dividing these injuries into two types: stable and unstable. A stable fracture, once reduced and fixed, resists medial

Figure 2

and compressive loads. Unstable fractures, despite anatomic reduction and fixation, tend to collapse into a varus deformity or the shaft will medialize on the proximal fracture segment in spite of excellent fixation. Some feel this classification helps in selecting the fixation device and this may prove true over time but the literature is very soft in showing any difference between long-term outcomes in patients treated with a Compression Hip Screw (CHS), plus or minus a Trochanteric Side Plate (TSP), or an Intramedullary Hip Screw (IMHS)3. The goals of treatment should be early operative treatment via a hemi-lithotomy or scissors’ position. The more complex, shortened and deformed, the more the scissor position should be considered as it allows more traction without pulling the patient around the post (Figure 2). Anatomic reduction and accurate placement of the femoral head screw is paramount in determining outcomes4. A study by Agni and Grey et al. looked at the tipapex distance as a predictor and found the IMHS did not achieve this as often as the CHS and thus had a higher cut out rate2. The stable fractures are best treated by CHS in most surgeon’s hands unless they have a particular skill in nailing proximal femurs7. The CHS is the most costeffective device with equivalent outcomes to more expensive devices. Unstable fractures can be treated with either sliding hip screw device (CNS or IMHS) with the caveat that placing the femoral head screw in last (IMHS), can reduce the odds of achieving an acceptable tipapex distance and thus can increase the cut out rate1,3. There are two frac- Figure 3 ture types which require a Trochanteric Side Plate when a CHS is utilized: 1) lateral wall blow out or 2) associated subtrochanteric extension. This may be a preoperative or intra-operative diagnosis but the TSP can be a better choice, rather than changing devices intra-operatively, and has the same outcome as the IMHS5. The use of this TSP prevents medialization of the femoral shaft and helps reduce the varus deformity by adding one more screw in the femoral head (Figure 3). The CHS, even with the addition of the TSP, is still the most cost-effective device with equal outcomes to IMHS. Harrington et al. studied over 100 patients in a randomized study and found that there was no significant difference between the two groups in radiological or functional outcome at 12 months. COA Bulletin ACO, Winter / Hiver 2014

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It, therefore, still remains to be shown that the theoretical advantages of intramedullary fixation of extracapsular hip fractures bring a significant improvement in final outcome3,6. The CHS has always demonstrated equal or superior outcomes in the majority of unbiased non-industry studies–you choose!! References 1. Wagner R., Weckbach A., Sellmair U., Blattert T. Extraarticular proximal femur fracture in the elderly--dynamic hip screw or intramedullary hip screw for fracture management? Langenbecks Arch Chir Suppl Kongressbd. 1996;113:963-6 2. Agni N., Sellers E., Johnson R., Gray A. Tip Apex Distance – Is It Enough To Predict Implant Failure? The Internet Journal of Orthopedic Surgery. 2012 Volume 19 Number 3. 3. Parker M.J. and Pryor G.A. Gamma versus DHS nailing for extracapsular femoral fractures. Meta-analysis of ten randomized trials. Internat Ortho 20:163-168, 1996.

4. Baumgaertner M.R., Curtin S.L, Lindskog D.M. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop 348:87-94, 1998. 5. Madsen J.E., Naess L., Aune A.K., et al. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: A comparative study with the gamma nail and compression hip screw. J Orthop Trauma 12:241-248, 1998. 6. Harrington P., Nihal A., Singhania A.K., Howell F.R. Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Injury 2002 Jan;33(1):23-8. 7. Wahl C.J. (a-Smith & Nephew, Richards), Baumgaertner M.R. (a-Smith & Nephew, Richards),Yale University School of Medicine, New Haven, CT. Intramedullary Fixation: A More Efficient Technique for Pertrochanteric Fractures of the Hip? OTA Poster and Personal communication with the author.

Intertrochanteric Fractures: Intramedullary Hip Screw is the Optimal Treatment Rudolf M. Reindl, M.D., FRCSC Assistant Professor, McGill University Health Centre Montreal, QC

he implant of choice for the surgical treatment of intertrochanteric fractures in North America has undergone a clear change over the past two decades. While the sliding hip compression screw was the predominant implant used in the 1980’s, the use of intramedullary nails has significantly increased1. The exact reason for this change is largely unknown, since the current literature does not clearly favour one implant over the other. The major theoretical benefit driving this change seems to be the biomechanical advantage of the intramedullary nails2. By placing the fixation closer to the mechanical axis of the extremity, lever forces on the implant are diminished. This may result in lower failure rates. Furthermore, lateral translation and shortening of the extremity are limited, as the femoral head and calcar portion abut the intramedullary device when the fracture collapses and heals. Overall, the vast majority of papers would suggest that the two implants perform similarly well when all types of intertrochanteric fractures are evaluated as a group. The aforementioned studies do not differentiate the stable from the unstable fracture patterns. Matre et al. found no difference in pain, function and complications in 684 patients randomized to DHS or Intertan nail3. This study echoes the results of a prior meta-analysis by Bhandari et al.4 Given the current status of the literature, it is likely that the DHS performs as well as the nail for simple AO/OTA A1 fractures. However, with increasing fracture complexity, higher grade fracture patterns (AO/OTA A2 and A3) may benefit from the mechanically-superior devices. 16

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A recent prospective randomized study of 205 patients with unstable (AO/OTA A2) patterns by the Canadian Orthopaedic Trauma Society (COTS) group showed significantly less shortening of the femoral neck in the nailed group of patients5. Similarly, another prospective randomized trial of 100 patients found significantly less sliding and shortening in the nail group compared to the DHS group. This was particularly true for higher grade fractures6. Two studies of 65 patients with fractures extending below the lesser trochanter demonstrated superior results using the IM nail compared to the DHS with regards to fixation failure in a recent Cochrane analysis7. Even more recently, a meta-analysis of the literature seems to favour the IM implant over the DHS. This study evaluated 669 patients in six randomized or quasi-randomized papers. The publication found blood loss, operative time and length of the incision all to be less with the nail8. The literature contains many papers on the treatment of intertrochanteric fractures using various IM nails. Most recently, a meta-analysis by Queally et al. did not find a significant benefit associated with a particular nail design or manufacturer9. Unfortunately, the literature is sparse with regards to the functional outcomes of patients treated for intertrochanteric fractures. In their prospective clinical outcome trial, Guerra et al., found that the patients treated with nails had better scores during the first six months after surgery10.

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We are currently in a phase of defining the indications for the two different implants used in the fixation of intertrochanteric hip fractures. The biomechanical advantages of the intramedullary devices are likely relevant in the higher grade unstable fractures involving the lesser trochanter and the lateral cortex (AO/OTA A2 and A3 fractures). Until the indications for the use of the two available implant designs are clarified, the current literature would suggest that the intramedullary devices are at least as effective as the DHS in the management of all types of intertrochanteric fractures. It would therefore seem reasonable to use an intramedullary device for all intertrochanteric fractures. References 1. Forte M.L., Virnig B.A., Kane R.L., Durham S., Bhandari M., Feldman R., et al. Geographic variation in device use for intertrochanteric hip fractures. The Journal of bone and joint surgery American volume. 2008 Apr;90(4):691-9. Epub 2008/04/03. 2. Kuzyk P.R., Bhandari M., McKee M.D., Russell T.A., Schemitsch E.H. Intramedullary versus extramedullary fixation for subtrochanteric femur fractures. Journal of orthopaedic trauma. 2009 Jul;23(6):465-70. 3. Matre K., Vinje T., Havelin L.I., Gjertsen J.E., Furnes O., Espehaug B., et al. TRIGEN INTERTAN intramedullary nail versus sliding hip screw: a prospective, randomized multicenter study on pain, function, and complications in 684 patients with an intertrochanteric or subtrochanteric fracture and one year of follow-up. The Journal of bone and joint surgery American volume. 2013 Feb 6;95(3):200-8. Epub 2013/02/08. 4. Bhandari M., Schemitsch E., Jonsson A., Zlowodzki M., Haidukewych G.J. Gamma nails revisited: gamma nails versus compression hip screws in the management of intertrochanteric fractures of the hip: a meta-analysis. Journal of orthopaedic trauma. 2009 Jul;23(6):460-4. Epub 2009/06/25.

5. Reindl R.M, Harvey E.J., Berry G.K., COTS. Intramedullary Versus Extramedullary Fixation of Unstable Intertrochanteric Hip Fractures: A Prospective Randomized Control Study. Orthopaedic Trauma Association Meeting; Phoenix, Arizona: OTA; 2013. 6. Hardy D.C., Descamps P.Y., Krallis P., Fabeck L., Smets P., Bertens C.L., et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. The Journal of bone and joint surgery American volume. 1998 May;80(5):618-30. Epub 1998/06/04. 7. Parker M.J., Handoll H.H. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. The Cochrane database of systematic reviews. 2010 (9):CD000093. Epub 2010/09/09. 8. Zhang K., Zhang S., Yang J., Dong W., Wang S., Cheng Y., et al. Proximal femoral nail vs. dynamic hip screw in treatment of intertrochanteric fractures: a meta-analysis. Medical science monitor : international medical journal of experimental and clinical research. 2014;20:1628-33. Epub 2014/09/13. 9. Queally J.M., Harris E., Handoll H.H., Parker M.J. Intramedullary nails for extracapsular hip fractures in adults. The Cochrane database of systematic reviews. 2014;9:CD004961. Epub 2014/09/13. 10. Guerra M.T., Pasqualin S., Souza M.P., Lenz R. Functional recovery of elderly patients with surgically-treated intertrochanteric fractures: preliminary results of a randomised trial comparing the dynamic hip screw and proximal femoral nail techniques. Injury. 2014 Nov;45 Suppl 5:S26-31.

Themes The Impact of Osteoporosis Initiatives Over the Past Decade

steoporosis, a condition that affects bone strength via alterations in both bone density and bone quality, is the most common bone disease that affects Canadians and greatly increases the risk of fractures. The condition is silent and undetected in many cases until fracture occurs. It affects women four times more commonly than men, and one out of every two women and one in every eight men over 50 will suffer a fragility-related fracture in their lifetime. Hip fractures have a very significant morbidity and socioeconomic impact. The oneyear mortality rate is as high as 20%, and half will no longer be able to walk without assistance. A high proportion of patients

who sustain an osteoporosis-related hip fracture will require longterm care. The burden of osteoporosis-related fractures will continue to rise over the next two decades. Given the magnitude of this musculoskeletal condition, I hope that you learn from and enjoy the following feature. Peter Lapner, M.D., FRCSC Scientific Editor, COA Bulletin COA Bulletin ACO, Winter / Hiver 2014

Epidemiology of Osteoporotic Fractures Aliya Khan, M.D., FRCPC, FACP, FACE Professor of Clinical Medicine, McMaster University Hamilton, ON

steoporosis is being increasingly recognized as a common condition associated with significant morbidity and mortality. Men are less likely than women to be diagnosed with osteoporosis or to receive adequate therapy. In women over 50, the lifetime risk of a hip fracture is 12.1%1. Approximately 23.5% of women with a hip fracture and 15.7% of women with an incident vertebral fracture die within five years following the fracture2. Mortality rates are higher in men at approximately 40% following a hip fracture in comparison to women. The incidence of fracture is bimodal. There is a peak in the adolescent years with boys having more fractures then girls. These fractures usually occur in the long bones and are associated with trauma. There is a second peak in older adults occurring in the 55 to 80 year age group. In this population women have more fractures than men and these fractures are low trauma fractures. When all fractures are considered, the incidence in women climbs steeply and the rates of fracture are twice as high in women than in men. Hip fracture The incidence of hip fracture increases exponentially with age4. After the age of 50 women have twice as many hip fractures as men. The majority of the hip fractures occur after a fall from standing height and 90% occur in people over the age of 505. Hip fractures appear to be associated with a sideways fall rather than

a forward fall6. The incidence of hip fracture varies significantly from country to country. Sweden has the highest rate of hip fracture globally followed by the USA and Canada. China, Korea, and Chile have one of the lowest rates of hip fracture globally. There are a number of factors which impact fracture risk and include genetic as well as environmental factors. Vertebral fracture The European Vertebral Osteoporosis Study (EVOS) demonstrated that the prevalence of vertebral fracture was similar in men and women between the ages of 50 and 79 at 12.2% for men and 12.0% for women7. It is most probable that the higher than expected incidence of vertebral fracture in men is in association with trauma. Vertebral fractures in elderly women usually occur with normal daily activities such as lifting, pushing or pulling. They can also occur with simple falls. Approximately, 2/3 of vertebral fractures are silent and are identified on plain films with only 1/3 of vertebral fractures actually coming to medical attention. Vertebral fractures both clinical and morphometric are powerful predictors of future fracture risk and are associated with increased morbidity and mortality11. Most of the vertebral fractures occur below T6 as noted in the Rotterdam Study8. Not all vertebral fractures are due to osteoporosis and a bone scan or an MRI should be completed if there is concern of a pathologic fracture. The presence of a low trauma vertebral fracture, whether it is clinical or simply

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morphometric, is an indication for pharmacologic intervention. Vertebral fractures are a strong marker of fragility. The presence of a vertebral fracture is associated with a greatly increased risk of future fracture, particularly in the spine and also at other skeletal sites. The higher the number and grade of prevalent vertebral fracture, the greater the risk of future fracture9. Forearm fractures The incidence of forearm fractures increases between the ages of 45 and 60 in women, although the risk above age 60 remains stable. A womenâ&#x20AC;&#x2122;s lifetime risk of a wrist fracture at the age of 50 is 16.6% and it decreases to 10.4% at 70 years. In men, the incidence of a forearm fracture does not rise with age, and the lifetime risk of fracture is 2.9% at the age of 50 and 1.4% at the age of 7010. In summary, osteoporosis is a common condition associated with significant morbidity and mortality. It is essential to identify the presence of osteoporosis following a fragility fracture. Intervention can significantly reduce the risk of further vertebral, non-vertebral, and hip fractures. Unfortunately, today, the majority of patients who have had a fragility fracture are not treated for their underlying osteoporosis. In 2008 the Recognizing Osteoporosis and its Consequences in Quebec (ROCQ) study showed that only 15% of women receive drug therapy eight months after a fragility fracture12. At our hospital we have a Geriatric Hip Fracture Program. All patients who have been admitted to the hospital with a hip fracture are seen by Geriatric Medicine and the underlying osteoporosis is evaluated and therapy is implemented prior to discharge from the hospital. We have implemented a nurse in the Fracture Clinic with funding from the Ontario Osteoporosis Strategy and Osteoporosis Canada. This nurse identifies individuals who have had a fragility fracture and ensures that appropriate investigation and implementation of appropriate pharmacologic therapy takes place. By focusing on identification of skeletal fragility and treating the underlying osteoporosis, we will be able to make a significant impact and reduce the risk of further fractures. We all need to support Osteoporosis Canadaâ&#x20AC;&#x2122;s goal of making the first fracture the last fracture13.

3. Garraway W.N., et al. Mayo Clinic Proceedings. 1979; 52: 701-707. 4. The European Perspective Osteoporosis Study (EPOS) Group, 2002 Incidence of Vertebral Fracture in Europe. JBMR 17: 716-724. 5. Gallagher J.C., Melton L.J., Riggs B.L., Bergstrath E. 1980. Clin Orthop 150: 163-171) 6. Nevitt MC, Cummings SR. 1993. The Study of Osteoporotic Fractures Research Group. J Am Geriatric Society 41: 12261234. 7. Oâ&#x20AC;&#x2122;Neill T.W., Felsenberg D., Varlow J., et al. 1996. JBMR 11: 1010-1018. 8. Van Der Klift, et al. JBMR 2002; 17: 1051. 9. Black D.M., et al. JBMR 1999; 14: 821-828. 10. Van Staa T.P., Dennison E.M., Lerfken H.G., Cooper C. 2001. Bone 29: 517-522. 11. Harrison, et al. JBMR 2007; 22: 447-457. 12. Bessette L., et al. Osteoporosis International 2008; 19: 79-86.

References 1. Hopkins, et al. Osteoporosis International, 2011. 2. Ioannidis G., et al. CMAJ, 2009.

13. Khan A., Fortier M., Reid R., Abramson B.L., Blake J., Desindes S., Dodin S., Graves L., Guthrie B., Johnston S., Rowe T., Sodhi N., Wilks P., Wolfman N. SOGC Guidelines. J Obstet Gynaecol Can. 2014;36(9):839-840.

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Falls and the Orthopaedic Surgeon Barbara Power, M.D. FRCPC Associate Professor, Vice-Chair, Education, Department of Medicine Program Director, Division of Geriatric Medicine Director, Clinical Skills, Anglophone Stream, UGME University of Ottawa Ottawa, ON

alls are the leading cause of injury requiring hospitalization for seniors in Canada. According to the Centre for Disease Control and Prevention (CDC), falls are the leading cause of fatal and non-fatal injuries in people age 65 years and older1-6. A fall is defined by the World Health Organization (WHO) as an “event that results in a person coming to rest inadvertently on the ground or floor or other lower level”2. Approximately onethird of community-dwelling elderly (persons >65 years) experience a fall and half of these fallers sustain multiple falls. Five to ten percent of falls result in major injuries including fractures, head trauma or major lacerations. Complications resulting from falls are associated with significant morbidity including a decline in functional status, restrictions of mobility and independence, and an increased likelihood of placement in a long-term facility3-7. Falls are not a normal consequence of aging but instead present an opportunity for physicians to intervene. Hip fractures are a leading consequence of elder fall injuries and up to 20% of these individuals die within the first year3. The majority of falls are not caused by a single factor but are due to a combination of a multitude of problems. These can be secondary to intrinsic factors to the patient such as health-related factors with the majority identified as cognitive impairment, medication use, chronic medical conditions such as Parkinson’s disease, stroke and impairments in muscle strength, gait, and balance or extrinsic factors (environment – related). The key for the physician is to determine which factors are involved in a particular patient and from this, identify which can be modified. The approach needs to determine which ones can be modified quickly, for example through a change in medications with a particular focus on psychotropic medications and alcohol use and which ones require a longer-term strategy such as exercise and muscle strengthening. Medications have been consistently associated with an increased risk of falls and can contribute to falls through unintended side effects such as dehydration from diuretics; confusion and drowsiness from medications for neuropathic pain, benzodiazepines and narcotics, and orthostatic hypotension from blood pressurereducing medications. The strongest risk association with falls occurs with psychotropic medications, including anxiolytics, sedatives, hypnotics and antipsychotic drugs10-12. Polypharmacy has been shown to be an independent predictor for one or more falls due to the increase in the additive and synergistic effects of medications11-12. Orthopaedic surgeons should be aware of the potential side effects on cognition, gait and balance when prescribing medications to improve the management of MSK or neuropathic pain. In collaboration with a pharmacist, they should educate patients and their families on the potential for 20

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these adverse effects and highlight the importance of reviewing and monitoring these medications with their family physicians. Gait and balance are measures of postural control and can be influenced by many factors including impaired proprioception and vestibular function, impaired vision, decreased motor strength, and foot problems. It is important for the physician to examine gait and balance through some simple screening tools such as the “get up and go test” (Table 3)15. If any abnormalities are detected, recommendations can be made to the family physician to evaluate the patient in more extensive detail. Extrinsic or environmental factors that are frequently implicated in falls include poor lighting, stairs and loose rugs and carpets. The multifactorial nature of falls highlights the need for a multifaceted approach to prevention. There is evidence from randomized controlled trials to support the efficacy of multidisciplinary intervention on community dwelling seniors to prevent falls1,14. The component of this intervention includes the assessment and modification of intrinsic and extrinsic risk factors. The risk assessment should be followed by interventions targeted at the identified risk factors. Exercise programs that include a combination of balance and gait training, endurance and flexibility as well as muscle strengthening are an important intervention. Previous recommendations highlighted the benefits of tai-chi but since there is “inadequate data”1 it is no longer singled out as a recommendation1,12. In addition to exercise, guidance and education on the importance of in-home safety modifications with a particular focus on high-risk areas such as bathrooms and stairs can be provided through a home safety checklist or formally by an occupational therapist. Client and family education on fall prevention strategies remains an important cornerstone of a multi-factorial falls prevention program. In addition, information on dietary, life style, and treatment choices for the prevention of osteoporosis is relevant to reducing the risk of fractures in high risk individuals. The American Academy of Orthopaedic Surgeons has developed guidelines to help seniors prevent falls. An orthopaedic surgeon may be the first point of contact with an elderly patient who has had a fall. This contact is an opportunity to potentially prevent further falls. Important questions should include the history of the circumstances around the fall, whether there is a history of previous falls, whether the falls were associated with any symptoms and if there has been a recent change in the individual’s cognition, medical history or medications. The physical examination should assess gait and balance, a neurological evaluation and a check for orthostatic hypotension. Any positive findings in the history or physical examination that identifies a patient at risk should be forwarded to the family physician for closer review with potential recommendations for referrals to a physiotherapist and/or occupational therapist. This contact is also an opportunity for the orthopaedic surgeon to encourage elderly patients to engage in exercise programs, as it is exercise that is the elixir of youth with its benefits on the mind and the potential to prevent falls.

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3. McGilton K.S., Mahomed N., Davis A.M., et al. Outcomes for older adults in an inpatient rehabilitation facility following hip fracture (HF) surgery. Arch Gerontol Geriatr 2009; 49:e23– 31.

Algorithm Summary Table 1 All patients older than 65 years should be asked annually: Have they fallen in the last year? If so, how many times? Do they have difficulty walking or with balance?

V Gait abnormalities/difficulties OR 2 or more falls

V Multifactorial risk assessment and multifactorial intervention

4. Ganz D.A., Bao Y., Shekelle P.G., et al. Will my patient fall? JAMA 2007; 297:77–86. 5. Scott V., Wagar L., Elliott S. (2010) Falls & Related Injuries among Older Canadians: Fall related Hospitalizations& Intervention Initiatives. Prepared on behalf of the Public Health Agency of Canada, Division of Aging and Seniors. Victoria, BC. 6. Statistics Canada (2009). Canadian Community Health Survey. Statistics Canada. 7. Tinetti M.E. , Baker D.I. , McAvay G., et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994; 331:821-7.

Table 2

8. Gillespie L.D., Gillespie W.J., Robertson M.C., et al. Interventions for preventing falls in elderly people (Cochrane review). The Cochrane Library, Issue 1, 2003.

Approach to falls • Reduce predisposing factors • Identify high risk fallers • Careful assessment

9. King M.D., Tinetti M.E. Falls in community dwelling older persons, J Am Geriatr Soc 1995; 43:1146-54.

Mobility Intrinsic factors

Extrinsic factors

Balance and Gait

Table 3 - Get Up and Go Test Ask the patient to perform the following series of maneuvers: 1. Sit comfortably in a straight-backed chair. 2. Rise from the chair. 3. Stand still momentarily. 4. Walk a short distance (approximately 3 metres). 5. Turn around. 6. Walk back to the chair. 7. Turn around. 8. Sit down in the chair. Observe the patient’s movements for any deviation from a normal performance.

References 1. American Geriatrics Society and British Geriatrics Society (AGS) - Clinical practice guideline for the prevention of falls in Older Persons adults. Journal of American Geriatrics Society 2011; 59:148-157.

10. U.S. Department of Health and Human Service. Physical activity and health – A report of the Surgeon General. Atlanta U.S. Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion. 11. Woolcott J.C., Richardson K.J., Wiens M.O., et al. Metaanalysis of the impact of 9 medication classes on falls in elderly persons. Arch Intern Med 2009; 69:1952–60. 12. Leipzig R.M., Cumming R.G., Tinetti M.E. Drugs and falls in older people: A systematic review and meta-analysis: I. Psychotropic drugs. J Am Geriatr Soc 1999;47:30–39. 13. Corsinovi L., Bo M., Aimonino N.R., Marinello R., Gariglio F., Marchetto C., Molaschi M. (2009). Predictors of falls and hospitalization outcomes in elderly clients admitted to an acute geriatric unit. Archives of Gerontology & Geriatrics: 49(1):42-145. 14. Gillespie L.D., Robertson M.C., Gillespie W.J., et al. Interventions for preventing falls in older people living in the community. Cochrane Database Syst Rev 2012;(9):CD007146. 15. Mathias S., Nayak U.S.L., Isaacs B. Balance in elderly patients: the “get-up and go” test. Arch Phys Med Rehabil. 1986;67:387389.

2. Falls. Geneva (Switzerland): World Health Organization, 2012.

COA Bulletin ACO, Winter / Hiver 2014

Atypical Femur Fractures and Bisphosphonate Use: Diagnosis, Management and Outcomes Aaron Nauth, M.D., MSc, FRCSC Assistant Professor, Division of Orthopaedic Surgery St. Michael’s Hospital, University of Toronto Toronto, ON

oncordant with increases in widespread bisphosphonate use for the treatment of osteoporosis, there has been a substantial increase in atypical fractures of the femur over the last decade. A contributing factor to the increased incidence of these fractures may, in fact, be an increase in understanding and awareness of these fractures on the part of orthopaedic surgeons and other physicians. Effective treatment of atypical femur fractures does require a specialized approach, which involves a number of critical steps: 1. Making the diagnosis of an atypical femur fracture 2. Appropriate surgical management of the fracture 3. Medical management of the patient 4. Screening of the contralateral limb Making the diagnosis of an Atypical Femur Fracture (AFF) The diagnosis of an AFF is made on the basis of history and analysis of radiographs. The American Society for Bone and Mineral Research (ASBMR) has identified and published the diagnostic criteria which define AFF’s (Table 1)1. An AFF is a fracture which occurs in the femoral shaft and meets at least four of the five major criteria identified by the ASBMR. Minor criteria are often present, but not required. It is important to note that a history of bisphosphonate use has not been included in either the major or minor criteria. The ASBMR has asserted that such associations should be sought after rather than be required for a diagnosis of AFF. The literature on AFF’s suggests that approximately 80% of patients presenting with an AFF will have a history of bisphosphonate use, and most will have been using a bisphosphonate for more than five years2. Figure 1 demonstrates radiographs of a 68 year-old female patient with an AFF. This patient fell from standing height and had been on Alendronate for eight years prior to her injury. She meets all five of the major criteria for the diagnosis of an AFF.

Figure 1 (A and B) Preoperative radiographs of a 68 year-old female patient with an atypical femur fracture. The patient had a low-energy fall and a history of long-term bisphosphonate use. Her radiographs demonstrate a non-comminuted, transverse fracture of the lateral cortex with associated “beaking” (dashed white arrow), and a medial spike (white arrows). (C and D) Intra-operative fluoroscopy images following attempted closed reduction demonstrating persistent wide displacement of the fracture, particularly in the sagittal plane. (E and F) Intra-operative fluoroscopy images showing percutaneous, clamp-assisted open reduction of the fracture. (G and H) Three month postoperative radiographs demonstrating early radiographic healing with anatomic reduction after treatment with a recon type cephalomedullary nail.

Appropriate surgical management of the fracture Appropriate surgical management of AFF’s requires an understanding of the unique features and challenges that these fractures present. First, it is critical that these fractures are managed with an intramedullary nail. These patients have impaired primary bone healing and high rates of delayed union (the average duration of healing in the literature is six to nine months) and nonunion, making a load-sharing intramedullary nail the implant of choice3-5. Second, use of a cephalo-medullary (CM) nail with fixation into the femoral neck and head is recom22

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mended to protect against future femoral neck fracture and optimize proximal fixation (as AFF’s most commonly occur in the subtrochanteric region). Third, to optimize chances of union it is critical to achieve as anatomic a reduction as possible. Due to the fact that these fractures are low-energy (resulting in minimal soft tissue disruption) and often in the subtrochanteric region, closed reduction is often unsuccessful. In these instances, open reduction using a percutaneous clamp is recommended (see Figure 1)6. In addition, it is critical to use an appropriate start point on the medial aspect of the greater trochanter to avoid varus malreduction (see Figure 2). Finally, AFF patients often have hypertrophic cortices and narrow intramedullary canals. In these instances, the use of a recon type CM nail with two smaller lag screws into the femoral head is preferable over an intramedullary hip screw type CM nail with a single, large lag screw and a larger proximal diameter to the nail, as such a nail is often oversized for this patient population (see Figure 1).

Medical management of the patient Appropriate medical management of the patient consists of stopping their bisphosphonate and referring the patient to a bone health specialist (such as rheumatology or endocrinology) for further management of their osteoporosis. Stopping the patient’s bisphosphonate decreases their risk of contralateral fracture by 68% and may have benefits with regard to healing of their AFF7. The bone health specialist will be able to counsel the patient on options for managing their osteoporosis including a bisphosphonate holiday or consideration of anabolic therapy with parathyroid hormone (PTH)8.

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Screening of the contralateral limb It is important to screen the contralateral limb both clinically and radiographically in all patients presenting with an AFF. The literature suggests that approximately 50% of patients with an AFF will have bilateral radiographic changes and the risk of contralateral fracture is approximately 18% even when bisphosphonate use is stopped immediately7. Patients who have radiographic changes and symptoms in the contralateral limb should undergo prophylactic nailing, particularly if a ‘dreaded black line’ is present (see Figure 3). This is supported by literature which shows high failure rates with conservative treatment of symptomatic incomplete fractures and excellent outcomes with prophylactic nailing9. Patients with asymptomatic radiographic changes and no ‘dreaded black line’ (e.g. lateral cortex hypertrophy and beaking only) can be treated non-operatively with close clinical and radiographic surveillance. Conclusions It is important to recognize that despite the increased attention that the complications of bisphosphonate therapy (including AFFs) have received recently both in the literature and the lay press, the benefits of bisphosphonate therapy still clearly outweigh the risks of these rare events. It has been estimated that for every AFF that occurs, bisphosphonate therapy prevents 100 hip fractures10. Figure 4 provides perspective on the risks of AFF relative to other rare events as well as relative to the risks of major osteoporotic fractures8. However, there is evolving literature suggesting that some patients with long-term bisphosphonate use at low risk of fragility fracture may be appropriate for a drug holiday8. Certainly it is imperative that all patients on long-term bisphosphonate treatment who present with thigh or groin pain have radiographs performed and be assessed by an orthopaedic surgeon.

Atypical femur fractures are presenting with increasing frequency and as orthopaedic surgeons, we must be prepared to manage the unique challenges that these patients present. An understanding of these challenges and adherence to the above principles can lead to a high rate of satisfactory outcomes.

Figure 3 (A and B) Radiographs of the contralateral limb from the same patient in Figure 1 demonstrating lateral cortical hypertrophy and beaking (white arrows) but no ‘dreaded black line’. This patient was symptomatic and complained of thigh pain with weight-bearing. (C) Postoperative radiograph after prophylactic nailing which was performed one week after her index procedure.

Table 1: Diagnostic criteria of the ASBMRa for Atypical Femur Fractures (as revised in 2013)1 Major Featuresb (at least 4/5 are required for diagnosis of an AFFc) 1. The fracture is associated with minimal or no trauma (eg fall from a standing height or less). 2. The fracture line originates at the lateral cortex and is substantially transverse in its orientation, although it may become oblique as it progresses medially across the femur. 3. Complete fractures extend through both cortices and may be associated with a medial spike; incomplete fractures involve only the lateral cortex. 4. The fracture is non-comminuted or minimally comminuted. 5. Localized periosteal or endosteal thickening of the lateral cortex is present at the fracture site (“beaking” or “flaring”). Minor Features (none are required but these have often been associated with AFFc)

Figure 2 (A) Preoperative radiographs of a 65 year-old female with an atypical femur fracture. (B) Postoperative radiographs demonstrating a lateral start point of the nail and resulting varus malreduction. (C) Nonunion of the fracture and failure of the nail at six months postoperatively. (D) Revision to compression plating with a blade plate results in a second failure with breakage of the plate. (E) Eventual healing following a third revision surgery and augmentation with Bone Morphogenic Protein (BMP).

1. Generalized increase in cortical thickness of the femoral diaphysis. 2. Unilateral or bilateral prodromal symptoms such as dull or aching pain in the groin or thigh. 3. Bilateral incomplete or complete femoral diaphysis fractures. 4. Delayed fracture healing. a. ASBMR = American Society for Bone and Mineral Research b. The fracture must be located in the femoral shaft (between the region just distal to the lesser trochanter and proximal to the supracondylar flare) c. AFF = Atypical femur fracture COA Bulletin ACO, Winter / Hiver 2014

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Figure 4 Risks of major osteoporotic fracture and other rare events. Used with permission from the Canadian Family Physician and Brown et al.8 Data in this figure comes from other sources.

References 1. Shane E., Burr D., Abrahamsen B., et al. Atypical subtrochanteric and diaphyseal femoral fractures: second report of a task force of the American Society for Bone and Mineral Research. J Bone Miner Res. Jan 2014;29(1):1-23.

4. Teo B.J., Koh J.S., Goh S.K., Png M.A., Chua D.T., Howe T.S. Post-operative outcomes of atypical femoral subtrochanteric fracture in patients on bisphosphonate therapy. The Bone & Joint Journal. May 2014;96-B(5):658-664.

2. Thompson N., Phillips J.R., McCauley S.H., Elliott J.R., Moran C.G. Atypical femoral fractures and bisphosphonate treatment: experience in two large United Kingdom teaching hospitals. J Bone Joint Surg Br. Mar 2012;94(3):385-390.

5. Edwards B.J., Bunta A.D., Lane J., et al. Bisphosphonates and nonhealing femoral fractures: analysis of the FDA Adverse Event Reporting System (FAERS) and international safety efforts: a systematic review from the Research on Adverse Drug Events And Reports (RADAR) project. J Bone Joint Surg Am. Feb 20 2013;95(4):297-307.

3. Prasarn M.L., Ahn J., Helfet D.L., Lane J.M., Lorich D.G. Bisphosphonate-associated femur fractures have high complication rates with operative fixation. Clin Orthop Relat Res. Aug 2012;470(8):2295-2301.

6. Afsari A., Liporace F., Lindvall E., Infante A., Jr., Sagi H.C., Haidukewych G.J. Clamp-assisted reduction of high subtrochanteric fractures of the femur. J Bone Joint Surg Am. Aug 2009;91(8):1913-1918.

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7. Dell R.M., Adams A.L., Greene D.F., et al. Incidence of atypical nontraumatic diaphyseal fractures of the femur. J Bone Miner Res. Dec 2012;27(12):2544-2550. 8. Brown J.P., Morin S., Leslie W., et al. Bisphosphonates for treatment of osteoporosis: expected benefits, potential harms, and drug holidays. Canadian family physician Medecin de famille canadien. Apr 2014;60(4):324-333.

9. Banffy M.B., Vrahas M.S., Ready J.E., Abraham J.A. Nonoperative versus prophylactic treatment of bisphosphonateassociated femoral stress fractures. Clin Orthop Relat Res. Jul 2011;469(7):2028-2034. 10. Wang Z., Bhattacharyya T. Trends in incidence of subtrochanteric fragility fractures and bisphosphonate use among the US elderly, 1996-2007. J Bone Miner Res. Mar 2011;26(3):553560.

Foundation Canadian Orthopaedic Foundation Director, Cy Frank, Named Recipient of the Order of Canada

he Canadian Orthopaedic Foundation is pleased to announce Director of the Board, Cy Frank, as a recipient of the Order of Canada. This is a Canadian national order within Canada’s honours system, and one of our country’s highest civilian orders, recognizing a lifetime of distinguished service in or to a particular community, group or field of activity. As a Director of the Board with the Foundation, Dr. Frank holds the position of Chair of the Governance and Nominating Committee. Dr. Frank was recognized for his contributions to advancing orthopaedic health care services in Alberta and for his scientific contributions to bone and joint repair research. His role in the Canadian health-care sector has benefited people from coast-tocoast and will have longstanding impact for generations to come. Dr. Cy Frank is one of the leading figures in the field of bone and joint injury both nationally and internationally and has recently been appointed the CEO of Alberta Innovates – Health Solutions. “Dr. Frank is an extraordinary leader and advocate for orthopaedics and health care in Canada,” comments Canadian Orthopaedic Foundation Board Chair, Dr. Geoffrey Johnston. “The Foundation is grateful for his enormous contributions and dedication to the organization. His passion for serving others and his unwavering commitment to the Foundation is recognized with esteemed honour.”

Dr. Frank notes, “I am humbled by this gracious honour. This tribute further reinforces the importance of bone and joint health in the country, the impact it has on Canadians and the significance orthopaedics plays within the health-care system.” “I am inspired by what the future holds for orthopaedics and how innovation can continue to progress and evolve to better serve the citizens of this great country”. Dr. Frank is joined by fellow director, Mr. Patrick Lafferty, to be the second member of the Board to hold such distinction. Mr. Lafferty was recognized as an Officer of the Order of Canada in early 2014 for his contributions to the advancement of Canada’s medical research infrastructure, notably the creation of the Ontario Institute of Cancer Research and the Canadian Institutes of Health Research. The Foundation takes pride in having two of its members be celebrated and held in such high regard.

COA Bulletin ACO, Winter / Hiver 2014

La Fondation Canadienne d’Orthopédie est heureuse d’annoncer la nomination du Dr Cy Frank, membre de son conseil d’administration, au sein de l’Ordre du Canada.

’Ordre du Canada est la pierre angulaire du Régime canadien de distinctions honorifiques, et l’une des plus prestigieuses distinctions honorifiques civiles de notre pays, qui vient reconnaître une vie vouée au service d’une communauté, d’un groupe ou d’un champ d’activité. À titre de membre du conseil d’administration de la Fondation, le Dr Frank assume la présidence du Comité des candidatures et de la gouvernance. Le Dr Frank a été reconnu pour son rôle dans l’avancement des services de soins orthopédiques en Alberta et pour sa contribution scientifique à la recherche sur les réparations osseuses et articulaires. Sa contribution au sein du système de santé canadien a profité à des gens d’un bout à l’autre du pays et aura une incidence pour bien des générations encore. Le Dr Frank fait partie des leaders dans le traitement des blessures des os et des articulations, tant à l’échelle nationale qu’internationale, et a récemment été nommé président-directeur général d’Alberta Innovates – Health Solutions. « Le Dr Frank est un leader extraordinaire et un grand défenseur de l’orthopédie et des soins de santé au Canada, affirme le Dr Geoffrey Johnston, président du conseil de la Fondation Canadienne d’Orthopédie. La Fondation lui est d’ailleurs reconnaissante pour son énorme contribution et son grand dévoue-

ment. Sa volonté d’aider les autres et son engagement indéfectible envers la Fondation sont aujourd’hui soulignés avec grande distinction. » « C’est avec beaucoup d’humilité que je reçois cet insigne honneur, déclare le Dr Frank. Cet hommage vient renforcer l’importance de l’orthopédie au sein du système de santé ainsi que de la santé des os et des articulations au pays, et l’incidence qu’elle a sur la population canadienne. L’avenir de l’orthopédie et le rôle de l’innovation dans l’amélioration continue des services à la population de notre merveilleux pays m’inspirent. » Le Dr Frank devient le deuxième membre du conseil d’administration de la Fondation, après Patrick Lafferty, à recevoir une telle distinction. M. Lafferty a en effet accédé au rang d’Officier de l’Ordre du Canada au début de 2014, en reconnaissance de sa contribution à l’avancement de l’infrastructure de recherche médicale au Canada, et plus particulièrement à la création de l’Ontario Institute of Cancer Research et des Instituts de recherche en santé du Canada. La Fondation est fière de voir deux de ses membres ainsi célébrés et tenus en si grande estime.

2014 J. Edouard Samson Award Dr. Brian Kwon’s spine research recognized

ach year, about a thousand Canadians suffer an acute spinal cord injury. While in the grand scheme of things this is a relatively small number, the impact of these types of injuries are often devastating and life-long – and expensive to the healthcare system, in the range of $3 billion annually. Moreover, in the critical hours after spinal trauma, clinicians have few options to help mitigate the extent of injury, says orthopaedic surgeon Dr. Brian Kwon: “Our current standard treatment is surgery. We can offer these patients rapid surgery, which we think may make a difference to their neurological outcome.” A full professor at UBC’s Department of Orthopaedics, Dr. Kwon is also the Canada Research Chair in Spinal Cord Injury, and a recent recipient of the Canadian Orthopaedic Foundation’s prestigious J. Edouard Samson Award. This latest acknowledge26

COA Bulletin ACO, Winter / Hiver 2014

ment underscores the excellence of his ongoing research into acute spinal cord injury, both at the patient’s bedside and in the lab. As a surgeonscientist, Kwon can translate basic-science insights into new clinical knowledge, which can in turn be used to inform further scientific laboratory studies. One line of his research stems from an initial observation that vascular surgeons

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often insert a catheter into a patient’s spinal cord to drain cerebrospinal fluid (CSF) in order to increase blood supply to injured spinal cord tissue. Kwon began by measuring changes in spinal-cord perfusion pressure, which is the difference between mean blood pressure and the spinal cord’s CSF pressure. With this, Kwon determined that the blood supply to the spinal cord may not be sufficient in the acute post-injury period. “We think that a drop in blood pressure is probably bad,” says Kwon. “One of the few things we can do is maintain the patient’s blood pressure and maintain the blood supply to the spinal cord. So while the patient is in intensive care, we do our best to keep the spinal cord perfused by draining cerebrospinal fluid. At the same time, we take samples of CSF. We know so little about the biological response in humans to spinal cord injury. A lot of the research we do into the biology of spinal cord injury depends on rodent models. So this is our opportunity to get biological data from human patients to understand human injury better.” With a nation-wide collaboration of surgeons in Vancouver, Halifax, Montreal and southern Ontario, Kwon’s library of CSF samples is now the world’s largest. This is no small feat, given that spinal-injury patients tend to be few and far between, and must also meet quite narrow inclusion criteria. Soon, he hopes to expand the research effort to US sites. So far, the samples have yielded an array of biomarkers for study. “We’re hoping to develop a therapy that would improve neurological function” says Kwon. “However, it’s very challenging to take a promising therapy and actually test it in human patients. You can do one-off anecdotal stories about effectiveness, but to rigorously test a therapy takes a lot of time and resources.” After

consulting with the scientific community about just how promising a therapy has to be to justify mounting a full-scale clinical trial, the consensus was “that it’s important to test therapies in an intermediate model rather than moving from rodents directly to humans. So we’ve developed a large animal model not only for testing novel findings as they move from the bench to bedside, but also for taking things we learn at the bedside – like CSF pressure data – back to the lab to see if we can understand the process a bit better.” This translational approach has reached a milestone with a “neuroprotective agent” now in human clinical trials after many years of pre-clinical study. Human trials can take up to a decade or more to complete, so Kwon and his colleagues still have a long road ahead of them, which makes receiving the Samson Award all the more welcome: “Some of the funding will go to expanding our research effort, and some will go into the educational component of our research, furthering the translational aspect of our work. Also, the Samson Award will almost certainly help attract more funding. It’s a very important award, and we are very pleased to have our work recognized in this manner.” Dr. Geoffrey Johnston, Chair of the Canadian Orthopaedic Foundation, and Dr. Erin Boynton, Chair of the Foundation’s Research Committee, are pleased with Kwon’s work. “Funding important research such as Dr. Kwon’s work is the very reason the Foundation was established 50 years ago,” comments Johnston. “Via the esteemed J. Edouard Samson Award, the Foundation takes pride in providing critical funds to further orthopaedic innovation and research in Canada.”

Prix J.-Édouard-Samson 2014

Reconnaissance des travaux sur le rachis du Dr Brian Kwon

haque année, un millier de Canadiens subissent un traumatisme médullaire aigu. Bien que ce nombre soit relativement peu élevé en soi, les répercussions de ce type de traumatisme sont souvent dévastatrices et permanentes, sans compter leurs coûts énormes pour le système de santé, qui sont de l’ordre de 3 milliards de dollars par année. De plus, dans les heures cruciales qui suivent le traumatisme médullaire, les cliniciens ont peu d’options pour en atténuer l’ampleur, comme l’explique le Dr Brian Kwon, orthopédiste : « Actuellement, le traitement standard repose sur la chirurgie. Nous pouvons opérer rapidement les blessés, ce qui, selon nous, peut influer sur les résultats neurologiques. » En plus de sa charge de professeur au département d’orthopédie de l’Université de la Colombie-Britannique, le Dr Kwon est titulaire de la Chaire de recherche du Canada sur les lésions médullaires et lauréat 2014 du prestigieux Prix J.-Édouard-Samson de la Fondation Canadienne d’Orthopédie. Cette reconnaissance vient souligner l’excellence de ses recherches sur les traumatismes médullaires aigus, tant au chevet des patients qu’en laboratoire. En tant que chercheur et orthopédiste, le Dr Kwon peut

user de la science fondamentale pour nourrir le savoir clinique, qui peut ensuite servir à étayer les études en laboratoire. Un pan de ses travaux découle de l’observation initiale que les chirurgiens vasculaires insèrent souvent une sonde dans la moelle épinière de leur patient pour drainer le liquide céphalorachidien (LCR) et accroître l’apport sanguin dans les tissus endommagés de la moelle épinière. Le Dr Kwon a commencé par mesurer les changements dans la pression de perfusion médullaire, soit la différence entre la tension artérielle moyenne et la pression du LCR. Grâce à ces données, le Dr Kwon a établi que l’apport sanguin dans la moelle épinière peut s’avérer insuffisant pendant la période suivant immédiatement un traumatisme. « Nous croyons qu’une baisse de la tension artérielle est probablement mauvaise, déclare-t-il. L’une des rares options dont nous disposons consiste à maintenir la tension artérielle du patient et l’apport sanguin à la moelle épinière. Ainsi, pendant que le patient est aux soins intensifs, nous nous efforçons de maintenir l’irrigation de la moelle épinière en drainant le liquide céphaCOA Bulletin ACO, Winter / Hiver 2014

(suite de la page 27)

lorachidien, dont nous prélevons des échantillons. Nous n’en savons que trop peu sur les réactions biologiques de l’humain aux traumatismes médullaires. Une grande part des recherches que nous faisons sur la biologie des traumatismes médullaires dépend de modèles rongeurs. Il s’agit donc là d’une occasion pour nous d’obtenir des données biologiques de patients de sorte à mieux comprendre les traumatismes chez l’humain. » Grâce à la collaboration de chirurgiens de Vancouver, de Halifax, de Montréal et du Sud de l’Ontario, la collection d’échantillons de LCR du Dr Kwon est maintenant la plus importante au monde. Et ce n’est pas une mince affaire, puisque les cas de traumatismes médullaires sont très rares et que les échantillons doivent respecter des critères assez restrictifs. Il espère élargir bientôt ses recherches à des centres américains. Jusqu’à maintenant, les échantillons ont permis d’établir un éventail de biomarqueurs. « Nous espérons développer des traitements pour améliorer la fonction neurologique, poursuit-il. Il est toutefois très difficile de mettre à l’essai des traitements prometteurs sur des patients. De temps à autre, on peut faire des observations sur leur efficacité en recourant à des cas isolés, mais procéder à des essais rigoureux nécessite beaucoup de temps et de ressources. » Afin de déterminer à quel point les traitements doivent être prometteurs pour justifier la mise en œuvre d’essais cliniques exhaustifs, on a consulté la communauté scientifique, qui a convenu de l’importance d’effectuer des essais sur un modèle intermédiaire plutôt que de passer directement des rongeurs aux humains. Nous

COA Bulletin ACO, Winter / Hiver 2014

avons donc conçu un grand modèle animal pour mettre à l’essai des découvertes en vue de leur transition des laboratoires aux patients, mais aussi pour étudier en laboratoire les résultats obtenus auprès des patients, comme les données sur la pression du LCR, pour voir si on peut ainsi mieux comprendre le processus. » Cette approche translationnelle a franchi une étape importante avec la mise en œuvre d’essais cliniques sur un « agent neuroprotecteur », après de nombreuses années d’essais précliniques. Les essais cliniques pouvant prendre au moins une décennie, le Dr Kwon et ses collègues ont encore beaucoup de chemin à parcourir, et c’est pourquoi le Prix J.-Édouard-Samson tombe vraiment bien : « Une partie des fonds servira à élargir nos recherches, et une autre sera affectée à leur volet éducationnel, de sorte à approfondir l’aspect translationnel de nos travaux. De plus, recevoir ce prix nous aidera certainement à obtenir davantage de financement. Il s’agit d’un prix très important, et nous sommes très heureux que nos travaux soient ainsi reconnus. » Le Dr Geoffrey Johnston, président de la Fondation Canadienne d’Orthopédie, et la Dre Erin Boynton, présidente du Comité de la recherche de la Fondation, sont enchantés des travaux du Dr Kwon. « La Fondation a été créée il y a 50 ans précisément pour financer des recherches importantes comme celles du Dr Kwon, observe le Dr Johnston. Grâce au réputé Prix J.-Édouard-Samson, la Fondation peut s’enorgueillir de verser des fonds essentiels à l’avancement de l’innovation et de la recherche en orthopédie au Canada. »

InFuturum

Hip Symposium Brochure 2015_2013 2015-01-26 9:57 AM Page 1

Here you will learn of future orthopaedic-related activities.

Ici vous découvrirez les activités orthopédiques professionnelles à venir.

St. Justine Paediatric Review Course (SPORC) March 11-13 mars Montréal, QC Web Site/Site Int. : http://saac.chu-sainte-justine.org/ sporc2015eng.html

37th National CONA Conference Reaching New Horizons in Orthopaedics May 24-27 mai Fredericton, NB Web Site/Site Int. : www.cona-nurse.org

AAOS Annual Meeting March 24-28 mars COA Reception for Members on March 26 Las Vegas, NV Web Site/Site Int. : www.aaos.org

Annecy Live Surgery International Shoulder Advanced Course June 11-13 juin Annecy, France Web Site/Site Int. : www.lafosseshoulder-annecy.com

OTA Specialty Day March 28 mars Las Vegas, NV Web Site/Site Int. : http://ota.org/education/ specialty-day-2015/

CORA Annual Meeting June 17 juin Vancouver, BC E-mail/Courriel : coraweb@canorth.org Web Site/Site Int. : www.coraweb.org

The 13th Annual Canadian Orthopaedic Residents Forum April 10-13 avril Fairmont Palliser Hotel Calgary, AB Contact (er) : Tracy Burke Tel./Tél. : 403 220-3366 E-mail/Courriel : corf@ucalgary.ca

on M U I S O P 11 SYM

Joint Preserving and Minimally Invasive Surgery of the Hip World renowned faculty, interactive format including case base discussions on hip arthroscopy techniques, open hip surgery, FAI, dual mobility cups, short stems, anterior approach surgery as well as a hands on skills laboratory for hip arthroscopy, osteotomy and less invasive total hip replacements.

The Classic for Hip Courses

June 4-6, 2015 Fairmont Chateau Laurier, and University Of Ottawa Skills and Simulation Centre, Ottawa, ON, Canada

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

2015 June 17-20 juin Vancouver, BC 2016 June 16-19 juin Québec City, QC

2017 June 16-18 juin Ottawa, ON

2018 June 21-23 juin Victoria, BC

Paul E. Beaulé, MD, FRCSC Course Chair Professor of Surgery Chair, Division of Orthopaedic Surgery, University of Ottawa

COA Bulletin ACO, Winter / Hiver 2014

Article submissions to the COA Bulletin are always welcome! Contact: Cynthia Vezina Tel: (514) 874-9003 ext. 3 E-mail: cynthia@canorth.org

Les contributions au Bulletin de l’ACO sont toujours les bienvenues! Contacter : Cynthia Vezina Tél.: 514-874-9003, poste 3 Courriel : cynthia@canorth.org

www.coaannualmeeting.ca is your onestop-shop for everything to do with the COA Annual Meeting. Online registration, social event tickets, program updates, guest speaker biographies, travel, tours and hotel information, details about the CORA and CORS meetings and so much more. We are updating the site regularly so check back often to stay informed.

www.coaannualmeeting.ca

Le site www.coaannualmeeting.ca est un guichet unique où vous pouvez tout trouver sur la Réunion annuelle de l’ACO, qu’il s’agisse de l’inscription en ligne, de la réservation de billets pour les activités sociales, des mises à jour du programme, de la biographie des conférenciers invités, des renseignements sur les déplacements, les visites proposées et l’hébergement, ou encore des détails sur les réunions de l’ACRO (CORA) et de la SROC. Nous mettons régulièrement le site à jour, alors jetez-y un coup d’œil souvent pour rester informé!

COA Reception in Las Vegas

Réception de l’ACO à Las Vegas

All Association members are invited to attend the COA’s reception during the upcoming AAOS meeting in Las Vegas, Nevada.

Tous les membres de l’ACO sont invités à sa réception à l’occasion du congrès de l’American Academy of Orthopaedic Surgeons (AAOS), à Las Vegas, dans le Nevada.

The event will be held on Thursday, March 26 from 18:00-21:00. We look forward to seeing you there. Location: Skyview 2 room on the 26th floor Bally’s Las Vegas 3645 Las Vegas Boulevard South

COA Bulletin ACO, Winter / Hiver 2014

Cette activité aura lieu le jeudi 26 mars de 18 h à 21 h. Au plaisir de vous y voir! Lieu : Salle Skyview 2, au 26e étage du Bally’s Las Vegas 3645 Las Vegas Boulevard South

MaRK YoUR CaLenDaR!

CeLebRaTing The

bienniaL

CanaDian oRThopaeDiC fOOT & ANkle SyMPOSiUM

april 14-16, 2016 eaton Centre Marriott, Toronto Topics:

Course Directors:

• Ankle Salvage Procedure

Johnny Lau MD FRCSC (Co-Chair)

• Diabetic foot Dilemma • foot and Ankle Sport injuries

Assistant Professor of Orthopaedics Department of Surgery, University of Toronto UHN Toronto Western Hospital, Toronto, Ontario

back by popular demand!

Timothy Daniels MD FRCSC (Co-Chair)

Wet lab on April 14, 2016 Register early to avoid being on the waiting list!

cpd.utoronto.ca/footankle

Associate Professor of Orthopaedics Department of Surgery, University of Toronto St. Michael’s Hospital, Toronto, Ontario

THERE’S A REASON SOME ORIGINALS ENDURE. Proven – Backed by 40 years of proven clinical performance.1,2 Progressive – Backed by an active medical education and design panel.3 One – Streamlined system for Primary, Revision and Hip Fracture procedures.4 To find out more about how one stem can fit all your needs, contact your Stryker Representative. 1. “The long-term results of the original Exeter polished cemented femoral component” Ling R, Charity J, Lee A, Whitehouse S, Timperley A, Gie G Journal of Arthroplasty, (2009); 24(4):511-1 2. National Joint Registry for England and Wales. 9th Annual Report 2012 3. The Exeter Hip 40 years of Innovation in Total Hip Arthroplasty. Issue 1. Ling et al. Exeter Hip Publishing 2010 4. The Exeter Hip 40 years of Innovation in Total Hip Arthroplasty. Issue 1. Chapter 3.1 “Exeter Hip Instrumentation” J Howell. Exeter Hip Publishing 2010

A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any Stryker product. 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 Stryker representative if you have questions about the availability of Stryker products in your area. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. EXETER-AD-1 © 2013 Stryker Corporation. All rights reserved. Printed in the USA.

Information you and your patients can trust. Reliable, surgeon-approved resources to help your patients’ understanding and help you to reclaim time. Tips For A More Speedy And Comfortable Recovery After Elective

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Une source de renseignements à laquelle vos patients et vous pouvez vous fier. Ces documents fiables et approuvés par des orthopédistes aident vos patients à comprendre leur situation tout en vous permettant de gagner du temps. Conseils Pour Un Rétablissement Rapide Et Agréable Après

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Active for Life From June 17-20, 2015, the Canadian orthopaedic community will come together in beautiful Vancouver, British Columbia. Iconic landscapes and breathtaking views will provide an ideal setting for those who enjoy an active lifestyle. It’s why we chose Vancouver to represent our 2015 theme: Active for Life. Orthopaedics is one of the most optimistic disciplines in medicine, where patient outcomes are often dramatic and quality of life soars. Our common goal is to ensure that our skills contribute to an active life for those we care for, and the lifestyle orthopaedics for Canadians.

coaannualmeeting.ca

Plan to join us June 17-20, 2015.

Actif pour la vie Du 17 au 20 juin 2015, la communauté orthopédique canadienne se réunira dans le cadre enchanteur de Vancouver, en Colombie-Britannique. Les paysages emblématiques et personnes privilégiant un mode de vie actif. C’est pourquoi nous

L’orthopédie est l’une des disciplines médicales les plus optimistes, puisque les patients obtiennent souvent des résultats spectaculaires, retrouvant une excellente qualité de vie. Notre objectif commun est de veiller à ce que nos compétences permettent à ceux que nous soignons d'avoir une vie active, et le mode de vie caractéristique de Vancouver est tout à fait désigné canadienne. Soyez des nôtres du 17 au 20 juin 2015.

COA Annual Meeting Réunion annuelle de l’ACO CANADIAN ORTHOPAEDIC ASSOCIATION ASSOCIATION CANADIENNE D'ORTHOPÉDIE

CANADIAN ORTHOPAEDIC RESEARCH SOCIETY SOCIÉTÉ DE RECHERCHE ORTHOPÉDIQUE DU CANADA

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Reference 1). Orthopedic Network News. A 2012 Extremity Update. Vol23 No 1. 2012.

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