__MAIN_TEXT__

Page 1

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

BULLETIN

Canadian Orthopaedic Association Association Canadienne d’Orthopédie HIGHLY TRAINED AND UNDEREMPLOYED:

ARE WE MAKING PROGRESS IN OUR PROFESSIONAL CRISIS?............................... p. 30

HAUTEMENT SPÉCIALISÉS ET SOUS-EMPLOYÉS :

Y A-T-IL DU PROGRÈS DANS LA CRISE TOUCHANT NOTRE PROFESSION?................................... p. 32

Summer Été 2019

124

#

Publication Mail Envoi Poste-publication Convention #40026541

4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3

www.coa-aco.org

Le président de l’ACO souligne l’importance de l’engagement des members� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3 Code Orange - Lessons Learned from Ottawa’s Mass Casualty Response � � � � � � � � � � � � � 20 Introducing Competence by Design (CBD) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41 New Bulletin Feature Highlights ‘Canadian Perspectives’� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 44

e: Ruptur o! n o d n ld d s Te Achille hat you wou w Tell us n: lcanée ! a c n o z nd us ferie e du te Ruptur ous ce que vo Dites-n


A NEW APPROACH to Biofilm Removal

Bactisure™ Wound Lavage is used to remove debris, including microorganisms, from wounds using pulsed (jet) lavage. Moreover, independent laboratory testing shows that Bactisure Wound Lavage can effectively remove common wound pathogens including the bacteria found in biofilms1,2.

How it Works: •

Breaks up crosslinks within biofilm EPS1,3

Solubilizes biofilms for easy removal via pulsed lavage1,3

Subjects exposed bacteria to lavage removal or inactivation via traditional antibiotics and the body’s normal defense mechanisms1,3

For more information visit zimmerbiomet.com/surgical or contact your local representative.

References 1. Antimicrobial Test Labs, Inc. study GLP1175. 2. Dr. Garth James, Montana State University Center for Biofilm Education; Next Science report TR-02-14-010. 3. Dr. Garth James, Montana State University Center for Biofilm Education; Next Science report TR-02-14-025. ©2018 Zimmer Biomet


Your COA / Votre association

Bulletin Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 124 - Summer / Été 2019 COA / ACO Mark Glazebrook President / Président Brendan Sheehan Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Paul A. Martineau Scientific Editor / Rédacteur scientifique William Weiss Current Issues Editor Rédacteur, questions d’actualité Cynthia Vézina Managing Editor Adjointe au rédacteur en chef Lexie Bilhete Editorial Assistant / Adjointe à la rédaction Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541

3

COA President Emphasizes the Importance of Member Engagement Le président de l’ACO souligne l’importance de l’engagement des membres

C

ongratulations are extended to Dr. Mark Glazebrook on becoming the 74th President of the Canadian Orthopaedic Association. During his President Elect Address delivered at the Annual Meeting, Dr. Glazebrook emphasized the importance and impact of member engagement: I want to begin by sharing my opinion and insight on your Canadian Orthopaedic Association. For me, what is most important for us all to understand is that we are the COA. Every one of you out there is a driving force of the COA, and if we want the COA to accomplish something, it falls on us to take action and do it. Your COA has over 1,300 members, along with an Executive Committee, Board of Directors, and multiple volunteer committees working behind the scenes. Of course, the dedicated staff acts as the driving engine behind the COA, there to help you and support the things that need to get done. Remember: You make up the COA. […] Let’s improve our specialty together. I’d ask you to bring your ideas and innovative projects to action by working with the Association. The COA has been addressing challenges but it needs you. Ask not what your COA can do for you, but what you can do for your COA.

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.

The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4060 St. Catherine Street West, Suite 620, Westmount, Quebec, H3Z 2Z3. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: cynthia@canorth.org

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

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

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

COA Bulletin ACO - Summer / Été 2019


Your COA / Votre association

4

(continued from page 3)

Toutes nos félicitations au Dr Mark Glazebrook, qui est devenu le 74e  président de l’Association Canadienne d’Orthopédie. Pendant son allocution à titre de président élu, à la Réunion annuelle, le  Dr  Glazebrook a souligné l’importance de l’engagement des membres.

Click here to read Dr. Glazebrook’s complete President Elect Address Cliquez ici pour lire l’allocution en anglais du Dr Glazebrook à titre de président élu

Cover photo credit: Dr. Yousef Marwan From l to r: Jordana Serrero (Med3), Drs. Susan Ge (R3), Bayan Ghalimah (R3), Ruth Chaytor (Ortho Staff) – McGill University

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 19 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 29 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 41

The Year in Review John Antoniou M.D., FRCSC Immediate Past President Canadian Orthopaedic Association

T

he past year was filled with challenges, interactions, advocacy, and planning. Our travels took Johanna and I around the world, where we had fruitful exchanges with our sister associations discussing our distinct challenges and how they are addressed in different health-care environments. These included orthopaedic human resources, diversity and trainee selection, surgeon performance review, end of career transition, and relationships with subspecialty societies. We also attended several presidential symposia throughout the year. At the British Orthopaedic Association meeting, the Carousel presidents discussed the role of physician assistants in our respective countries. It was reported that Canada currently has the lowest concentration of orthopaedic surgeons per 100,000 population in the Western world (3.6/100k), which is less than half that in the US, and a far cry from Sweden (19.5/100k). At the Australian Orthopaedic Association meeting, we discussed spiralling health-care costs around the world with varied system performances. Canada spends 10% of its GDP on health care, yet ranks 9th out of 11 industrialized nations when it comes to markers of performance. This compares poorly to Australia’s 9% of GDP with a 2nd place ranking. At the South African Orthopaedic association meeting, all carousel presidents presented on the subject of physician wellCOA Bulletin ACO - Summer / Été 2019

ness in their respective countries. Shockingly, orthopaedic surgeon burnout rates have reached over 50% in some parts of the world. The COA’s CPD Committee led by Drs. Veronica Wadey and Carrie Kollias distributed a wellness survey to the entire membership. The results indicate that 55% of attending surgeons and 40% of trainees screened positive for distress using validated outcome tools. At our COA Annual Meeting this year, the Carousel presidents shared ideas on the important symposium topic of “Identifying and managing surgeon under performance and surgeon competence”. Being able to evaluate our performance is critical to positive professional growth. Throughout the year, I met with representatives from provincial associations in British Columbia, Alberta, Ontario and Nova Scotia amongst others to discuss current issues and strategies in


Your COA / Votre association

5

(continued from page 4)

orthopaedic advocacy and development. The COA offers advocacy resources and materials needed to facilitate conversations with respective ministries. Dr. Olga Huk from our Association met with Québec health ministry representatives to go through the logistics of populating the province’s data into the Canadian Joint Replacement Registry through the use of the hospital DAD information. The new government in Québec seems keen on finally making this happen, which would achieve over 90% compliance for the CJRR. We continue to advocate on physician employment and under employment issues. When the Royal College published a report on the job status of newly certified specialists, highlighting the underemployment issue in resource-intensive specialties, we responded with an advocacy push resulting in press coverage. The paradox of having the lowest orthopaedic surgeons per capita in the G7, and the longest wait times while having unemployed graduates points to the bottleneck being government underfunding rather than an overtraining issue. As a short-term solution, programs have reduced the number of CARMS spots from 81 in 2011 to 52 in 2018. This begs the question: will there be enough trained surgeons available in the future to serve the needs of an aging population? Further limiting the number of trainees may compromise patient care in future decades. We must continue our longstanding advocacy effort for improved access to care and increased resources dedicated to orthopaedic care in Canada.

Through the leadership of Dr. Jeff Gollish and the Standards Committee, the COA published a position statement on responsible opioid use in clinical practice in 2018. We have also been working on a cobranded COA, AAC, and CAS position statement on Intra-Articular injections for Knee Osteoarthritis which will be published shortly. Position statements are an important part of the COA’s mission. They set standards of care and medico-legal precedents. It is incumbent upon our Association to ensure that COA positions are standardized, regularly reviewed, and updated when necessary. We formed a subcommittee headed by Dr. Mohit Bhandari to formalize this process, and thank them for their good work. As part of our diversity efforts, an annual session for local women medical and undergraduate students was inaugurated at this year’s meeting. The session is meant to increase exposure to our specialty, debunk myths, and encourage discussion with role models and leaders in the profession. On the topic of research, a big part of our year was spent organizing and promoting this important combined meeting. As a clinician scientist, I’m proud of the work we have done to organize the largest COA meeting to date. The program promoted interaction and fruitful collaboration between clinicians and scientists from around the globe. Johanna and I are honoured to have served over the past year. Thank you to the Executive, the Board and the COA staff for their work and support.

Retour sur l’année John Antoniou, MD, FRCSC Président sortant Association Canadienne d’Orthopédie

L

a dernière année a été remplie de défis, d’interactions, d’activités de défense des droits et intérêts et de planification. Johanna et moi avons voyagé partout dans le monde, ce qui nous a permis d’avoir des échanges fructueux avec nos homologues à propos de nos défis respectifs et de la façon dont nous les relevons dans des milieux de soins différents. Parmi ces défis, mentionnons les ressources humaines en orthopédie, la diversité et la sélection des résidents et fellows, l’évaluation de la performance des orthopédistes, la transition en fin de carrière et les relations avec les sociétés de sous-spécialité. Nous avons en outre assisté à plusieurs symposiums des présidents des associations d’orthopédie membres du groupe Carousel. Au congrès de la British Orthopaedic Association, les présidents du groupe Carousel ont discuté du rôle des adjoints au médecin dans leur pays. On a signalé que c’est au Canada qu’on trouve actuellement le taux d’orthopédistes par 100  000  habitants le plus faible en Occident (3,6/100 000 habitants), soit moins de la moitié qu’aux États-Unis, et bien moins que la Suède  (19,5/100  000  habitants). Au congrès de l’Australian Orthopaedic Association,

on a discuté de la hausse vertigineuse des coûts en santé partout dans le monde et des variations de rendement des systèmes de santé. Le Canada consacre 10 % de son PIB aux soins de santé, mais figure au neuvième rang parmi 11  pays industrialisés pour ce qui est des indicateurs de rendement. La comparaison avec l’Australie est peu flatteuse : elle y consacre 9 % de son PIB, mais arrive au deuxième rang. Au congrès de la South African Orthopaedic Association, chaque président du groupe Carousel a traité du mieux-être des médecins dans son pays. J’ai été stupéfait d’apprendre que le taux d’épuisement professionnel chez les orthopédistes atteint plus de 50 % dans certains pays. Le Comité de perfectionnement professionnel  (CPP) de l’ACO, sous la houlette des Dres  Veronica  Wadey et Carrie Kollias, a envoyé à tous les membres un sondage sur le mieux-être. Selon les résultats obtenus au moyen d’outils validés, 55 % des orthopédistes et 40 % des résidents et fellows sont en détresse. Cette année, à la Réunion annuelle de l’ACO, les présidents ont échangé sur le sujet important choisi pour le symposium : « Déceler et gérer les problèmes de performance et de compétence des orthopédistes.  » La capacité d’évaluer notre performance est essentielle à notre épanouissement professionnel. J’ai rencontré toute l’année des représentants des associations provinciales, dont celles de la Colombie-Britannique, de COA Bulletin ACO - Summer / Été 2019


Your COA / Votre association

6

(suite de la page 5)

l’Alberta, de l’Ontario et de la Nouvelle-Écosse, afin de discuter des enjeux actuels et des stratégies de défense des droits et intérêts et de développement en orthopédie. L’ACO offre les ressources et le matériel de défense des droits et intérêts nécessaires dans les conversations avec les ministères provinciaux. La Dre Olga Huk, de l’ACO, a rencontré les représentants du ministère de la Santé du Québec dans le but de revoir la logistique derrière l’intégration des données du Québec au Registre canadien des remplacements articulaires  (RCRA) par l’intermédiaire de la Base de données sur les congés des patients (BDCP) des hôpitaux. Le nouveau gouvernement semble tenir à aller de l’avant, enfin, ce qui permettrait d’atteindre un taux de conformité de plus de 90 % pour le RCRA. Nous continuons de nous faire entendre sur les enjeux de l’emploi et du sous-emploi des médecins. Quand le Collège royal a publié un rapport sur la situation d’emploi des médecins spécialistes nouvellement certifiés, soulignant les difficultés à trouver un emploi dans les spécialités qui nécessitent beaucoup de ressources, la campagne de défense des droits et intérêts que nous avons lancée en réaction a trouvé écho dans les médias. Le paradoxe de compter le nombre d’orthopédistes par habitant le plus faible des pays du G7 et d’avoir les temps d’attente les plus longs, tandis que des diplômés n’ont pas d’emploi, suggère qu’il s’agit d’un problème de sous-financement plus que de surformation. Comme solution à court terme, les responsables des programmes ont réduit les jumelages dans CaRMS, qui sont passés de 81 en 2011 à 52 en 2018. Cela soulève une question : y aurat-il suffisamment d’orthopédistes disponibles pour répondre aux besoins de la population vieillissante? Limiter davantage le nombre de places en formation pourrait compromettre les soins pendant des décennies. Nous devons poursuivre nos efforts de longue date et militer pour une amélioration de l’accès aux soins et une augmentation des ressources allouées aux soins orthopédiques au Canada.

Winners Announced: COA Diversity in Leadership Scholarship

T

he COA is pleased to announce the winners of the inaugural Diversity in Leadership Scholarship, Dr. Patricia Larouche from the Centre mère-enfant du Centre hospitalier universitaire de Québec and Dr. Magdalena Tarchala from McGill University, who will be awarded $500 each to defray costs of attending a leadership course of their choice. Honourable mention goes to Dr. Kelly Hynes from the University of Chicago and Dr. Teresa Li from the University of Alberta. Please join us in congratulating these successful applicants. The COA is committed to promoting access to leadership opportunities in order to develop and support underrepresented groups within the orthopaedic community. Look out for the next application period to be announced in the Spring of 2020. Dr. Patricia Larouche COA Bulletin ACO - Summer / Été 2019

Grâce au leadership du Dr Jeff  Gollish et du Comité sur les normes, l’ACO a publié en 2018 un énoncé de position sur l’usage responsable des opioïdes en pratique clinique. L’ACO a également collaboré à la rédaction d’un énoncé de position conjoint avec l’Arthroscopy Association of Canada  (AAC) et la Société canadienne d’arthroplastie  (CAS) sur les infiltrations intraarticulaires dans le traitement de l’arthrose du genou qui paraîtra sous peu. Les énoncés de position constituent une part importante de la mission de l’ACO et établissent des normes de soins et des précédents médicolégaux. Il incombe à notre association de s’assurer que les énoncés de position sont normalisés, revus régulièrement et mis à jour au besoin. Nous avons créé un souscomité, présidé par le Dr Mohit Bhandari, en vue d’officialiser ce processus, et nous en remercions les membres pour leur bon travail. Dans le cadre de nos initiatives en matière de diversité, une première séance annuelle à l’intention des étudiantes locales en médecine de tous les cycles a eu lieu à la dernière réunion annuelle. La séance a pour but de donner de la visibilité à la spécialité, de détruire les mythes et de favoriser la discussion avec des modèles et des leaders dans la profession. Enfin, pour ce qui est de la recherche, nous avons consacré une bonne partie de l’année à l’organisation et à la promotion de cette importante manifestation conjointe. En tant que clinicien-chercheur, je suis fier du travail que nous avons accompli en organisant la plus imposante Réunion annuelle de l’ACO à ce jour. Le programme favorisait les interactions et les collaborations fructueuses entre cliniciens et chercheurs de partout dans le monde. Johanna et moi sommes fiers de vous avoir servis depuis un an. Merci au Comité de direction, au conseil d’administration et au personnel de l’ACO pour leur travail et leur soutien.

Annonce des lauréates de la bourse Diversité et leadership de l’ACO

L

’ACO est heureuse d’annoncer les lauréates de sa première bourse Diversité et leadership, les Dres  Patricia  Larouche, du Centre mère-enfant du Centre hospitalier universitaire de Québec, et Magdalena Tarchala, de l’Université McGill, qui recevront chacune 500 $ en vue d’assister à un cours ou à une conférence sur le leadership de leur choix. Les Dres Kelly Hynes, de l’université de Chicago, et Teresa Li, de l’Université de l’Alberta, méritent quant à elles des mentions honorables. Veuillez vous joindre à nous pour féliciter ces lauréates!

Dr. Magdalena Tarchala

L’ACO s’engage à promouvoir l’accès à des possibilités de leadership de sorte à favoriser et soutenir les groupes sousreprésentés au sein de la communauté orthopédique. Ne manquez pas la prochaine période de soumission de candidatures, qui sera annoncée au printemps 2020.


Your COA / Votre association

7

#101020: COA Staff Members Celebrate Milestones Brendan Sheehan, M.D., FRCSC Secretary, Canadian Orthopaedic Association

A

t the recent Annual Meeting, three staff members celebrated significant professional anniversaries and were recognized for their years of service at the COA head office. Dedicated and consistent staff are crucial to the successful accomplishment of the COA’s mission and vision. We thank them for their hard work, commitment and salute their #101020 years of loyal service. 10 Years of Service Trinity Wittman first joined the COA staff in 2006 as Meetings & Fellowships Coordinator. Here she excelled thanks to her keen eye for detail and drive for innovation and improvement. In 2010, Trinity took maternity leave and subsequently left the COA while she had her two daughters and completed her Masters degree. In the Fall of 2014, the COA was fortunate enough to hire her again, this time as Manager, Development and Advocacy. In this role, Trinity oversees external communications, manages our government relations and advocacy program, supports the committees in their important work, and works closely with the subspecialty societies. “The COA’s advocacy and development focus has progressed with the needs of its membership throughout my time at the Association. Being part of that effort to develop diversity projects, our global surgery committee, employment strategies, and social awareness programs has been extremely inspiring and exciting. Working at the COA is truly a unique experience, and I draw on the positive energy and mentorship from collaborating so closely with my colleagues, our leadership, and committee members.”  - Trinity When Trinity left our employ for her maternity leave, the COA hired Meghan Corbeil as our Meetings & Events Manager. She proved so adept at juggling the myriad of details involved in planning meetings, that COA staff managed to convince her to stay on a permanent basis. Meghan has demonstrated the ability to work under tremendous pressure and still maintain a sense of humour and grace. Her troubleshooting skills, quick decision-making capability, and big picture thinking have greatly served COA events over the past ten years. “Seeing the Annual Meeting grow and develop into the event it is today has been such a rewarding experience. Member participation and educational content continues to improve and expand every year, and I am grateful to play a role in such an extraordinary meeting. Getting to see so much of our incredible country through this process is also one of the highlights of my ten years at the COA.” - Meghan

Meghan Corbeil, Trinity Wittman and Cynthia Vezina celebrate significant COA anniversaries this year

20 Years of Service Cynthia Vezina joined the COA staff in March of 1999 as Administrative Coordinator. Throughout the years, her performance excellence has earned her increasingly senior positions, becoming involved in almost every aspect of the COA’s operations, projects, and initiatives. In 2016, she was promoted to Executive Director, Strategic Initiatives where she has introduced tremendous levels of innovation to the COA. In January 2020, Cynthia will assume the role of CEO as Doug Thomson retires from the position. Her vision for the COA and future successes will continue to be instrumental for the organization. “It’s an honour to see so many of the residents I used to work with now in positions of leadership making significant impact on Canadian orthopaedics. In many ways, we’ve grown up together and developed our careers with each other’s support. I am grateful to have been on this path with our members over the past 20 years, and I look forward to this next chapter as CEO.” - Cynthia

COA Bulletin ACO - Summer / Été 2019


Your COA / Votre association

8

#101020 : Célébration de jalons pour des membres du personnel de l’ACO Brendan Sheehan, MD, FRCSC Secrétaire de l’Association Canadienne d’Orthopédie

À

la dernière réunion annuelle, trois membres du personnel célébraient des anniversaires professionnels marquants, et on en a profité pour souligner leurs années de service aux bureaux de l’ACO. Un personnel dévoué et stable est essentiel à la concrétisation de la mission et de la vision de l’ACO. Nous les remercions pour leur travail acharné et leur engagement et saluons leurs #101020 années de loyaux services. 10 années de service Trinity Wittman s’est jointe à l’équipe de l’ACO en 2006 à titre de coordonnatrice des réunions et des bourses. Elle s’est distinguée par son grand souci du détail et sa quête constante d’innovation et d’amélioration. En 2010, Trinity a pris un congé de maternité, puis a quitté l’ACO pour élever ses deux filles et effectuer sa maîtrise. À l’automne  2014, l’ACO a eu la chance de pouvoir la réembaucher, cette fois en tant que directrice du développement et des activités de défense des droits. À ce titre, Trinity supervise les communications externes, gère nos relations gouvernementales et nos activités de défense des droits et intérêts, appuie les comités dans leurs importants travaux et travaille en étroite collaboration avec les sociétés de sous-spécialité. « Le volet de défense des droits et intérêts et de développement de l’ACO a évolué avec les besoins de ses membres au fil de mes années passées à l’Association. Participer à cet effort de création de projets axés sur la diversité, aux activités de notre comité Planète  ortho, à nos stratégies sur la situation d’emploi et à nos programmes de sensibilisation sociale a été extrêmement inspirant et passionnant. Travailler à l’ACO est une expérience tout à fait unique, et je me nourris de l’énergie positive et de l’encadrement que permet une collaboration si étroite avec mes collègues, notre direction et les membres de nos comités. » – Trinity Quand Trinity est partie en congé de maternité, l’ACO a embauché Meghan Corbeil à la direction des réunions et des bourses. Elle s’est avérée si douée pour jongler avec la foule de détails inhérents à la planification de réunions que le personnel de l’ACO s’est arrangé pour la convaincre de rester en permanence. Meghan a prouvé sa capacité de travailler sous une énorme pression tout en gardant son sens de l’humour et sa grâce. Sa capacité à résoudre les problèmes et à prendre des décisions rapidement, de même qu’à avoir une perspective globale, a été fort utile pendant les manifestations de l’ACO de la dernière décennie.

COA Bulletin ACO - Summer / Été 2019

« Voir la Réunion annuelle prendre l’ampleur qu’elle a aujourd’hui est tellement gratifiant. La participation des membres et le contenu scientifique continuent de s’améliorer chaque année, et je suis heureuse de jouer un rôle dans une manifestation si extraordinaire. Avoir la possibilité de parcourir notre fabuleux pays par la même occasion fait aussi partie des grands plaisirs de mes dix années à l’ACO. » – Meghan 20 années de service Cynthia Vezina est arrivée à l’ACO en mars 1999 à titre de coordonnatrice de l’administration. Au fil des ans, son excellence lui a valu de gravir progressivement les échelons et de s’impliquer dans presque tous les volets des activités, projets et initiatives de l’ACO. En 2016, elle a été promue directrice générale des Initiatives stratégiques, poste qui lui a permis d’apporter beaucoup d’innovations au sein de l’ACO. En janvier  2020, Cynthia prendra la relève de Doug Thomson à la direction de l’Association. Sa vision pour l’ACO et ses réalisations futures continueront d’être essentielles à notre organisation. « C’est un honneur de voir autant des résidents avec qui j’ai travaillé occuper des postes de leadership et avoir une incidence considérable sur l’orthopédie au Canada. De bien des façons, nous avons grandi ensemble et nous nous sommes appuyés les uns les autres dans nos carrières. Je suis reconnaissante d’avoir parcouru ce chemin avec nos membres au cours des 20  dernières années, et j’ai hâte d’entamer ce nouveau chapitre en tant que directrice de l’Association. » – Cynthia

Appel de témoignages de membres de l’ACO Qu’est-ce que votre adhésion à l’ACO vous apporte? Comment profitez-vous des services et des avantages offerts aux membres? Assistez-vous à la Réunion annuelle? L’ACO aimerait obtenir votre témoignage et le publier sur son site Web afin de faire connaître l’opinion de ses membres et la manière dont ils utilisent leur adhésion. Vous souhaitez participer? Rien de plus facile! Écrivez à Lexie Bilhete, à lexie@canorth.org, pour plus de renseignements.


Your COA / Votre association

9

Diversity in the COA: Spotlight on Women in Orthopaedics with Dr. Colleen Weeks Lexie Bilhete Coordinator, Membership Services & Affiliate Programs Canadian Orthopaedic Association

D

r. Colleen Allison Weeks works at the Royal Alexandra Hospital in Edmonton, Alberta, specializing in adult reconstruction surgery. She attended medical school at the Northern Ontario School of Medicine and completed her residency training at the University of Alberta. Dr. Weeks went on to complete two fellowships, at both Western University and University of Alberta, in arthroplasty. Read her powerful, insightful, and truly inspiring interview below! 1) What drew you to orthopaedics (and your subspecialty)? I started my academic career as an engineering physicist with a minor in mechanical engineering. I was drawn to understanding how things work, but also to challenging myself with the most The COA recognizes the difficult program possible. I had always strength in diversity and considered medicine, having been on the promotes equity across its wrong side of the knife on an orthopaedic OR table multiple times in my younger, membership, services, and sportier days. Knowing how difficult entry all community engagement. into Ontario medical schools can be, I wantEach edition of the COA ed a solid backup career. Had engineering Bulletin will feature one of worked out, I’d have aimed to work buildthe many women members ing engines for Ferrari, or perhaps work on of the Association, their rocket propulsion systems for NASA.

several years. His father brought him to us via bus, travelling thousands of kilometres and then carried his son on his back to get him to CAMTA – all for a chance for him to walk again. Less than 12 hours after we replaced both of his hips, he walked down the hall singing “Eye of the Tiger”. I’ve never been prouder to be an orthopaedic surgeon, and I will forever carry it with me during the tough times.

3) What does diversity mean to you? Diversity in an interesting concept. It means not experiences and insights, having to build a class of medical students or Ultimately, I chose to specialize in arthrocontributions to the specialty residents chosen only to “tick boxes” and make plasty for three reasons: 1) Hitting things and advice for junior a program on paper show up as “diverse”. For really hard makes me happy; 2) The majorme, the day we reach true diversity is when colleagues and students. Get ity of the patients we treat recover well and marginalized people (women, people of colour, to know the membership! there is a huge overall societal gain from it; LGBQT+) have been empowered to the point 3) I still work with the technology that drew that they can compete on an equal playing field me into engineering, and there is no end of complex cases with the traditionally privileged. It is when we are all repthat require a team problem-solving approach. I never resented based on merit, no longer needing preferential want to be bored, and arthroplasty provides a constant hiring. I hope for the day that, as a female surgeon, I can challenge. walk into a room with five male residents and finally have someone assume I am the surgeon. It is the day I no longer 2) Can you recount a defining moment in your career thus have to answer questions like “do you do the surgeries?”, “do far? women really belong in this field” and “are you really strong I recently had the privilege of accompanying the Canadian enough?”. I will do everything I can to support the change Association of Medical Teams Abroad (CAMTA) on a trip to needed to make these experiences a thing of the past. Quito, Ecuador. Burnout is a huge issue in our profession, constantly being immersed in difficult situations with our 4) What advice would you give to orthopaedic residents? patients day after day wears on one’s spirit. I was struggling Orthopaedic residency is hard. The actual challenge of to find some joy in my local practice prior to leaving for which is really only understood by the lucky few accepted Quito. Thankfully, my time in Ecuador restored drive and into the elusive world. It’s designed this way because at passion for my profession. The most memorable patient the end of those five years you are expected to emerge we treated was a young man with a bone disease unable to as a superhuman, fearless and able to operate on whatwalk for over a year. Ecuador is an extremely hilly country ever comes through the door. We don’t get there instantly, with minimal handicapped access, and he was trapped in and there are many hard days throughout the program. his jungle home, depressed and contemplating suicide for My advice would be to understand you are definitely COA Bulletin ACO - Summer / Été 2019


Your COA / Votre association

10

(continued from page 9)

not alone. Everyone else is also struggling, regardless of the confidence portrayed on the outside. Sometimes a resident just needs a colleague to say they’re also having a hard time, to normalize just how tough residency is. You’re not the first or last to go through this, and there is an army of people out there who want nothing more than to make it easier for you. Just reach out and you will be amazed at the number of people standing beside you. 5) What is one professional goal and one personal goal you hope to achieve in the next five years? My professional goal is to gain entry into the Hip Society through the American Academy of Orthopaedic Surgeons. It has a notoriously low number of women members and I believe this discourages qualified women from entering the field. My goal is to gain membership and use this to show young women in orthopaedics that hip arthroplasty is a reachable goal for women, and that I support them in their future endeavors and am working diligently to remove any barriers from choosing this as a career.

For a personal goal, I recently got married to the most amazing, supportive partner I could ever have imagined. But because of residency, I am starting my family life 15 years later than the average woman. As we are both in our late thirties, this comes with certain challenges. We are currently in the process of having a baby through either IVF or adoption. Both are challenging enough without running a full-time surgical practice. I am very lucky to work with a supportive group of colleagues, but this is not always the case for women in medicine. My partner and I hope that being open with our struggles will help destigmatize infertility in the medical field, and make the hard journey for the up to one in three women facing similar circumstances just a little bit easier. 6) Name one of your go-to tricks or hacks that has helped you in your day to day life? I have two go-to life hacks that help a lot. My friends know I am absolutely terrible for misplacing items (including my car after a very long day). I found these fabulous devices called Tiles that track where your lost objects are located, such as your keys, ID cards, parking passes, wallet, and cell

phone. If you’re so focused on work, passing your exam or patient care you can use these devices to save a little brain space for more important things.

My second life hack is to hire someone to help with the little things in life that take time away from studying, or more importantly, getting some work-life balance. Try to hire a housecleaner or send laundry out whenever possible – I also buy a lot of pre-shopped meals. Your family and personal time are so precious, don’t waste it. In 20 years, you won’t look back and think: damn, I’m happy I cleaned that floor myself!

Diversité au sein de l’ACO : Pleins feux sur les femmes en orthopédie avec la Dre Colleen Weeks Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés Association Canadienne d’Orthopédie

L

a Dre Colleen  Allison  Weeks travaille à l’hôpital Royal Alexandra, à Edmonton, en Alberta, où elle se spécialise en chirurgie de reconstruction chez l’adulte. Diplômée de l’École de médecine du Nord de l’Ontario, elle a fait sa résidence à l’Université de l’Alberta. Elle a ensuite fait deux spéCOA Bulletin ACO - Summer / Été 2019

cialisations, à l’Université Western et à l’Université de l’Alberta, en arthroplastie. Voici l’entrevue forte, perspicace et vraiment inspirante qu’elle nous a donnée! 1) Qu’est-ce qui vous a amenée à choisir l’orthopédie (et votre sous-spécialité)? J’ai commencé ma carrière universitaire en tant qu’ingénieure physicienne, avec une mineure en génie mécanique. Je cherchais à comprendre le fonctionnement des choses, mais aussi à me mettre au défi en choisissant le


Your COA / Votre association

11

(suite de la page 10)

programme le plus difficile possible. J’avais toujours envisagé la médecine, étant passée sous le bistouri en chirurgie orthopédique plusieurs fois dans ma jeunesse plutôt sportive. Comme je savais à quel point il peut être difficile d’être admise en médecine en Ontario, je voulais un plan B solide. Si ça avait fonctionné en génie, j’aurais essayé de concevoir des moteurs chez Ferrari, ou peut-être des systèmes de propulsion par fusée pour la NASA. En fin de compte, j’ai choisi de me spécialiser en arthroplastie pour trois raisons : 1) frapper très fort sur des choses me rend heureuse; 2) la majorité des patients que nous traitons se rétablissent bien, et des avantages sociétaux énormes en découlent globalement; 3)  je travaille toujours avec la technologie qui m’a attirée en génie, et il y a énormément de cas complexes qui nécessitent une approche d’équipe pour résoudre les problèmes. Je ne veux pas m’ennuyer, et l’arthroplastie est une source constante de défis. 2) Racontez-nous un moment marquant de votre carrière. J’ai récemment eu le privilège d’accompagner la Canadian Association of Medical Teams Abroad (CAMTA) à Quito, en Équateur. L’épuisement professionnel est un enjeu majeur en orthopédie; être constamment plongés, jour après jour, dans des situations difficiles avec nos patients finit par miner le moral. Avant de partir pour Quito, j’avais beaucoup de mal à trouver du plaisir dans ma pratique locale. Heureusement, mon voyage en Équateur a ravivé mon dynamisme et ma passion pour ma profession. Le patient le plus inoubliable que nous avons traité était un jeune homme atteint d’un trouble des os qui ne pouvait plus marcher depuis plus d’un an. L’Équateur est un pays extrêmement accidenté et L’ACO reconnaît la force inhérente très peu accessible aux personnes hanà la diversité et fait la promotion dicapées, et il était prisonnier de sa maid’une culture d’équité chez ses son dans la jungle, dépressif et suicidaire membres ainsi qu’en ce qui a trait depuis plusieurs années. Son père nous l’avait amené en autobus, un trajet de à ses services et à son engagement milliers de kilomètres, puis l’avait porté communautaire. Chaque numéro sur son dos jusqu’aux installations de du Bulletin comprendra le portrait la CAMTA, tout ça pour lui donner une de l’une des nombreuses femmes chance de remarcher. Moins de 12 heures membres de l’ACO. On en apprendra après une double arthroplastie de la davantage sur son expérience hanche, il marchait dans le corridor en et ses idées, sa contribution à la chantant «  Eye of the Tiger  ». Je n’ai jamais été aussi fière d’être orthopédiste, profession et ses conseils pour ses et je vais toujours m’en souvenir dans les jeunes collègues et les étudiants. moments difficiles. Apprenez à connaître vos collègues! 3) Pour vous, que signifie la diversité? La diversité est un concept intéressant. Ça ne signifie pas choisir des étudiants en médecine ou des résidents seulement pour « cocher des cases » et rendre un programme plus «  diversifié  » sur papier. Pour moi, nous atteindrons une véritable diversité le jour où des personnes marginalisées (femmes, minorités visibles, LGBTQ+) pourront compétitionner sur un pied d’égalité avec les gens traditionnellement privilégiés. C’est lorsque nous serons tous représentés en fonction du mérite et que nous n’aurons plus besoin d’embauche préférentielle. Je rêve au jour où, en tant que chirurgienne, je pourrai entrer dans une salle avec cinq résidents masculins et que quelqu’un présumera

enfin que je suis l’orthopédiste. Ce sera le jour où je n’aurai plus à répondre à des questions comme : «  Vous faites les chirurgies?  », «  Les femmes ont-elles vraiment leur place dans ce domaine?  » et «  Êtes-vous vraiment assez forte? » Je ferai tout ce que je peux pour favoriser les changements nécessaires pour faire de ces expériences une chose ancienne.

4) Quels conseils donneriez-vous aux résidents en orthopédie? La résidence en orthopédie est difficile. Et le véritable défi n’est réellement compris que par les quelques privilégiés admis dans ce monde insaisissable. Elle est conçue ainsi parce que, à la fin de ces cinq années, on s’attend à ce que vous soyez devenus des surhumains, courageux et capables d’opérer tout cas qui franchit la porte. Tout ça ne se fait pas instantanément, et les jours difficiles sont nombreux durant le programme. Mon conseil serait de comprendre que vous n’êtes vraiment pas seuls. Tous les autres en arrachent, même si de l’extérieur, ils semblent parfois pleins d’assurance. Il arrive qu’un résident ait seulement besoin qu’un collègue avoue avoir aussi du mal pour normaliser la difficulté de la résidence. Vous n’êtes pas les premiers ni les derniers à passer par là, et il y a une armée de gens qui seraient plus qu’heureux de vous faciliter les choses. Il suffit de demander un coup de main; vous serez surpris de voir le nombre de personnes sur qui vous pouvez compter. COA Bulletin ACO - Summer / Été 2019


Your COA / Votre association

12

(suite de la page 11)

5) Pouvez-vous me parler d’un objectif professionnel et d’un objectif personnel que vous voulez atteindre au cours des cinq prochaines années? Mon objectif professionnel est d’être admise au sein de la Hip Society par l’intermédiaire de l’American Academy of Orthopaedic Surgeons. Le nombre de femmes au sein de la société est notoirement bas, et je crois que ça décourage des femmes compétentes de choisir le domaine. Mon objectif est de devenir membre et de me servir de mon adhésion pour montrer aux jeunes femmes en orthopédie que l’arthroplastie de la hanche est un objectif accessible pour les femmes, que je vais les soutenir dans leurs efforts et que je travaille d’arrache-pied pour supprimer les obstacles à ce choix de carrière. Pour ce qui est de mon objectif personnel, j’ai épousé récemment le partenaire le plus extraordinaire, le plus grand allié que j’aurais pu imaginer. Mais, en raison de ma résidence, je commence ma famille 15 ans plus tard que la femme moyenne. Nous sommes tous les deux à la fin de la trentaine, et cela pose certains défis. Nous essayons actuellement d’avoir un bébé, soit par fécondation in vitro, soit par adoption; les deux options sont déjà assez difficiles sans pratique chirurgicale à temps plein. Je suis très chanceuse de travailler avec une équipe de collègues d’un grand soutien, mais ce n’est pas le cas de toutes les femmes en médecine. Mon partenaires et moi espérons, en parlant ouvertement de nos difficultés, contribuer à déstigmatiser

l’infertilité dans le milieu médical, et à faciliter un peu le parcours difficile de la femme sur trois qui vit des circonstances semblables. 6) Nommez le truc ou l’astuce que vous appliquez au quotidien pour vous faciliter la vie. J’ai deux trucs qui m’aident beaucoup. Mes amis savent que j’ai un don pour égarer les choses (y  compris ma voiture après une très grosse journée). J’ai trouvé de merveilleux dispositifs de marque Tile pour repérer les objets perdus comme les clés, cartes d’identité, cartes de stationnement, portefeuilles et cellulaires. Quand vous êtes très concentrés sur votre travail, un examen ou les soins à vos patients, vous pouvez utiliser ces dispositifs pour gagner un peu d’espace dans votre cerveau pour des choses plus importantes. Mon deuxième truc est d’embaucher quelqu’un pour m’aider avec les petites choses de la vie qui m’enlèvent du temps pour étudier, ou plus important, pour avoir un certain équilibre travail-vie personnelle. Essayez d’embaucher quelqu’un pour faire le ménage ou de faire affaire avec un service de buanderie quand c’est possible; j’achète aussi beaucoup de repas prêts à assembler. Le temps pour soi et en famille est tellement précieux, ne le gaspillez pas. Dans 20 ans, quand vous vous remémorerez le passé, vous ne vous direz pas : « Ah! que je suis contente d’avoir lavé ce plancher moi-même! »

The Humbling and Rewarding Path to SpiNepal: From Teachers to Mentors to Senior Peers Peter C. Wing, M.D., FRCSC Vancouver, BC

L

ate one dark November night in 2009 found my wife Claire, a physiatrist, and I in a jeep-cum-hospital ambulance riding along eerily illuminated, increasingly deserted and potholed Kathmandu streets to a large apparently impregnable locked gate in the Jorpati district. We were about to embark on an adventure more far-reaching than we could ever have anticipated. Claire and I had been active members of the International Spinal Cord Society (ISCoS) and, in particular, its Education Committee for years. The stark contrast between outcomes of spinal cord injury (SCI) in better- and lesser-resourced countries stimulated our interest in pursuing international work in our fields after retirement (spinal cord injury, SCI, rehab for Claire, orthopaedic spine surgery for me). Through ISCoS, we met Stephen Muldoon of Livability (a charity running disability care services), an energetic Irish-trained nurse who had lived and worked in Asia setting up and assisting the development of SCI units in Bangladesh and Sri Lanka, and was now involved in a younger unit in Nepal. We enthusiastically accepted his request to spend a couple of weeks teaching the young doctor recently COA Bulletin ACO - Summer / Été 2019

The COA Global Surgery (COAGS) Committee is pleased to share Canadian global health initiatives. If you are interested in COAGS featuring your organization in the Bulletin, or if you are a resident and you would like to share an essay about your global surgery experience, please contact trinity@canorth.org for details. hired to work at the Spinal Injury Rehabilitation Centre (SIRC), a free-standing rehab facility near Kathmandu. In 2009, when we first visited, the well-designed, earthquake-resistant SIRC facility was operating at about 60% occupancy of its approximately 50 beds. Since inception, the organization had been staffed by mostly aide-level physiotherapists, occupational therapists, nurses, a social worker and others, but without a dedicated physician. Morbidity remained high, especially with pressure


Your COA / Votre association

13

(continued from page 12)

Houses in Samagaon on the trail to Manaslu before and after the the 2015 earthquake Figure 1: Peter Wing/Claire Weeks - Figure 2: Dawa Norbu

sores probably mostly arising due to deficiencies in prehospital and acute care. Aware of this problem, the organization had recently hired Dr. Raju Dhakal, referred to as Dr. Raju, in keeping with the tradition of formal address. Dr. Raju proved to be a hard-working, energetic and enthusiastic recent medical school grad, the first disabled person in Nepal to do so (he is paraplegic due to polio contracted when he was two), who was teaching anatomy part time while integrating into the SIRC team. SCI was new to him, and he absorbed information like a thirsty sponge. SIRC had made a good choice, but he clearly needed more education and skills-training in SCI than we could hope to provide by annual trips of short duration. To become Nepal’s first rehab specialist, Raju wished to pursue residency training in Physical Medicine and Rehabilitation (PMR). Comparisons of rehab medicine residencies in Canada and the West with those in Asian centres led to his choice of the five-year program in Dhaka, at the Bangabandhu Sheikh Mujib Medical University. We supported this decision and offered to sponsor him. Dr. Prakash Paudel (Dr. Prakash), a bright and energetic neurosurgical medical officer (= hospitalist) who could not afford neurosurgical training, also caught our attention, and we decided that we could sponsor both men, a decision we have not regretted for a moment. And so, we had found our niche: while the Swiss Paraplegic Centre was annually sending multidisciplinary teams to train the SIRC team, and while individual clinicians of various disciplines came and went, no one was supporting development of appropriate specialist medical and surgical management of people with SCI. Our focus was on training and mentoring two potential future medical leaders in these disciplines. The costs to us? Tuition and manageable cost-of-living stipends for both of them, with additional costs of travel for SCI observerships, and to attend meetings and workshops. USTOP’s logistician (see COA Bulletin #115), Nathan O’Hara, helped us establish our web presence and financial management through UBC. What began as a two-week teaching session for Dr. Raju evolved into establishment of the nonprofit Spinal Cord Injury Collaboration, also known as SpiNepal, operating within the

UBC Development Office. This two-week commitment is now in its tenth year. Dr. Raju excelled in his PMR training program and was one of the rare Nepali candidates to pass the Fellowship qualifying exams on his first try. Dr. Prakash followed the College of Surgeons of Pakistan neurosurgery curriculum with a Kathmandu-based preceptor and similarly (and unusually) passed his Fellowship exams on his first try; in addition he won the Gold Medal for the best performance on the exam. Thus was our primary goal reached in the projected time. Along the way, a number of events have occupied our interest. The most tragic being the April 2015 earthquake, killing 9000, injuring over 21,000, and rendering 3.5 million homeless. SIRC quickly sent health-care staff to each of the Kathmandu major trauma hospitals for the first few days until admissions could be arranged; 27 were received in the first week. By the time the Kathmandu airport could be reopened, Dr. Raju had assembled a team in Bangladesh including two physician colleagues, dividing the service up into three clinical units. SpiNepal raised funds for expenses, directing a considerable amount of money both through UBC and Handicap International. We spoke with them on Skype regularly, reviewing imaging and discussing cases. With three physicians on site, each with local accommodation and support, sharing the work, we felt it best to work with them at a distance and we were assisted by Canadian medical and surgical colleagues. The acute hospitals soon had surgical help; well-equipped foreign medical teams came after a couple of weeks, and SIRC added a coordinator to manage this support. Raju was in Nepal three times that year. Altogether SIRC admitted 117 people with spinal cord injury from the earthquake, and had to rapidly more than double its bed capacity to care for these as well as those in hospital previously, using public spaces in the hospital as well as large tents. Médecins Sans Frontière (MSF) supported a second floor expansion, nearing completion when we returned to Nepal for the Asian Spinal Cord Network meeting that winter. We were very impressed by the way that SIRC had risen to the occasion. Each trainee has visited Canada once: Dr. Prakash presented a paper at the Bethune Round Table surgical meeting in Vancouver in 2013, and Dr. Raju was hosted in 2016 by the SCI group of the Canadian Association of Physical Medicine and COA Bulletin ACO - Summer / Été 2019


Your COA / Votre association

14

(continued from page 13)

to teachers. Their additional achievements are too numerous to mention here but are detailed on our web site - link below. Our vision is that SpiNepal will continue to support the development of SCI education in Nepal, as SIRC plans to lead in development of a rehabilitation medicine residency program. In parallel, spine surgery standards are improving. Spine surgery fellowships are increasingly required and, as was the Canadian experience, orthopaedics has been leading with the fairly recent formation within the Nepal Orthopaedic Association of the Association of Spine Surgeons of Nepal. We believe that spine surgery requires skills drawn from orthopaedic and neurosurgical disciplines as is modeled by the Canadian Spine Society.

Claire and Peter (in masks) on the hospital bus Nov 2015 Figure 3: Peter Wing/Claire Weeks

Rehabilitation to visit two Canadian SCI centres and take the one-week FRCP examination review course which undoubtedly helped him pass his fellowship exam in 2017. We have visited SIRC approximately yearly, organizing and participating in local and regional workshops and conferences. Between visits we often meet online, our role evolving from teachers to mentors to senior peers.

Our program has provided a small piece of Nepal’s spine care edifice: SpiNepal arose from a humble beginning and only succeeds because of the creative talent of our Nepali friends. We thank the colleagues from Vancouver and elsewhere who have joined and supported the effort, and the many financial supporters who have sustained us. Among our many rewards: Raju and Sheela’s delightful five-day Hindu wedding, her Master’s degree in public health, the birth of three children to the two families to date, Raju’s first-time fellowship pass, and Prakash’s gold medal as top candidate. However, we mostly thank the day we said yes when asked if we could help.

By 2017, both doctors were specialists but have required additional subspecialty training. We supported Dr. Raju to join his team who were invited for a month at the Swiss Paraplegic Centre; Prakash took a threemonth neuroendoscopy fellowship in Germany, and visited the renowned Spinalis SCI rehab centre in Sweden. He is expected to take a one-year spine surgery fellowship soon; he will be the first neurosurgeon in Nepal to do so. Mentorship is ongoing and we are increasingly reassured by the help from our former colleagues in Vancouver when we are asked about challenging cases. SpiNepal has, with the help of our many supporters, financed emergency training workshops at the time of Peer counsellors Sonika Dhakal and Ram Bahadur Tamang lead exercises at SIRC Dec 2015 the recent windstorms in southern Nepal, and Figure 4: Peter Wing/Claire Weeks. Used with permission of SIRC has contributed to the Nepalese SCI Network’s children’s hostels. This is our tenth rewarding year. Raju is now the wise and hardworking medical director of SIRC; the only specialist looking after about 70 inpatients and 20-30 weekly outpatients with the help of a hospitalist and part-time support from a wonderful physiatrist colleague from Indiana. SIRC has added vocational training and is developing a stroke service. Raju’s team ran three-day SCI-training workshops last year reaching about 460 caregivers in southern Nepal, 20-30 at a time, and swung into action again after the recent tornado. We are looking for ways to encourage increasing autonomy as Raju and Prakash continue their metamorphosis from students COA Bulletin ACO - Summer / Été 2019

For more information about Spine Nepal and to support the Spinal Cord Injury Collaboration, please visit spinepal.med.ubc.ca. For more information about the 2015 earthquake (we collaborated with HI Canada), read the Earthquake Final report to Handicap International Canada and the article by Groves et al 2017: Descriptive study of earthquake-related spinal cord injury in Nepal.


Your COA / Votre association

Welcome Aboard the COA Team

15

Bienvenue au sein de l’équipe de l’ACO

Lexie Bilhete Coordinator, Membership Services & Affiliate Programs Canadian Orthopaedic Association

E

À

ach year at the COA’s Annual Meeting, members in good standing, who have been highly involved in both the Association and orthopaedic community, are nominated to hold office in one of the many positions amidst the COA’s committees. Visit the COA web site under the About the COA tab to see a complete listing of committee members.

chaque Réunion annuelle, des membres en règle de l’ACO qui jouent un rôle actif à l’Association et dans le milieu de l’orthopédie sont nommés à l’un des nombreux postes disponibles au sein des comités de l’ACO. Consultez l’onglet « Qui nous sommes », sur le site Web de l’ACO, pour la liste complète des membres des comités.

We are proud to highlight the newest members* of the COA’s various committees, announced at the Annual Meeting in Montréal this past June 2019. The COA looks forward to working with all our committees toward the positive future and advancement of Canadian orthopaedics.

Nous sommes également fiers de souligner la nomination des tout derniers membres* des comités, annoncée en juin dernier à la Réunion annuelle de Montréal, et nous avons hâte de travailler avec tous nos comités à l’avancement de l’orthopédie au Canada.

Stay tuned! This year, the COA welcomes 22 new committee members, who will be highlighted in upcoming Bulletin editions.

Gardez l’œil ouvert! Cette année, l’ACO accueille au sein de ses comités 22 nouveaux membres, qui seront présentés dans les prochains numéros du Bulletin.

*French biographies for those listed below available upon request to: info@canorth.org

* Les notices biographiques en français des membres suivants sont disponibles sur demande à info@canorth.org

CORA Co-Chairs, Kevin Morash, M.D. and Patrick Thériault, M.D. Dr. Kevin Morash is a fourth year orthopaedic resident at Dalhousie University. He is originally from Cole Harbour, Nova Scotia, and obtained his medical degree from Queen’s University. Dr. Morash is also currently completing a Master of Education degree through Acadia University. Upon graduation, he intends to undertake fellowship training in paediatric orthopaedics, in hopes of pursuing an academic career incorporating his interest in medical education.

Dr. Patrick Thériault is a fourth-year orthopaedic resident at Dalhousie University. He is originally from Ottawa where he completed his medical degree. Dr. Thériault’s primary interest is in arthroplasty and will be pursuing a fellowship in Auckland, New Zealand upon completion of his residency. Aside from orthopaedics, his interests include carpentry and automechanics.

CORS Member at Large, Dominique Rouleau, M.D., Msc Dr. Dominique Rouleau is an orthopaedic surgeon at the Hôpital du Sacré-Coeur de Montréal, specialized in shoulder and elbow surgery and traumatology. She received her medical degree in 2006 with best student mention of the Edouard Samson program at the Université de Montreal. She completed a fellowship in trauma surgery at the Hôpital du Sacré-Coeur de Montréal from 2006-2007. In 2007-2008, she completed a fellowship in shoulder surgery at Western University. In 2009, she became Assistant Professor in the surgery program of the Université de Montréal and was promoted to Associate Professor in 2015. Her research interests include shoulder and elbow trauma and reconstruction. She founded and chaired the Canadian Shoulder Course in 2012 and 2013.

Dr. Rouleau is Secretary of the Canadian Shoulder and Elbow Society, an editor of OTSR-RCO, and reviewer for 10 different journals. For 10 years, she was in charge of the “Fonds de recherche et d’enseignement en orthopédie de Montréal - Programme d’orthopédie” (FREOM). She has delivered more than 50 presentations at international and national meetings, and has published more than 87 papers and four books chapters.

COA Bulletin ACO - Summer / Été 2019


Your COA / Votre association

16

(continued from page 15)

Continuing Professional Development Committee, Paediatrics Rep, Ron El-Hawary, M.D., MSc, FRCSC Dr. El-Hawary is Chief of Orthopaedics at the IWK Health Centre and is Professor, Department of Surgery, Dalhousie University (Cross-appointments with the School of Biomedical Engineering and with the Division of Neurosurgery). He is past Chair of the Royal College of Physicians and Surgeons of Canada Orthopaedic Examination Committee, President of the Canadian Paediatric Orthopaedic Group, Vice President of the Children’s Spine Foundation, and was Founding President of the Canadian Paediatric Spine Study Group. Dr. El-Hawary is a Board Member of the Scoliosis Research Society, and is a member of their Education Resource and of their Growing Spine Committees. He is a member of the Paediatric Orthopaedic Society of North America and was a recent member of their Board of Directors.

Dr. El-Hawary obtained a Bachelor of Mechanical Engineering (1994), Bachelor of Science in Medicine (1998), and Medical Doctorate (1998) all from Dalhousie University in Halifax. He completed his orthopaedic residency (2003), and his Master of Science in Medical Biophysics (2004) from the University of Western Ontario in London. He received further education as an Edwards Fellow in paediatric orthopaedics and scoliosis surgery at the Texas Scottish Rite Hospital for Children in Dallas, Texas (2005). In 2006, he was chosen to be a Scoliosis Research Society Dawson Travelling Fellow and, in 2010, was selected to be a Paediatric Orthopaedic Society of North America European Travelling Fellow. His clinical interests are varied, with the main focus being the correction of spinal deformity. His research interests include scoliosis, paediatric trauma, and radiostereophotogrammetric analysis (RSA).

CORS President, Rizhi Wang, B.Eng (Zhejiang), M.A.Sc, Ph.D. (Harbin), P.Eng Dr. Rizhi Wang is a Professor in Biomaterials at the Department of Materials Engineering and the School of Biomedical Engineering, University of British Columbia. He is also an associate faculty member at the Department of Orthopaedics, and a core member at the Centre for Hip Health and Mobility. Dr. Wang received a Ph.D. in Materials at Harbin Institute of Technology, China, in 1993. Before joining UBC as an Assistant Professor in 2001, he had worked at Tsinghua University (Beijing) and the Weizmann Institute of Science, the University of Minnesota, and Princeton University. Dr. Wang held a Canada Research Chair in Biomaterials from 2002-2012, and served as the president of the Canadian Biomaterials Society in 2012-2013. He

is a Fellow in Biomaterials Science and Engineering (FBSE) and a member of the Executive Committee of the Canadian Orthopaedic Research Society since June 2016. Since joining UBC in 2001, Dr. Wang has been focusing his research on materialrelated issues around hip replacement. His current research interests include orthopaedic implants, drug delivery biomaterials, anti-infection solutions, bone structure and mineralization, as well as mechanisms and prevention of hip fracture.

COA/ICORS 2019 Meeting Photos Available!

T

hank you to all COA and ICORS members for making the Montréal Meeting from June 19-22 a success! You can review the Meeting photo gallery by clicking here. You can then download images of your choice. Questions? Contact lexie@canorth.org

COA Bulletin ACO - Summer / Été 2019

Photos de la Réunion 2019 de l’ACO et du congrès des ICORS disponibles!

M

erci à tous les membres de l’ACO et des ICORS d’avoir fait de la manifestation de Montréal, du 19 au 22 juin, un grand succès! Vous pouvez consulter la galerie de photos de la manifestation en cliquant ici. Vous pourrez ensuite télécharger des photos. Des questions? Écrivez à lexie@canorth.org.


Your COA / Votre association

17

COA 1978 Past President Delivers R.I. Harris Lecture

W

e were honoured to welcome Dr. Richard L. Cruess to the Annual Meeting as this year’s R.I. Harris Lecturer. His lecture, From Professionalism to Professional Identity - An Educational Journey, included profound lessons and messages for our entire membership. Below is an excerpt from his compelling address: Over the course of the years from 1955 to 2019, I have been living two parallel journeys: that of my medical education on one hand, and that of orthopaedic surgery on the other. The objective of our educational journey has been to determine how Medicine could ensure that its traditional values are passed on to future generations of physicians in a constantly changing world. For instance, I have not been in an operating room, nor seen a patient since 1981. However, I do not identify myself as an ex-Dean or as a medical educator, but as an orthopaedic surgeon. Why? Simply because I continue to regard myself first and foremost as a member of the orthopaedic surgeon community. This is who I am, this is my professional identity. I now put forward the question to you: how do you introduce yourself? How do you come to think, act, and feel like an orthopaedic surgeon? In the 1980s and 90s, a medical professional movement arose from perceived threats to medicine’s professionalism. These threats included health-care systems that failed to support professional values and behavior and well-publicized failures of the profession to meet the obligations necessary to justify its professional status. Medicine’s values had traditionally been embedded in the word “professionalism” as they were transmitted from one generation to another. It was assumed that understanding professionalism would lead students, residents, and ultimately practitioners, to behave professionally – with an emphasis professional actions, behaviors, and “doing”. This eventually led to the examination of the concept of personal and professional identities as being relevant to medical education and practice.

Drs. Richard and Sylvia Cruess have published widely on professionalism and professional identity formation in medicine, and been invited speakers at universities, hospitals, and organizations throughout the world

What does my identity as an orthopaedic surgeon mean to me? Well, as stated by Rt. Hon. David L. Johnston in “Trust” (2018), “Acquiring a professional identity entails a commitment to something outside of one’s self that “enables one to belong to something larger and more meaningful than one’s own existence and, in the process, make one’s life richer and more consequential.” Did You Know? Dr. Cruess was President of the COA in 1978. Here is a little gem from his Presidential Address delivered at Annual Meeting held that same year in Vancouver. Enjoy!

Dr. Richard Cruess delivers the R.I. Harris Lecture at the 2019 Annual Meeting in Montréal

No matter where we live in Canada, we will face similar clinical situations. We must retain our ability to communicate in the future as we have in the past. It is how we make certain that progress reaches each Canadian patient. Let us, therefore, remember that countries and associations are directly affected by the individual actions of their citizens or members. We can by our individual acts do either immense harm or great good to both our country and to the Canadian Orthopaedic Association. Let each of us attempt to conduct ourselves so that our contribution is a positive one. If we do so, there will always be hope.

COA Bulletin ACO - Summer / Été 2019


" The best way to predict the future is to create it." - Abraham Lincoln

Trident II Acetabular System

Let’s create the future together with Trident II Looking for implants with staying power? With the new Trident II Tritanium, have confidence in a powerful combination: a system built on Trident’s clinical legacy1-5 paired with our latest additive manufactured Tritanium In-Growth Technology.

References: 1. Australia Orthopaedic Association National Joint Replacement Registry. Annual Report. AOA; 2017. 2. UK National Joint Registry. Annual Report. ISSN; 2017. 3. Naziri, et al.: Excellent Results of Primary THA Using a Highly Porous Titanium Cup. Orthopedics. Vol. 36, No. 4 pp. 390-394, 2013. 4. Ramappa et. al.: Early Results of a New Highly Porous Modular Acetabular Cup in Revision Arthroplasty. Hip International. Vol. 19, No. 3. Pp. 239-244, 2009. 5. Capello et. al.: Arc-deposited Hydroxyapatite-coated Cups: Results at Four to Seven Years. Clinical Orthopedics and Related Research. Number 441, pp. 305-312, 2005. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker’s product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any of Stryker’s products. Please contact your sales representative if you have questions about the availability of products in your area. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker, Trident, Tritanium. All other trademarks are trademarks of their respective owners or holders. TRITRI-AD-1_15706


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

TELL US WHAT YOU WOULD DO! We’re polling the readers on whether or not you would treat an Achilles tendon rupture operatively or nonoperatively and which factors influence your decision making. Two foot and ankle experts will weigh in on the debate in the next edition of the COA Bulletin and we’ll share a summary of the survey results. Stay tuned!

Click here to vote now! Cliquez ici pour répondre à cette question dès maintenant!

DITES-NOUS CE QUE VOUS FERIEZ! Nous aimerions savoir si vous opteriez pour une intervention chirurgicale ou non chirurgicale pour le traitement d’une rupture du tendon calcanéen et quels facteurs influenceraient votre décision. Deux spécialistes du pied et de la cheville donneront leur opinion sur le sujet dans un numéro à venir du Bulletin de l’ACO, et nous vous transmettrons le sommaire des résultats de ce sondage. Gardez l’œil ouvert!

COA Bulletin ACO - Summer / Été 2019

19


20

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

Code Orange Lessons Learned from Ottawa’s Mass Casualty Response Allan S. Liew, M.D., FRCSC Director of Orthopaedic Trauma, The Ottawa Hospital Associate Professor, University of Ottawa Ottawa, ON

O

n Friday, January 11, 2019, at 4:00pm, tragedy struck as an OC Transpo double decker bus collided with a bus shelter at the Westboro Station in Ottawa. Three passengers were killed and 23 passengers were injured, with the most severely affected brought to the Civic Campus of the Ottawa Hospital. With the pre-hospital notification of many simultaneous critically injured patients, a Code Orange (mass casualty) was called, with general surgeon Dr. Jacinthe Lampron overseeing all the trauma codes. Dr. Geoff Wilkin (orthopaedic trauma) quickly responded and took control of the orthopaedic assessment and triage in the emergency department. He provided a vital link between the ER and OR throughout the duration of the evening. We received twelve passengers, of which four had bilateral injuries with either traumatic above knee amputations or combined open tibia and femur fractures with vascular injuries. Three others had bilateral open injuries of the lower extremities. An orthopaedic fan-out call was organized with an overwhelmingly positive response from thirteen residents and fellows, and nine orthopaedic surgeons. Most had already left for the day, but all willingly returned to ensure these patients were well looked after. We provided damage control stabilization for seven patients that evening, working collaboratively with four vascular surgery teams who did an admirable job of revascularizing five lower extremities. We received many compliments on the orthopaedic residents’ contributions with the multiple concurrent ATLS assessments in a mass casualty setting, as well as in the OR where everyone put in maximal effort to ensure these patients received the highest quality of care. Several of the responding surgeons were from other hospitals in our community who also brought extra equipment with them. We are fortunate to have skilled colleagues in the ER and trauma staff who did a great job with resuscitation. Acknowledgements also go to our OR staff who rapidly opened six rooms for the four simultaneous A and two D cases. Having gone through their initial successful resuscitation, all of these patients faced a long week ahead of multiple surgeries for definitive fixation and soft tissue management. They faced many more months of rehabilitation and recovery, and they continue to adapt to these life-changing injuries. COA Bulletin ACO - Summer / Été 2019

Lessons Learned Through multiple debriefing meetings on all levels, we were able to discuss and analyze the strengths and areas of improvement in our organization’s response to this mass casualty event. The “take home points” list that follows is familiar to our military colleagues, who can teach us how to be prepared for these incidents. • Making the mass casualty call: Accurate pre-hospital information from the accident scene to determine the scale of the accident, number of people affected requiring medical care, and number of people to be transported to hospitals is paramount. Set thresholds to involve local hospitals and surrounding regional hospitals. • On scene triage: A robust protocol exercised by EMS services can distribute patients to the appropriate level of care hospitals, preserving the resources of the level I centre for the most critically injured. • System preparations: In the emergency department, all service levels are affected, which requires clearing out ER trauma bays, and urgent assessment areas. Extra personnel are put on notice for recall to hospital, including porters, house cleaning staff, and restocking personnel. • Set up a command centre in the ER: With a large number of patients, a trauma lead, nursing lead, and OR charge nurse to oversee all patient assessments, triage, and OR preparations keep all patient priorities in perspective. In situations like ours where many patients had orthopaedic injuries, a specialty lead is necessary. • OR preparations: OR staffing includes not only nursing and anaesthesia for the sufficient number of operating rooms, but also imaging technologists, porters, PCAs (patient care assistants), OR supply personnel, and instrument reprocessing personnel. Industry/supplier representatives to assist in instrument or implant reallocation from surrounding health regions can also play a key role. • Communications: A pre-established fan-out list to notify and reserve an appropriate number of staff and residents to meet clinical demands. We made effective use of group text messaging, but consider methods of communication and possible interference, such as cell signal blocking in terrorist situations or areas of poor reception and WIFI signal loss.


Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 20)

• Resource management: There are significant increased resource requirements for five to seven days after the initial incident. This affects staffing, supplies, and equipment. Consider postponing or cancelling other elective activity to accommodate. Also consider the need to ration personnel to manage the “first wave” of response, with other personnel on reserve to manage the second wave (subsequent debridements and definitive fixation procedures) or subsequent incidents/attack. • Resource management – supplies: Rapid resupply and processing of equipment to prepare for subsequent damage control and definitive operations as well as other urgent activity. Consider involving regional facilities to borrow equipment and supplies. • Rehabilitation: Increased demand for physiotherapy and physiatry.

• Employee assistance program: Events are stressful for all involved and some may benefit from counseling. • Timing considerations: We were fortunate this incident occurred at the end of the day shift on a weekday, with many personnel able to stay longer and others available to come in. This may have been much more challenging in the middle of the night on a weekend. Certainly, we had resupply issues for the subsequent days related to standard resource reductions on the weekend. It was rewarding to see that many aspects of the simulation planning events we held several months earlier were successfully put in to action. From the points raised during the debriefing, we plan to further improve our mass casualty response plan and continue with regular simulation drills for the benefit of our future patients.

So Weird, They’re Wonderful Unusual Cases Wanted for COA Bulletin Feature

Si bizarres, si extraordinaires : Cas insolites recherchés pour une série d’articles du Bulletin de l’ACO

o you have a bizarre or unusual case that has presented in your clinic or OR? Something that may have had unexpected results? We want it!  The COA Bulletin includes a new feature where weird (and wonderful) cases will be presented to the membership.  Submit the following to cynthia@canorth.org for consideration:

vez-vous déjà eu un cas bizarre ou insolite en clinique ou salle d’opération? Quelque chose qui a eu des résultats inattendus? Nous voulons le savoir! Le Bulletin de l’ACO propose aux membres une nouvelle série d’articles sur des cas bizarres (et extraordinaires). Soumettez ce qui suit à cynthia@canorth.org :

D

A

1) Imaging – up to 5 images

1) Jusqu’à 5 images

2)

2)

500-word case summary including: a) Brief clinical history and diagnosis b) Treatment measures c) Outcomes d) Take-home message

3) 5 references maximum

IMPORTANT TIPS FOR CASES! - The best stories are told through images – make sure that your photos are high-quality and clear. - Keep it brief! Stick to the most important information as it relates to the unusual nature of your case submission.

Résumé du cas en 500 mots, y compris ce qui suit : a) Court historique clinique et diagnostic b) Traitement c) Résultats d) Conclusion

3) Maximum de 5 références

CONSEILS IMPORTANTS POUR LES CAS! - Une image vaut mille mots; assurez-vous que vos photos sont de grande qualité et nettes. - Soyez concis! Tenez-vous-en aux renseignements les plus importants afin d’illustrer la nature insolite du cas soumis.

COA Bulletin ACO - Summer / Été 2019

21


22

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

This edition’s case was submitted by Drs. Susan Ge and Adam Hart from McGill University

Using a 3D Printed Model to Help Plan a Complex Arthroplasty Revision Clinical History .S. is a 46-year-old female treated with multiple hip and knee arthroplasties for juvenile rheumatoid arthritis. Currently, she has a right proximal femoral replacement that has become painful - limiting her ability to ambulate, and has an ipsilateral knee replacement that is asymptomatic. Her right leg is approximately three centimetres shorter than the left. She is otherwise healthy, lives independently and works as a psychologist.

N

Treatment Measures Challenges to reconstruct her hip included: her short stature and proportionally small pelvis and femur, extensive acetabular and femoral bone loss, young age, and multiple prior surgeries. A custom Triflange was not feasible, nor was a compress device in the femur due to her small dimensions. A metal suppression CT-scan was therefore used to print a 3D model of her hemipelvis in order to prepare and plan her reconstruction with augments and a cup cage (Figure 2).

X-rays of the pelvis and right femur (Figure 1), shows a failed proximal femoral replacement with a dislocated cup and proximal migration of the femoral head, which is now articulating in a false acetabulum. The femoral stem is loose with subsidence in varus and protrusion of the distal end outside the anterior cortex of the femur. There is osteolysis around the ipsilateral total knee replacement without definite evidence of loosening. Her infection workup was negative.

Figure 1 COA Bulletin ACO - Summer / Été 2019

Figure 2


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

After straightforward exposure and explantation of her implants, the acetabulum was reconstructed using the implants that were established with the preoperative model. An augment was placed, bone grafting, then insertion of a highly porous hemispherical cup with multiple screws. A half cage was then fashioned overtop the cup for additional fixation, and liner cemented in place (Figure 3). The entire femur was removed in addition to her knee replacement and a total femur prosthesis was implanted (Figure 4).

Figure 4

Outcomes Postoperatively, the patient was toe-touch weightbearing for six weeks. Due to significant lengthening of the soft tissues, she had a foot drop for the first 24hrs postop with spontaneous recovery. Her leg was lengthened appropriately and she could ambulate with a walker from postop day two. She stayed in hospital for a total of eight days. At her six-week follow-up, she was able to ambulate independently with marked improvement in pain and range of motion.

Figure 3

Take Home Message • 3D printing has become easily accessible and affordable, available in most engineering laboratories or via online printing services with turnover times of only a few days. • In complex cases, a printed model greatly facilitates preoperative planning and intra-operative efficiency. One should therefore consider obtaining such a model in cases of unusual anatomy and large bone loss.

Advancing Hip & Knee Arthroplasty PROMs in Ontario Shannon Weir-Seeley MSc; Nicole de Guia MHSc Canadian Institute for Health Information In partnership with the Ontario Ministry of Health and Cancer Care Ontario

I

n September 2017, the Ontario Ministry of Health (MOH) launched a pilot project to test the implementation of standardized hip and knee replacement Patient-Reported Outcome Measures (PROMs) collection in Ontario, in support of the hip and knee replacement QualityBased Procedure (QBP) program. CIHI and Cancer Care Ontario (CCO) co-execute the project with complementary roles. CIHI leads the development of national collection standards, the creation of analytical files for Ontario, and health-system reporting for the project. CCO leads PROMs implementation across participating sites and regularly submits data to CIHI. Implementation began at an early adopter site in Toronto in April 2018. The project has gained momentum, and as of July 2019, PROMs collection has been integrated into routine clinic flow at 25 hospital sites (including academic teaching hospitals) and growing. Hip and Knee PROMs Standards and Reporting CIHI has developed national standards for hip and knee replacement PROMs in collaboration with a PROMs Hip and Knee Working Group and the Canadian Joint Replacement Registry (CJRR) Advisory Committee. Considerations when developing the PROMs standards included alignment with recommendations, guidelines and best practices from existing programs and registries across Canada and internationally. These standards are available in the June 2018 CIHI publication PROMs Data Collection Manual: Hip and Knee Arthroplasty and on the web site www.cihi.ca/proms. The two standard time points for PROMs collection as part of these national standards are:

a) Preoperative (acceptable window is within eight weeks prior to surgery) b) 12 months postoperative (acceptable window is 9-15 months postop) An additional time point was added for the Ontario Hip and Knee PROMs project to align with the key patient interactions of the bundled hip and knee QBP program: c) Three months postoperative (acceptable window is 90-150 days postop) *Some Ontario hospital sites may also collect PROMs at a Rapid Access Clinic (RAC): a centralized intake and assessment model live in some regions. CCO’s electronic PROMs collection platform, the Interactive Symptom Assessment and Collection (ISAAC) tool, was leveraged and enhanced to accommodate the collection of PROMs from hip and knee replacement patients. It is accessed through any device able to connect to the Internet, which allows patients to quickly and securely complete PROMs and make these scores available to their health-care team in real time. ISAAC enhancements include histograms of PROMs scores, providing both clinicians and patients with a snapshot of how the patient is doing across all time-points to assess patient-level trends over time. CIHI prepares data progress reports for the MOH as well as reports back to participating sites. As the pilot project matures and data grows, CIHI plans to develop more robust reports to support health system monitoring and the evaluation of performance and effectiveness of care. The Canadian Institute for Health Information (CIHI) has a national program on patient-reported outcome measures (PROMs), which includes focused work on hip and knee arthroplasty. Information on the PROMs program can be found at www.cihi.ca/proms.

COA Bulletin ACO - Summer / Été 2019

23


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

24

Canadian Joint Replacement Registry (CJRR) Update Carolyn Sandoval, MSc; Nicole de Guia, MHSc Canadian Institute for Health Information

2019 CJRR Annual Report Highlights In June 2019, CIHI released Hip and Knee Replacements in Canada, 2017–2018: Canadian Joint Replacement Registry Annual Report, which provides updated key statistics related to hip and knee replacement surgeries performed in Canada. The report also presents cumulative revision risk estimates based on CJRR data from provinces with mandatory reporting. Stratified Kaplan–Meier survival analysis was used to estimate the survival curves and Cox proportional hazards model was used to compare different groups while adjusting for age, sex or cement fixation as appropriate.

The Canadian Joint Replacement Registry (CJRR) is Canada’s only pan-Canadian medical device registry. It was launched in 2001 in collaboration with the Canadian Orthopaedic Association and is managed by the Canadian Institute for Health Information (CIHI). The CJRR Advisory Committee is co-chaired by Drs. Eric Bohm and Michael Dunbar. National Coverage of Hip and Knee Replacement Prosthesis Data n 2018-2019, CJRR hip and knee prosthesis data for approximately 104,000 surgeries were submitted to CIHI from all acute care facilities. As shown in Figure 1, this represented an overall national coverage rate of 75%, an increase from 72% in 2017-2018.

I

Selected highlights include: • For knee replacements due to osteoarthritis, primary total knee replacements had lower revision risk compared with all partial primary knee replacements (Figure 2). Among total replacements, revision risk was significantly lower when the patella was resurfaced as compared with no patella resurfacing [HR=1.21 (1.13–1.30), p=<0.0001]. Regardless of whether or not the patella was resurfaced, infection was the most common reason for revision (37.0% when patella was resurfaced, 29.0% with no patella resurfacing), followed by instability and aseptic loosening. • For partial hip replacements after hip fracture, cementless femoral fixation was associated with higher risk of revision than cemented femoral fixation, regardless of surgeon volume1 (adjusting for patient age and sex) (Figure 3). When cemented fixation was used, surgeon volume showed no difference in risk until 1.5 years; then, low-volume surgeons had more than three times the revision risk compared with high-volume surgeons [HR=3.19 (1.19–8.54), Canada p=0.021]. 75%

These gains were due to increases across several provinces, with the most notable being Newfoundland and Labrador (now 96%, previously 16%), and Alberta (now 78%, previously 48%). This year also coincided with the ability for the CJRR prosthesis data to be submitted through an additional method: CIHI’s Discharge Abstract Database (DAD), the national hospitalization database, which collects data largely supported by coding specialists employed by hospitals (or health regions, depending on the jurisdiction).

` Y.T. 0% 0%

72%

N.W.T. 99 %

N.U. 0%

0%

B.C.

Alta.

95%

78%

94%

48%

Que.

Sask.

Man.

90%

99%

Ont.

85%

97%

97% 91%

4%

0%

P.E.I .

23%

Coverage in 2018-2019 Coverage in 2017-2018

87%

Figure 1. CJRR Prosthesis Coverage, 2018-2019 COA Bulletin ACO - Summer / Été 2019

96% 16%

N.S.

For more information about CJRR report or the registry, contact us at CJRR@cihi.ca.

90%

N.B 1%.

Mandated submission as of 18-19

N.L.

For other revision risk curves for hip and knee replacements, refer to the full report on CIHI’s web site.

67%

Surgeon volume refers to the number of hip arthroplasties performed by the surgeon in a fiscal year. Low: <50 hip arthroplasties/year, High: 50+ hip arthroplasties/year. 1


Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 24)

Figure 2 Cumulative percentage revision for knee replacement (primary diagnosis of osteoarthirits), 2012–2013 to 2017–2018

HR — adjusted for age and sex Total knee arthroplasty without patellar resurfacing versus Total knee arthroplasty with patellar resurfacing HR = 1.21 (1.13–1.30), p <0.0001 Medial unicompartmental arthroplasty versus Total knee arthroplasty with patellar resurfacing HR = 2.02 (1.80–2.26), p <0.0001 Lateral unicompartmental arthroplasty versus Total knee arthroplasty with patellar resurfacing HR = 2.82 (1.97–3.89), p <0.0001 Patellofemoral arthroplasty versus Total knee arthroplasty with patellar resurfacing 0–1 year: HR = 1.50 (0.68–2.81), p = 0.256 1 year+: HR = 4.60 (3.03–6.67), p <0.0001

Type of knee arthroplasty Total knee arthroplasty with patellar resurfacing

Total knee arthroplasty without patellar resurfacing

Medial unicompartmental arthroplasty

Lateral unicompartmental arthroplasty

Patellofemoral arthroplasty

Years after primary replacement 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Cumulative percentage revision (%) 0.97 1.55 1.98 2.24 2.45 1.04 1.84 2.46 2.90 3.23 2.05 3.38 4.26 5.34 6.09 3.74 5.80 6.14 6.97 7.57 1.66 5.01 7.30 9.46 12.84

95% confidence interval 0.92–1.03 1.48–1.62 1.89–2.07 2.15–2.34 2.34–2.56 0.95–1.12 1.72–1.96 2.31–2.61 2.73–3.07 3.03–3.44 1.74–2.36 2.97–3.79 3.77–4.74 4.75–5.93 5.39–6.79 2.17–5.32 3.77–7.84 4.01–8.27 4.57–9.38 4.91–10.24 0.51–2.80 2.84–7.19 4.51–10.09 6.02–12.90 8.18–17.49

Number at risk 105,209 82,346 60,026 38,769 18,494 46,710 34,611 24,504 15,360 6,974 7,149 5,617 4,151 2,718 1,436 478 353 273 177 100 403 292 204 132 59

Notes HR: Hazard ratio. p: p-value. Sources Canadian Joint Replacement Registry (Ontario, Manitoba and British Columbia only), Discharge Abstract Database and National Ambulatory Care Reporting System, 2012–2013 to 2017–2018, Canadian Institute for Health Information. COA Bulletin ACO - Summer / Été 2019

25


26

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

Figure 3 Cumulative percentage revision for primary partial hip replacement, by femoral fixation and surgeon hip arthroplasty volume (primary diagnosis of acute hip fracture), 2012–2013 to 2017–2018

HR — adjusted for age and sex Cementless, <50 hip arthroplasties/year versus Cementless, 50+ hip arthroplasties/year HR = 1.11 (0.93–1.33), p = 0.234 Cemented, <50 hip arthroplasties/year versus Cemented, 50+ hip arthroplasties/year 0–1.5 years: HR = 0.95 (0.65–1.38), p = 0.782 1.5 years+: HR = 3.19 (1.19–8.54), p = 0.021 Cementless, <50 hip arthroplasties/year versus Cemented, <50 hip arthroplasties/year HR = 1.31 (1.00–1.70), p = 0.047 Cementless, 50+ hip arthroplasties/year versus Cemented, 50+ hip arthroplasties/year HR = 1.35 (1.02–1.78), p = 0.033

Femoral fixation Cementless

Surgeon volume 50 or more procedures a year

Fewer than 50 procedures a year

Cemented

50 or more procedures a year

Fewer than 50 procedures a year

Years after primary replacement 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5 1 2 3 4 5

Cumulative percentage revision (%) 2.75 3.29 3.86 4.25 4.51 3.15 3.82 4.41 4.84 4.93 2.16 2.48 2.58 2.97 2.97 2.11 2.79 3.18 3.68 4.47

95% confidence interval 2.39–3.12 2.87–3.70 3.39–4.33 3.72–4.78 3.92–5.10 2.68–3.62 3.29–4.36 3.81–5.01 4.17–5.51 4.24–5.62 1.58–2.75 1.84–3.13 1.91–3.25 2.17–3.77 2.17–3.77 1.52–2.69 2.09–3.49 2.40–3.96 2.76–4.59 3.18–5.77

Number at risk 6,024 4,567 3,214 1,958 889 4,258 3,217 2,324 1,453 636 1,821 1,260 830 466 234 1,842 1,359 971 607 296

Notes HR: Hazard ratio. p: p-value. Surgeon volume refers to the number of hip arthroplasties performed by the surgeon in a fiscal year. Sources Canadian Joint Replacement Registry (Ontario, Manitoba and British Columbia only), Discharge Abstract Database and National Ambulatory Care Reporting System, 2012–2013 to 2017–2018, Canadian Institute for Health Information.

COA Bulletin ACO - Summer / Été 2019


PROstepâ&#x201E;¢ Minimally Invasive Surgery


YOU MAKE AN IMPACT YOU MAKE THINGS HAPPEN YOUR DUES DOLLARS DIRECTLY SUPPORT ORTHOPAEDICS IN CANADA

As a member of the Canadian Orthopaedic Association (COA), you are directly contributing to the advancement of our specialty. Every membership sustains and develops national and local initiatives for our collective orthopaedic community. Your membership contributions extend far beyond the scope of the Annual Meeting. Instead, consider some of the many recent COA initiatives that your membership dues played a key role in developing.

DIVERSIFYING OUR SPECIALTY Female university and medical students can now participate in an interactive session with leaders in the orthopaedic specialty. This program hopes to increase the number of women applying for residency positions by providing earlier and more comprehensive exposure to orthopaedics.

MENTORSHIP PROGRAM Residents and fellows are matched with active members for a day at the Annual Meeting. This endeavour fosters professional development and career planning, and provides leadership and role modeling opportunities.

ADVOCATING FOR ACCESS TO CARE Lending advocacy support to provincial orthopaedic associations through a lobbyist with expertise in government meetings, drafting briefings/messaging, and gathering intelligence, as well as providing national support to existing provincial advocacy initiatives.

SURGEON EMPLOYMENT Hiring and employment data over a 5-year period has been collected and analyzed for the purposes of strategic discussion related to the ongoing underemployment crisis with orthopaedic training programs, the Royal College, and the media.

CME YEAR-ROUND Accredited learning opportunities through webinars and summarized evidence-based research studies on OrthoEvidence are available to members throughout the year.

SOCIAL RESPONSIBILITY The COA partnered with the Centre for Evidence-Based Orthopaedics at McMaster University to offer members access to EDUCATE, a program that teaches health-care professionals to identify and assist patients who present to the fracture clinic with a history of intimate partner violence.

INTERNATIONAL COLLABORATIONS Educational exchanges and research collaborations are established between the COA and orthopaedic associations in India and Europe, with increasing partnerships developing across the globe. The COA and its members are active participants on the world stage of orthopaedics.

TOGETHER, WE MAKE THE DIFFERENCE Your COA membership is important and your contributions make a difference. These improvements would not be possible without your support. Thank you for being a member.

www.coa-aco.org


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

Innovative Management of Modern Challenges: Our early experience in a job sharing career model Stephanie Atkinson, M.D., FRCSC Clinical Assistant Professor, Memorial University of Newfoundland Alanna Husch, M.D., FRCSC Corner Brook, NL

COA members, Drs. Stephanie Atkinson and Alanna Husch, manage their orthopaedic practice in Corner Brook, Newfoundland through a job share model of their very own design. They share insight and valuable information on their practice model and how this unconventional paradigm results in effective patient care, surgeon wellbeing, and job satisfaction. The COA features innovative orthopaedic care pathways from across the country. If you would like to submit your model of care for publication in the Bulletin, please contact Trinity Wittman at policy@canorth.org.

I

t is difficult to discuss surgical practice in 2019 without at the very least mentioning burnout. There are many theories about the risks, causes, and aspects of modern life that lead to such large numbers of surgeons identifying with burnout symptoms. Our own personal experience and understanding of burnout as residents, combined with the concerning job shortage facing this generation of orthopaedic surgeons, has led us down the path of a job share. We are of the opinion that job sharing is good for surgeons, patients, as well as the healthcare system, and hope to provide awareness and a deeper understanding into our job share experience. Initial Concerns Our initial conception of the idea of a job share was met with responses ranging from encouragement and enthusiasm, to quizzical looks, confusion and a healthy dose of thinly-veiled doubt and criticism. While there are already job share models in orthopaedic surgery, they certainly are not the norm. Naysayers cite financial strain, difficulty maintaining a skill set, and inconsistent patient care as reasons why job sharing is implausible. These concerns are all reasonable and valid, and by the end of residency, we had let the idea of a two-headed orthopaedic surgeon fade. As fellowship year melted away, we saw an opportunity materialize. The idea resurfaced when a position became available in Corner Brook, Newfoundland where we were both providing locum coverage during our fellowship year. After some discussion, we decided to approach the chief of surgery with our idea. Much to our delight, she, along with Western Health, was open to trying something new. As we progressed through the interview process and initial setup of our practice, we kept the aforementioned list of concerns in mind. We agreed that if one of us decided to leave the arrangement, the remaining surgeon would provide full-time coverage of the practice until suitably replaced. Financial Viability At the beginning of practice, it was difficult to know whether the endeavor was financially plausible. Up front, we decided

Drs. Alanna Husch and Stephanie Atkinson manage their orthopaedic practice in Corner Brook, Newfoundland through a job share model

on shared costs which we revisit on an as-needed basis. At this point, we have encountered no major hurdles, and we advise any others to begin their job share model founded upon a clear financial agreement. The economic aspect of practice sharing is something that will differ for everybody’s situation, and we are fortunate that our friendship made this transition easier than it might have been for two strangers. That being said, we encourage anybody who is considering a job share not to discount the system based solely on economic apprehension. The initial startup new practice costs were in many ways mitigated by the sharing of expenses, and as we have progressed through our first year in practice with relative financial ease. As such, we believe this model to be a financially sustainable career path. Patient Care and Maintaining Skill Set Admittedly, we were concerned about inconsistent patient care and skill set maintenance. We devised a model where each patient is ‘our patient’ - aware of the job share situation, and that they are treated by both of us throughout their care. Due to our division of time, our practice never closes, virtually eliminating the need for patients to be rescheduled, cancel appointCOA Bulletin ACO - Summer / Été 2019

29


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

30

(continued from page 29)

ments, or have difficulty booking follow up. This also allows us flexibility for our personal lives as well as professional development, CME or other appointments, without overwhelming patient loads or leaving any patients without consistent care. Often, we assist and learn from each other in the operating room, which is particularly helpful for complex cases. With two pairs of hands, we can pick up extra call, acute care, and elective operating time which has kept our wait times reasonable, and our patients as well as the administration very happy. Surgeon Wellbeing Ultimately, we have found this to be a healthy and effective transition from residency into practice. We believe that the roots of burnout are related not simply in the number of hours worked, but also in how valuable one perceives their workrelated and extra-curricular contributions are to them, their environment, and to others. In modern medical care, many of us spend increasing amounts of time on tasks we perceive as clinically irrelevant, and encounter increasing barriers to providing meaningful care: limited resources, outdated policies, and burnout in other health-care professionals. Similarly, the collective strains of modern life find us rushing, and often failing, to be attentive to our families, friends, and own self-care. Our experience with our job share model has allowed us to improve in both areas simply by having ‘recovery time’ to dedicate where we feel it is needed. While the anxieties of starting a career are ever-present, there is a great sense of security and wellbeing to have a dependable partner to learn from, as well as time built into your schedule to write that book or shred that powder on a weekday.

The Future of Job Sharing We believe that job sharing can help mitigate the risk of surgeon burnout, as well as the forecasted risk of unemployment. While the future of health care is difficult to foresee, the COA predicts an ongoing problem with employment of new surgeons in Canada. Our own bespoke practice share model has proven itself successful early on in our career, and we have identified no reason to assume it unsustainable for the future. While we are practicing in a community-based setting, it is conceivable that a similar model applied in an academic setting would be equally as successful, potentially bringing richer experiences and expertise to learners and seasoned surgeons alike. Key Takeaway Points • Key issues facing orthopaedic surgeons and the future of our profession can be solved using unique models of proving care for patients and each other. • A significant amount of planning should be undertaken to ensure each party’s concerns are considered. • Job sharing is a sustainable option to improve work/life harmony while mitigating the effects of a crippling job shortage. At the 2019 American Academy of Orthopaedic Surgeons Annual Meeting, President Dr. Kristy Weber began her term by asking that we ‘let go of the stereotype of what orthopaedic culture has been.’ It is possible that millennial orthopaedic practice will take on a brand-new look and approach. If you have any questions about our job share model, please direct them to: satkinson@mun.ca or huscha@gmail.com.

Highly Trained and Underemployed: Are We Making Progress in our Professional Crisis? Click Here for More COA Employment Data

C

anadians continue to lack adequate access to musculoskeletal care in many regions while orthopaedic surgeons are highly trained and underemployed. Canada has the lowest number of orthopedic surgeons per capita and the longest wait times for elective procedures in the Western world. By any metric, we are not over-training, but the employment issue is being addressed in the worst possible way. By reducing the number of residency positions in orthopedic surgery, from COA Bulletin ACO - Summer / Été 2019


Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 30)

81 matches in 2011 to 52 in 2018, we may face inadequate capacity resulting in compromised patient care in future decades. The COA leadership has been addressing these issue for well over a decade, but more must be done to advocate for patients and our members. Get Involved • Tell us your ideas directly: Click below to answer two brief questions about what else the COA should be doing to address underemployment.

Click Here to Share Your Ideas

Review the June 2018 COA Bulletin article for a summary of other actions the COA has taken to address the unemployment crisis. Contact policy@canorth.org with questions or comments.

Poor access to job listings

In a recent report, the Royal College of Physicians and Surgeons of Canada released findings from their annual employment study (1) based on a survey of medical specialists newly certified in 2017, about their job prospects. The top six barriers to employment are below. The COA is limited in its ability to effect meaningful change in some of these areas, but continues to address needed changes in other areas. References

(1-minute survey)

Barriers to Employment (1)

• Talk to your Provincial Presidents! They are all members of the COA Practice Management Committee which is responsible in part for directing initiatives related to employment. Your provincial chairs can bring forward solutions to the COA leadership on your behalf.

Royal College Employment Patterns of Canada’s Newly Certified Medical Specialists: Findings from the Royal College Employment Study (2019) Royal College of Physicians and Surgeons of Canada [PDF file]. Retrieved from http://www. royalcollege.ca/rcsite/documents/health-policy/royal-collegeemployment-study-2019-media-backgrounder-e.pdf

COA Influence The COA encourages all hospitals to maintain a transparent hiring process by widely circulating opportunities. Members can take advantage of the free COA Job Board in the passwordprotected membership portal. To post a position, email lexie@canorth.org.

Lack of available health-care resources (e.g. funding, operating room time)

The COA leadership will continue its advocacy efforts with government and other stakeholders to promote innovative and cost-neutral models of MSK care which improve patient care and system efficiency, ultimately leading to further job creation.

The delayed retirement of established physicians and surgeons (and their general reluctance to share resources)

The COA Practice Management subcommittee on Transition to Retirement is advocating for provincial health ministries to implement programs which allow newly graduated surgeons to transition into practice and allow retiring surgeons to transition out of the health-care system in a step-wise fashion while ensuring seamless, high quality continuity of care for patients.

Too few available positions in Canada Desire or need to stay near family

Limited Influence

The need for spousal employment

COA Bulletin ACO - Summer / Été 2019

31


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

32

Hautement spécialisés et sous-employés : Y a-t-il du progrès dans la crise touchant notre profession? Cliquez ici pour plus de données sur l’emploi de l’ACO

L

a population canadienne continue d’avoir un accès inadéquat aux soins de l’appareil locomoteur dans de nombreuses régions, tandis que des orthopédistes hautement spécialisés demeurent sous-employés. Le Canada compte le nombre d’orthopédistes par habitant le plus faible et les temps d’attente pour les procédures non urgentes les plus longs en Occident. À tous points de vue, il n’y a pas lieu de parler de surformation, mais la question de l’emploi est gérée de la pire manière qui soit. En réduisant le nombre de places en résidence en chirurgie orthopédique (de 81 jumelages en 2011 à 52 en 2018), nous pourrions nous retrouver devant une capacité inadéquate, ce qui compromettrait les soins aux patients au cours des prochaines décennies. La direction de l’ACO travaille sur le dossier depuis plus d’une décennie, mais il faudra redoubler d’efforts pour défendre les droits et intérêts des patients et des membres. Faites-vous entendre • Transmettez-nous vos idées directement : Cliquez sur le bouton ci-dessous pour répondre à deux  courtes questions sur ce que l’ACO devrait faire d’autre pour lutter contre le sous-emploi.

Cliquez ici pour nous transmettre vos idées

• Parlez au président de votre association provinciale! Tous les présidents des associations provinciales sont membres du Comité sur la gestion de l’exercice de l’ACO, qui est en partie responsable des initiatives liées à l’emploi. Le président de votre association provinciale peut transmettre vos solutions à la direction de l’ACO en votre nom. Dans un rapport récent, le Collège royal des médecins et chirurgiens du Canada présentait les résultats de son enquête annuelle sur l’emploi (1), découlant d’un sondage sur les perspectives d’emploi des médecins spécialistes certifiés en 2017. Les six plus grands obstacles à l’obtention d’un emploi sont présentés ci-après. La capacité de l’ACO d’instaurer des changements significatifs pour certains de ces facteurs est limitée, mais elle continue de militer pour des changements par rapport à d’autres facteurs. Références

(sondage d’une minute) Consultez l’article publié en juin 2018 dans le Bulletin de l’ACO pour un aperçu des mesures prises par l’ACO pour lutter contre la crise du sous-emploi. Pour toute question ou tout commentaire, écrivez à policy@canorth.org.

COA Bulletin ACO - Summer / Été 2019

COLLÈGE ROYAL DES MÉDECINS ET CHIRURGIENS DU CANADA. Tendances de l’emploi des nouveaux médecins spécialistes certifiés au Canada : Résultats de l’Enquête sur l’emploi du Collège royal, mai  2019. Internet  : www.royalcollege.ca/rcsite/health-policy/ employment-study-f


Advocacy & Health Policy / Défense des intérêts et politiques en santé (suite de la page 32)

Obstacles à l’obtention d’un emploi (1) Mauvais accès aux offres d’emploi

Influence de l’ACO L’ACO recommande à tous les hôpitaux de maintenir un processus d’embauche transparent en diffusant massivement les possibilités d’emploi. Les membres peuvent profiter du babillard des possibilités d’emploi de l’ACO, dans le portail des membres, auquel ces derniers accèdent par mot de passe. Pour annoncer un poste, écrire à lexie@canorth.org.

Manque de ressources liées aux soins de santé (p. ex. financement, temps d’accès aux salles d’opération)

La direction de l’ACO poursuit ses efforts de défense des droits et intérêts auprès du gouvernement et d’autres intervenants afin de promouvoir des modèles de soins de l’appareil locomoteur novateurs et sans conséquence sur les coûts qui améliorent les soins et l’efficacité du système, entraînant éventuellement la création d’emplois.

Départ à la retraite tardif des médecins et chirurgiens chevronnés (et leur hésitation à partager les ressources)

Le sous-comité sur la transition vers la retraite du Comité sur la gestion de l’exercice de l’ACO milite auprès des ministères provinciaux de la Santé pour la mise en œuvre de programmes de transition permettant aux nouveaux orthopédistes d’accéder à l’exercice et aux orthopédistes qui prennent leur retraite de quitter le système de santé en une série d’étapes tout en assurant la continuité de soins de grande qualité.

Pas assez de postes disponibles au Canada Désir ou nécessité de rester près de la famille

Influence limitée

Contraintes liées à l’emploi du conjoint/de la conjointe

ADVERTISING SPACE AVAILABLE

ESPACE PUBLICITAIRE

The COA Bulletin, the official journal of the Canadian Orthopaedic Association, has been declared by our membership as one of the most valuable membership services.

Le Bulletin, publication officielle de l’Association Canadienne d’Orthopédie (ACO), a été désigné par nos membres comme l’un des services les plus utiles que nous leur offrons.

By placing your advertisement in the COA Bulletin, you will be communicating with the largest number of Canada’s leading orthopaedic specialists.

Placer une annonce dans le Bulletin de l’ACO assure une visibilité inégalée auprès des orthopédistes les plus influents au pays.

Don’t miss out on this kind of opportunity! Become a part of our publication cycle by contacting Cynthia Vezina at the COA Office Tel: (514) 874-9003 ext. 3 or e‑mail: cynthia@canorth.org and details will be forwarded to you.

Ne manquez pas cette occasion! Pour faire partie de notre cycle de publication, communiquez avec Cynthia Vezina, au bureau de l’ACO, au 514-874-9003, poste 3, ou à cynthia@canorth.org.

COA Bulletin ACO - Summer / Été 2019

33


VOUS AVEZ UNE INCIDENCE VOUS FAITES BOUGER LES CHOSES VOTRE COTISATION SOUTIENT DIRECTEMENT L’ORTHOPÉDIE AU CANADA.

En tant que membre de l’ACO, vous contribuez directement à l’avancement de notre profession. Chaque adhésion à l’ACO soutient et stimule des initiatives nationales et locales pour notre communauté orthopédique. Votre contribution à titre de membre va bien au-delà de la Réunion annuelle. En effet, votre cotisation a joué un rôle clé dans de nombreuses initiatives de l’ACO, dont voici quelques exemples récents :

DIVERSIFICATION DE NOTRE SPÉCIALITÉ Des étudiantes en médecine et d’autres étudiantes universitaires participent à une séance interactive avec des leaders en orthopédie. Nous espérons ainsi accroître le nombre de candidatures de femmes pour les places en résidence en les exposant plus tôt et plus exhaustivement à la spécialité.

PROGRAMME DE MENTORAT Les résidents et fellows sont jumelés à des membres actifs pendant une journée à la Réunion annuelle. Ce programme favorise le perfectionnement et la planification de carrière, en plus de constituer une occasion d’exercer son leadership et d’être un exemple.

LUTTE POUR UN MEILLEUR ACCÈS AUX SOINS Soutenir les associations provinciales d’orthopédie dans leurs efforts de défense des droits et intérêts par l’intermédiaire d’un lobbyiste spécialisé dans les réunions gouvernementales, la rédaction de notes d’information et d’autres messages et la collecte de renseignements, et offrir un soutien national à des initiatives provinciales existantes de défense des droits et intérêts.

SITUATION D’EMPLOI DES ORTHOPÉDISTES On a recueilli et analysé des données sur l’embauche et la situation d’emploi sur une période de 5 ans à des fins de discussion stratégique sur la crise persistante du sous-emploi avec les responsables des programmes de formation en orthopédie, le Collège royal et les médias.

ÉDUCATION MÉDICALE CONTINUE À L’ANNÉE Des possibilités de formation agréée grâce à des webinaires et aux résumés de travaux de recherche fondés sur des données probantes publiés dans OrthoEvidence, accessibles toute l’année.

RESPONSABILITÉ SOCIALE L’ACO et le Centre for Evidence-Based Orthopaedics de l’Université McMaster collaborent afin d’offrir aux membres l’accès au programme EDUCATE, qui enseigne aux professionnels de la santé œuvrant dans les cliniques de traitement des fractures à repérer les victimes de violence conjugale et à les aider.

COLLABORATIONS INTERNATIONALES Des programmes d’échange à des fins de formation et des collaborations en recherche ont été établis entre l’ACO et des associations d’orthopédie en Inde et en Europe, et les partenariats du genre sont en croissance partout dans le monde. L’ACO et ses membres jouent un rôle actif sur la scène mondiale.

ENSEMBLE, NOUS AVONS UNE INCIDENCE Votre adhésion à l’ACO est importante, et votre contribution a une incidence. Ces améliorations ne seraient pas possibles sans votre soutien. Merci d’être membre.

www.coa-aco.org/fr


More possibilities

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

A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does su not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any Stryker product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your uc Stryker representative if you have questions about the availability of Stryker products in your area. Stryker Corporation or its divisions or other corporate af�iliated entities own, use or have applied for the following trademarks or service marks: AxSOS 3, SOMA, Stryker. All other trademarks are trademarks of their respective owners or holders. AXSOS-FL-2 Rev. 1, 11-2015 Copyright © 2015 Stryker


Foundation / Fondation

36

GLA:DTM Canada Update

O

steoarthritis (OA) in the hip and knee leads to pain and disability for people across the world with about 10% of men and 18% of women over 60 years experiencing symptoms. Due to the extent of the disease and resultant disability, the Public Health Agency of Canada (PHAC) completed surveillance on the disease and their 2016–17 report finds that 13% (3.9 million) people in Canada have OA with an incidence of nine per every 1000. It has been noted that this rate is expected to increase, resulting in a prevalence of over ten million (or one in four Canadians) in 30 years. OA often results in a person limiting their activity levels therefore reducing their productivity, including their ability to work, causing reduced quality of life and financial hardship. For many people with OA, physical activity levels decrease as symptoms increase, which can increase their risk for other comorbidities such as diabetes or heart disease. Osteoarthritis is known to be a disease of the whole joint, and evidence indicates that many people experienced significant symptomatic improvement with education and exercise as the first line of treatment. This can be supported as needed by medication and assistive devices (e.g. ambulatory aids, orthotics, braces) as second line of treatment for some individuals. Given the success of these treatments, the proportion of individuals with major joint arthritis who go on to surgery, including arthroplasty, is relatively small. What is GLA:D™ Canada? GoodLife with osteoArthritis in Denmark (GLA:D®)1 is an individualized education and exercise program developed at the University of Southern Denmark. The GLA:D® program was introduced to Canada in 2016 as part of a licensing agreement with the Canadian Orthopaedic Foundation (COF). It has been adapted to the Canadian healthcare setting through a trial study2 and has been implemented across the country over the last three years through Bone and Joint Canada (BJC).3 The GLA:D® Program consists of three components: 1) A standardized training course for health-care providers (HCPs) who treat hip and knee OA – for example, physiotherapists, chiropractors, kinesiologists, and exercise physiologists – to ensure consistent and high quality program delivery across Canada. 2) A patient education and exercise program: Patients in the GLA:D® program attend two education sessions, and 12 sessions of individualized exercises over six to eight weeks. The exercise program uses NEuroMuscular Exercises, or NEMEX, a type of exercise training that works to improve muscle control and stability. NEMEX exercises focus on muscle exercises in the standing position, similar to the activities of daily living.

COA Bulletin ACO - Summer / Été 2019

3) A Canadian outcomes database where data is collected on patient pain, function and quality of life at baseline, three-month and 12-month follow-up intervals, and is used to support a high quality of care across Canada.

RESULTS WITH GLA:D® Training Programs Training courses on the GLA:D® program have been held across the country, with over 900 health-care providers having now received training in the evidence-based management of hip and knee OA. The training is available for physiotherapists, chiropractors, kinesiologists and other health professionals who can demonstrate an expertise in the management of OA using exercise as well as groupbased programming. At the end of 2018, 74% of the attendees were physiotherapists with 11% chiropractors and 12% kinesiologists. GLA:D® Sites Across Canada There are currently over 200 GLA:D® sites across the country which are situated in public and privately-funded rehabilitation clinics as well as in wellness centres. There are sites in all provinces except Québec, with plans to launch in French in early 2020. Patient Outcomes Results from patients that have attended the program up to the end of 2018 have been analysed. A total of 1,634 people with hip and knee OA have provided their data to the GLA:D® database following their participation in the GLA:D® program. These results show that there is a high participation rate in the exercise and education sessions with 79% of participants attending two or more education sessions; and 81% attending 11 or more exercise sessions. Most participants found the GLA:D® program to be beneficial or very beneficial, and were satisfied or very satisfied with the program. There was also carry over from the learning with 93% of individuals using the knowledge they had gained at least weekly.


Foundation / Fondation

37

(continued from page 36)

As the program is designed to improve symptoms from hip and knee OA, improvements in pain, function, quality of life, and medication were reported at three months and one year after the GLA:D® program. Three months after participating in the GLA:D® program most participants reported or showed a clinically meaningful improvement in pain of 15% or more, based on numeric pain rating (NPR) outcomes, and a decreased fear of damaging their joints with activity by over 47%. Twelve months after the GLA:D® program over 40% of participants reported a 30% or more improvement in pain, or no pain at all. Regarding the use of pain medication, at the 12-month followup, knee participants reported they were significantly less likely to use any medications in the prior three months compared to before starting the GLA:D® program, and had fewer injections. Hip participants reported no significant changes in their use of medications, either at three-month or 12-month follow-ups. Participants answered questions about their ability to manage their activities of daily Living (ADL), sports and recreation, and about their quality of life (QoL). Overall, most patients reported modest or marked improvements in their joint-related measures of quality of life, activities of daily living, and sports and recreation after the GLA:D® program. For each patient, function is measured objectively and the results in 2018 found there was a significant increase in the number of times individuals were able to manage sitting to standing in 30 seconds (i.e. the 30-second chair stand test) as well as improvements in their walking speed over a distance of 40 metres. Building a Program for the Future Based on the results from across Canada, the GLA:D® program is successfully supporting people with hip and knee OA to manage their symptoms, improve their function and their quality of life. Now that we are seeing the positive results in Canada for thousands of individuals with hip and knee OA, we need to develop a planned approach to allow individual access including removing barriers such as funding for those who cannot afford to pay, as well as earlier access to the program to reduce the progression of their symptoms. In Ontario a pilot project has been undertaken to allow patients seen for consultation for a joint replacement, and who are deemed not to be surgical candidates, to access the GLA:D® program at no cost. The patients are accessing the program and benefiting with reduction in their symptoms and have reported reduced interest in considering a joint replacement. To support the ongoing growth of the program, plans are underway to increase the number of sites available across the country to make the program available in all communities. The HCP training sessions are being made available in BC, Alberta, Ontario and the Atlantic provinces in 2019. French translation is also being completed to make the program available in French communities in 2020.

GLA:D™ Canada Project Team Project Co-Leads Rhona McGlasson, PT MBA Executive Director Bone and Joint Canada Michael G. Zywiel, M.D., MSc, FRCSC Orthopaedic Surgeon Toronto Western Hospital, University Health Network, University of Toronto michael.zywiel@uhn.ca For more information: www.gladcanada.ca. Acknowledgements GLA:D™ Canada is licensed to the Canadian Orthopaedic Foundation (COF) with implementation under Bone and Joint Canada, the knowledge translation division of the COF. Details of the program can be found at www.gladcanada.ca. Implementation in Ontario is supported by a Grow Grant to COF from the Ontario Trillium Foundation (01/2016-12/2018). References 1. Skou S.T., Roos E.M. Good Life with osteoArthritis in Denmark (GLA:D): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide. BMC Musculoskelet Disord 2017;18:72. 2. Davis A.M., Kennedy D., Wong R., et al. Cross-cultural adaptation and implementation of Good Life with osteoarthritis in Denmark (GLA:DTM): group education and exercise for hip and knee osteoarthritis is feasible in Canada. Osteoarthritis Cartilage 2017. 3. Roos E.M., Barton C.J., Davis A.M., et al. GLA:D to have a high-value option for patients with knee and hip arthritis across four continents: Good Life with osteoArthritis from Denmark. British Journal of Sports Medicine 2018;52:15445. 4. Nelson A.E., Allen K.D., Golightly Y.M., Goode A.P., Jordan J.M. A systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Semin Arthritis Rheum 2014;43:701-12. 5. McAlindon T.E., Bannuru R.R., Sullivan M.C., et al. OARSI guidelines for the non-surgical management of knee osteoarthritis. Osteoarthritis Cartilage 2014;22:363-88. 6. Fernandes L., Hagen K.B., Bijlsma J.W., et al. EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis. Ann Rheum Dis 2013;72:1125-35. 7. Ageberg E., Nilsdotter A., Kosek E., Roos E.M. Effects of neuromuscular training (NEMEX-TJR) on patient-reported outcomes and physical function in severe primary hip or knee osteoarthritis: a controlled before-and-after study. BMC Musculoskelet Disord 2013;14:232. 8. Ageberg E., Roos E.M. Neuromuscular exercise as treatment of degenerative knee disease. Exerc Sport Sci Rev 2015;43:14-22. COA Bulletin ACO - Summer / Été 2019


Foundation / Fondation

38

Mise à jour sur le programme GLA:DMC Canada

L

’arthrose de la hanche et du genou est une source de douleur et d’incapacité partout dans le monde, 10 % des hommes et 18 % des femmes de plus de 60 ans en présentant des symptômes. Vu l’ampleur de l’affection et l’incapacité qui en résulte, l’Agence de la santé publique du Canada (ASPC) en a effectué la surveillance, et son rapport de 2016-2017 indique que 13 % de la population (3,9  millions de Canadiens et Canadiennes) font de l’arthrose, pour une incidence de 9 personnes sur 1 000. On a souligné que ce nombre devrait augmenter et atteindre plus de 10 millions de personnes, pour un taux d’une personne sur 4, dans 30 ans. L’arthrose amène souvent la personne qui en souffre à limiter l’activité physique, et par conséquent à réduire sa productivité, y compris sa capacité à travailler, ce qui entraîne une baisse de sa qualité de vie et des difficultés financières. Chez de nombreuses personnes atteintes d’arthrose, l’activité physique diminue avec l’augmentation des symptômes, ce qui accroît les risques de comorbidités comme le diabète et les maladies du cœur. On sait que l’arthrose est une affection qui touche toute l’articulation, et les données probantes montrent que de nombreuses personnes connaissent une amélioration considérable des symptômes lorsque le traitement de première intention comprend de la sensibilisation et des exercices. Au besoin, chez certaines personnes, ceux-ci peuvent être complétés par de la médication et des accessoires fonctionnels (p.  ex. appareils déambulatoires, orthèses et attelles) comme traitement de deuxième intention. Vu le succès de ces traitements, la proportion de personnes atteintes d’arthrite grave qui subissent une chirurgie, y compris une arthroplastie, est relativement faible. Qu’est-ce que GLA:D Canada? Good Life with osteoArthritis in Denmark (GLA:DMD)1 est un programme de sensibilisation et d’exercices conçu à l’université du Danemark du Sud. Le programme GLA:D a été lancé au Canada en 2016 conformément à une licence octroyée à la Fondation Canadienne d’Orthopédie. Il a été adapté au milieu de soins canadien grâce à une étude clinique,2 et mis en œuvre dans tout le pays au cours des trois dernières années par l’intermédiaire de Santé des os et des articulations au Canada.3 Le programme GLA:D comprend les trois volets suivants : 1) Formation normalisée à l’intention des professionnels de la santé qui traitent des patients atteints d’arthrose de la hanche et du genou (p.  ex.  physiothérapeutes, chiropraticiens, kinésiologues et physiologistes de l’exercice), de sorte à assurer la constance et la grande qualité de la prestation du programme partout au pays. 2) Programme de sensibilisation et d’exercices à l’intention des patients  : Les participants au programme GLA:D assistent à deux séances de sensibilisation et douze séances d’exercices personnalisés sur une période de six à huit semaines. Le programme d’exercices fait appel à des exercices neuromusculaires, un type d’entraînement visant à améliorer le contrôle musculaire et la stabilité. Les exercices neuromusculaires sont axés sur les exercices de renforcement musculaire effectués debout et basés sur les activités de tous les jours. COA Bulletin ACO - Summer / Été 2019

3) Base de données canadienne des résultats, y compris des données sur la douleur, la fonction et la qualité de vie au départ, puis au suivi après trois mois et douze mois, de sorte à assurer la grande qualité des soins partout au pays.

RÉSULTATS AVEC GLA:D Programmes de formation Des formations sur le programme GLA:D ont été données partout au pays; plus de 900 professionnels de la santé ont maintenant bénéficié d’une formation sur le traitement fondé sur des données probantes de l’arthrose de la hanche et du genou. La formation est offerte aux physiothérapeutes, chiropraticiens, kinésiologues et autres professionnels de la santé qui peuvent faire preuve d’un savoir-faire dans le traitement de l’arthrose par l’exercice et la gestion de programmes de groupe. À la fin de 2018, 74  % des participants étaient des physiothérapeutes, 11 % des chiropraticiens et 12 % des kinésiologues. Centres GLA:D au Canada On compte actuellement plus de 200  centres GLA:D au pays, dans des cliniques de réadaptation tant publiques que privées ainsi que dans des centres de mieux-être. On trouve des centres dans toutes les provinces sauf au Québec, où le programme doit être lancé en français au début de 2020. Résultats pour les patients On a analysé les résultats pour les patients ayant participé au programme jusqu’à la fin de 2018. Au total, 1  634  personnes atteintes d’arthrose de la hanche et du genou ont fourni des données pour la base de données après avoir participé au programme GLA:D. Ces résultats montrent un fort taux de participation aux séances de sensibilisation et d’exercices, 79 % des participants ayant assisté à au moins 2 séances de sensibilisation, et 81 % à au moins 11 séances d’exercices. La plupart des participants ont trouvé le programme GLA:D bénéfique ou très bénéfique et en étaient satisfaits ou très satisfaits. Il y a également eu transfert de l’apprentissage, 93  % des participants appliquant les connaissances acquises au moins de manière hebdomadaire.


Foundation / Fondation

39

(suite de la page 38)

Comme le programme est conçu pour atténuer les symptômes d’arthrose de la hanche et du genou, des améliorations quant à la douleur, à la fonction, à la qualité de vie et à la médication ont été signalées trois mois et un an après la participation au programme GLA:D. Ainsi, 3 mois après la participation au programme GLA:D, la plupart des participants signalaient ou présentaient une réduction significative sur le plan clinique (au moins 15 %) de la douleur, selon l’échelle numérique de la douleur, et une diminution de leurs craintes de blessures articulaires à l’activité de plus de 47 %. Puis, 12 mois après le programme GLA:D, plus de 40 % des participants signalaient une réduction d’au moins 30 % de la douleur, ou aucune douleur. En ce qui concerne la prise d’antidouleurs, au suivi après douze mois, les personnes atteintes d’arthrose du genou déclaraient avoir été beaucoup moins susceptibles de prendre tout médicament au cours des trois mois précédents qu’avant le programme GLA:D, et avoir eu moins d’infiltrations. Les personnes atteintes d’arthrose de la hanche n’ont déclaré aucun changement significatif dans la prise de médicaments, tant au suivi après trois mois qu’après douze mois. Les participants ont répondu à des questions sur leur capacité à gérer leurs activités quotidiennes, sportives et de loisirs, ainsi que sur leur qualité de vie. Globalement, les participants ont déclaré des améliorations modestes ou marquées pour les indicateurs de la qualité de vie liés aux articulations ainsi que les activités quotidiennes, sportives et de loisirs après le programme GLA:D. La fonction est évaluée de manière objective pour chaque participant, et les résultats en 2018 montrent une augmentation considérable du nombre de fois où les participants étaient capables de passer de la position assise à debout en 30 secondes (test du lever de chaise – 30 secondes) ainsi que de leur vitesse de marche sur une distance de 40 mètres. Avenir du programme D’après les résultats obtenus au Canada, le programme GLA:D aide vraiment les personnes atteintes d’arthrose de la hanche et du genou à gérer leurs symptômes et à améliorer leur fonction et leur qualité de vie. Maintenant que nous constatons des résultats positifs pour des milliers de Canadiens et Canadiennes atteints d’arthrose de la hanche et du genou, nous devons concevoir une approche planifiée afin de permettre l’accès individuel, y compris supprimer les obstacles à celui-ci, grâce à du financement pour les personnes qui ne peuvent pas payer, ainsi qu’un accès plus précoce au programme de sorte à réduire la progression des symptômes. En Ontario, on a lancé un projet pilote visant à permettre aux patients qui ont une consultation pour une arthroplastie, et qui n’ont finalement pas besoin de chirurgie, d’accéder au programme GLA:D sans frais. Les patients accèdent au programme, profitent d’une atténuation de leurs symptômes, et se disent moins intéressés à subir une arthroplastie. Dans le but de soutenir la croissance du programme, on planifie une augmentation du nombre de centres au pays afin de rendre le programme accessible dans toutes les collectivités. En 2019, les séances de formation à l’intention des professionnels de la santé sont offertes en Colombie-Britannique, en Alberta, en Ontario et dans les provinces de l’Atlantique. On procède également à leur traduction en français de sorte à proposer le programme dans les collectivités francophones en 2020.

Équipe du programme GLA:D Canada Coresponsables du programme Rhona McGlasson, physiothérapeute, MBA Directrice générale Santé des os et des articulations au Canada Michael G. Zywiel, MD, M.Sc., FRCSC Orthopédiste Hôpital Western de Toronto, Réseau universitaire de santé, Université de Toronto michael.zywiel@uhn.ca Pour plus de renseignements : www.gladcanada.ca (en anglais seulement) Remerciements La Fondation Canadienne d’Orthopédie détient la licence pour la prestation du programme GLA:DMC Canada. C’est sa division de transfert des connaissances, Santé des os et des articulations au Canada, qui en assure la mise en œuvre. Les détails sur le programme sont disponibles à www.gladcanada.ca. La Fondation Canadienne d’Orthopédie a reçu une subvention de croissance de la Fondation Trillium de l’Ontario pour la mise en œuvre du programme en Ontario (01/2016-12/2018). Références 1. SKOU, S.T., et ROOS, E.M. « Good Life with osteoArthritis in Denmark (GLA:D™): evidence-based education and supervised neuromuscular exercise delivered by certified physiotherapists nationwide  », BMC Musculoskeletal Disorders, vol. 18, no 72 (7 février 2017). 2. DAVIS, A.M., KENNEDY, D., WONG, R., et al. «  Cross-cultural adaptation and implementation of Good Life with osteoArthritis in Denmark (GLA:DTM): group education and exercise for hip and knee osteoarthritis is feasible in Canada », Osteoarthritis and Cartilage, vol.  26, no  2 (février  2018), p. 211-219. 3. ROOS, E.M., BARTON, C.J., DAVIS, A.M., et al. « GLA:D to have a high-value option for patients with knee and hip arthritis across four continents: Good Life with osteoArthritis from Denmark », British Journal of Sports Medicine, vol. 52, no 24 (décembre 2018), p. 1544-1545. 4. NELSON, A.E., ALLEN, K.D., GOLIGHTLY, Y.M., GOODE, A.P., et JORDAN, J.M. «  A  systematic review of recommendations and guidelines for the management of osteoarthritis: The chronic osteoarthritis management initiative of the U.S. bone and joint initiative  », Seminars in Arthritis and Rheumatism, vol. 43, no 6 (juin 2014), p. 701-712. 5. McALINDON, T.E., BANNURU, R.R., SULLIVAN, M.C., et al. «  OARSI guidelines for the non-surgical management of knee osteoarthritis  », Osteoarthritis and Cartilage, vol.  22, no 3 (mars 2014), p. 363-388. 6. FERNANDES, L., HAGEN, K.B., BIJLSMA, J.W., et al. «  EULAR recommendations for the non-pharmacological core management of hip and knee osteoarthritis  », Annals of the Rheumatic Diseases, vol. 72, no 7 (juillet 2013), p. 1125-1135. 7. AGEBERG, E., NILSDOTTER, A., KOSEK, E., et ROOS, E.M. « Effects of neuromuscular training (NEMEX-TJR) on patientreported outcomes and physical function in severe primary hip or knee osteoarthritis: a controlled before-andafter study », BMC Musculoskeletal Disorders, vol. 14, no 232 (8 août 2013). 8. AGEBERG, E., et ROOS, E.M. «  Neuromuscular exercise as treatment of degenerative knee disease », Exercise and Sport Sciences Reviews, vol. 43, no 1 (janvier 2015), p. 14-22. COA Bulletin ACO - Summer / Été 2019


Calling all researchers! The Canadian Orthopaedic Foundation invites applications for: The J. Édouard Samson Award The premier award for orthopaedic research in Canada, the $30,000 J. Édouard Samson Award recognizes the best orthopaedic research over a period of five (5) years or more at a Canadian Centre. The Canadian Orthopaedic Research Legacy (CORL) Grant Each award consists of a $20,000 grant to be used by the winner to further their research project. The deadline for applications is October 31, 2019. Click here for application forms, guidelines and instructions.

Invitation à tous les chercheurs en orthopédie! La Fondation Canadienne d’Orthopédie est heureuse d’annoncer qu’il est maintenant possible de soumettre sa candidature à un nouveau prix. La Fondation Canadienne d’Orthopédie acceptera les candidatures pour la bourse et le prix suivants : Le Prix J.-Édouard-Samson Principal prix canadien en recherche orthopédique, le Prix J.-Édouard-Samson, d’une valeur de trente mille dollars (30 000 $), reconnaît la meilleure recherche en orthopédie menée sur une période d’au moins cinq (5) ans dans un centre canadien. La bourse de l’Héritage de la recherche orthopédique au Canada (HROC) Chaque bourse de 20 000 $ du HROC permet au lauréat de poursuivre ses recherches. La date limite de soumission des candidatures est le 31 octobre 2019. Cliquez ici pour les formulaires de soumission et lignes directrices.


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

Introducing Competence by Design (CBD) How CBD Changes Orthopaedic Surgery Training

Wade Gofton, M.D., MEd, FRCSC Ottawa, ON Tyson Gofton, PhD Toronto, ON

The Royal College of Physicians and Surgeons of Canada is introducing a transformative approach to specialty medical education. Orthopaedic surgery is on track to implement Competence by Design (CBD) in July 2020. Here is what you need to know about this new program. – Ed.

Entrustable Professional Activities CBD operationalizes the roles and competencies defined in the CanMEDS framework by defining specialty-specific Entrustable Professional Activities (EPAs). EPAs are discrete, observable and measurable units of professional practice that would be expected of any new graduate. These goals can seem distant or insurmountable for a new trainee, so the RC has elected to make EPAs stage specific (Figure 1). This helps define clear goals for both a trainee and supervisors, allows for successes, and can identify challenges earlier. EPAs are part of a national curriculum, and all must be observed and achieved to meet the national standards and progress towards certification. While there has been a significant focus on determining which EPAs are core to the specialty, EPAs do not define the curriculum or the knowledge and skills expected of a graduate. Programs must also provide other training experiences (required/recommended/optional) as defined by the specialty committee, and should continue to use assessment tools that have worked well for them in the past.

Why CBD? BD provides a set of tools and best practices that build on the strength of Canada’s system of postgraduate medical education. Competency-based medical education (CBME) began with a 1978 World Health Organization report highlighting the need to align training programs to produce physicians who can practice at a defined level of proficiency to meet local needs. In Canada, the Educating Future Physicians of Ontario process led to a redefinition of the scope of professional practice, later developed by the Royal College (RC) into CanMEDs roles and competencies. CBD is the Royal College’s vision for ensuring that we continue to train competent physicians and support physicians working toward expertise and mastery through Continued Professional Development (CPD) (Figure 1).

C

Figure 1

Misconception #1: CBD is the same as Toronto’s competency program. The University of Toronto worked hard to design and implement a program with a goal to accelerate training (<5 years of residency training) by advancing trainees when competence was achieved, rather than after completion of the traditional full five-year timeline. While the U of T demonstrated success with this program, reduced training time (<5 years for some trainees) in Canada it is not feasible for a variety of reasons at the present time. Trainees are unlikely to flow through programs and rotations on a ‘time free’ basis. What we learnt from Toronto’s experience is that a well-developed curriculum and program of frequent assessment (nearly six times more) makes it easier to define trainee competence and defend decisions to promote, remediate or terminate training. While the Toronto experience has helped to shape the RC’s CBD framework, the framework and approach are different.

Misconception #2: CBD does away with CanMEDs. CBD uses CanMEDs Milestones linked to each EPA to define the CanMEDs competencies likely required to perform the core skills of the specialty. The selected Milestone for each EPA are seen as essential competencies and meant to help frontline faculty focus their feedback for performance improvement. This structure not only defines where these competencies are taught and observed more explicitly, but when combined and reviewed by the competence committee (CC), help better define competencies the trainee needs to focus on.

Coaching and Deliberate Practice CBD promotes the use of a coaching approach to training by actively recruiting the supervisor’s expertise to shape the learning development of the trainee. Faculty provide trainees with frequent, specific and situational feedback (coaching) that rapidly enhance performance and corrects mistakes before they are reinforced as habits. You are probably already coaching your trainees, so the implementation of CBD will only formalize what you already do and facilitate ‘deliberate practice’. The coaching model requires one to build a positive professional relationship with trainees; defining expectations and planned observation (direct or indirect) at the beginning of a rotation, clinic or case; have a discussion with the trainee about their performance, and provide opportunities to improve and pro-

COA Bulletin ACO - Summer / Été 2019

41


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

42

(continued from page 41)

gress towards competence (Figure 2). Continuous deliberate practice ensures that trainees are provided with learning tasks appropriate to their level, improving learning efficiency with specific and attainable learning goals. Misconception #3: CBD changes everything. You will continue to involve trainees in your daily work environment, provide specific learning activities/tasks with graduated responsibility, observe performance, make judgements about competence in practice, and provide feedback about how to progress. CBD only asks you to take a few minutes to discuss progress and assessment directly with the trainee, and to document feedback and assessment ‘in the moment’ rather than at end of rotation. These frequent observations are faster and easier than ITERs, and with improved voice to text can make rich narrative feedback quick to record. In the setting when ITERs are still requested, this documented information can make their completion faster, easier and more accurate.

How CBD Changes Evaluation Formative Feedback CBD provides new tools for workplace-based assessment (WBA). End of rotation evaluations (ITERs) miss opportunities for corrective feedback, rely on supervisor recall, have low acceptability, and lead to “failure to fail”. CBD provides tools and best practices for frequent, low-stakes feedback that lowers barriers to corrective feedback and ensures that competence is observed in all required areas. Multi-rater records of trainee performance provide a proof of attainment, simplifying sum-

Figure 2 COA Bulletin ACO - Summer / Été 2019

mative evaluations, promotions and, as needed, decisions to provide remediation or terminate training. In environments where ITERs are used in combination with CBD formative feedback, the routine low-stakes observations can improve ITER reliability and acceptability. Misconception #4: CBD increases faculty burden. At first glance many see these observations as a major increase in work for frontline faculty. While the ask is for more feedback and documentation, CBD will provide shorter forms and electronic tools allowing for more frequent, timely, and useful feedback. CBD curriculum only applies to incoming residents; however, some programs may choose to use CBD tools for their ‘non-CBD’ trainees in the traditional curriculum. The ‘non-CBD’ trainees can also complete observations (as determined by the program) for CBD trainees which can provide more information to the CC and also reduce faculty burden. However, keep in mind it is you, the expert, that likely has the most to provide to the trainee. Entrustment-based Assessment Currently supervisors routinely assign tasks to trainees (e.g. assess patient in the ER; perform reduction). These decisions are entrustment judgments, representing the supervisor’s confidence in the trainee’s ability to carry out the task independently and report back. By implementing a framework of explicit EPAs, CBD uses the everyday clinical judgments as a tool for training, feedback and performance monitoring. As frontline faculty you will observe EPAs in-clinic/OR/Floor/


Training & Practice Management / Formation et gestion d’une pratique (continued from page 42)

ER and provide feedback on their performance, competence (potential for independence performance of that activity) and opportunities for improvement based on what you observed (directly or indirectly) that day. As an observer, you are not stating a trainee did the task without oversite or whether a trainee can “do it” independently moving forward. Keep in mind the RC has mandated that an entrustment scale must be used for observations and CC assessment. Your university may not be using the RC platform (eportfolio) or the same entrustment scale, however, all entrustment scales ask the same basic question: based on today’s observation where do you feel the trainee is with respect to progression towards safe independent performance of the EPA? Misconception #5: “I did not need to be there” means they are competent. Keep in mind that frontline faculty (you) observing these activities and providing feedback and opinion with respect to a trainee’s safe and independent completion of the activity (relative to a newly graduated orthopaedic surgeon and not your performance) are simply saying they ‘could have done it independently’, not that they ‘did’ or ‘can’ do it independently moving forward. It is multiple assessments from a variety of observers that provide a clear picture of competence or progression of competence for the CC and RPC to make progression decisions. Misconception #6: “I did not need to be there” puts me at risk. Some faculty are concerned with the “I did not need to be there” rating, concerned that it suggests they were not there, or that they let the resident do it without support or oversight - thus putting the faculty observer at medicolegal risk. Keep in mind that to accurately complete an assessment, you must have been observing and providing oversite.

Misconception #7: “I did not need to be there” means I don’t need to give feedback. Using this rating means the trainee could have done it independently and safely without your feedback. Perhaps not as efficiently as smoothly as you the expert, but they were competent. Ideally you are still providing verbal and documented feedback to provide guidance to improving beyond a competent performance.

How CBD Changes Promotion Competence Committees CBD implements CC to review the readiness of trainees to progress to the next stage in training and certification. Competence committees are tasked with ensuring that trainees have demonstrated competence in required areas, and have had the opportunity to do so. Because CBD implements systematic WBA, the CC can base their decision on a broader sample of observations and evaluations and justify decisions to promote, provide remediation or terminate training. These decisions are presented to the resident program committee (RPC), who ratify promotion decisions. Misconception #8: Once an entrustment decision is reached, the trainee is fully independent. Achieving independence with a particular task is one step towards professional practice. Even the most competent trainees can improve their performance through targeted, contextual feedback. Frequent observation after attaining ‘independence’ is critical to maximizing trainee learning through effective coaching and deliberate practice. While the CC and the RPC recommend when EPAs and stages are achieved, it does not mean the trainee will always perform entrusted EPAs independently. Each supervisor can (and should) determine a trainee’s safe level of independence based on contextual factors and case difficulty.

Upcoming COA/CORS/CORA Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO 2020

2021

June 3-6 juin

June 16-19 juin

CORA Meeting Réunion de l’ACRO June 3 juin Halifax, NS

CORA Meeting Réunion de l’ACRO June 16 juin Vancouver, BC

COA Bulletin ACO - Summer / Été 2019

43


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

44

The Pediatric and Adolescent Hip: Essentials and Evidence

A

fter more than 2 1/2 years in the making, the new text, «The Pediatric and Adolescent Hip: Essentials and Evidence” (Springer Nature), has finally been released. Co-edited by Drs. Sattar Alshryda, Jason Howard, Jim Huntley, and Jonathan Schoenecker, the goal of the book was to provide a comprehensive text from respected global experts in paediatric and adolescent hip, combining essentials of management with the most up to date evidence. Dr. Schoenecker also showed his artistic talents by providing original medical art throughout the book. The chapter authors feature several COA members, part of a global who’s who of paediatric orthopaedics represented within, and true greats in the field of the paediatric and adolescent hip. If you have any interest in the paediatric hip, you should enjoy this this comprehensive book. For adult hip surgeons, the chapters on femoroacetabular impingement, hip dysplasia, and total hip replacement in paediatric disorders will be especially relevant. The table of contents is linked here so you can see the calibre of the authors that have been assembled, and the breadth of topics therein. For more information, visit: https://www.springer.com/us/book/9783030120023).

New Bulletin Feature Highlights Canadian Perspectives

I

n this new feature, COA members currently working outside of the country share their insight on various differences they’ve realized working in the United States or abroad in comparison to their orthopaedic training in Canada. These experiences highlight the perspectives of the COA’s growing number of members now working outside of Canada. With the rising costs of health-care in both Canada and the United States, options to mitigate on both sides of the border are actively sought. The prevalence of ambulatory surgical centres in the United States is an obvious contrast in practice between our neighbouring countries, and may be worth exploring in Canada. As discussed by Dr. Kevin Chan, who is Canadian trained but currently working in the United States, ambulatory surgical centres may improve efficiency and decrease costs associated with some procedures in appropriate patients. However, how these ambulatory surgical centres, which are often (but not exclusively) for profit and privately owned in the United States, could be (or in some cases are already) implemented in the Canadian system remains to be discussed and determined. – Dr. William Weiss, Critical Issues Editor

COA Bulletin ACO - Summer / Été 2019

If you are a COA member working in the U.S. or overseas, and would like to contribute your perspective to this feature, please contact Current Issues Editor, Dr. William Weiss: william.m.weiss@ttuhsc.edu


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

Ambulatory Surgery Centres – A Possible Solution for Outpatient Procedures Kevin Chan, M.D., FRCSC Grand Rapids, MI

A

s a Canadian-trained COA member now practicing in the United States, I have certainly experienced a number of differences between working in the two countries. One particular topic I’d like to discuss seems especially relevant in today’s increasingly cost-conscious health-care system. As a disclaimer, the views expressed are my own and reflect my experience both training and working at a small number of orthopaedic centres across the United States and Canada. I am currently a hand and upper extremity surgeon and Clinical Professor at Spectrum Health | Michigan State University. In upper extremity surgery, particularly the hand, we benefit from performing many operations on “outpatients”, who do not require hospital admission. This is no different than a Canadian practice, except there is a striking shift from hospital-based outpatient departments to free-standing ambulatory surgery centres (ASC) in the United States. Whereas hospital-based outpatient departments offer an extended range of services, including the option of inpatient and emergency services, ASCs specialize exclusively in outpatient surgery. A 2015 survey of the American Society for Surgery of the Hand showed that 65% of hand surgeons performed their operations at an ASC1. This reflects my personal experience, and I suspect that the proportion may now be higher in 2019. ASCs have several distinct advantages, with the major driver behind their popularity being reduced health-care costs. Health-care spending in both the U.S. and Canada continues to rise, in the U.S. reaching $3.5 trillion or $10,739 per person in 20172. On average, this represents almost twice as much as comparable countries3. Thus, surgeons face mounting pressure to reduce costs and deliver value-based services. ASCs may be an option to assist in the reduction of the cost associated with surgery. Nguyen et al.4 examined the charges for carpal tunnel release and found that there was a cost savings of approximately 30% by simply moving out of the hospital and into an ASC. Similarly, Mather et al.5 identified that facility type was the only predictor of total cost and surgical time. Compared with the hospital, care delivered at an ASC costs an average of 46% less. Another advantage of freestanding ASCs is efficiency. Gottschalk et al.6 showed that turnover times were shorter at an ASC compared to a specialized orthopaedic hospital. In a larger review, Munnich and Parente7 reviewed the 2006 National Survey of Ambulatory Surgery and found that surgeries performed in an ASC took 31.8 fewer minutes than those performed in a hospital setting. The factors driving these differences are numerous, including volume and specialization, leading to greater familiarity and efficiency8. In ASCs, facilities may be smaller with the operating rooms closer to the preoperative areas and recovery rooms. In addition, perioperative staff may have more consistent roles, and staffing may not be shift-based, creating an

incentive to work quickly as all staff are motivated to complete the day’s operative list7,9. Furthermore, by their very nature, hospitals are more likely to have emergency cases that directly compete with outpatient surgeries for operative time7,9. ASCs offer safe and effective outpatient surgical services. In a retrospective review of 28,737 cases, Goyal et al.10 reported an overall complication rate of 0.20%. However, a direct com- Dr. Kevin Chan completed parison between ASCs and hospitals his orthopaedic residency is confounded by the fact that ASCs at McMaster University and often treat healthier patients suitable now practices in the United for outpatient surgery7. Regardless, States this would suggest that surgical “cherry-picking” might not be a bad thing for the system. Given the issues currently faced by the Canadian health-care system, including access to care, prolonged wait-times, and physician unemployment, ASCs may merit further discussion. As of January 2011, there were only 69 facilities accredited by the Canadian Association for Accreditation of Ambulatory Surgical Facilities (CAAASF)11. In contrast, a 2014 estimate reported that approximately 5,300 ASCs provided more than 25 million procedures annually in the U.S.7 ASCs are a high-quality alternative to hospital-based outpatient departments for the correct patients. Increasing the number of ASCs in Canada may be an option to decrease surgical wait lists, improve access to care, and decrease associated health-care costs. The real question remains: How can a publicly-funded system pay for free-standing ASCs? Further discussion is certainly merited. As Canadians, we may be in the midst of a transition from entirely hospital-based surgical services for emergency treatment unhealthy patients, and palliative care to the inclusion of ASCs for appropriate patients. As health-care costs continue to rise and patient demand increases, finding effective solutions for our surgical patients is imperative for both countries. References: 1. Munns J.J., Awan H.M. Trends in carpal tunnel surgery: an online survey of members of the American Society for Surgery of the Hand. J Hand Surg Am. 2015;40(4):767-771. e762. 2. National Health Care Expenditure Data. https://www.cms. gov/research-statistics-data-and-systems/statistics-trendsand-reports/nationalhealthexpenddata/nationalhealthaccountshistorical.html. Accessed January 6, 2019.

COA Bulletin ACO - Summer / Été 2019

45


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

46

(continued from page 45)

3. Sawyer B., Cox C. How does health spending in the U.S. compare to other countries? 2018; https://www.healthsystemtracker.org/chart-collection/health-spending-u-s-compare-countries/ - item-u-s-increased-public-private-sectorspending-faster-rate-similar-countries. Accessed May 10, 2019. 4. Nguyen C., Milstein A., Hernandez-Boussard T., Curtin C.M. The Effect of Moving Carpal Tunnel Releases Out of Hospitals on Reducing United States Health Care Charges. J Hand Surg Am. 2015;40(8):1657-1662. 5. Mather R.C., 3rd, Wysocki R.W., Mack Aldridge J., 3rd, Pietrobon R., Nunley J.A. Effect of facility on the operative costs of distal radius fractures. J Hand Surg Am. 2011;36(7):1142-1148. 6. Gottschalk M.B., Hinds R.M., Muppavarapu R.C., et al. Factors Affecting Hand Surgeon Operating Room Turnover Time. Hand (N Y). 2016;11(4):489-494.

8. Thompson N.B., Calandruccio J.H. Hand Surgery in the Ambulatory Surgery Center. Orthop Clin North Am. 2018;49(1):69-72. 9. Trentman T.L., Mueller J.T., Gray R.J., Pockaj B.A., Simula D.V. Outpatient surgery performed in an ambulatory surgery center versus a hospital: comparison of perioperative time intervals. Am J Surg. 2010;200(1):64-67. 10. Goyal K.S., Jain S., Buterbaugh G.A., Imbriglia J.E. The Safety of Hand and Upper-Extremity Surgical Procedures at a Freestanding Ambulatory Surgery Center: A Review of 28,737 Cases. J Bone Joint Surg Am. 2016;98(8):700-704. 11. Ahmad J., Ho O.A., Carman W.W, Thoma A, Lalonde DH, Lista F. Assessing patient safety in Canadian ambulatory surgery facilities: A national survey. Plast Surg (Oakv). 2014;22(1):3438.

7. Munnich E.L., Parente S.T. Procedures take less time at ambulatory surgery centers, keeping costs down and ability to meet demand up. Health Aff (Millwood). 2014;33(5):764769.

Current Trends in Orthopaedics, Sicily, Italy April 26-May 2, 2020 Paul R. Kim, M.D., FRCSC Course Chair

T

he University of Ottawa Division of Orthopaedics is pleased to present Current Trends in Orthopaedics in beautiful Sicily, Italy April 26-May 2, 2020. This event follows the incredible success of our inaugural meeting in the Loire Valley, France in 2018. We are now heading to Sicily known for its rich history, delicious food, and magnificent views of the Mediterranean. There will be an in-depth, educational program concentrating on current trends in orthopaedics designed specifically for orthopaedic professionals. First class speakers, interactive sessions including case reviews are all accompanied with ample time for discussion. The academic portion of the meeting is complemented by daily guided cycling and hiking options allowing you to explore the countryside and ancient Roman ruins up close. The program includes accommodation at the stunning beachfront five-star Verdura Resort, gourmet dining, fabulous wines and some of the best hiking and cycling in all of Italy. The resort is also home to three top rated Kyle Phillips golf courses. Please join us to experience this fascinating and unique educational event. 

COA Bulletin ACO - Summer / Été 2019

The program is 80% sold out. Click here for information and registration. Space is extremely limited. This University of Ottawa CME event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada and approved by the Canadian Orthopaedic Association.


FREE

Better Evidence . Better Analytics Better Decisions

PREM ACC IUM ESS

COA MEMBER BENEFIT Access Over 5000+ High Quality Research Summaries Personalize Your Experience. Earn CME Credits Access our Exclusive OE Original Content

Insights on Emerging Topics Review Conference Summary Reports Vote on Treatment Recommendations Insights to Your Inbox

BUILT FOR THE ORTHOPAEDIC COMMUNITY BY ORTHOPAEDIC EXPERTS

JOIN OUR GROWING COMMUNITY OF 50,000+ GLOBAL MEMBERS SIGN UP TODAY

www.myorthoevidence.com


Join Us As We Celebrate 75 Years of Being Your COA

Venez célébrer le 75e anniversaire de votre ACO

Celebrate the COA’s 75th Anniversary in Halifax, Nova Scotia at the 2020 Annual Meeting from June 3-6.

Venez célébrer le 75e anniversaire de l’ACO à Halifax, en Nouvelle-Écosse, à l’occasion de la Réunion annuelle 2020, qui aura lieu du 3 au 6 juin.

Mark your calendars and make your plans to join us in Halifax.

www.coa-aco.org

Faites une croix à votre calendrier et planifiez dès maintenant votre séjour à Halifax.

www.coa-aco.org/fr


Have you activated your online subscription? If youâ&#x20AC;&#x2122;re an Associate or Active Member of the COA, you receive a complimentary online subscription to The Bone & Joint Journal (formerly JBJS Br) andBone & Joint

360

Go to: online.boneandjoint.org.uk/action/registration If you do not know your login details to activate please email subs@boneandjoint.org.uk

Form e know rly n as JBJS ( Br)

www.bj360.boneandjoint.org.uk

www.bjj.boneandjoint.org.uk

Would you like to receive print copies in addition to your online access? Email subs@boneandjoint.org.uk for more information

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

Profile for Canadian Orthopaedic Asssociation

COA Bulletin #124 - Summer 2019  

The Summer 2019 edition of the COA Bulletin, the official journal of the Canadian Orthopaedic Association

COA Bulletin #124 - Summer 2019  

The Summer 2019 edition of the COA Bulletin, the official journal of the Canadian Orthopaedic Association

Profile for coa-aco