COA Bulletin #126 - Spring 2020

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

BULLETIN

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

FROM COAST TO COMPUTER:

IT’S THE FIRST VIRTUAL COA, CORS, AND CORA ANNUAL MEETING. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 17

DE LA CÔTE À VOTRE ORDINATEUR :

VOICI LA TOUTE PREMIÈRE RÉUNION ANNUELLE VIRTUELLE DE L’ACO, DE LA SROC ET DE L’ACRO.. . . . p. 17

Spring Printemps 2020

126

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Publication Mail Envoi Poste-publication Convention #40026541

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

www.coa-aco.org

The Strength of Our Orthopaedic Community Shines Through. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Leading without a Plan An Open Letter from the CEO. . . . . . . . . . . . . . . . . . . . . . . . . 6 Offrir un soutien spécialisé aux sociétés de sous-spécialité en orthopédie canadiennes. . . . . . . . . . 16 Reducing Hospital Length of Stay is an Opportunity to Optimize Our Patients’ Recovery.. . . . . . . . . . . . . . . . 20 Corrective Valgus Open Wedge Proximal Humerus Osteotomy in a Case of Varus Malunion. . . . . . . . . . . 26

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2. Landge V, Shabtai L, Gesheff M, et al. Patient satisfaction after limb lengthening with internal and external devices. J of Surg Orthop Advanc 2015;24(3):174-9.

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Your COA / Votre association

Bulletin Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 126 - Spring / Printemps 2020 COA / ACO

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The Strength of our Orthopaedic Community Shines Through Mark Glazebrook, M.D., MSC, PhD, FRCSC President, Canadian Orthopaedic Association

Mark Glazebrook President / Président Brendan Sheehan Secretary / Secrétaire Cynthia Vezina Chief Executive Officer / Directrice générale 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 Dan Cohen Contributor / Contributeur Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher.

Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur.

The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement.

If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website.

L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

The COA Executive Committee meets via Zoom

W

ow, where to start? It goes without saying that we are currently living in a most interesting time. We started the year off with a great plan for the COA’s Annual Meeting in Halifax, a promising strategic review design, and made headway on gender equity projects and initiatives to assist with the orthopaedic human resource dilemma. However, our best laid plans and efforts were shaken with the COVID-19 global pandemic that rocked our personal and professional worlds, sending many of us into a tailspin.

We went from busy clinical schedules and wearing OR greens to self-isolation in our comfiest loungewear at home. We also quickly became teleconference and videoconference amateurs overnight, filling our days with virtual meetings for patients, staff, colleagues, professional organizations and hopefully some fun virtual socials as well.

Our collective effort is paying off as we are seeing a flattening of the curve, though not without the tragic loss of thousands of Canadian lives and difficulties to our professional practice and resident education. In Nova Scotia, the light at the end of the COVID-19 tunnel was temporarily extinguished by the tragic events of the worst mass shooting in Canada’s history and my deepest sympathies go out to all those affected.

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

Please send address changes to the Bulletin at the: cynthia@canorth.org

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

Veuillez faire parvenir tout changement d’adresse à : cynthia@canorth.org

Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the author’s perso­nal observations and do not imply endorsement by, nor official po­licy of the Canadian Orthopaedic Association.

Legal deposition: National Library of Canada ISSN 0832-0128

À moins que le contraire ne soit spécifié, les opinions exprimées dans cette revue sont celles de leur auteur et ne reflètent aucu­ne­­­ment un endos­sement ni une position de l’Association Canadienne d’Orthopédie.

Dépot légal : Bibliothèque nationale du Canada ISSN 0832-0128

COA Bulletin ACO - Spring / Printemps 2020

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(continued from page 3)

Despite all this great loss and hardship, there are hints of a new beginning in the horizon and I am proud of the COA membership that weathered the storm in fine fashion. First and foremost, congratulations to all our COA members who stepped up on the frontlines. Not only did you provide the care your patients needed, but you did so whilst knowingly and selflessly putting yourself at risk, and for that you are profoundly commended and thanked by the COA and Canada as a whole.

Further, COA members across the country stepped up to develop and distribute important position statements and communications to appropriate authorities voicing our collective concerns with PPE, income stability, and most importantly, enabling ongoing patient care. Also, through collaboration with affiliate stakeholder groups, our COA members were provided guidance on navigating patient care and safety during pandemic times. Our important collaboration efforts with industry partners and Medtech continues to provide continued safe and effective patient care through data sharing for cancelled surgeries and reintroductions into the OR. The loss of our chance to gather in Halifax for our 75th Annual Meeting pales in comparison to the tragic loss of life and significant adversities caused by COVID-19. However, I personally invite all COA members to continue standing together with your colleagues and friends. The Annual Meeting is not

cancelled, but simply transitioning platform, so surf (via the Internet) to the East coast for the first ever Virtual COA Annual Meeting!

Special thank you to the COA Staff and Executive for all your hard work, dedication, and your positive smiles on Zoom conference calls.

“Stay Positive, Test Negative” Dr. Paul Wright, COA Member

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 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 34

La force de notre communauté orthopédique rayonne Mark Glazebrook, MD, M.Sc., Ph.D., FRCSC Président de l’Association Canadienne d’Orthopédie

l’histoire canadienne; toutes mes sympathies aux personnes touchées par cette tragédie.

B

Malgré ces pertes et ces épreuves immenses, un nouveau départ semble poindre à l’horizon, et je suis fier des membres de l’ACO, qui ont su affronter la tempête de belle manière.

Tout d’abord, félicitations à tous les membres de l’ACO qui ont donné un coup de main en première ligne; non seulement vous avez donné à vos patients les soins dont ils avaient besoin, mais vous l’avez fait en vous mettant sciemment et généreusement à risque. L’ACO et tout le Canada vous saluent haut et fort et vous remercient.

on, où commencer? Il va sans dire que nous vivons actuellement une période des plus intéressantes. Nous avons commencé l’année avec d’excellents plans pour la Réunion annuelle de l’ACO à Halifax et un concept prometteur pour l’examen stratégique, et nous avions fait des progrès sur des projets et initiatives d’équité entre les sexes en vue d’atténuer le dilemme des ressources humaines en orthopédie.

Nos plans et efforts si réfléchis ont toutefois été bouleversés par la pandémie mondiale de COVID-19, qui est venue ébranler notre vie personnelle et professionnelle, partie en vrille pour beaucoup d’entre nous.

Nous sommes passés d’un horaire clinique chargé et des uniformes verts de salle d’opération au confinement à la maison dans nos tenues de détente les plus confortables. Du jour au lendemain, nous sommes aussi devenus amateurs de téléconférences et de vidéoconférences, meublant nos journées de rencontres virtuelles avec nos patients, notre personnel, nos collègues, nos associations professionnelles et, espérons-le, de quelques activités sociales virtuelles. Nos efforts collectifs rapportent, puisque la courbe tend à s’aplatir, mais non sans des milliers de morts tragiques au pays et des problèmes liés à notre exercice professionnel et à la formation des résidents. En Nouvelle-Écosse, la lumière au bout du tunnel de la COVID-19 a en outre été temporairement obscurcie par la pire tuerie de COA Bulletin ACO - Spring / Printemps 2020

De plus, des membres de l’ACO partout au pays ont mis la main à la pâte et élaboré, puis diffusé, d’importants énoncés de position et autres communications aux autorités concernées afin d’exprimer nos préoccupations communes par rapport à l’équipement de protection individuelle, à la stabilité du revenu et, plus important encore, à la continuité des soins. En outre, grâce à une collaboration avec des sociétés affiliées, les membres de l’ACO ont pu bénéficier de conseil sur les soins aux patients et la sécurité pendant la pandémie. Nos efforts de collaboration importants avec des partenaires de l’industrie et la technologie médicale continuent de permettre des soins sécuritaires et efficaces grâce au partage de données pour les chirurgies annulées et la réintroduction en salle d’opération.

L’impossibilité de nous réunir à Halifax à l’occasion de notre 75e Réunion annuelle semble bien dérisoire par rapport à la

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perte tragique d’une vie et aux grands malheurs causés par la COVID-19. Par contre, j’invite personnellement tous les membres de l’ACO à continuer de rester forts avec leurs collègues et amis. La Réunion annuelle n’est pas annulée, elle change simplement de plateforme; alors naviguez (sur Internet) vers la côte Est pour la toute première Réunion annuelle virtuelle de l’ACO!

J’aimerais remercier tout particulièrement les membres du personnel et de la direction de l’ACO pour leur travail acharné, leur dévouement et leur sourire lors des téléconférences sur Zoom.

Letter to the Editor

Lettre au rédacteur en chef

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naugurated in 1983, the COA Bulletin publishes articles written by and for its membership. It values reciprocal communication at its core. Would you like to express an opinion about a topic of interest? Do you agree or disagree with something published in a previous COA Bulletin edition or want to contribute to a past discussion? We’d love to hear from you. Please send in your Letter to the Editor via e-mail to lexie@canorth.org.

« Soyez positif, testez négatif » – Dr Paul Wright, membre de l’ACO

C

réé en 1983, le Bulletin de l’ACO publie des articles rédigés par et pour ses membres. La communication bidirectionnelle est au cœur de ses valeurs. Vous aimeriez vous exprimer sur un sujet d’intérêt pour les membres de la communauté orthopédique canadienne? Vous êtes d’accord ou en désaccord avec un article publié dans un numéro du Bulletin ou souhaitez contribuer à une discussion qui y a eu lieu? C’est toujours un plaisir de vous lire. Veuillez envoyer votre lettre au rédacteur en chef à info@canorth.org.

Bahamas Bone & Joint Centre, The Ladies Medical Centre Nassau, Bahamas November 23, 2019 Dear COA Bulletin,

I

n August 2019, two of 700 islands in the Bahamas suffered the devastating wrath of Hurricane Dorian: Marsh Harbour, Abaco and Freeport, Grand Bahama. Mass casualties occurred - many of whom had open pilon ankle fractures, femur and tibia fractures as well as traumatic upper limb amputations. The open fractures were not simple since they were soaked in sewage-contaminated water for several days before being able to get treatment. The government of the Bahamas still does not know the death toll since many undocumented immigrants as well as Bahamian Nationals have simply not been found, presumably from being washed out to sea.

From l to r: Dr. Ross Leighton, Dr. Dane Bowe, Dave Simpson (CEO), Rob Pikula and Jeff Deane representing the Canadian office of Johnson & Johnson.

On September 1, 2019, the Bahamas was devastated by Dorian, a Category 5 hurricane in the Atlantic. Marsh Harbor and Freeport were hit terribly, but fortunately Nassau was left relatively unhurt. The country was inundated with people suffering from major compound injuries, but also severely lacked medical resources. Hospitals had bare shelves and no equipment to handle the onslaught despite the manpower and expertise to treat these patients.

Dane Bowe, an orthopaedic surgeon trained at Dalhousie University in Halifax, Nova Scotia, contacted me for help. I am grateful to have been able to respond quickly and coordinate valuable assistance from our industry partners.

We were blown away by these absolutely incredible humanitarian responses. A special thanks to Matt Duffett, our local Smith and Nephew representative and Ryan Huggett, in the head office, who oversaw this shipment. Also, profound thanks to Clair Horne, National Sales Director, Jeff Deane, Rob Pikula and Dave Simpson from Johnson & Johnson for all their aid to a weather-torn country.

Please read the more detailed letter from Dr. Dane Bowe. esteemed COA member.

Ross Leighton, M.D., FRCSC Halifax, Nova Scotia

COA Bulletin ACO - Spring / Printemps 2020

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(continued from page 5)

Fortunately, the island of New Providence, where the city of Nassau is located, was left relatively unharmed. However, our main hospital (The Princess Margaret Hospital) was so inundated that the orthopaedic supplies were limited despite having manpower and expertise to treat these patients. As a Dalhousie orthopaedic graduate, I contacted Dr. Ross Leighton and he was able to do two things immediately: 1) Gather over $200,000.00 of equipment that had been made ready and saved to go to such an effort. This was shipped by Smith & Nephew along with some basic insertion equipment ($100,000); 2) Contacted Johnson & Johnson, who also responded spectacularly as they gathered over $1000,000.00 worth of external fixator sets as well as battery operated drills that we desperately needed. This was delivered to Nassau within five days.

The equipment donated is certainly a gift of a life time. I would like to express my gratitude firstly to Dalhousie University for training me and assisting with the donation. I can never stop thanking Dr. Ross Leighton for his generosity and for being a mentor. I also would like to thank Dave Simpson, Jeff Deane and Rob Pikula representing the Canadian office of Johnson & Johnson. Gratitude is also extended to Gwenael Gouery, Amanda Paniagua, Ryan Huggett and Matt Duffett for their aid in getting the equipment to us from Smith & Nephew and Dalhousie University (QEII HSC). We are forever in your debt.

Sincerely, Dane Bowe, BSc, M.B., B.S., FRCSC Nassau, Bahamas

Leading without a Plan - An Open Letter from the CEO Cynthia Vezina Chief Executive Officer, Canadian Orthopaedic Association

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had a plan when I became CEO in January this year. The COA was in strategic review, we were mapping out new directions with exciting projects and collaborations on the horizon, I was growing our staff to support expanding programs, and we were celebrating the Association’s 75th anniversary at the Annual Meeting in Halifax. Barely two months into my tenure, I instead found myself cancelling meetings, desperately trying to recover financial losses, reprioritizing and rescheduling every single project, reassessing what members need and value from the COA, and managing a smaller staff virtually from my living room in the middle of a global health crisis. Release the murder hornets.

As a planner by trade and by nature, leading without a blueprint after all of your plans go up in smoke is daunting. There is uncertainty. There is a learning curve. The seemingly endless video and teleconference meetings we’re experiencing are evidence of our need to be reactive, to quickly figure out how to do things differently, learn new processes, and make decisions in the midst of so much unknown.

face new challenges practicing in a COVID-19 world, the ways we educate, communicate, advocate, and engage will be different from anything we’re used to or what we experienced before. Something so unprecedented and devastating as COVID-19 resets our focus and reveals what matters the most. Amid the rubble of my first year’s plans emerge new opportunities and a stronger connection to the members we represent. I have never seen our orthopaedic community step up to support their Association so quickly, willingly and profoundly in my over 20 years at the COA. Thank you. Your support keeps the COA standing on its feet.

The fragility of voluntary membership-based organizations like the COA becomes shockingly apparent in times of crisis. With our two primary revenue streams compromised, we don’t have much in our back pocket. As an Association that already operates on a very lean budget, there are not a lot of funds to rely on. Like everyone, we’ve been hit tremendously hard by all of this. Recovery will take time, strategy, innovation and leadership. Recovery will take member support and commitment.

Thank you for contributing your Annual Meeting registration and ticket fees to the COA, for paying membership dues despite reduced income and remuneration, for leading advocacy efforts, for being available for last minute Zoom meetings, for data gathering, for sharing best practices and key learnings from your experiences, and for being there for each other and for the COA. We commend our members who are working on the front lines, investigating new research innovations, and advocating for access to care and resumption of orthopaedic procedures. I’d also like to thank our industry partners for committing to ongoing collaborations and support.

The COA is changing with the needs of our members and their practices. As the country reopens and our members

The COA is here for you and with you. I suppose that’s essentially been my plan all along.

COA Bulletin ACO - Spring / Printemps 2020

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Diriger sans plan - Lettre ouverte de la directrice générale Cynthia Vezina Directrice générale de l’Association Canadienne d’Orthopédie

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uand je suis devenue directrice générale, en janvier, j’avais un plan. L’ACO était en plein examen stratégique, nous établissions de nouvelles orientations, et des collaborations et projets passionnants pointaient à l’horizon, j’augmentais nos effectifs afin de soutenir l’expansion de nos programmes, et nous nous apprêtions à célébrer le 75e anniversaire de l’ACO à la Réunion annuelle de Halifax. À peine deux mois plus tard, je devais plutôt annuler des réunions, essayer désespérément de récupérer les pertes financières, revoir la priorité et l’horaire de chaque projet, réévaluer ce dont les membres ont besoin et ce qu’ils veulent de l’ACO, et gérer virtuellement un personnel réduit à même mon salon au beau milieu d’une crise sanitaire mondiale. Il ne manquait plus que des frelons géants. Étant planificatrice de profession et dans l’âme, diriger sans plan parce que tous les plans sont tombés à l’eau est décourageant. Il y a de l’incertitude. Il y a une courbe d’apprentissage.

Le nombre apparemment sans fin de vidéoconférences et téléconférences que nous tenons vient prouver notre besoin de réagir, de trouver rapidement comment faire les choses autrement, d’apprendre de nouveaux processus et de prendre des décisions malgré l’incertitude ambiante.

La fragilité des associations auxquelles l’adhésion est volontaire, comme l’ACO, devient terriblement évidente en temps de crise. Une fois nos deux principales sources de revenus compromises, il ne nous reste plus grand-chose en poche. Et puisque nous fonctionnons déjà selon un budget très sobre, nous ne disposons pas de beaucoup de fonds. Comme tout le monde, nous sommes extrêmement affectés par la situation. Nous aurons besoin de temps, d’efforts stratégiques, d’innovation et de leadership pour récupérer. Nous aurons besoin du soutien et de l’engagement de nos membres.

YOUR CYBER COA

L’ACO change au gré des besoins de ses membres et de l’évolution de leur exercice. Alors que le pays se prépare au déconfinement et que nos membres doivent relever de nouveaux défis dans un monde où sévit la COVID-19, les façons d’apprendre, de communiquer, de militer et de participer seront différentes de ce à quoi nous étions habitués ou de ce que nous avons vécu jusqu’ici. La pandémie de COVID-19 est une situation sans précédent et si dévastatrice qu’elle recentre notre attention et révèle ce qui importe le plus. Au milieu des cendres de mes plans pour ma première année à la direction générale naissent de nouvelles possibilités et une connexion plus forte avec les membres que nous représentons. En plus de 20 ans à l’ACO, je n’avais jamais vu notre communauté orthopédique se lever si volontiers, rapidement et entièrement afin de soutenir son association. Merci. Grâce à votre soutien, l’ACO peut rester debout.

Merci d’avoir donné vos droits d’inscription à la Réunion annuelle et le coût de vos billets à l’ACO, d’avoir payé votre cotisation malgré des revenus moindres, de mener les efforts de défense des droits et intérêts, d’être disponibles pour des réunions de dernière minute sur Zoom, de recueillir des données, de partager vos pratiques exemplaires et les leçons clés que vous tirez de votre expérience, et d’être là pour vos collègues et pour l’ACO. Nous saluons nos membres qui travaillent en première ligne, étudient les nouvelles innovations en recherche, et militent pour l’accès aux soins et la reprise des interventions orthopédiques. J’aimerais enfin remercier nos partenaires de l’industrie pour leur engagement à maintenir leur collaboration et leur soutien.

L’ACO est ici pour vous et avec vous. J’imagine que c’était mon plan depuis le début, au fond.

VOTRE CYBER-ACO

PLENARY SESSION FOR MEMBERS - JUNE 19

SÉANCE PLÉNIÈRE POUR LES MEMBRES LE 19 JUIN

All members are invited to attend the Your Cyber COA on Friday, June 19 during the Virtual Annual Meeting.

This session includes Q&A with the COA leadership, the transfer of office from Dr. Mark Glazebrook to Dr. Mohit Bhandari, the business meeting, and the announcement of the next 2nd President Elect. Held from 19:00-20:00 EDT on Friday, June 19, this session closes off day 1 of the COA, CORS and CORA Annual Meeting (June 19-20).

Tous les membres sont invités à la séance Votre cyber-ACO, le vendredi 19 juin, dans le cadre de la Réunion annuelle virtuelle.

C’est séance comprend des questions avec la direction de l’ACO, la cérémonie de transfert des charges du Dr Mark Glazebrook au Dr Mohit Bhandari, la Séance de travail et l’annonce du deuxième président élu de l’ACO. La séance se tiendra de 19 h à 20 h (HNE), le vendredi 19 juin, et viendra clore la première journée de la Réunion annuelle de l’ACO, de la SROC et de l’ACRO (les 19 et 20 juin).

Information about accessing the Your Cyber COA session will be provided shortly.

L’information nécessaire pour accéder à la séance Votre cyber-ACO vous sera communiquée sous peu.

CLICK HERE TO LEARN MORE

CLIQUEZ ICI POUR PLUS DE DETAILS

COA Bulletin ACO - Spring / Printemps 2020

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Diversity in the COA: Spotlight on Women in Orthopaedics

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r. Supriya Singh is specializing in adult and paediatric spine orthopaedic surgery. She recently completed her residency training, graduating from Western University in 2019. She is currently completing a fellowship in adult spine surgery in Vancouver, BC. 1. What drew you to orthopaedics (and your subspecialty)?

I was drawn to orthopaedics by the immediate gratification that comes from the ability to help restore function and independence for patients after an injury. Mentorship was also a significant motivating factor that encouraged me to pursue orthopaedics as a career. I really enjoy the surgical challenges of spine surgery and hope to pursue both adult and paediatric spine surgery in the future.

2. Can you recount a defining moment in your career thus far?

This is a difficult question because I feel as though there have been many defining moments in my career, from specific patient interactions to unique surgical cases, and recently passing the orthopaedic Royal College examination. If I had to pick one at this moment, it would be choosing Western University, London, Ontario to complete my residency training. The quality of surgical training and the mentorship I received was phenomenal. To those who trained me and my co-resident Western family, I would not be where I am or who I am today without all of you. It was certainly a tough but rewarding five years of training that I have truly come to appreciate after leaving for fellowship.

3. What does diversity mean to you?

To me, diversity means people of various backgrounds and different walks of life that form a cohesive and supportive group.

4. What advice would you give to orthopaedic residents?

The advice I would give to orthopaedic residents is to continue to work hard and learn from every patient, every case, and every opportunity.

Find a mentor, someone you feel you can look up to in your field or subspecialty, because that menCOA Bulletin ACO - Spring / Printemps 2020

torship can help you through residency. I would tell residents that this career path is lifelong learning and we all make mistakes; it is how we deal with them and learn from them that make us better.

5. What is one professional goal and one personal goal you hope to achieve in the next five years?

Professional goal: I hope to become a proficient adult and paediatric spine surgeon.

The COA recognizes the strength in diversity and promotes equity across its membership, services, and all community engagement. Each edition of the COA Bulletin will feature one of the many women members of the Association, their experiences and insights, contributions to the specialty and advice for junior colleagues and students. Get to know the membership!

“I would tell residents that this career path is lifelong learning and we all make mistakes; it is how we deal with them and learn from them that make us better.”

Personal goal: I hope to find a better balance between work and life.

As a trainee for the past five years, it has been hard to find a healthy balanced lifestyle.

6. Name one of your go-to tricks or hacks that has helped you in your day to day life?

Not sure this is a go-to trick, but whenever life gets overwhelming and work is challenging or you feel as though you have let a patient or colleague down, turn to your support network. I am lucky to have amazing friends and family that give me a healthy dose of a reality check and the love that I need to remember that everything will be okay. Having a supportive community around you is the key to getting through day to day life.

In residency, I almost always had some form of sugar on me, usually Jolly Rancher candies, to help get through the day and keep the glucose running.

Finally, something simple that we all know but sometimes can be hard to practice is just to simply be respectful of those around you. The way you treat others (with kindness, respect, and patience) will help you significantly in your day to day life.

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Diversité au sein de l’ACO : Pleins feux sur les femmes en orthopédie

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a Dre Supriya Singh se spécialise dans la chirurgie du rachis chez l’adulte et l’enfant. Elle a terminé sa résidence à l’Université Western en 2019. Elle effectue actuellement un fellowship en chirurgie du rachis chez l’adulte à Vancouver, en Colombie-Britannique.

1. Qu’est-ce qui vous a amenée à choisir l’orthopédie (et votre sous-spécialité)?

Ce qui m’a attirée en orthopédie, c’est la satisfaction immédiate qui vient avec la capacité de pouvoir restaurer la fonction et l’autonomie des patients après une blessure. Le mentorat a également été un facteur de motivation considérable dans mon choix de faire carrière en orthopédie. J’aime vraiment les défis chirurgicaux posés par la chirurgie du rachis, et j’espère pouvoir exercer tant auprès d’adultes que d’enfants.

2. Racontez-nous un moment marquant de votre carrière.

erreurs, que c’est la façon dont nous les gérons et ce que nous en tirons qui nous rend meilleurs.

L’ACO reconnaît la force inhérente à la diversité

5. Pouvez-vous me parler d’un objectif professionnel et d’un objectif personnel que vous voulez atteindre au cours des cinq prochaines années?

C’est une question difficile, car j’ai et fait la promotion d’une culture d’équité chez l’impression d’avoir vécu beaucoup ses membres ainsi qu’en ce qui a trait à ses de moments marquants dans ma services et à son engagement communautaire. carrière, allant de certaines interacObjectif professionnel : J’espère tions avec des patients à des cas Chaque numéro du Bulletin comprendra le devenir une orthopédiste experte chirurgicaux uniques, en passant portrait de l’une des nombreuses femmes en chirurgie du rachis chez l’adulte par mon examen du Collège royal membres de l’ACO. On en apprendra et l’enfant. en chirurgie orthopédique, plus davantage sur son expérience et ses idées, récemment. Si je devais en garder Objectif personnel : J’espère mieux un seul, en ce moment, ce serait sa contribution à la profession et ses conseils concilier mon travail et ma vie permon choix d’effectuer ma résidence pour ses jeunes collègues et les étudiants. sonnelle. En résidence depuis 5 ans, à l’Université Western, à London, en Apprenez à connaître vos collègues! j’ai eu du mal à maintenir un mode Ontario. La qualité de la formation de vie sain et équilibré. en chirurgie et du mentorat dont j’ai bénéficié était phénoménale. À ceux qui m’ont formée et à 6. Nommez le truc ou l’astuce que vous appliquez au quotima famille de résidents de Western, je ne serais pas où je suis dien pour vous faciliter la vie. ni qui je suis aujourd’hui sans vous tous. Ces cinq années de formation ont certes été difficiles, mais aussi enrichissantes, et Je ne suis pas certaine que c’est un « truc », mais quand la vie maintenant que je suis partie faire mon fellowship, j’ai vraiment devient trop lourde et que le travail est difficile ou qu’on a appris à les apprécier. l’impression d’avoir laissé tomber un patient ou un collègue, il faut se tourner vers notre réseau de soutien. J’ai la chance 3. Pour vous, que signifie la diversité? d’avoir une famille et des amis merveilleux qui me ramènent juste assez les pieds sur terre et me donnent l’amour dont j’ai Pour moi, la diversité signifie que des personnes de différents besoin pour me rappeler que tout va bien aller. Avoir une comhorizons et milieux forment un groupe cohésif et bienveillant. munauté bienveillante autour de soi est la clé pour survivre au quotidien.

4. Quels conseils donneriez-vous aux résidents en orthopédie?

Pendant ma résidence, j’avais presque toujours quelque chose de sucré sur moi, en général des bonbons Jolly Rancher, pour Le conseil que je donnerais aux résidents en orthopédie est m’aider à passer la journée et maintenir mon glucose. de continuer à travailler dur et à apprendre de chaque patient, de chaque cas et de chaque occasion. Trouvez un mentor, Enfin, un principe simple que nous connaissons tous, mais qui quelqu’un que vous pouvez admirer dans votre domaine ou peut parfois être difficile à appliquer : être respectueux envers sous-spécialité, parce que ce mentorat peut vous aider penles gens qui nous entourent. La façon dont on traite les autres dant votre résidence. Je dirais aux résidents que l’on apprend (avec gentillesse, respect et patience) nous aide considérabletout le long de cette carrière et que nous faisons tous des ment au quotidien.

COA Bulletin ACO - Spring / Printemps 2020

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Here’s What YOU Said About the 2019 Annual Meeting

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he 2019 COA, CORS and CORA Annual Meeting was enhanced by a special collaboration, held in conjunction with the ICORS Annual Meeting in the vibrant city of Montréal, Québec from June 19-22. This unique combined Meeting brought together surgeons, residents, fellows, researchers and allied health professionals from all parts of Canada and the globe, with a truly international component.

COA President Dr. John Antoniou, alongside ICORS president Dr. Theodore Miclau, CORS President Dr. Paul Beaulé, and ICORS Program Chair Dr. Fackson Mwale, worked together to present all attendees with an informative and high-quality Meeting.

Below are some of the many informative comments and feedback we received directly from our members and participants*. Thank you for your suggestions, we take each response into consideration and will apply them whenever possible to enhance the Annual Meeting.

Comments from the 2019 Annual Meeting Attendees: TOP Reasons You Attended: 1. “The COA Annual Meeting incorporates my subspecialty group’s Annual Meeting, and supporting the COA is important to me.”

2. “To introduce my students to the COA.” 3. “I was a workshop organizer and moderator.”

4. “To learn about different research that other institutions are doing.”

5. “Amazing. Great learning opportunity. Nice to re-connect with colleagues and staff from the orthopaedic community.”

TOP Takeaways: 1. “I learned new ideas for clinical research and new technologies.”

2. “New research methods, received valuable feedback about my own research.”

3. “The magnitude of the crisis in physician health within Canadian orthopaedics and the depth of barriers to achieving true diversity.”

4. “I learned new updates on the science behind the practice.”

Satisfaction Stats: How Do We Measure Up? • 76% were satisfied with symposia • 73% were satisfied with paper sessions • 97% found that the 2019 program’s faculty and speakers adequality represented diversity of the orthopaedic profession *Responses received through the 2019 COA, CORS & CORA Annual Meeting session and overall evaluation forms.

COA Bulletin ACO - Spring / Printemps 2020

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Voici ce que VOUS aviez à dire sur la Réunion annuelle 2019

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a Réunion annuelle 2019 de l’ACO était marquée par une collaboration spéciale, puisqu’elle avait lieu conjointement avec le congrès annuel des International Combined Orthopaedic Research Societies (ICORS), dans la dynamique ville de Montréal, au Québec, du 19 au 22 juin. Cette manifestation conjointe unique réunissait des orthopédistes, résidents, fellows, chercheurs et professionnels des soins de santé connexes provenant d’un peu partout au Canada et dans le monde grâce à un volet véritablement international. Les Drs John Antoniou, président de l’ACO, Theodore Miclau, président des ICORS, Paul Beaulé, président de la SROC, et Fackson Mwale, président du Comité responsable du programme des ICORS, ont travaillé ensemble en vue de proposer à tous les participants un programme informatif et de grande qualité.

Voici une partie des nombreux commentaires instructifs que nous avons reçus des membres et des autres participants.* Merci pour vos suggestions; nous prenons chaque commentaire au sérieux et nous en tenons compte autant que possible afin d’améliorer la prochaine réunion annuelle.

Commentaires des participants à la Réunion annuelle 2019 PRINCIPALES raisons pour lesquelles vous avez assisté à la Réunion annuelle : 1. « La Réunion annuelle de l’ACO englobe la Réunion annuelle de mon groupe de sous-spécialité, et il est important pour moi de soutenir l’ACO. » 2. « Faire connaître l’ACO à mes étudiants. » 3. « J’organisais et animais un atelier. » 4. « Pour être au courant des recherches menées par les autres établissements. » 5. « Incroyable. Une excellente possibilité d’apprentissage. C’était bien de revoir des collègues et des membres du personnel de la communauté orthopédique. »

PRINCIPAUX apprentissages : 1. « J’ai pris connaissance de nouvelles idées pour la recherche clinique et de nouvelles technologies. » 2. « Nouvelles méthodes de recherche; j’ai reçu de précieux commentaires sur mes propres recherches. » 3. « L’ampleur de la crise de la santé des médecins au sein de la communauté orthopédique canadienne et des obstacles à l’atteinte d’une véritable diversité. » 4. « J’ai pris connaissance des derniers développements sur la science derrière l’exercice. »

Données sur la satisfaction : Comment nous en sommes-nous tirés?

• 76 % des participants étaient satisfaits des symposiums.

• 73 % des participants étaient satisfaits des séances de présentation de précis.

• 97 % des participants croient que les présentateurs et conférenciers au programme de la Réunion annuelle 2019 représentaient bien la diversité du milieu de l’orthopédie.

* Réponses fournies dans les formulaires d’évaluation des séances et de la Réunion annuelle 2019 de l’ACO, de la SROC et de l’ACRO. COA Bulletin ACO - Spring / Printemps 2020

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Pivotal Moments: The Impact of Serendipity on My Career as an Academic Surgeon T. Derek V. Cooke, M.D., FRCSC Maberly, ON

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his story begins in 1967 in Western Canada, when I was a resident in the UBC orthopaedic program led by Frank Patterson (FP as we knew him). At the time synovectomy, removing the inflamed joint, was the accepted surgery for severe rheumatoid arthritis (RA). The problem was the high incidence of recurrent disease. The inflammation typical of RA is chronic with flare-ups, affecting mostly larger synovial joints of middle-aged people, in a remarkably symmetrical side-to-side pattern. With time, the damage results in severe deformities; many patients became crippled. As a young surgeon seeing these patients’ disease progress inexorably was both puzzling and disappointing. ‘Why did synovectomy not work?’ remained a compelling question.

Time-Capsule Testimonials: Celebrating the COA’s 75 years with Memories from our Membership In recognition of the COA’s 75th anniversary, we are collecting testimonials of pivotal moments in the careers of our membership. Help us celebrate 75 years! Have a story from your residency, training, or professional practice that you’d want to share with your colleagues? E-mail Lexie at lexie@canorth.org.

Capsules temporelles : Célébrons le 75e anniversaire de l’ACO grâce aux souvenirs de ses membres Pour souligner le 75e anniversaire de l’ACO, nous recueillons des témoignages sur des moments marquants de la carrière de ses membres.

Aidez-nous à célébrer nos 75 ans! Vous avez une histoire vécue pendant votre résidence, votre formation ou votre exercice professionnel et vous aimeriez la partager avec les membres? Écrivez à Lexie, à lexie@canorth.org.

I had a growing interest in academics and discussed this with FP. He was a remarkable man, espousing education versus training in surgery and programs embracing combined approaches of medicine and surgery for RA care.

For me, he represented the RI Harris of Western Canada. FP’s view was that to make a meaningful contribution, an academic surgeon needed to do more than good surgery and teach; also, to be productive in research. This was a big challenge as I did not like research. However, FP helped me consider doing research in RA if the opportunity arose.

In 1969, with the FRCS behind me, I was offered an academic position at McMaster University with a McLaughlin Foundation research award. My opportunity had arrived! I wanted to be where the rheumatology action was, but this presented another challenge. These rheumatologists had skills in immunology and biochemistry. And, to put their views politely, an orthopaedic surgeon was essentially a ‘blue collar worker.’ However, with funding, I was accepted at most of the programs (why look a gift horse in the mouth). I selected the rheumatology program in Dallas, led by Prof. Morris Ziff, a very prominent scientist. I learned many research methods, including the use of a rabbit model for RA called antigen-induced arthritis (AIA). In AIA a chronic synovitis, strongly resembling RA, developed after injecting an antigen into the knees of previously immunized rabbits.

COA Bulletin ACO - Spring / Printemps 2020

My research question was ‘Why did the synovitis continue for so long after a single injection of antigen?’ Antigen retention was unlikely because they were easily degraded. But retention had never been investigated. Using tissue cultures, we found that weeks after induction, the inflamed synovium was making substantial antibody against the antigen. So how best to track the antigen? We hit on the idea of tagging it with a radioisotope and using a Geiger counter to assess change over time.

Imagine our excitement when the knees were ‘hot’ weeks after induction assuming that antigen was persisting in the synovium. The time came to measure the radioactivity directly. I well remember almost running to the radioisotope counter with the excised synovium. But, I was shocked by their low levels; far less than I had been expecting. ’Had I the wrong animal? No, not the case’. ‘What had gone wrong?’ I was near panic as the so-promising experiment seemed to have blown up in my face! Worse, I had to tell Prof. Hugo Jasin, my research adviser…I was sure about his view on my incompetence!

My research companions were a diverse international bunch.

We shared our progress and became close. I sought out my good friend Guy Burtonbois from Belgium and told him the ‘bad news’. He listened carefully as I reviewed the whole pro-

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cess, and then said, ‘Well, if synovium did not retain the antigen, it must still be in the rabbit’. Astonished at his insight, I raced back to retrieve the rabbit, Geiger counter in hand. Sure enough (and most unexpectedly based on our expectations) the knee was ‘hot’; the antigen was there! I removed the knee in parts to measure antigen in each. These samples were ‘hot’, with the highest levels in fibrocartilage and joint ligaments.

We described the affected joint parts collectively as Articular Collagenous Tissues (ACT). It was an astonishing and most unexpected finding. Our reports of antigens, as immune complexes in ACT, took the rheumatology world by storm. My life in orthopaedics was changed forever!

I was now back in Canada, at McMaster, in my surgical domain with research space in an interactive immunology laboratory.

The next big question was ‘If immune complexes persisted in ACT of animals with AIA, was the same process happening in RA?’ We found that the ACT biopsies of RA cases needing surgery were loaded with immune.

So many of the curious but consistent features of RA fell into place. Might immune complexes in ACT be driving the inflammation? If yes, this would explain the poor response to synovectomy. Also, when other surgery was done with removal of ACT (resection arthroplasties), these joints became quiet; fused joints never became inflamed again. This idea that immune complexes in ACT drove the synovitis also explained a great deal of the side-to-side symmetry of joint involvement in RA. We subsequently showed that the extent and distribution of ACT matched the pattern for RA involvement. As the innovations of hip and knee joint replacements arrived, we consistently found that the replaced RA joints became quiet, cool, and remained well-functioning! So as surgeons, we now had effective and lasting surgery to offer RA cases for damaged joints.

That remains true to this day.

Laboratory, and, in 1984, the Clinical Mechanics Group (CMG).

CMG was one of the first musculoskeletal interdisciplinary groups in Canada. Over the ensuing years, much new knowledge gained about RA and OA was published in over 100 papers with several awards.

Currently, the far better understanding of the disordered immune mechanisms, central to RA, has led to the development and use of powerful biological therapies that largely control the disease. But, when surgery is needed, it has a very valuable role to play.

Special thanks belong to those who taught me that the many conclusions I jumped to were wrong, and the ‘truth’ in those serendipitous moments, was in searching out and explaining the unexpected.

I was recruited to Queens in 1973 and, with MRC support, helped create unique research programs; a Connective Tissue

Note: This abridged story is available in a complete version, with figures, references and acknowledgements by contacting Lexie at lexie@canorth.org.

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 - Spring / Printemps 2020

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Surgery: An Essential Component in Universal Health Coverage heart surgery, and orthopaedic procedures. Our recommendations align with those of a study in the World Journal of Surgery which aimed to draw the link between surgery and public health. It is important to prioritize surgical care based on health burden, success of a surgical intervention, and cost-effectiveness. We strongly advocate for increased investment in these “Essential Children’s Surgical Procedures” to improve health for children and gain economic benefit for a society1.

Prof. Jim Harrison, MA, FRCS Orth Orthopaedic Trauma Surgeon, former Medical Director of CURE Malawi Hospital Reprinted with permission from cure.org. Original publication date: October 10, 2019

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n the past two decades much The COA Global Surgery (COAGS) Committee is pleased to share emphasis was placed on priCanadian global health initiatives. If you are interested in COAGS mary health care, including prevention and management featuring your organization in the Bulletin, or if you are a resident of infectious diseases, as well as and you would like to share an essay about your global surgery mother and child care. The milexperience, please contact schneida@canorth.org for details. lennium development goals had three goals targeting such areas: reduce child mortality, improve maternal health, and combat HIV/AIDS, malaria, and other diseases.

The context for provision of surgical services is a challenge even in high-income countries, since emergency care can The global health agenda is now changing with a growing transfer pressure and reduce efficiency of elective services. realization that non-communicable diseases play an increasing Furthermore, mixing the potentially infective environment of role in the global burden of disease - even in low- and middleemergency care with an environment of clean elective surincome countries. gery has drawbacks. Specialist elective facilities have potential advantages in quality and efficiency. CURE International is one Whilst some non-communicable diseases relate to degengroup supporting specialty elective hospitals for paediatric surerative disease (such as lifestyle and aging), others may strike gical care in low-income countries. Its hospitals focus on paeyounger people and have the potential for curative treatment diatric orthopaedic, plastic, and neurosurgical disciplines. Such options. The surgically treatable conditions often fall into this facilities can be highly-effective components of a health service category. Injury is one such bracket of disease which kills more in providing surgical care, with the added ability to deliver high people than all the communicable diseases combined. Of quality training to health-care workers2. those who die from injury, 90% live in low- and middle-income countries, and the majority are young males. For every one who dies, at least ten remain with permanent disability. Improved emergency surgical care systems could alleviate much of this disease burden.

Though “injury”’ is getting some publicity as the most neglected global disease entity (albeit still not specifically mentioned in the sustainable development goals), elective surgical interventions for children with physical deformities and disabilities also suffer from a lack of awareness.

It may seem expensive to provide elective surgical care for children, but these individuals expect to have many remaining years of life, and a one-off intervention may achieve a transformative increase in their life potential. In this way, the cost per DALY (disability adjusted life year) may be significantly cheaper than more established medical treatments for cancer, cardiac disease, or even HIV. Several particular areas of surgical care for children offer great economic value and are supported by high-quality evidence. These should be considered as “Essential Children’s Surgical Procedures,” and include inguinal hernia repair, trichiasis surgery, cleft lip and palate repair, circumcision, congenital COA Bulletin ACO - Spring / Printemps 2020

Cathrine (Before & After)

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(continued from page 14)

Another challenge in provision of universal health coverage is the tendency for single disease entities to be promoted and funds to be channeled accordingly. This may happen in communicable disease (e.g. malaria) or non-communicable diseases (e.g. clubfoot). The advantage of this approach is that it has appeal to donors and celebrity champions. Skills may be developed and measurable gains documented. The disadvantage is that development of health systems which deal with emergency and elective care scenarios would provide a more strategic approach to cover the spectrum of surgically treatable diseases. The facility and skill set to provide cleft lip and palate surgery generally relates closely to that which provides for a wide variety of surgically treatable paediatric conditions.

Equally, the facility and skill set which offers laparotomy for acute intestinal obstruction may easily be developed to provide emergency caesarean section and open fracture management. Surgical care systems need to develop in a strategic and coordinated way and not piecemeal, as may happen when driven by external donors who hold specific, focused aims.

Finally, surgical care has reached the global health agenda!

As the policy makers advocate for expansion of global surgical access and national surgical plans, clear thinking will be required to plan emergency surgical systems and elective surgical systems and facilities which promote economic and quality services with access for all.

Chisomo-Sagawa & Dr. Jim Harrison - At CURE Hospital Malawi

About CURE

Click to view the original article including external links.

1. Saxton A.T. et al Economic analysis of children’s surgical care in low and middle income countries: systematic review and analysis. PLOS Open access 2016;11(10)e0165480.

CURE International was founded by Scott and Sally Harrison in 1996 and, two years later, CURE’s first hospital opened. CURE has since established a presence in 14 countries, performed 213,800 procedures, treated more than 126,600 children at CURE clubfoot partner clinics, and performed more than 15,000 procedures to treat hydrocephalus and spina bifida.

2. Gocken E. Orthopaedic surgery residency training in East Africa. J Am Acad Orth Surg 2019; 3(7):1-7.

To learn more about CURE, please visit their web site at www.cure.org

References

Article submissions to the COA Bulletin are always welcome!

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

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

Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : cynthia@canorth.org

COA Bulletin ACO - Spring / Printemps 2020

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Providing Dedicated Support to Canadian Orthopaedic Subspecialty Societies Meet Schneïda Bruny, the newest addition to the COA Team

Offrir un soutien spécialisé aux sociétés de sous-spécialité en orthopédie canadiennes

Voici Schneïda Bruny, la nouvelle venue au sein de l’ACO

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he COA welcomes Schneïda Bruny to the head office team as our Coordinator of Specialty Societies. Schneïda joins our staff as the designated point person dedicated to supporting the growth and development of the various orthopaedic subspecialty societies administered by the COA. Schneïda is multilingual and has a background in academic and hospitality sectors, with operations management and event planning experience. She recently moved from Vermont to Montréal and is excited to continue her career at the COA. Schneïda can be reached at schneida@canorth.org or 514 874-9003 x 7.

“I look forward to fostering collaboration and synergy between the various specialty societies and the COA, and to working with diverse groups of surgeons and researchers from across the country.”

The 2021 ABC Fellowship is a Go: Canadians still going on tour!

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n light of the current COVID-19 pandemic, the COA Leadership and Exchange Fellowship Committee, in collaboration with the AOA, have opted to prioritize the health, safety, and well-being of its membership. As such, the 2021 ABC Tour application deadline has been extended to October 1, 2020 until further notice. Considering applying but need some inspiration? Read Drs. Sukhdeep Dulai and Ruby Grewal’s experience on the 2019 tour here. The 2021 application form is accessible here and you can contact Lexie Bilhete via e-mail with any questions. Thank you for your interest in representing the COA and Canadian orthopaedics on this exceptional international fellowship experience.

COA Bulletin ACO - Spring / Printemps 2020

’ACO souhaite la bienvenue à Schneïda Bruny à titre de coordonnatrice des sociétés de spécialistes au sein de l’équipe de son siège social.

Schneïda se joint à notre personnel comme personne-ressource spécialisée dans le soutien aux sociétés de sous-spécialité en orthopédie administrées par l’ACO et leur développement. Schneïda est polyglotte et possède de l’expérience dans les secteurs universitaire et de l’accueil, et plus particulièrement en gestion des opérations et en planification d’événements. Elle habitait jusqu’à récemment au Vermont, et est emballée de poursuivre sa carrière avec l’ACO. On peut la joindre à schneida@canorth.org ou au 514-874-9003, poste 7.

« J’ai hâte de nourrir la collaboration et la synergie entre les sociétés de spécialité et l’ACO, et de travailler avec des groupes diversifiés de chirurgiens et chercheurs de tout le pays. »

C’est parti pour la Bourse de voyage ABC 2021 : Les lauréats canadiens partent toujours en tournée!

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n raison de la pandémie de COVID-19, la direction et le Comité des bourses de voyage de l’ACO, en collaboration avec l’American Orthopaedic Association (AOA), ont décidé de prioriser la santé, la sécurité et le bien-être des membres. Par conséquent, la date limite de soumission des candidatures pour la Bourse de voyage américano-britanno-canadienne (ABC) 2021 est reportée au 1er octobre 2020 jusqu’à nouvel ordre.

Vous avez besoin d’inspiration? Lisez le journal de la tournée des Dres Sukhdeep Dulai et Ruby Grewal, en 2019. Remplissez le Formulaire de demande 2021, et n’hésitez pas à écrire à Lexie Bilhete si vous avez des questions. Merci de votre intérêt à représenter l’ACO et la communauté orthopédique canadienne dans le cadre de cette expérience internationale exceptionnelle.

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The Annual Meeting is not cancelled, we’re bringing it to YOU on June 19-20, 2020

La Réunion annuelle n’est pas annulée, nous l’amenons CHEZ VOUS les 19 et 20 juin 2020.

Due to COVID-19, we’re going from coast to computer for the first COA, CORS, and CORA Virtual Annual Meeting on June 19 and 20, 2020. We are offering educational content, discussions, and networking through an interactive online platform including live webinar symposia with expert faculty and e-poster sessions in all subspecialties. You can also visit our virtual exhibit hall and participate in industry webinars and demonstrations. After the Meeting, the COA is offering complete webinar recordings and eposters accessible until September.

En raison de la pandémie de COVID-19, nous passons de la côte à votre ordinateur comme cadre pour notre première Réunion annuelle virtuelle de l’ACO, de la SROC et de l’ACRO, qui aura lieu les 19 et 20 juin 2020. Du contenu scientifique, des discussions et des possibilités de réseautage – y compris des symposiums-webinaires en direct avec spécialistes et des séances de présentation d’affiches électroniques dans toutes les sous-spécialités – seront offerts en ligne grâce à une plateforme interactive. Vous pourrez également visiter notre salle d’exposition virtuelle et participer à des démonstrations et webinaires de l’industrie. Après la Réunion annuelle, l’ACO donnera accès à tous les webinaires et à toutes les affiches électroniques jusqu’en septembre.

Join us for many of your favorite annual events such as the Opening Ceremonies, celebrating your colleagues with awards and grants recipient announcements, the presidential Transfer of Office Ceremony, nomination of 2nd President-Elect and much more!

Assistez à bon nombre de vos activités annuelles préférées, comme les cérémonies d’ouverture, les remises de prix et bourses à vos collègues, la cérémonie de transfert des charges, la nomination du deuxième président élu, et bien plus encore!

Click here to learn more

COA Bulletin ACO - Spring / Printemps 2020

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

Readership Poll – The Impact of COVID-19 on COA Members

Sondage auprès des lecteurs – Incidence de la COVID-19 sur les membres de l’ACO

he COVID-19 pandemic has resulted in significant and rapid changes in the way health-care is being delivered in Canada. As orthopaedic surgeons, this restructuring has had significant and unexpected changes on the scope of our practice. The cancellation of elective surgical cases, reduction in clinic availability, limitations regarding number of OR personnel and resident redeployment are only of some of the major changes that we have come to face. To better characterize how the pandemic has affected our members, we are sending out the following questionnaires to both staff and resident surgeons. The goals of these voluntary and confidential surveys are to gather information on the manner and extent to which the COVID-19 pandemic has affected our members, and understand how they are coping with these changes.

Choose the link below that is appropriate for your current position (staff or resident/fellow). Responses will remain confidential. A summary of the results will be published in the next edition of the COA Bulletin. Your participation is greatly appreciated.

a pandémie de COVID-19 a changé de façon rapide et drastique la prestation des soins de santé au Canada. En tant que chirurgiens orthopédistes, cette restructuration a eu des effets significatifs et inattendus sur notre pratique.

L’annulation de chirurgies électives, la réduction des heures d’ouverture des cliniques, la limitation du nombre de personnes présentes en salle d’opération et le redéploiement des résidents sont seulement quelques exemples des changements majeurs auxquels nous sommes confrontés. De ce fait, pour mieux caractériser la façon dont la pandémie affecte nos membres, nous faisons parvenir ces sondages auprès des chirurgiens en poste ainsi que des résidents et fellows partout au pays. Le but de ces sondages, qui sont effectués sur une base volontaire et confidentielle, est de recueillir de l’information sur l’incidence de la pandémie de COVID-19, et ainsi de comprendre comment nos collègues s’adaptent à ces changements.

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Pour ceux et celles qui désirent participer, nous vous demandons de choisir le lien ci-dessous qui est le plus approprié selon votre situation (chirurgien en poste ou résident ou fellow).

Comme mentionné ultérieurement, les réponses sont confidentielles. Un sommaire des résultats des sondages sera publié dans le prochain numéro du Bulletin de l’ACO. Votre participation est grandement appréciée.

Attending surgeons (staff) Click here to participate

Chirurgiens en poste (personnel) Cliquez ici pour y répondre

Residents and fellows Click here to participate

Résidents et fellows Cliquez ici pour y répondre

COA Bulletin ACO - Spring / Printemps 2020

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

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Reducing Hospital Length of Stay is an Opportunity to Optimize Our Patients’ Recovery Pascal-André Vendittoli, M.D., MSc, FRCS Karina Pellei, Pht, MSc 2 Carla Williams, RN MHSM CPPS 3 Claude Laflamme M.D., FRCPC 1 1

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2 3

Hôpital Maisonneuve-Rosemont, Université de Montréal, Department of Surgery, Montréal, QC Canadian Patient Safety Institute, Edmonton, AB Sunnybrook Health Sciences Centre, University of Toronto, Department of Anesthesia, Toronto, ON

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n recent years, there has been growing interest for outpatient and shortstay protocols for patients undergoing total hip arthroplasty (THA) or total knee arthroplasty (TKA). Pressure to reduce healthcare costs, limited hospital availability along with improvements in surgical technique and perioperative care motivated many centres to focus on hospital length of stay reduction. Moreover, with the COVID-19 pandemic, reduced hospital length of stay and outpatient surgery will be favored when resuming orthopedic elective surgery.

However, in many short-stay protocols, the focus has shifted away from aiming to reduce complications and improved recuperation, to using length of stay as the main factor of success. To improve patient outcomes and maintain safety, the best way to implement a successful outpatient program would be to combine it with the principles of enhanced recovery after surgery (ERAS), and to improve patient recovery to a level where the patient is able to leave the hospital sooner. ERAS programs focus on minimizing potential adverse events and improving patient recovery.

evidence-based protocols in perioperative care and who adjust their practice based on evolving scientific knowledge. In 20142015, we developed a perioperative THA and TKA short-stay protocol following the ERAS principles and successfully implemented our first cases in 2016. Our ERAS protocol was very efficient at reducing the frequency of patient complications including pain, nausea, vomiting, dizziness, headache, constipation, hypotension, anemia, oedema, lameness, and urinary retention (overall, 50% reduction).

Implementing these best practices also resulted in savings of $1,489 CAD for THA and $4,158 CAD for TKA. Applied broadly and systematically, these savings would have a major impact for the Canadian health-care system.

To be effective, ERAS protocols should be applied systematically and include the patient and family at the core, supported through the efforts of the interdisciplinary team. In most cases, it involves important practice modifications and following a common goal is the key.

Preoperative education is an essential part of a patient’s preparation for surgery.

During a pandemic, minimizing in person activities, helpful patient engagement animations in multiple languages can be found at www.precare.ca.

Orthopaedic Surgery- The Next Goal for Enhanced Recovery Canada (ERC) Founded in 2017, Enhanced Recovery Canada is a project of the Canadian Patient Safety Institute. Dr. Claude Laflamme, anesthesiologist at Sunnybrook HSC, Toronto, is the current chair of the ERC Governance Committee. To date, ERC has focused on the development, The key elements of a shortdissemination and implemenstay ERAS protocol should be tation of Enhanced Recoveryeffective in: reducing perioperarelated best practices supporttive adverse events, improving ing elective colorectal surgeries. function, and enabling patients ERC is supporting the developVendittoli PA, Pellei K, Desmeules F, Massé V, Loubert C, Lavigne M, to quickly resume to their norment of ERC Ortho pathways Fafard J, Fortier LP. Enhanced recovery short-stay hip and knee joint mal activities. It should also be for THA and TKA. Pascal-André replacement program improves patients’ outcomes while reducing hospital applicable in our public healthVendittoli was designated as costs. Orthop Traumatol Surg Res. 2019 Oct 3. pii: S1877-0568(19)30285-3. care system without significant the Chair of the lead group doi: 10.1016/j.otsr.2019.08.013 implementation costs. ERAS composed of other Canadian aims to: reduce pain while minileaders in the field of outpatient mizing opioid use and side effects, avoid patient sedation, TKA/THA surgery. Our goal is to provide all Canadians with improve patients’ early function and mobilization, minimize helpful tools and resources to effectively implement and suspostoperative anemia, improve perioperative bowel function, tain ERAS protocols. The lead group is composed of key opinion decrease wound complications and finally reduce the risk of leaders from across the country: Drs. G. Dervin (Ottawa), M. DVT. ERAS Short-stay protocols require the involvement of Dunbar (Halifax), B. Lanting (London), M. Tanzer (Montreal), patients and their families supported by a multidisciplinary and R. Sharma (Calgary). Our group includes patients and team including: anesthesiologists, surgeons, nurses, nutritionother experts in: physiotherapy, nursing, internal medicine, ists and physiotherapists who adhere to specifically-designed, pharmacy, etc.

Detailed HMR protocols and results are available by clicking here

COA Bulletin ACO - Spring / Printemps 2020

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

Applying these principles to a short-stay protocol for THA and TKA is the key to improved patient outcome by reducing the rate of adverse events while achieving a hospital LOS below 24h. Shorter hospital LOS after THA and TKA increases bed availability in a restricted environment and is favourable

economically for the care provider. It is an ‘all win’ situation.

Learning from the development of ERAS THA and TKA protocols, we will transfer this knowledge to other orthopaedic treatment (fracture, sport medicine, oncology, arthroplasty, etc.) and improve outcome for all orthopaedic patients.

Robotics in Arthroplasty – Is it the future or just a fad?

Jason Werle, M.D., FRCSC Clinical Professor and Head, Section of Orthopaedic Surgery, University of Calgary Senior Medical Director, Bone & Joint Strategic Clinical Network, Alberta Health Services Calgary, AB

Khoplas et al.9 has suggested superior improvements in walking, standing, satisfaction, and functional scores in patients undergoing RA TKA compared to manual TKA at six weeks postoperatively. However, there is substantial bias in these results as the study was non-randomized and all authors had significant identified conflicts of interest involving the vendor of the robotic system they studied.

Horizons The practice of orthopaedic surgery continues to evolve. We are faced with an explosion of information stemming from published cutting-edge research (bench and clinical). Likewise, an increasingly informed public has rapid access to information about novel therapies and surgical techniques. Oftentimes the best way to integrate evidence-based practice and innovative treatments is unknown or challenging. To add some perspective on how to approach emerging and/or controversial topics, we have developed this Horizons feature in the COA Bulletin.

Introduction obotic technology has The disadvantages of using been used in manufacturrobotics in arthroplasty include ing for decades with resultincreased hardware costs, the ant gains in efficiency, accuracy, need for updated software, sursafety, cost effectiveness, and geon learning curve (garbage production. Total joint arthroin/garbage out), increased plasty, as it exists today, is one operative time, imaging for preof the most successful and costop templating, and, potentially, effective surgical interventions no difference in long-term outavailable worldwide1. It makes comes2. sense, then, that the two techIn the Horizons articles, thought leaders from various nologies are now being comThe Costs subspecialties will provide insights based on their extensive bined to potentially improve The costs of robotics is generally clinical experience and ongoing research.

The goal of this feature the same parameters in surgical minimized by its proponents10. is to “shed some light” on the best way forward. care delivery. Currently, every The robot itself is expensive implant vendor is in one stage (greater than C$1,000,000), Paul A. Martineau, M.D., FRCSC or another of offering roboticrequires technical support staff assisted (RA) arthroplasty techbeyond a vendor sales associScientific Editor, COA Bulletin nology for unicompartmental, ate, requires additional dispostotal knee (TKA), and/or total hip arthroplasty (THA). ables, and also requires a preoperative CT scan for digital templating and surgical planning. This comes with added costs to The Evidence the system and significant inconvenience to the patient.

The advantages of using robotic technology include the potential to improve implant placement (i.e. reduce outliers), reduce Mont et al.11 published a healthcare utilization and payer cost 2 complications, and complete less invasive surgery . The litanalysis of RA TKA versus conventional manual TKA at 30, 60, erature is clear that robotically-assisted arthroplasty provides and 90 Days post-op indicating lower costs and healthcare accuracy and precision3-5 that is superior to manual techniques. utilization in favour of RA TKA. However, this study did not It is also a safe technology6. However, the translation of this include the cost of the robot, disposable costs, or costs of preprecision to improved patient outcomes has not been estabop imaging. All of these additional costs would likely negate lished. A recent systematic review showed that postoperative the study’s conclusions. functional outcomes were comparable between robotic and conventional total hip and knee arthroplasty at short-, mediIn this era of cost containment in the Canadian health-care um-, and long-term follow-up7. Furthermore, the authors system, new innovations should improve the quality of arthrofound no significant difference in pain, quality of life, or patient plasty care in order to justify their increased cost to provincial satisfaction with surgery when comparing the two techniques. health budgets. This is a bar, one could argue, that has not been met by RA arthroplasty.

A systematic review by Han et al8 compared conventional total hip arthroplasty to robotic-assisted THA and found betChallenges Specific to the Canadian Health-care System ter radiographic outcomes (cup inclination/version), fewer As most Canadian orthopaedic surgeons practice relatively intra-operative complications, but a longer operative time and close to the US border, we are often confronted by patient-drivsimilar functional scores with RA THA. en requests for new technology, new implants, or new surgical

R

COA Bulletin ACO - Spring / Printemps 2020

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Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 21)

techniques available in the US market. And that is exactly what the United States is, a market where a competitive advantage such as offering the latest technology, even if unproven, is necessary to sustain a surgical practice. Contrast that to the Canadian system which, as we all know, is publicly funded and a competitive marketplace does not exist. No orthopaedic surgeon in Canada has to advertise or market their business. As a result, waitlists and access challenges abound due to limits and inefficiencies in provincial health-care funding models. How then, do we reconcile the desire for innovation and research, with the limits imposed by hospital budgets? Robotically assisted arthroplasty would appear to fall into this paradigm.

Given these access challenges, introducing a new technology that is more expensive and requires a larger amount of operating room resource would seem counterintuitive. Especially, if superior patient outcomes have not been demonstrated. We all know that waitlists will continue. Therefore, should our energy be more appropriately directed to finding methods to improve patient arthroplasty outcomes in other ways? This could include surgical care pathways, specialized operating room teams, central triage for patients, measurement of key performance indicators, shared savings models to drive efficiency, choosing proven implant technology, and other quality improvement tactics that can improve surgical patient flow.

This is a truly Canadian conundrum, whereby orthopaedic surgeons want to be innovative in their research and clinical practice, and yet realize that cost containment and finding efficiencies in the system should also be a priority. This concept challenges all orthopaedic surgeons and subspecialties in Canada and it’s not going away any time soon.

And so, the challenge remains, and the path forward would appear to be well designed randomized controlled trials that are free from industry and surgeon bias. Trials that identify whether the new technology can provide cost-effective improvements in patient outcome. The Canadian Arthroplasty Society and its research arm, in my opinion, is the best agent to drive the investigation of robotic-assisted arthroplasty (and other technologies) forward in a meaningful way.

Conclusion Robotic-assisted arthroplasty holds promise for accurate and precise implant placement and reduced intra-operative complications. However, this has not translated into improved implant longevity or improved patient outcomes. In addition, increased costs related to procuring the robotic system, maintaining it, and operating it are substantial. The cost effectiveness of this technology has not been established.

The adoption of RA arthroplasty in Canada may mirror that of computer-assisted navigation. Whereby, a limited number of centres use the technology extensively but the majority of cases in Canada are performed with conventional instrumentation.

Nonetheless, it is interesting technology and robotics have never left an industry once they have been introduced. Patient outcomes will drive the era of robotics in arthroplasty; if patient outcomes improve, the utilization of robotics will undoubtedly increase. However, if there is minimal or no functional and/or clinical improvement for patients, the era of robotics in arthroplasty may be limited and, with the benefit of hindsight, its uptake may be looked upon as a fad.

COA Bulletin ACO - Spring / Printemps 2020

References 1. Daigle M.E., Weinstein A.M., Katz J.N., Losina E., The costeffectivness of total joint arthroplasty: a systematic review of published literature. Best Pract Res Clin Rheumatol. 2012 Oct;26(5):649-658 2. Chen A.F, Kazarian G.S., Jessop G.W., Makhdom A., Current Concepts Review: Robotic technology in orthopaedic surgery. J Bone Joint Surg Am. 2018;100:1984-92 3. Parratte S., Price AJ, Jeys L.M., Jackson W.F., Clarke H.D., Accuracy of a new robotically assisted technique for total knee arthroplasty: a cadaveric study. J Arthoplasty. 2019 June; 34(2019):2799-2803 4. MacCallum K.P., Danoff J.R., Geller J.A., Tibial baseplate positioning in robotic-assisted and conventional unicompartmental knee arthroplasty. Eur J Orthop Traumatol. 2016; 26: 93-98 5. Hampp E.L., Chughtai M., Scholl L.Y., Sodhi N., BhowmikStoker M., Jacofsky D.J., Mont M.A., Robotic-arm assisted total knee arthroplasty demonstrated greater accuracy and precision to plan compared to manual techniques. J Knee Surg. 2019; 32:239-250 6. Lonner J.H., Kerr G.J., Low rate of iatrogenic complications during unicompartmental knee arthroplasty with two semiautonomous robotic systems. The Knee. 2019 Feb; 26(2019):745-749 7. Karunaratne S., Duan M., Pappas E., Fritsch B., Boyle R., Gupta S., Stalley P., Horsley M., Steffens D., The effectiveness of robotic hip and knee arthroplasty on patient-reported outcomes: a systematic review and meta-analysis. Int Orthop. 2019; 43:1283-1295 8. Han P.F., Chen C.L., Zhang Z.L., Han Y.C., Li P.C., Wei X.C., Robotics-assisted versus conventional manual approaches for total hip arthroplasty: a systematic review and metaanalysis of comparative studies. Int J Med Robot. 2019 Jun; 15(3):e1990 9. Khoplas A., Sodhi N., Hozack W.J., Chen A.F., Mahoney O.M., Kinsey T., Orozco F., Mont M.A., Patient-reported functional and satisfaction outcomes after robotic-arm-assisted total knee arthroplasty: early results of a prospective multicenter investigation. J Knee Surg. 2019 Apr 8. doi: 10.1055/s-00391684014 (Epub ahead of print) 10. Booth R.E., Sharkey P.F., Parvizi J., Robotics in hip and knee arthroplasty: real innovation or marketing ruse. J Arthroplasty. 2019 Aug; 34(2019): 2197-2198 11. Mont M.A., Cool C., Gregory D., Coppolecchia A., Sodhi N., Jacofsky D.J., Health care utilization and payer cost analysis of robotic arm assisted total knee arthroplasty at 30, 60, and 90 days. J Knee Surg. 2019 Jul. doi: 10.1055/s-0039-1695741

HELP YOUR PATIENTS GET BACK TO AN ACTIVE LIFESTYLE WITH A FAST * + SUSTAINED† COMBINATION THERAPY

Cingal® is the only viscosupplement that combines the early benefits of a corticosteroid with the lasting, lubricating effect† of hyaluronic acid (HA) to relieve pain caused by osteoarthritis (OA) of the knee in a single injection.1–3 Cingal® (HA and triamcinolone hexacetonide) is indicated for the treatment of pain in OA of the knee in patients who have failed to respond adequately to conservative non-pharmacologic therapy and to simple analgesics (e.g., acetaminophen). Cingal® includes an ancillary steroid to provide additional short-term pain relief.

See how Cingal® compares to both HA and saline at

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For more information: See Warnings, Cautions, and Directions of Use at www.cingal.ca for information to assist in benefit-risk assessment. Always direct the patient to read the label. The Product Licence is also available upon request by calling 1-888-550-6060 or by emailing medinfo@pendopharm.com.

WOMAC: Western Ontario and McMaster Universities Osteoarthritis Index; ITT: intent to treat *Significant reduction in WOMAC score from baseline seen at Week 1 vs. saline (ITT p=0.008).2 †Demonstrated long-term pain relief through 26 weeks.

1. Cingal® Package Insert. Pendopharm. February 2016.

2. Data on file. Clinical study report: Cingal® 13-01. Anika Therapeutics Inc. January 2015.

3. The Arthritis Society. Arthritis medications: A reference guide. Accessed on September 9, 2019.

Available from: https://arthritis.ca/treatment/medication/medications-to-treat-inflammatory-arthritis.

Cingal®, Monovisc®, and Orthovisc® are trademarks of Anika Therapeutics, Inc., used under licence

by Pharmascience Inc. Pendopharm, Division of Pharmascience Inc. Product licences are pertinent to use in Canada. Product licences herein are not approved for use in the U.S.

* Réduction significative du score de la douleur une semaine après l’injection, comparativement à l’injection de solution saline (population en intention de traiter, p = 0,008).

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

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 feature where weird (and wonderful) cases are 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 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) 500-word case summary including: a) Brief clinical history and diagnosis b) Treatment measures c) Outcomes d) Take-home message

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

3) 5 references maximum

3) Maximum de 5 références

IMPORTANT TIPS FOR CASES!

CONSEILS IMPORTANTS POUR LES CAS!

- 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.

- 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 - Spring / Printemps 2020

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

This edition’s case was submitted by Dr. Dominique Rouleau from Université de Montréal

Corrective Valgus Open Wedge Proximal Humerus Osteotomy in a Case of Varus Malunion Patrick Goetti, M.D. Dominique M. Rouleau, M.D., Msc, FRCSC Department of Surgery, Hôpital du Sacré-Coeur de Montréal Université de Montréal Montréal, QC

Clinical History 54 y.o. female patient presented at our outpatient clinic with right shoulder pain, 18 months after sustaining a two-part proximal humeral fracture. The patient was initially treated conservatively with a sling for six weeks, followed by physiotherapy to regain strength and range of motion. Her main complaints were painful limitation of range of motion interfering with activities of daily living, particularly for longdistance swimming. The patient has postmenopausal osteoporosis and does not smoke. First, an arthroscopic arthrolysis was performed which improved range of motion slightly.

Nonetheless, it remained limited to 120° of forward flexion and 45° of external rotation with the arm to the side (Figure 1).

A

The anteroposterior and axial radiographs of the right shoulder revealed a varus malunion of the proximal humerus with a head-shaft angle of 80 degrees (Figure 2).

To further characterize the bony malunion a computed tomography of the shoulder was performed, ruling out additional rotational deformity (Figure 3).

Treatment Measures Varus malunion is a Figure 1 well-known sequela Patient’s range of motion. after proximal humeral fractures. Corrective valgus osteotomy has been reported to be a reliable treatment option, although the potential complications involved curtail its use (avascular necrosis, nonunion or neurologic lesion). There are various corrective valgus osteotomy surgical techniques, here, to preserve deltoid length and strength, an opening wedge osteotomy was chosen. The patient was placed in a beach chair position and underwent an interscalene nerve block and a general anaesthesia. Developing the deltopectoral interval, the cephalic vein was reclined laterally. Once the deltopectoral fascia was opened and the deltoid muscle released from its underlying adhesions, particular attention was paid to carefully dissect and preserve the lateral ascending branch as well as the anterior circumflex artery (Figure 4). This step is COA Bulletin ACO - Spring / Printemps 2020

Figure 2 AP and axial radiographs of the right shoulder with varus proximal humeral fracture malunion.

crucial to limit the risk of iatrogenic avascular necrosis of the humeral head. Suture tags were placed through the rotator cuff to help mobilize the proximal fragment. Then, two Kirschner wires were placed just posterior to the bicipital groove, proximal and distal to the osteotomy line, to help correct the deformity and control humeral rotation. The osteotomy line went below Figure 3 the surgical neck, under the 3-D reconstruction of the computed circumflex vessels. Following tomography of the right shoulder. preoperative measurements, a femoral neck wedge-shaped allograft was positioned to fill the gap and reshaped to fill the defect for maximal correction.

Full correction was impossible because of soft tissue restrictions. Prior to allograft impaction, an acellular sponge allograft (OsteoAMP, Bioventus LLC, Durham, NC, USA) was cut in two parts. Each of them was impacted into the bone on each side of the osteotomy. The correction was fixed with an angular stable proximal humeral plate (Wright Medical, Memphis, TN, USA) as well as a second anteromedial buttress plate to prevent secondary varus collapse and graft displacement.

Outcomes There were no intra-operative or postoperative complications.

The patients’ active shoulder range of motion increased to 160 degrees of elevation at only three months postoperative, external rotation remained unchanged. Postoperative radiographs show varus deformity correction, with a head shaft angle of 115 degrees (Figure 5).

Take-Home Message • Preservation of the vascular supply to the humeral head (especially the lateral ascending branch of the anterior circumflex artery) is recommended to limit the risk of iatrogenic avascular necrosis.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 27)

Figure 4 Intra-operative view with identification and preservation of the biceps tendon as well as the anterior circumflex artery and its ascending branch.

• Adding a medial buttress plate as well as grafting the medial defect in the calcar is helpful to prevent mechanical failure of the lateral locking plate and secondary loss of correction.

• Open wedge corrective osteotomy has the benefit of restoring physiological deltoid tension.

Figure 5 Postoperative anteroposterior and axial radiographs at 12 weeks of follow-up.

Acknowledgments The authors wish to thank Drs. George Athwal, Philippe Clavert, Kenneth Faber, Jonah Hebert-Davies, and Mr. C. Michael Robinson for their useful advice as well as Ms. K. Beaumont for manuscript preparation. (kathleen_beaumont@yahoo.ca)

Improved Complex Skill Acquisition by Immersive Virtual Reality Training: A Randomized Controlled Trial

M

embers of the Canadian Shoulder and Elbow Society (CSES) analyzed the effects of a novel, immersive virtual reality (iVR) training platform during the 2019 Canadian Shoulder and Elbow Society Residents’ Course. The system, created by Dr. Danny Goel and his team at PrecisionOS (Vancouver, BC, Canada), provides an immersive operating room experience using consumer grade virtual reality equipment. Using the iVR system, senior (PGY4 and 5) residents from across Canada completed training sessions to learn difficult glenoid exposure techniques. A similar cohort simultaneously completed training using traditional teaching methods with a journal article.

Members of the CSES then evaluated the performance of participants in completing a glenoid exposure on fresh frozen cadaveric specimens in the University of Calgary Advanced Technical Skills Simulation Lab. The CSES members were blinded to training modality for the assessment.

The results showed many significant improvements for resident training over the traditional model for the first time in orthopaedics. Residents could train 570% faster, with 3-5 more repetitions of completed learning, coupled with greater enjoyment of experience. Importantly, the iVR trained group completed an actual glenoid exposure significantly faster with superior performance scores for instrument handling.

New methods of teaching technical and non-technical skills are important to combat resident training heterogeneity. The current disruption due to COVID-19 particularly emphasizes

this need. Skill acquisition is optimized when combining multiple sensory inputs, practicing tasks deliberately, and in an environment conducive to productive failure and enhanced feedback.

The authors demonstrated that iVR is a validated method of simulation that could be incorporated into training programs to teach complex surgical skills.

Further study is needed to determine the effectiveness compared to other traditional methods of teaching such as video training, other simulators, or cadaveric training, as well as the retention of skill longitudinally. The study, however, offers promise of supplementary, validated learning to standard training curricula.

The paper, authored by Drs. Ryan Lohre, Aaron Bois, George Athwal, Danny Goel, and the CSES was recently published in the March 2020 edition of Journal of Bone and Joint Surgery America (JBJS Am.) COA Bulletin ACO - Spring / Printemps 2020

27

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CingalMD (AH et hexacétonide de triamcinolone) est indiqué dans le traitement de la douleur causée par l’arthrose du genou chez les patients n’ayant pas adéquatement répondu à un traitement non pharmacologique conservateur et à de simples analgésiques (p. ex., acétaminophène). CingalMD comprend un stéroïde auxiliaire qui fournit un soulagement supplémentaire à court terme de la douleur.

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cingal.ca.

UNE GAMME COMPLÈTE DE VISCOSUPPLÉMENTS POUR UN SOULAGEMENT DURABLE DE LA DOULEUR CAUSÉE PAR L’ARTHROSE DU GENOU

Pour de plus amples renseignements : Consulter les mises en garde, les précautions et le mode d’emploi au www.cingal.ca afin d’obtenir de l’information permettant d’évaluer le rapport risques-bienfaits. Toujours recommander au patient de lire l’étiquette du produit. Il est également possible d’obtenir la licence de mise en marché de ce produit par téléphone au 1-888-550-6060 ou par courriel à medinfo@pendopharm.com.

ITT : intention de traiter; WOMAC : Western Ontario and McMaster Universities Osteoarthritis Index 2 de la douleur * Réduction significative score * Diminution significative du score WOMAC à la semaine 1 par rapport aux valeurs initiales en comparaison avec le soluté physiologique (ITT, p =du 0,008) une semaine après l’injection, comparativement † Soulagement à long terme de la douleur démontré pendant 26 semaines. à l’injection de solution saline (population 1. Notice d’emballage de CingalMD. Pendopharm. Février 2016. en intention de traiter, p = 0,008).

2. Données internes. Rapport d’étude clinique : CingalMD 13-01. Anika Therapeutics, Inc. Janvier 2015.

3. La Société de l’arthrite. Les médicaments contre l’arthrite : Un guide de référence. Accessible au : Fabriqué par : https://arthrite.ca/traitement/medicaments/medicaments-contre-l-arthrite. Consulté le 9 septembre 2019.

Distribué par : Anika Therapeutics Inc., Bedford, MA CingalMD, MonoviscMD et OrthoviscMD sont des marques déposées d’Anika Therapeutics Inc., utilisées sous licence par Pharmascience inc.

Pendopharm, division de Pharmascience inc.

Les licences de mise en marché de ces produits ne s’appliquent qu’au Canada; leur utilisation n’est pas approuvée aux États-Unis.

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

COVID-19: The COA is Responding

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he COA recognizes that our professional and personal lives have been affected by the unprecedented COVID-19 pandemic. Your COA leadership is regularly reviewing the emerging issues and encourages you to get involved and contribute to related advocacy projects as we face these challenges together. In response, a COVID-19 Resource centre has been added to the COA web site since March 2020. The resource provides straightforward access to related COA advocacy initiatives and relevant resources from public health authorities and affiliate stakeholder organizations. It also includes evidencebased education through OrthoEvidence, remuneration and billing information, telemedicine guidelines, resources on physician well-being, and links to the latest advisories. This page is updated regularly and serves as a point of reference to find answers and information on your COVID-19 related concerns.

The online COVID-19 Resource Centre also includes position statements from the COA and from various affiliated orthopaedic specialty groups.

Thank You for Standing Strong with your Orthopaedic Community We thank all our members for their ongoing support during these uncertain times. Your volunteer contributions through our Committees, task forces, and special projects are valued and appreciated. Your role as medical specialists and scientists continues to evolve with the pandemic and we commend your efforts and are grateful for your contributions.

– The Canadian Orthopaedic Association

COVID-19 : L’ACO réagit

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’ACO reconnaît que notre vie professionnelle et personnelle est affectée par la pandémie sans précédent de COVID-19. La direction de l’ACO revoit régulièrement les enjeux émergents et vous incite à vous impliquer et à contribuer aux projets de défense des droits et intérêts afin que nous relevions ces défis ensemble. En réaction à la pandémie, l’ACO a intégré un centre de ressources sur la COVID-19 à son site Web en mars 2020. Vous y trouverez en un seul et même endroit les initiatives connexes de défense des droits et intérêts de l’ACO et des ressources pertinentes des services de santé publique et des sociétés affiliées. Il contient également de l’information fondée sur des données probantes (par l’intermédiaire d’OrthoEvidence), de l’information sur la rémunération et la facturation, des lignes directrices sur la télémédecine, des ressources sur le bien-être des médecins et des liens vers les derniers avis publiés par les autorités. Cette page est mise à jour régulièrement et peut servir de point de référence pour vos questions et préoccupations liées à la COVID-19.

Le centre de ressources en ligne sur la COVID-19 comprend aussi des énoncés de position de l’ACO et de sociétés de sousspécialités orthopédiques.

Merci de rester forts pour votre communauté orthopédique Nous remercions tous nos membres pour leur soutien continu en ces temps incertains. Votre contribution bénévole, par l’intermédiaire de nos comités, groupes de travail et projets spéciaux, est fort appréciée. Votre rôle en tant que spécialiste de la médecine et scientifique continue d’évoluer au fil de la pandémie, et nous applaudissons vos efforts et sommes reconnaissants de votre contribution.

– L’Association Canadienne d’Orthopédie

COA Bulletin ACO - Spring / Printemps 2020

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Foundation / Fondation

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COF Presents the 2019 and 2020 Community Innovation Awards

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he Canadian Orthopaedic Foundation (COF) announces two recipients of its Community Innovation Awards competition. The award celebrates community-based surgeons and research studies dedicated to improving patient care or musculoskeletal health in their community. Researchers describe their projects here.

Correlation Between the Capitateto-Axis-of-Radius Distance (CARD) Radiographic Index and PatientReported Outcomes One Year Post Distal Radius Fracture – Dr. Ahaoiza (Diana) Isa, Moncton, NB A broken wrist/wrist fracture (distal radius) is a very common injury in adults, which can result from low energy falls on an outstretched hand or from higher force trauma such as a car accident. To ensure a distal radius fracture heals properly, the bones of the wrist must be properly stabilized. This can be done surgically in the operating room or non-surgically in a cast depending on the severity of the fracture. If the bones are not accurately aligned during healing, future problems with wrist and elbow movement can occur which can impact patients’ quality of life.

Successful healing is determined from patient feedback and by using x-rays to monitor the position of the wrist bones over time.

Researchers in London, Ontario, Canada have developed a new method that uses x-ray images to measure the distance and alignment of the bones of the wrist which indicate normal wrist alignment. This measurement is called the Capitate-to-Axis-of Radius Distance (CARD). The CARD is a new measurement and this can be used as a measure to help ensure the wrist is in a normal position at the time of treatment and in assessing healing over time in addition to other well established x-ray parameters.

The purpose of this study is to compare the CARD with patient surveys on wrist function and satisfaction to determine how well the CARD corresponds with patient outcomes at a minimum of one year after the injury. This research will determine how well the CARD correlates with patient-reported outcome measures and if it can be used as an additional tool in monitoring distal radius fracture treatment and outcomes in adults.

Randomized comparison between narcotic free multimodal anesthesia and standard of care anesthesia for hallux valgus patients undergoing a percutaneous distal metatarsal osteotomy: a multi-center trial – Dr. Marie Gdalevitch, Montreal, QC Hallux valgus remains a common orthopedic foot problem for which surgical treatment has been feared by patients due to anecdotally high post-operative pain. The current trend in anesthesia management during hallux valgus and forefoot surgery is multimodal pain control, however opioid agonists COA Bulletin ACO - Spring / Printemps 2020

remain the mainstay for post-operative pain. Despite the advances of regional anesthesia, many centers do not perform ultrasound guided ankle blocks for hallux valgus surgery and when they do, it is as an adjunct to other forms of anaesthesia. Our centers have been doing ultrasound guided ankle blocks with sedation as the main method of anesthesia for forefoot surgery for over 2 years and we have noted an immense improvement in patient’s post-operative recovery and pain control. However, patients still require narcotic medication to alleviate the pain once the ankle block has worn off and this puts them at risk of developing a dependency. Orthopedic surgeons remain amongst the highest prescribers of opioids.

In this randomized control trial, we will compare a group of patients that will receive narcotic sparing peri-operative multimodal anesthesia with use of tramadol versus our current standard of care for hallux valgus surgery with a percutaneous distal metatarsal osteotomy. Tramadol is a pain medication that functions much less on the opioid receptor system. As such, tramadol has about one-tenth the potency of morphine, is considered a drug with low potential for dependence and is not listed as a controlled drug and substance in Canada. We hypothesis that the use of an ultrasound guided ankle block with perioperative adjuvant medications will eliminate narcotic use to control pain in the first 48hrs post-operatively and thereafter. Our goal is to demonstrate that the use of highly addictive narcotics such as hydromorphone and morphine are unnecessary following hallux valgus surgery.

Changing the prescribing habits of orthopedic surgeons is essential in addressing the ongoing opioid crisis. This would be the first study attempting to eliminate narcotic use in hallux valgus surgery and given the alarming number of opioid addictions and overdoses, would have a dramatic impact on clinical practice.

The Canadian Orthopaedic Foundation’s Community Innovation Awards competition represents the Foundation’s recognition that there are important projects across the country, identified by orthopaedic surgeons working in the community, which would benefit from some much-needed funding.

Dr. Rick Buckley, Chair of the COF Research Committee, says, “This competition continues to fill a gap in the orthopaedic research environment, enabling us to fund some communitylevel research that otherwise might not be funded. We’re pleased to provide funding for these projects which will have a direct impact on the orthopaedic community.”

The COF’s research program is supported by industry partners in the Powering Pain Free Movement campaign: Zimmer Biomet and DePuy Synthes Canada; and by orthopaedic surgeons and patients across the country.

The Canadian Orthopaedic Foundation is pleased to have awarded the following research grants for 2019: J. Edouard Samson Award Dr. Olufemi Ayeni (Hamilton, ON) – “A Comprehensive Approach to Evaluating and Managing FAI: An Evidence Based Program” Carroll A. Laurin Award Drs. Kristen Barton and Brent Lanting (London, ON) – “The role of knee joint synovitis in dissatisfied total knee arthroplasty patients” Robert B. Salter Award Drs. Charles G. Fisher and Raphaële Charest-Morin (Vancouver, BC) – “Denosumab for Giant Cell Tumors of the Spine; Molecular Predictors of Clinical Response” Cy Frank Award Dr. Glen Richardson (Halifax, NS) – “The Effect of Sagittal Plane Resection during Total Knee Arthroplasty on RSA Migration of Tibial Baseplates” Canadian Orthopaedic Research Legacy (CORL) Awards Dr. Herman Johal (Hamilton, ON) – “Changes in Reliability when Assessing Multiple Patient-Reported Outcome Measures (CRAM-PROMs)” Dr. Vickas Khanna (Hamilton, ON) – “Predicting Persistent Pain and Dissatisfaction after Knee Arthroplasty: A Prospective Multicentre Cohort Study” Dr. Paul R. Kuzyk (Toronto, ON) – “Targeted Delivery of Fetuin Using Titania Nanotubes for Prevention and Treatment of Heterotopic Ossification” Dr. Brad Meulenkamp (Ottawa, ON) – “Development and Field-Testing a Patient Decision-Aid for Management of Acute Achilles Tendon Rupture” Drs. K.C. Geoffrey Ng and Paul E. Beaulé (Ottawa, ON) – “The Effects of Anteverting Periacetabular Osteotomy on Acetabular Retroversion and Hip Capsular Mechanics” Drs. Jesse Wolfstadt and Amir Khoshbin (Toronto, ON) – “DIFFIR: Geriatric DIstal Femur: FIxation versus Replacement - A Randomized Controlled Trial of Acute Open Reduction Internal Fixation (ORIF) versus Distal Femur Replacement (DFR)” For research summaries, go to www.whenithurtstomove.org: click on ‘Grant and Award Recipients’ under ‘Research & Awards’.

The COF thanks all generous donors who make our research program possible, with special thanks to Powering Pain Free Movement Partners: Benefactor:

Champion:

DePuy Synthes Canada

Foundation / Fondation

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La FCO remet le Prix d’innovation communautaire 2019 et 2020

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a Fondation Canadienne d’Orthopédie (FCO) annonce les deux lauréates de son prix d’innovation communautaire.

Ce prix récompense les orthopédistes en milieu communautaire et les projets de recherche visant à améliorer les soins ou la santé de l’appareil locomoteur dans leur collectivité. Voici la description des projets par les lauréates : Correlation Between the Capitate-to-Axis-of-Radius Distance (CARD) Radiographic Index and PatientReported Outcomes One Year Post Distal Radius Fracture – Dre Ahaoiza (Diana) Isa, Moncton (Nouveau-Brunswick) Les fractures du poignet (radius distal) sont une blessure très courante chez les adultes, et elles peuvent être causées par une chute de faible puissance sur une main tendue ou par un impact plus violent, comme un accident de la route. Pour assurer la bonne guérison d’une fracture du radius distal, les os du poignet doivent être stabilisés de manière appropriée. Cela peut être fait par intervention chirurgicale, en salle d’opération, ou non chirurgicale, à l’aide d’un plâtre, selon la gravité de la fracture. Un mauvais alignement des os pendant la guérison peut entraîner de futurs problèmes de mouvement du poignet et du coude, ce qui peut influer sur la qualité de vie du patient. La bonne guérison de la fracture est déterminée par les commentaires du patient et par des radiographies de la position des os du poignet au fil du temps.

Des chercheurs de London, en Ontario (Canada), ont mis au point une méthode utilisant des radiographies pour mesurer la distance et l’alignement des os du poignet, qui indiquent l’alignement normal de celui-ci. Cette mesure est appelée la « distance entre le capitatum et l’axe du radius » (Capitate-toAxis-of-Radius Distance ou CARD). La CARD est une nouvelle mesure qui peut être utilisée pour s’assurer que le poignet est dans une position normale au moment du traitement et du suivi de la guérison au fil du temps, en plus d’autres paramètres de radiographie bien établis.

Ce projet de recherche a pour but de comparer la CARD avec des sondages auprès des patients sur la fonction de leur poignet et leur satisfaction afin de déterminer à quel point la CARD correspond aux résultats pour les patients au moins un an après la blessure. Il permettra de déterminer à quel point la CARD correspond aux résultats déclarés par les patients, et si elle peut servir d’outil supplémentaire dans le suivi du traitement des fractures du radius distal chez les adultes et des résultats connexes.

leur; les agonistes opioïdes demeurent toutefois le principal outil de gestion de la douleur postopératoire. Malgré les avancées en anesthésie locorégionale, de nombreux centres n’effectuent pas de blocs de la cheville échoguidés dans le cas de la chirurgie de l’hallux valgus et, lorsqu’ils en font, c’est en complément d’autres formes d’anesthésie. Nos centres effectuent des blocs de la cheville échoguidés avec sédation comme principale méthode d’anesthésie pour la chirurgie de l’avant-pied depuis plus de deux ans, et nous avons remarqué une énorme amélioration du rétablissement et de la gestion de la douleur postopératoire chez les patients. Par contre, les patients ont toujours besoin de narcotiques afin de soulager la douleur une fois que le bloc de cheville s’estompe, et cela entraîne des risques de dépendance.

Les orthopédistes continuent de figurer parmi les plus grands prescripteurs d’opioïdes.

Dans cet essai clinique aléatoire, nous comparerons un groupe de patients recevant une anesthésie périopératoire multimodale sans narcotiques avec tramadol à un autre recevant nos normes de soins actuelles pour l’ostéotomie métatarsienne distale percutanée dans la correction chirurgicale de l’hallux valgus.

Le tramadol est un antidouleur fonctionnant beaucoup moins sur le système de récepteurs opioïdes. Ainsi, le tramadol a environ le dixième de la puissance de la morphine, est considéré comme un médicament ayant un faible potentiel de dépendance et ne fait pas partie des médicaments et substances contrôlés au Canada. Nous posons l’hypothèse que le recours au bloc de cheville échoguidé avec médication périopératoire complémentaire éliminera le recours à l’administration de narcotiques pour le traitement de la douleur dans les 48 heures suivant l’opération et par la suite.

Notre objectif est de démontrer que le recours à des narcotiques créant une forte dépendance, comme l’hydromorphone et la morphine, n’est pas nécessaire à la suite d’une chirurgie de l’hallux valgus.

Changer les habitudes de prescription des orthopédistes est essentiel dans la gestion de la crise persistante des opioïdes. Il s’agirait de la première étude à tenter d’éliminer le recours aux narcotiques pour la chirurgie de l’hallux valgus; vu le nombre alarmant de dépendances aux opioïdes et de surdoses connexes, cela aurait une incidence spectaculaire sur l’exercice clinique.

Randomized comparison between narcotic free multimodal anesthesia and standard of care anesthesia for hallux valgus patients undergoing a percutaneous distal metatarsal osteotomy: A multi-center trial – Dre Marie Gdalevitch, Montréal (Québec)

En remettant le Prix d’innovation communautaire, la FCO vient reconnaître que des projets importants au pays, soumis par des orthopédistes en milieu communautaire, ont bien besoin de financement. Selon le Dr Rick Buckley, président du Comité de la recherche de la FCO : « Ce prix continue de combler une lacune dans le milieu de la recherche orthopédique, en nous permettant de financer des projets de recherche à l’échelle communautaire qui ne le seraient peut-être pas autrement. Nous sommes heureux de pouvoir financer ces projets, qui auront une incidence directe sur la communauté orthopédique. »

L’hallux valgus demeure un trouble orthopédique du pied courant dont le traitement chirurgical fait peur aux patients en raison de douleurs postopératoires empiriquement élevées. La tendance actuelle en anesthésie pendant la chirurgie de l’hallux valgus et de l’avant-pied est une gestion multimodale de la dou-

Le programme de financement de la recherche de la FCO est propulsé par les partenaires de l’industrie dans sa campagne Misons sur une vie sans douleur, Zimmer Biomet et DePuy Synthes Canada, sans oublier des orthopédistes et patients de partout au pays.

COA Bulletin ACO - Spring / Printemps 2020

La Fondation Canadienne d’Orthopédie est heureuse d’accorder les prix et bourses de recherche suivants pour 2019 : Prix J.-Édouard-Samson r D Olufemi Ayeni (Hamilton, Ont.) – A Comprehensive Approach to Evaluating and Managing FAI: An Evidence Based Program Bourse Carroll-A.-Laurin re r D Kristen Barton et D Brent Lanting (London, Ont.) – The role of knee joint synovitis in dissatisfied total knee arthroplasty patients Bourse Robert-B.-Salter r re D Charles G. Fisher et D Raphaële Charest-Morin (Vancouver, C.-B.) – Denosumab for Giant Cell Tumors of the Spine; Molecular Predictors of Clinical Response Prix Cy-Frank r D Glen Richardson (Halifax, N.-É.) – The Effect of Sagittal Plane Resection during Total Knee Arthroplasty on RSA Migration of Tibial Baseplates Bourses de l’Héritage de la recherche orthopédique au Canada (HROC) r

D Herman Johal (Hamilton, Ont.) – Changes in Reliability when Assessing Multiple Patient-Reported Outcome Measures (CRAM-PROMs) r

D Vickas Khanna (Hamilton, Ont.) – Predicting Persistent Pain and Dissatisfaction after Knee Arthroplasty: A Prospective Multicentre Cohort Study r

D Paul R. Kuzyk (Toronto, Ont.) – Targeted Delivery of Fetuin Using Titania Nanotubes for Prevention and Treatment of Heterotopic Ossification r

D Brad Meulenkamp (Ottawa, Ont.) – Development and Field-Testing a Patient Decision-Aid for Management of Acute Achilles Tendon Rupture rs

D K.C. Geoffrey Ng et Paul E. Beaulé (Ottawa, Ont.) – The Effects of Anteverting Periacetabular Osteotomy on Acetabular Retroversion and Hip Capsular Mechanics rs

D Jesse Wolfstadt et Amir Khoshbin (Toronto, Ont.) – DIFFIR: Geriatric DIstal Femur: FIxation versus Replacement A Randomized Controlled Trial of Acute Open Reduction Internal Fixation (ORIF) versus Distal Femur Replacement (DFR) Pour le sommaire de ces projets de recherche, rendez-vous à www.whenithurtstomove.org/fr et cliquez sur « Lauréats des bourses de recherche », dans le menu « Prix, bourses et subventions ».

La Fondation Canadienne d’Orthopédie remercie tous les généreux donateurs qui soutiennent ses programmes de financement de la recherche, et tout particulièrement les partenaires de la campagne Misons sur une vie sans douleur : Bienfaiteur :

Champion :

DePuy Synthes Canada

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Canadian Perspectives

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n this feature, COA members currently working outside of the country share their insight on various differences they’ve realized working in the United States (US) 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.

Canadian Perspectives: Active Shooter - El Paso, Texas William M. Weiss, M.D., MSc, FRCSC Director of Orthopaedic Sports Medicine & Research Texas Tech University Health Sciences Center - El Paso Associate Director of Research - US Army WBAMC Orthopedic Residency Medical Director of Sports Medicine - University Medical Center El Paso, Texas

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s is surely always the case in situations like this, it was an otherwise entirely typical Saturday morning.

August 3, 2019. I was on leave, when I received a text from our Medical Director of Trauma…

El Paso is as far “West Texas” as you can get.

The centre of a multinational tri-state complex referred to as the Paso del Norte or The Borderplex that consists of a million in El Paso, Texas, almost another million up the interstate in Las Cruces, New Mexico, and about three million across the border in Ciudad Juárez, Mexico. The Borderplex is the largest bilingual and multinational community in the Western Hemisphere.

It has been home since 2016 when I started working at Texas Tech University Health Sciences Center (TTUHSC). …Active shooter. Receiving multiple victims, at least six critical.

More expected. All available staff report to UMC. University Medical Center (UMC) is the only level 1 trauma centre in a 300-mile (500 km) radius encompassing the entire Borderplex and surrounding communities. It is very common that trauma patients are brought from out of state or over the border to UMC in various stages of distress. Today, they came from just up the highway. …Four of our nine orthopaedic surgeons are in town, all respond.

One already in the OR with a trauma patient from the night before.

I am next to arrive, and check in with the team in the OR. The junior resident has been called to the emergency department (ED), but has not returned. The other surgeons still en route…

The first victim did not arrive by ambulance. There was no warning. A mother still shielding her child. Suddenly, it is real.

COA Bulletin ACO - Spring / Printemps 2020

The scene remains active. Unconfirmed rumours of multiple shooters. On scene triage is forgone due to the ongoing threat.

Victims are transferred from shopping carts or trolleys to ambulances or police and civilian vehicles, and immediately taken to hospital. It is only minutes to UMC. There is no time to establish a triage point. The young woman rushed to a trauma bay, her child passed to colleagues from El Paso Children’s Hospital. Our trauma surgeon, who had worked the entire night before, would later testify to US congress on the magnitude of her injuries. He is unable to save her. He asks for a ban on weapons that cause such damage and loss of life. We would learn her husband was also killed, protecting his wife and children. Their other child carried to safety by a stranger. … Both ambulances and staff are converging on UMC. With no triage, six trauma bays are filled and cleared as patients are assessed and transferred: unstable - direct to the OR; stable - to the ED for monitoring. As I walk in, the trauma team immediately takes me to two patients - both need the OR now. I lay eyes on them. A resident assigned, and an orthopaedic surgeon will be in the OR. We form a multi-specialty team in each trauma bay as victims arrive. Most have extremity injuries requiring an orthopaedic surgeon, so I assess the victims acutely with the trauma team - always with one of our residents, who have responded in force. Patients not arriving by ambulance or immediately rushed into a trauma bay are identified by our residents, assessed, and reviewed. Our military associates call to assist - we have enough boots on the ground here, but our military colleague is on call and alone at the level 2 also receiving patients from the incident.

Our orthopaedic program is the only combined military and civilian program in the US. Representative of El Paso itself. Fort Bliss providing a strong military presence as one of the largest bases on US soil. El Paso’s illuminated ‘Star on the Mountain’ serves as a beacon for our deployed soldiers. US Army residents comprise the majority of our program, and gain exposure to acute trauma and complex extremity reconstruction at TTUHSC. As level 1 trauma centre, with only the bare essentials

Training & Practice Management / Formation et gestion d’une pratique (continued from page 34)

for arthroscopy, I joke that their time with me is “Battlefield Sports Medicine, Arthroscopy and Trauma Reconstruction”. But combat casualty care and mass casualty incidents (MCI) are discussed.

Triage is intended to maximize resources and outcomes in MCI, simplifying decisions around limited resources: available care in the field, transport to a higher level of care, and OR time. Military models rely on a senior surgeon, drawing on experience for rapid and accurate assessment. In El Paso, the combination of an active scene with readily available transport (25 responding ambulances, with additional police and civilian vehicles) and the level 1 trauma centre only minutes away resulted in the absence of triage both in the field and at the door in favour of almost direct access to definitive care.

After the initial wave of critical patients, I’m taken to review an elderly woman with a close-range shoulder wound… though there is not much shoulder left. She is alone, stoic. Speaks mostly Spanish. She has sustained an all too obvious open fracture with a significant soft tissue defect exposing bone and vital structures.

Amazingly, stable and neurovascularly intact. Her wound is in keeping with the others we have seen. Our military colleagues comment that these are combat wounds. She will go to the OR today…

Ten critical patients arrive at UMC in the first 34 minutes. Four of these without warning, by means other than ambulance. Seven are rushed to the OR in this time frame with multi-specialty teams. UMC receives 15 patients direct from the scene, with two more transferred later that day. Though the threat of additional patients remains, once stability is reached, departments meet with UMC administrators. Lists of victims and missing are run. While it seems simple, patient identification and accurate lists are a challenge. Initially, unidentified patients are given “trauma names”, so there are both duplicated and unidentified patients. With two centres receiving victims, and unknown numbers deceased at the scene, many of the missing are unaccounted for, and coordination between the receiving centres and the scene is needed. One of our responding orthopaedic nurse practitioners maintained a list of patients seen by myself and our residents, with injuries and OR designation noted. This proved to be invaluable. Our department is commended for our response, organization, and presence.

Patients are reassessed. Those who can be discharged safely, are… but they are few. Many continue to decompensate and must return to the OR. They are split between our four responding orthopaedic surgeons. I hold the arm of the elderly woman with the open shoulder injury while she is being sedated, her bandages unwrapped by our resident. She tells us in Spanish the last thing she remembers... her husband’s face. He was protecting her. We tell her she is safe, and we will take care of her. We know he did not leave the scene. None of us know what else to say.

Our Medical Director of Trauma reminds us all that situations like this are not a sprint, but a marathon. Those who responded must go home. Rest. Process. Spend time with our families. Others must take over. This is just the first battle. It will be a war.

El Paso’s professional soccer team, for which I am the team surgeon, has a home game that night. It of course slips my mind. I have a message waiting after the OR from the team. In a “small town” like this, they know what has happened, and where I am.

The game is postponed while El Paso grieves. A week later, our next home game is the first unrelated public gathering following the incident. There are tributes and statements of “El Paso Strong”, but tension remains in the city, in the stands, on the bench, and on the field. At the 22nd minute, all the lights except a few on the field fall dark… the stadium silent. The players hesitate but continue. Thousands of cell phone lights are raised to honour the 22 killed and 25 injured in one of the largest acts of civilian violence Texas and the US has ever seen. A statement of solidarity and defiance. Moments later, a spectacular bicycle-kick goal for El Paso.

The stadium erupts as one… as usual. The Borderplex will not be intimidated. It will not change. But it will remember.

Lessons Learned While the circumstances in El Paso were very different from the Ottawa crash, many of the lessons discussed by Dr. Allan Liew from the “Code Orange” in Ottawa are relevant. This is an area where much of what we know is learned from past experience, whether it be in Canada or the US, military or civilian.

• Practice: UMC had recently participated in a mass casualty simulation. Even though our trauma director was returning to El Paso at the time of the shooting, plans to mobilize staff were in place. Simulation is vital in preparation for rare events like an active shooter or MCI - even just discussion of scenarios between leaders or within departments is valuable. Problems identified in simulation can be addressed before it really matters. In surgery and trauma, it is absurd to think that you will perform well if you have not practiced. This is just as true here as it is in sports and combat.

• Communication: In The Borderplex, a regional authority initiates and coordinates emergency situations, notifying police, fire, other uniformed services, and institutions.

UMC/TTUHSC trauma leaders were notified to mobilize staff via text message. Staff received text messages from our Medical Director of Trauma, but I was also almost simultaneously aware of the situation due to social media. Text messaging is fast and effective, but alternatives may be needed if networks are compromised. The use of multiple platforms is wise, and social media may be a useful (but not entirely trustworthy) adjunct for “real time” information.

• Triage: Military models rely on an experienced surgeon for rapid assessment to maximize outcomes and resources. Both Ottawa and El Paso followed this model. The El Paso situation was unique in that the scene remained active during the initial response. Transit time to the Trauma Center was among the shortest for recent MCI in the US, so circumstance minimized field triage. Once patients arrived in the trauma bay, triage was simplified to immediate OR versus monitoring. With an active scene and ample available transport, the next resourcebased decision point was access to the OR at the site of definitive care. While this is not in keeping with classic models, it was effective in this situation.

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Training & Practice Management / Formation et gestion d’une pratique (continued from page 35)

• Re-triage: Due to the lack of pre-hospital triage, most patients underwent initial evaluation in the trauma bay.

In all situations, including these, patients require additional and ongoing assessment as they may deteriorate and missed injuries may be later identified. Assessment should be continuous during transit, and re-triage should occur at every level of care from the field to the hospital. Once in hospital, status should be re-evaluated with serial examination and re-triage, if needed.

• Mass Shooter vs Mass Casualty Situations: Safety of responding personnel at the scene is always of primary importance, and will impact patient triage and transport.

In most MCI, once the event has occurred the area can be secured. After this, first responders are cleared to help the injured. In an evolving situation like an active shooter, the scene remains unsafe until the shooter is subdued. In El Paso, rumours of multiple shooters delayed the ability of law enforcement to secure the scene, resulting in inability of first responders to reach victims, with many transported out by civilian bystanders and law enforcement. On scene triage and treatment was limited, in favour of immediate transport out of danger and to definitive care. This impacted preparation at the receiving hospitals. Also, due to the nature of an active shooter event, there is an increase in the volume of penetrating trauma. Principles of haemorrhage control are vital, and programs such as “Stop the Bleed” have been established to train the public in tourniquet use in the US. • Teamwork: As in Ottawa, the response in El Paso was only possible due to teamwork between all pre-hospital and hospital staff, both medical and support. Multispecialty physicians, nurses, residents, students, and technicians worked in conjunction with first responders

of all kinds. Multiple specialties worked in the OR on the same patient, sometimes simultaneously. Trauma bays and ORs were cleared and turned over constantly by support staff, with cleaning of equipment and replenishment of supplies by both hospital staff and vendors. The importance of this teamwork in the ability to respond to events like this cannot be overstated.

• Patient Lists: Though it seems simple, starting and continuously updating a physical list of patients (with both “trauma” and real names as they became available) seen by our department was vital to our ability to effectively triage and monitor our patients. This can be particularly challenging in settings where an electronic medical record (EMR) is used that requires unknown patients to have a “trauma name” before orders can be submitted, creating confusion when many such patients exist and once they are subsequently identified.

• Resource Management: As stated by our Medical Director of Trauma, incidents like this are a marathon, not a sprint. Significant resources, both human and physical, are consumed in the initial response. Physical resources must be continually replenished. Human resources must be also. Those who responded must be relieved. They must be allowed to rest and process. Forums for discussion, and counselling should be made available.

As I have told those who ask that, situations like that which occurred in El Paso are not something I, or anyone else, ever wants to be a part of. But it is also why many of us do what we do, and I was glad to be able to help. The importance of preparation by simulation, communication, and teamwork cannot be overstated. As these are fortunately rare events, it is important that we take the lessons from them to improve our outcomes from the next.

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