COA Bulletin #122 - Winter 2018 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Winter Hiver 2018 Publication Mail Envoi Poste-publication Convention #40026541 4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3

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

BULLETIN

122

CHOOSING WISELY CANADA:

ADVANCING CONVERSATIONS ABOUT OVERUSE IN ORTHOPAEDICS (p.52)

CHOISIR AVEC SOIN :

PROMOUVOIR LA CONVERSATION SUR LA SURUTILISATION EN ORTHOPÉDIE

Here’s What YOU Said About the 2018 Annual Meeting � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 13 Thromboprophylaxis in Trauma Patients: Is There a Consensus? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 32 Opioid Use in Orthopaedics: The Need for Orthopaedic Surgeon Stewardship � � � � � � � � � � � � � � � � � 43 La Fondation Canadienne d’Orthopédie remet deux prix d’innovation communautaire � � � � � � � 58

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Bulletin Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 122 - Winter / Hiver 2018 COA / ACO John Antoniou President / Président Kishore Mulpuri Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Femi Ayeni Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

Entering the Winter Season …. An Update John Antoniou M.D., PhD, FRCSC President, Canadian Orthopaedic Association

s we settle into another Canadian winter, Johanna and I have enjoyed a very busy fall travel season returning from informative meetings in the UK, Australia, and New Zealand. Our respective hosts were extremely gracious and all society meetings raised thought-provoking themes and discussions. During a symposium at the British Orthopaedic Association (BOA) meeting, the Carousel Presidents were asked to discuss the role of physician assistants in our respective countries.. Canada currently has the lowest concentration of orthopaedic surgeons per 100,000 population in the Western world (3.6/100k), which is less than half that in the US, and a far cry from Sweden (19.5/100k). We need to continue advocating for increased resources from our government to help employ our graduating residents. A continued inclusion of physician extenders is critical to delivering orthopaedic care in Canada. At the Australian Orthopaedic Association meeting, we discussed spiralling healthcare costs around the world with varied system performances. Canada spends 10% of its GDP on health care, yet ranks 9th of 11 industrialized nations when it comes to markers of performance. This compares poorly to Australia’s 9% of GDP with a number two ranking. We have ample room to improve our system’s efficiency, and must learn from our counterparts. Also revealed at the AOA meeting was the latest registry data. It is becoming clear that the revision burden is diminishing overall, as we improve our implant choices. One apparent outlier is the increasing revision rates for infection in the obese population. We must continue advocating and informing our patients about the consequences of the rising obesity rates around the world. The COA’s 2019 Annual Meeting planning committee met recently to develop next year’s COA and ICORS meeting programs. The event promises to be very stimulating and well attended, with participants and speakers attending from around the world to share knowledge, research, and developments in the field of orthopaedics. Please see page 11 of this edition for a list of this year’s invited guest speakers. Next year’s program will also feature a compelling symposium where Carousel Presidents address the important topic of identifying and managing surgeon under-performance and competence. The ICORS program will feature keynote lecturers within many of the 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 - Winter / Hiver 2018

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various paper sessions, along with 38 workshops hosted by the ICORS member societies like the ORS and EORS. In a special Closing Ceremony, leaders in orthopaedic research from around the world will be honoured with a Fellow of International Orthopaedic Research (FIOR) designation. Fifteen CORS members will be recognized as FIORs at the 2019 meeting, and a special debate and panel discussion among international FIOR members will also be included in the program. With over 1000 abstracts submitted, this is expected to be the largest and most educational combined meeting yet! Abstract notifications have been sent out to all submitters and registration will open in the New Year. Please contact meetings@canorth.org if you have any questions about your podium or poster presentation. The COA’s Executive, Board of Directors, and various committees will be meeting in early January at the Mid-Winter Meeting to discuss important new initiatives and projects. These conversations include the results of the physician wellness survey that was distributed last month to COA members. A number of leadership and mentorship programs will also be launched in 2019. A session for local women medical students will take place at the Annual Meeting where students from McGill University and Université de Montréal are invited to participate in a session led by female faculty. The session is meant to provide more exposure to the specialty, debunk myths, answer questions, and encourage discussion. We hope to offer this program to local students at every Annual Meeting. Please

have a look through the second installment of our spotlight on women leaders in the specialty on page 9. A different member will be featured in each edition of COA Bulletin. On behalf of the COA leadership and staff, I would like to wish you all safe and happy holidays and thank you for your support and commitment. 2019 will be filled with exciting new projects, initiatives and programs, and I encourage your involvement, engagement, and participation throughout the year.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 25 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 43 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 60

L’hiver s’installe... Une mise à jour John Antoniou, MD, Ph.D., FRCSC Président de l’Association Canadienne d’Orthopédie

lors que s’installe un autre hiver canadien, Johanna et moi terminons un automne de voyages à la fois intense et agréable où nous avons assisté à des congrès fort instructifs au Royaume-Uni, en Australie et en Nouvelle-Zélande. Nos hôtes ont été à chaque fois très accueillants, et les thèmes et discussions proposés à chacun des congrès étaient stimulants. Lors d’un symposium au congrès de la British Orthopaedic Association, on a demandé aux présidents du groupe Carousel de discuter du rôle des adjoints au médecin dans leur pays. C’est au Canada qu’on trouve actuellement le taux d’orthopédistes par 100 000 habitants le plus faible en Occident (3,6/100 000 habitants), soit moins de la moitié qu’aux États-Unis, et bien moins que la Suède (19,5/100 000 habitants). Nous devons continuer de demander à nos gouvernements d’augmenter les ressources afin d’embaucher nos jeunes diplômés. L’inclusion constante d’auxiliaires est essentielle à la prestation des soins orthopédiques au Canada. Au congrès de l’Australian Orthopaedic Association, on a discuté de la hausse vertigineuse des coûts en santé partout dans le monde et des variations de rendement des systèmes de santé. Le Canada consacre 10 % de son PIB aux soins de santé, COA Bulletin ACO - Winter / Hiver 2018

mais figure au neuvième rang parmi 11 pays industrialisés pour ce qui est des indicateurs de rendement. La comparaison avec l’Australie est peu flatteuse : elle y consacre 9 % de son PIB, mais arrive au deuxième rang. Notre système de santé peut être beaucoup plus efficace, et nous devons apprendre de nos homologues. Nous avons également pu prendre connaissance des dernières données des registres. Il semble de plus en plus évident que le fardeau des reprises diminue globalement au fur et à mesure que nous améliorons nos choix de prothèses. Un cas particulier est la hausse des taux de reprise pour des raisons d’infection chez les patients obèses. Nous devons poursuivre les efforts de sensibilisation et informer nos patients des conséquences de la hausse des taux d’obésité dans le monde. Le Comité responsable du programme s’est réuni récemment afin d’élaborer le programme de la Réunion annuelle 2019 de l’ACO et du congrès annuel 2019 des International Combined Orthopaedic Research Societies (ICORS). La manifestation promet d’être très stimulante et populaire; des participants et conférenciers viendront de partout dans le monde pour partager leurs connaissances, travaux de recherche et développements en orthopédie. Rendez-vous à la page 11 de ce numéro pour la liste des conférenciers invités cette année. Le programme comprendra également un symposium fascinant où les présidents du groupe Carousel aborderont une question importante, soit le dépistage et la gestion des problèmes de performance et de compétence des orthopédistes. Le pro-

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gramme des ICORS comprendra des conférenciers principaux dans bon nombre des séances de présentation des précis, de même que 38 ateliers animés par les sociétés membres des ICORS, comme l’Orthopaedic Research Society et l’European Orthopaedic Research Society. À l’occasion de cérémonies de clôture spéciales, des leaders en recherche orthopédique de partout dans le monde recevront le titre de Fellow of International Orthopaedic Research (FIOR). Quinze membres de la Société de recherche orthopédique du Canada (SROC) recevront le titre de FIOR au congrès annuel 2019, et un débat spécial entre des membres FIOR internationaux est également au programme. Il devrait s’agir de la réunion annuelle conjointe la plus grande et la plus instructive à ce jour, avec plus de 1 000 précis soumis! Les avis relatifs aux précis ont été envoyés à toutes les personnes qui en ont soumis, et il sera possible de s’inscrire à la Réunion annuelle au début de l’année. Écrivez à meetings@canorth.org si vous avez des questions sur la présentation de votre précis. Le Comité de direction, le conseil d’administration et les comités de l’ACO se rencontrent début janvier à la Réunion d’hiver afin de discuter d’importants nouveaux projets et initiatives, y compris les résultats du sondage sur la santé des orthopédistes, résidents et boursiers qui a été diffusé aux membres de l’ACO le mois dernier.

Des programmes de leadership et de mentorat seront également lancés en 2019. Une séance pour les étudiantes en médecine de la région aura lieu à la Réunion annuelle; des étudiantes de l’Université McGill et de l’Université de Montréal sont invitées à prendre part à cette séance animée par des femmes. La séance a pour but de donner de la visibilité à la spécialité, de détruire les mythes, de répondre aux questions et de favoriser la discussion. Nous espérons offrir une telle séance aux étudiantes locales à toutes les réunions annuelles. Jetez un coup d’œil au deuxième article de notre série sur les femmes leaders en orthopédie, à la page 10. Chaque numéro du Bulletin de l’ACO met en vedette une de ses membres. Au nom du Comité de direction et du personnel de l’ACO, j’aimerais vous souhaiter à tous et à toutes de joyeuses Fêtes! Merci de votre soutien et de votre engagement. Une foule de nouveaux projets, initiatives et programmes emballants sont au menu en 2019; je vous invite à y prendre part activement toute l’année.

Are You Ready to Register?

Êtes-vous prêt à vous inscrire?

Registration for the 2019 COA and ICORS Annual Meeting opens in the New Year. Ensure that your dues are all paid to date in order to benefit from the free or reduced early-bird registration rates offered exclusively to COA members. Log in to your COA profile online or contact Lexie Bilhete at lexie@canorth.org or 514 874-9003 x 6 to pay any outstanding invoices or to confirm that your membership is in good standing. A registration announcement will be sent in January.

Il sera possible de s’inscrire à la Réunion annuelle 2019 de l’ACO et au congrès 2019 des International Combined Orthopaedic Research Societies (ICORS) au début de la nouvelle année. Assurez-vous que toutes vos cotisations sont réglées à temps afin de profiter de l’inscription gratuite ou des droits réduits offerts exclusivement aux membres de l’ACO qui s’inscrivent à l’avance. Accédez à votre profil de l’ACO en ligne ou communiquez avec Lexie Bilhete, à lexie@canorth.org ou au 514-874-9003, poste 6, pour régler toute cotisation en souffrance ou vérifier si votre compte est en règle. On annoncera en janvier le début de la période d’inscription.

Visit www.2019icors.org for information and updates about the 2019 COA and ICORS Annual Meeting being held in Montréal from June 19-22.

Rendez-vous à www.2019icors.org pour les renseignements et les mises à jour sur la Réunion annuelle de l’ACO et le congrès annuel des ICORS, qui auront lieu à Montréal du 19 au 22 juin 2019.

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Lessons Learned While Treating Hip Dysplasia with Operation Walk London in Ecuador Supriya Singh, M.D. PGY5, Western University London, ON

ne of our first great milestones in life is learning how to walk. Walking is meaningful - not only does it represent an ability to move from point A to point B, but it represents freedom and a sense of independence. For some, these can be impeded by developmental dysplasia of the hip (DDH). In North America, due to newborn screening, hips at risk of dysplasia and dislocated hips are detected and treated early. With common treatment such as the Pavlik Harness or open reduction and spica casting, children’s hips are maintained in joint and this leads to a relatively normal progression of developmental milestones. Unfortunately in Ecuador, there is a higher incidence of DDH, and untreated DDH is not an uncommon occurrence. As such, there are many young adults who are severely disabled due to arthritis from a dislocated hip. These patients suffer from loss of independence and often share heart-breaking stories of life-long pain and suffering. The unfortunate reality is that this is largely preventable with adequate neonatal screening programs. An important understanding of paediatric hip examination is important worldwide to detect DDH and prevent hip dislocations and arthritis. Operation Walk Canada is a wonderful organization which treats patients in Ecuador in need of total joint arthroplasties. I was fortunate to participate in the 2018 Operation Walk mission to Cuenca, Ecuador, with Drs. James Howard and Douglas Naudie from Western University in London, Ontario. The mission was an incredible learning opportunity for me, as the severity of untreated DDH was devastating. We got straight to work after a long day and half of travel, and tackled a busy outpatient clinic on our first day in Cuenca. There were no simple cases. Each patient presented with high riding hip dislocations with severe arthritis. Left and right, patients were limping around as well as they Dr. Supriya Singh flanked by Dr. Douglas could, with leg length Naudie (left) and Dr. Michael Decker (right), outside the Cuenca hospital.

COA Bulletin ACO - Winter / Hiver 2018

Hip X-rays of a patient with DDH preop and postop THA.

discrepancies of up to six centimetres. I was overwhelmed at first by the number of patients and the complexity of the cases, but with an The COA Global Surgery (COAGS) outstanding multidisciplinary effort, 24 Committee is pleased to share patients were treated Canadian global health initiatives. If with total hip arthroplasties in one week. you are interested in COAGS featuring From the clinic to the your organization in the Bulletin, or if stifling hot operating you are a resident and you would like theatres, I marveled at the hard work, creato share an essay about your global tivity, and ingenuity surgery experience, please contact put forward by each member of our team. trinity@canorth.org for details. We were all making do under less than ideal conditions, with our patients’ best interests at heart. Whether a PACU nurse, an OR scrub nurse, a resident, a fellow, a staff surgeon, a sterile processing department technician or translator, everyone played a vital role, and I discovered the true meaning of teamwork. Rounding on the patients after surgery was probably the most rewarding component of the trip. Patients’ smiles, words of thanks, and incredible resilience was the greatest reward of all. This overseas trip, near the end of my fourth year of residency, was in many ways rejuvenating. It reminded me how incredible orthopaedic surgery can be, how surgery can change a life, and how much good we can do in the world. It reminded me of the importance of team work. Most importantly, it reminded me of how lucky we are. I am truly grateful for this experience and recommend global health travel to all residents during their training, as a means of developing a greater appreciation and understanding of the scope of our profession around the world.

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Canadian Global Surgery Highlighted at SICOT Meeting in Montréal

he COAGS Committee was pleased to be invited by Dr. John Dormans, incoming president of the Société Internationale de Chirurgie Orthopédique et de Traumatologie (SICOT), and Dr. James Waddell, SICOT Secretary General, to present a symposium at the esteemed SICOT Orthopaedic World Congress held in Montréal in October 2018. The session, moderated by Drs. Waddell and Dormans, focused on the response and involvement of Canadian orthopaedic surgeons in austere environments of low- and middle-income countries. COAGS Chair, Dr. Andrew Furey, introduced the group’s purpose and the numerous humanitarian projects led by Canadian orthopaedic surgeons since its inauguration in 2014. He highlighted global academic partnerships such as the COAGS Norman Bethune Scholarship and the Canadian-Indian Orthopaedic partnership. He also shared personal insight from his own work with Team Broken Earth. In addition to his plenary talk on better data and analytics, COA Second PresidentElect, Dr. Mohit Bhandari, gave a global surgery update on the road traffic trauma epidemic and the INORMUS research project. Finally, COAGS member Dr. Norgrove Penny engaged the audience with a discussion on global surgery as an academic discipline, highlighting the success of the UBC Branch for International Surgical Care.

The continuous collaboration between SICOT member countries is essential in fulfilling the shared goals of promoting an international database of global surgery opportunities, as well as improved orthopaedic care to vulnerable communities across the globe. Join us at the next COAGS symposium at the COA Annual Meeting in June: “Residency to Retirement: Global Surgery Involvement Throughout the Stages of your Orthopaedic Career.” See you there!

Drs. Norgrove Penny and John Dormans leads an engaging discussion and asks tough questions of the audience.

Dr. Andrew Furey presents Canadian global surgery initiatives. Never enough time for discussion! Post-session collaboration chats spill out into the hallway for Drs. Rameez Qudsi, John Dormans, Keith Dip-Kei Luk, Norgrove Penny, and Alaa Azmi Ahmad.

COA Bulletin ACO - Winter / Hiver 2018

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COA Bulletin – Online Reading Tip #5

Did You Know That There Are LIVE Links in the Bulletin?

Bulletin de l’ACO – Conseil de lecture en ligne no 5

Saviez-vous qu’il y a des liens ACTIFS dans le Bulletin?

any of the articles in the COA Bulletin include live links to exterior web sites and additional resources or references. This allows you to learn and access so much more information than what is simply in the journal. Here is how to find and use the live links embedded in the COA Bulletin.

eaucoup des articles du Bulletin de l’ACO comprennent des liens actifs vers des sites Web externes et des ressources et références supplémentaires, ce qui permet d’accéder à bien plus d’information que ce qu’il est possible de fournir dans une simple revue, et donc d’approfondir son apprentissage. Voici la façon de repérer et d’utiliser les liens actifs intégrés au Bulletin de l’ACO.

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

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

1) Any links within an article or on an image will flash in gray for one second when you first turn to a new page. You can repeat this highlight feature by sim- Hovering ply clicking on the page with or clicking your mouse. Any embed- on any ded links will have a gray page will highlight. Hovering over an higlight image or link will also have live links the same effect.

1) Tout lien fourni dans un article ou une image clignote en gris pendant une seconde lorsqu’on ouvre la page correspondante. Vous Passer la pouvez remettre les liens en souris ou surbrillance au besoin en clicliquer sur une quant sur la page avec votre page en met souris; tout lien intégré s’affiche les liens en alors en gris. Passer la souris sur surbrillance une image ou un lien a le même effet.

2) Click on the highlighted area to follow the link to additional information and related online resources. Whether or not in fullscreen mode, you could always ZOOM in to the Bulletin to increase the Clicking size of the print and images here by clicking on the PLUS SIGN found at the bottom of the journal.

2) Cliquez sur la zone en surbrillance pour suivre le lien vers de l’information supplémentaire et des ressources en ligne connexes. Que le mode plein écran soit activé ou non, on peut toujours utiliser le ZOOM pour augmenter la taille du texte et des images en cliquant sur le SIGNE PLUS au bas du lecteur.

Cliquer ici...

3) Any email addresses published in the COA Bulletin is a live link too! Click on the e-mail address to send a message through your Will lead you here e-mail provider (Outlook, Gmail etc.)

3) Tout courriel publié dans le Bulletin de l’ACO est aussi un lien actif! Cliquez sur le courriel pour envoyer un message grâce à ...vous mènera ici votre application de courriel (p. ex. Outlook ou Gmail).

Reading the Bulletin on a mobile device (smartphone or tablet)? Follow the same instructions above, but use your touchscreen instead of a mouse to highlight or click on any links.

Lecture du Bulletin sur téléphone ou tablette – Suivez les mêmes étapes, mais utilisez votre écran tactile au lieu de votre souris pour mettre les liens en surbrillance ou cliquer dessus.

Look for more online reading tips in future editions of the COA Bulletin.

D’autres conseils de lecture en ligne seront publiés dans les prochains numéros du Bulletin de l’ACO.

COA Bulletin ACO - Winter / Hiver 2018

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Diversity in the COA: Spotlight on Women in Orthopaedics with Catherine Coady, M.D., FRCSC Lexie Bilhete Coordinator, Membership Services & Affiliate Programs Canadian Orthopaedic Association

his issue features Dr. Catherine Coady, Canadian orthopaedic surgeon specializing in arthroscopy and sport medicine. As a COA member since 1991, Dr. Coady has had a fulfilling orthopaedic career thus far. She continues to work at both the adult hospital QEII Health Sciences Centre, as well as the paediatric hospital at IWK Health Centre. She is also affiliated with the orthopaedic resident training program at Dalhousie University in Halifax, Nova Scotia. We were fortunate enough to catch up with Dr. Coady and ask her a few questions on her experience in orthopaedics, defining moments in her career, tips & tricks, and more! Read the interview below:

3. What does diversity mean to you? Diversity, in my opinion, is far more than creating an “inclusive” environment. Diversity is bringing people with different skill sets, strengths, experiences, perspectives, and working styles, together to hopefully create an efficient and effective team. Diversity helps foster innovation which is crucial in our ever-evolving field. 4. What advice would you give to orthopaedic residents? First and foremost, care about each and every one of your patients and treat them well. Be humble. Be honest. Be accountable. Learn something new from someone every day. Most importantly, find a hobby or activity outside of orthopaedics that makes you happy.

1. What drew you to orthopaedics (and your subspecialty)? I was drawn to orthopaedics and specifically sports medicine after I did a sports medicine elective in my first year of medical school at Dalhousie. I entered orthopaedics in 1991 at a time when there weren’t many women in the specialty. Moreover, The COA recognizes the strength in there were some individuals who attemptdiversity and promotes equity across ed to dissuade my career path. Thankfully, its membership, services, and all I had many supportive people in my life community engagement. Each edition who helped make my dream a reality and of the COA Bulletin will feature one encouraged me to pursue the career path I wanted, regardless of my gender. of the many women members of the

5. What is one professional goal and one personal goal you hope to achieve in the next five years? • Professional goal: An immediate professional goal is to get my act together and finally complete all of the required documents for my promotion to Associate Professor at Dalhousie.

• Personal goal: My main goal is to be in betAssociation, their experiences and 2. Can you recount a defining moment in ter physical shape in my 50’s than I was in insights, contributions to the specialty your career thus far? my 40’s! I have been doing regular strength and advice for junior colleagues For me, the most defining moment came and agility training over the past 18 months. early in my career. One of my patients was Recently, I have started running with a local and students. Get to know the a seven-year-old boy who tragically lost his group known as the Halifax Roadhammers membership! arm in a farming accident. He has truly been which is a very inspirational (and competione of the most incredible human beings tive), running group. I plan on running a half that I have ever met. At a very young age, he proved that hard marathon in February 2019. I really hope work and determination would allow a person of any ability that my body will cooperate! to achieve whatever goal they chose in life. He can now tie his shoes faster than I could ever hope to, he can cross country ski 6. Name one of your go-to tricks or hacks that has helped you faster than most, he can shoot a rifle with incredible precision in your day to day life? and he has incredible drive and determination. He is kind and Be organized! It’s not really a trick or a hack but this life skill is he loves to share his passion with others. He did not let the loss crucial to my survival. As a working mother of seven children, of his left arm define him. This seven-year-old boy is now a very my organizational skills have certainly evolved to a whole new successful three-time Paralympian named Mark Arendz, who in level. This has helped me maintain sanity at home and at work! fact won the most medals for Canada in the 2018 Paralympic games. It was truly an uplifting and inspirational moment in my career to see and speak with him again recently, 21 years later.

COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

Diversité au sein de l’ACO : Pleins feux sur les femmes en orthopédie avec Catherine Coady, MD, FRCSC Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés Association Canadienne d’Orthopédie

e numéro met en vedette la Dre Catherine Coady, orthopédiste canadienne spécialisée en arthroscopie et en médecine sportive. Membre de l’ACO depuis 1991, la Dre Coady a mené jusqu’ici une carrière florissante en orthopédie. Elle travaille à la fois au Queen Elizabeth II Health Sciences Centre, un hôpital général, et à l’IWK Health Centre, un hôpital pédiatrique, à Halifax, en Nouvelle-Écosse. Elle est également affiliée au programme de formation en orthopédie de l’Université Dalhousie, aussi à Halifax. Nous avons eu la chance de discuter avec la Dre Coady et de lui poser quelques questions sur son expérience en orthopédie et les moments marquants de sa carrière, de lui demander quelques trucs et conseils, et bien plus encore! Voici notre entrevue : 1. Qu’est-ce qui vous a amenée à choisir l’orthopédie (et votre sous-spécialité)? Je me suis intéressée à l’orthopédie, et plus particulièrement à la médecine sportive, après avoir effectué un stage optionnel en médecine sportive pendant ma première année en médecine à Dalhousie. J’ai fait mes débuts en orthopédie en 1991, donc à une époque où il n’y avait pas beaucoup de femmes dans la profession. Il y a même quelques personnes qui ont tenté de me dissuader de suivre cette voie. Heureusement, bien des gens autour de moi m’ont appuyée et m’ont aidée à réaliser mon rêve; ils m’ont incitée à suivre la voie que j’avais choisie, même si je suis une femme.

L’ACO reconnaît la force inhérente à la diversité et fait la promotion d’une culture d’équité chez ses membres ainsi qu’en ce qui a trait à ses services et à son engagement communautaire. Chaque numéro du Bulletin comprendra le portrait de l’une des nombreuses femmes membres de l’ACO. On en apprendra davantage sur son expérience et ses idées, sa contribution à la profession et ses conseils pour ses jeunes collègues et les étudiants. Apprenez à connaître vos collègues!

2. Racontez-nous un moment marquant de votre carrière. Le moment le plus marquant que j’ai vécu remonte au début de ma carrière. L’un de mes patients, un garçon de 7 ans, avait perdu un bras dans un accident agricole. Il est vraiment l’un des êtres humains les plus incroyables que j’aie jamais rencontré. Dès un très jeune âge, il a démontré que, peu importe la capacité d’une personne, avec beaucoup de travail et de détermination, on peut atteindre n’importe quel objectif qu’on s’est fixé dans la vie. Il peut maintenant attacher ses souliers plus vite que je ne pourrai jamais le faire, il est plus rapide au ski de fond que la plupart des fondeurs, il tire de la carabine avec une précision incroyable et il est très dynamique et déterminé. Il est gentil et il aime transmettre sa passion. Il n’a pas laissé la perte de son bras gauche le définir. Ce garçon de 7 ans, Mark Arendz, est devenu un triple paralympien brillant, et c’est même lui qui a remporté le plus de médailles pour le Canada aux Jeux paralympiques de 2018. J’ai pu lui reparler récemment, 21 ans plus tard, et ce fut un moment vraiment inspirant de ma carrière. COA Bulletin ACO - Winter / Hiver 2018

3. Pour vous, que signifie la diversité? À mon avis, la diversité, c’est bien plus que créer un environnement « inclusif ». La diversité, c’est rassembler des personnes qui ont des compétences, forces, expériences, perspectives et styles de travail différents dans l’espoir de former une équipe efficace. La diversité favorise l’innovation, qui est essentielle dans une profession en constante évolution comme la nôtre. 4. Quels conseils donneriez-vous aux résidents en orthopédie? Surtout, préoccupez-vous de chacun de vos patients et traitez-les bien. Soyez modestes, honnêtes et responsables. Tous les jours, apprenez quelque chose de nouveau des gens autour de vous. Autre aspect très important : trouvez-vous un passe-temps ou une activité non liée à l’orthopédie qui vous rend heureux. 5. Pouvez-vous me parler d’un objectif professionnel et d’un objectif personnel que vous voulez atteindre au cours des cinq prochaines années? • Objectif professionnel : Un de mes objectifs professionnels immédiats est de me ressaisir et de finir, enfin, de remplir tous les documents requis pour ma promotion au titre de professeure agrégée à l’Université Dalhousie.

• Objectif personnel : Mon principal objectif est d’être en meilleure forme dans la cinquantaine que je l’étais dans la quarantaine! Je fais de l’entraînement musculaire et en agilité régulièrement depuis 18 mois. Récemment, j’ai commencé à courir avec un groupe de coureurs local très inspirant (et compétitif ), les Halifax Roadhammers. J’ai l’intention de courir un demi-marathon en février 2019. J’espère vraiment que mon corps va coopérer! 6. Nommez le truc ou l’astuce que vous appliquez au quotidien pour vous faciliter la vie. Être structurée! Ce n’est pas vraiment un truc ni une astuce, mais cette habileté est essentielle à ma survie. En tant qu’orthopédiste et mère de sept enfants, mon sens de l’organisation a certainement atteint un tout autre niveau. Cela m’a aidée à ne pas perdre la tête, autant à la maison qu’au travail!

Your COA / Votre association

Internationally Renowned Specialists and Experts Participate as 2019 Annual Meeting Guest Speakers

ddressing a variety of topics from adapting to continuous change, professional identity, and innovation in orthopaedic research, our extraordinary roster of guest speakers at the 2019 COA and ICORS Annual Meeting are not to be missed! Visit the Programs tab at www.2019icors.org to see the full guest and keynote speaker lineup, lecturer biographies and up to date Annual Meeting program information.

Des spécialistes de renommée mondiale conférenciers invités à la Réunion annuelle

e manquez pas notre brochette extraordinaire de conférenciers invités à la Réunion annuelle 2019 de l’ACO et au congrès 2019 des International Combined Orthopaedic Research Societies (ICORS), où ils aborderont un éventail de sujets allant de l’adaptation aux changements constants et de l’identité professionnelle à l’innovation en recherche orthopédique! Cliquez sur l’onglet « Programmes », à www.2019icors.org, pour consulter la liste complète des conférenciers invités et principaux, leur notice biographique et les renseignements à jour sur les programmes de la Réunion annuelle et du congrès annuel.

Presidential Guest Speaker / Conférencière invitée par le président Roberta L. Bondar, O.C., O.Ont., MD, Ph.D., FRSC, ICD.D / IAS.A Astronaut | Physician | Scientist | Photographer Astronaute | Médecin | Scientifique | Photographe Change, Adaptation & Risk / L’art de changer, de s’adapter et de prendre des risques Wednesday, June 19 – Opening Ceremonies Le mercredi 19 juin – Cérémonies d’ouverture

Macnab Lecturer / Conférencier Macnab Mauro Alini, Ph.D. Head of Musculoskeletal Regeneration, AO Foundation | International Pioneer in Orthopaedic Research Responsable du programme de régénération musculosquelettique, AO Foundation | Pionnier international en recherche orthopédique 25 Years of Spine Basic Research: Nothing New on the Clinical Horizon? / Un quart de siècle de recherche fondamentale sur le rachis : Y a-t-il du neuf sur le plan clinique? Thursday, June 20 Le jeudi 20 juin

R.I. Harris Lecturer / Conférencier R.I. Harris Richard L. Cruess, C.C., O.Q., MD, FRCSC COA and CORS Past President | Professor of Orthopaedic Surgery, McGill University Ancien président de l’ACO et de la SROC | Professeur de chirurgie orthopédique, Université McGill From Professionalism to Professional Identity: An Educational Journey / Du professionnalisme à l’identité professionnelle : Un apprentissage de longue haleine Friday, June 21 Le vendredi 21 juin COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

Wanted! COA Bulletin Scientific Editor Position Now Open

he position of Scientific Editor of the COA Bulletin will be available next year. Applications from interested candidates are now being accepted until January 15, 2019.

The Scientific Editor works closely with the COA Bulletin’s editorial team and Communications Committee on developing clinical content published the COA Bulletin. This includes suggesting topics, themes and articles, coordinating submissions, author invitations, editing, proofreading, development and creation of new features, regular columns or original content. As a member of the COA Bulletin’s editorial team, you will also hold a seat on the Communications Committee. This Committee meets two to three times annually by teleconference. This volunteer position is a three-year mandate, with option for extension or renewal, and is open to all Active and Active International members of the COA. As Scientific Editor, you will be well-supported by the staff, editorial team and committee members.

Interested in Applying? Contact Cynthia Vezina: cynthia@canorth.org by January 15 with the following: 1) A copy of your CV 2) Brief outline or summary of any experience you have in an editorial position on medical journals or society journals 3) Positions you have held on any communications or publications committee (COA and other) This is a great opportunity to contribute to quality of the COA’s educational content, to engage with your colleagues and to ensure that Canadian orthopaedic research and education are well-featured in COA communications.

Recherché! Rédacteur ou rédactrice scientifique du Bulletin de l’ACO – Poste vacant

e poste de rédacteur ou rédactrice scientifique du Bulletin de l’ACO se libèrera l’an prochain. Les candidatures sont acceptées jusqu’au 15 janvier 2019.

Le rédacteur ou la rédactrice scientifique travaille en étroite collaboration avec l’équipe de rédaction du Bulletin de l’ACO et le Comité des communications afin de créer le contenu clinique publié dans le Bulletin. Cela implique la suggestion de sujets, de thèmes et d’articles pour le Bulletin, la coordination de la soumission des articles, les invitations aux auteurs, la révision, la lecture d’épreuves et la création de nouvelles séries d’articles, de chroniques régulières ou de contenu original. À titre de membre de l’équipe de rédaction du Bulletin de l’ACO, le ou la titulaire du poste siège en outre au sein du Comité des communications. Le Comité tient généralement deux ou trois téléconférences par année. Il s’agit d’un poste bénévole assorti d’un mandat de trois ans qui peut être prolongé ou renouvelé. Il est ouvert à tous les membres actifs et membres actifs internationaux de l’ACO. Le ou la titulaire du poste bénéficie du soutien du personnel, de l’équipe de rédaction et des membres du Comité.

COA Bulletin ACO - Winter / Hiver 2018

Vous souhaitez présenter votre candidature? Écrivez à Cynthia Vezina, à cynthia@canorth.org, d’ici le 15 janvier en fournissant ce qui suit : 1) Votre curriculum vitæ 2) Un court profil ou sommaire de toute expérience à des postes de rédaction de revues médicales ou de sociétés 3) La liste des postes que vous avez occupés au sein de comités des communications ou de publications (de l’ACO et d’autres organisations) Il s’agit d’une excellente occasion de contribuer à la qualité du contenu scientifique produit par l’ACO, d’établir des liens avec vos collègues et de veiller à ce que la recherche et le contenu scientifique en orthopédie au Canada soient au premier plan dans les communications de l’ACO.

Your COA / Votre association

Here’s What YOU Said About the 2018 Annual Meeting

he 2018 COA, CORS and CORA Annual Meeting was held on the beautiful island of Victoria this past June, bringing together 1036 surgeons, residents, fellows, researchers and allied health professionals from all parts of Canada and the globe. COA president Dr. Kevin Orrell, alongside the Program Committee chair Dr. Peter Dryden and Local Arrangements Chair Dr. Colin Landells, offered a high-quality, immersive, and wide-ranging educational Meeting for all attendees.

Below are just some of the comments and feedback we’ve received directly from our members and participants*. Thank you for your responses and suggestions for next year’s Annual Meeting. *Responses received through the 2018 COA, CORS & CORA Annual Meeting session and overall evaluation forms.

Satisfaction Stats: How Do We Measure Up?

of respondents were satisfied with the Annual Meeting from an educational perspective

82%

were satisfied with the full Subspecialty Day

felt that the scientific program represented the diverse nature of Canadian orthopaedics

71%

learned new techniques or approaches to clinical challenges

were either satisfied or very satisfied with the ease of the new on-site registration check-in process

70%

were VERY SATISFIED with the symposia

Suggestions: How Can We Make Next Year Even Better? App Malfunctioned Once – But No More!

• Last year, we inaugurated some new technologies at the Annual Meeting to streamline the program and registration experience. Some, like the registration barcodes at check-in, were successful, while others, like our COA App, not so much. • We’ve since changed our App’s interface and will be using an improved and updated version at the 2019 Meeting.

More ICLs

• “I think more ICLS with experts leadings sessions is always a good way to learn.”

More Labs and Workshops

• You asked for “more hands-on sessions”, and you got it! The 2019 Meeting in Montréal will be offering wet labs, stay tuned for more info!

“Increase Diversity” ... and we couldn’t agree more

• The 2018 Meeting was the first to include the new Gender and Leadership session, which will continue to be a part of all Annual Meeting programs from here on out. • CPD and Program Committee members will continue to ensure that presenters, faculty and contributors to our Annual Meeting program represent diversity in the orthopaedic community. • Building off of last year’s success, the 2019 Meeting will also have a full session on gender and diversity in orthopaedics with a networking coffee break.

Increase focus on community and rural medicine

• “I would love to have a full session with surgeons from communities with populations under 100,000.” • The COA is working with community surgeons on developing sessions and services that are relevant to those working outside of academic centres and in rural communities. Keep your eye on COA communications for updates on these initiatives. COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

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You Liked it – We’re Bringing It back! • Back by popular demand, Squidjigger will return to the COA Gala in Montréal next year to entertain us with their incredible music and performance. • “The gala was amazing, bring that band back again.” • Easy, fast, and simple registration barcodes will be used to check you in again! • Networking and collaboration opportunities • “As a research coordinator and PhD student, I was able to make connections with other researchers across the country and share ideas.” • In 2019, the COA Annual Meeting will be held in conjunction with the International Combined Orthopaedic Research Societies (ICORS) - providing both research-scientists and clinician-scientists incredible networking and collaboration opportunities! • ICLs will continue to run FREE of any additional charge. • A symposium including presentations by the visiting presidents of the Carousel orthopaedic societies will also be featured in the Montréal 2019 program. • The upcoming symposium is titled “Identifying and Managing Surgeon Under-performance/Competence” and moderated by this year’s COA president, Dr. John Antoniou. • The Full Subspecialty Day was a hit in Victoria, so we’re bringing it back to Montréal. • Saturday, June 22 will be once again dedicated to a full Subspecialty Day, with sessions offered from all of the orthopaedic subspecialties. • More Hand & Wrist sessions – It will be our featured subspecialty in 2019!

Call for Engagement: We Need You, Too! Only 18% of respondents attended the Your COA in Review session (business meeting) at the Annual Meeting in Victoria. However, 97% of those who attended the session had a better sense of what the COA is currently doing on behalf of orthopaedics in Canada, as a result. • The “Your COA in Review” session is an important opportunity for you to engage with your Association; come vote, voice your opinion, and learn more about what the COA is working on and where we’re going next! Did you know: you can STILL complete the Annual Meeting evaluation forms to receive CME credits! Click here to get started.

Future Developments: Thanks for the Tips • “Include an end of week session, summarizing the best papers submitted across the board.” • We will also be continuously exploring ways to improve: • The AV services offered during our events • The location of the poster presentations • The timing and scheduling of sessions and breaks

COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

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TOP 3 REASONS TO ATTEND THE 2019 ANNUAL MEETING IN MONTRÉAL, JUNE 19-22

First ever combined meeting with the International Combined Orthopaedic Research Societies!

• Get ready for sessions dedicated to the most up to date, cutting-edge orthopaedic research.

Extensive Program Filled with Symposia, ICLs, and Labs!

• Your comments and feedback demonstrate how the COA Annual Meeting is an exceptional learning experience for all those who participate. We will continue to strive for excellence.

Networking, Collaboration, and Community

• You’ve said it yourself, the Annual Meeting is a prime opportunity to reconnect with colleagues and make new connections with orthopaedic surgeons and health-care practitioners from across Canada! Plans are already well underway for next year’s Annual Meeting, in Montréal June 19-22. Get ready for a dynamic and exciting scientific program, complimented by fun social events and, of course, access to the ICORS meeting, in the heart of one of Canada’s most cosmopolitan cities! Make regular visits to the Annual Meeting web page at www.2019icors.org for updated information about next year’s event.

Voici ce que VOUS aviez à dire sur la Réunion annuelle 2018

a Réunion annuelle 2018 de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO) avait lieu en juin dernier sur la magnifique île de Victoria, où s’étaient réunis 1 036 orthopédistes, résidents, fellows, chercheurs et professionnels des soins de santé connexes provenant d’un peu partout au Canada et dans le monde. Le Dr Kevin Orrell, président de l’ACO, le Dr Peter Dryden, président du Comité responsable du programme, et le Dr Colin Landells, président du Comité organisateur, proposa-

ient aux participants une réunion immersive de grande envergure et de grande qualité. Voici une partie de la rétroaction que nous avons reçue des membres et des participants.* Merci pour vos réponses et vos suggestions en vue de la prochaine réunion annuelle. * Réponses fournies dans les formulaires d’évaluation des séances et de la Réunion annuelle 2018 de l’ACO et de la SROC.

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

Du point de vue de la formation, 99 % des répondants étaient satisfaits de la Réunion annuelle.

82%

étaient satisfaits de la journée complète des sous-spécialités.

étaient d’avis que le programme scientifique reflétait la diversité du milieu de l’orthopédie au Canada.

71%

ont appris de nouvelles techniques ou approches des problèmes cliniques.

étaient satisfaits ou très satisfaits de la convivialité du nouveau processus d’inscription ou d’enregistrement sur place.

70%

étaient TRÈS SATISFAITS des symposiums.

COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

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Suggestions : Comment pouvons-nous faire encore mieux l’an prochain? L’application a fait défaut une fois... mais c’est réglé!

• L’an dernier, nous lancions de nouvelles technologies à la Réunion annuelle afin de simplifier tout ce qui a trait au programme et à l’enregistrement. Certaines, comme les codes-barres pour l’enregistrement sur place, ont été une réussite, tandis que d’autres, comme l’application de l’ACO, ont connu un déploiement plus ardu. • Depuis, nous avons modifié l’interface de notre application, et c’est une version améliorée que nous utiliserons à la Réunion annuelle 2019.

Plus de conférences d’enseignement

• « Plus de conférences d’enseignement menées par des spécialistes. C’est toujours une bonne façon d’apprendre. »

Plus de laboratoires et d’ateliers

• Vous avez demandé « plus de séances pratiques », et vous en aurez! À la Réunion annuelle 2019, à Montréal, des laboratoires de travaux pratiques sont au programme. Plus d’information à cet effet bientôt!

« Plus de diversité »... Nous sommes parfaitement d’accord avec vous!

• La Réunion annuelle 2018 était la première à inclure une séance sur le sexe et le leadership, qui deviendra une tradition à la Réunion annuelle. • Les membres du Comité de perfectionnement professionnel et du Comité responsable du programme continueront de veiller à ce que les intervenants au programme de la Réunion annuelle reflètent toute la diversité du milieu de l’orthopédie. • Nous miserons sur le succès obtenu l’an dernier pour offrir à la Réunion annuelle 2019 une séance complète sur le sexe et la diversité en orthopédie, y compris une pause-café pour le réseautage.

Plus d’attention accordée à la médecine en milieu communautaire et rural

• « J’aimerais qu’il y ait une séance complète avec des orthopédistes provenant de collectivités de moins de 100 000 habitants. » • L’ACO travaille avec des orthopédistes en milieu communautaire à l’élaboration de séances et de services pertinents pour les professionnels œuvrant à l’extérieur des centres universitaires et en milieu rural. Les détails à venir dans les communications de l’ACO.

Vous avez aimé ça... alors nous répéterons l’expérience! • À la demande générale, les Squidjigger seront de retour au Souper-réception de l’ACO à Montréal cette année pour nous divertir avec leur musique et leur sens du spectacle incroyables. • « La réception était fantastique. Ramenez-nous ce groupe encore une fois! » • Nous utiliserons à nouveau des codes-barres pour vous enregistrer sur place. C’est si simple et rapide! • Les possibilités de réseautage et de collaboration • « Comme coordonnateur de la recherche et aspirant au doctorat, j’ai pu nouer des liens et échanger avec d’autres chercheurs de partout au pays. » • En 2019, la Réunion annuelle de l’ACO aura lieu simultanément avec le congrès des International Combined Orthopaedic Research Societies (ICORS); cela implique donc de belles possibilités de réseautage et de collaboration, tant pour les chercheurs scientifiques que pour les cliniciens-chercheurs! • Les conférences d’enseignement continueront d’être offertes SANS FRAIS supplémentaires. • Un symposium comprenant des exposés par les présidents des associations d’orthopédie membres du groupe Carousel figurera également au programme de la Réunion annuelle de Montréal. • Le symposium, intitulé « Déceler et gérer les problèmes de performance et de compétence des orthopédistes », sera animé par le Dr John Antoniou, président de l’ACO. • Comme la journée complète des sous-spécialités a connu un succès retentissant à Victoria, nous répéterons l’expérience à Montréal. • La journée complète des sous-spécialités aura lieu le samedi 22 juin; toutes les sous-spécialités de l’orthopédie seront représentées. • Plus de séances sur la main et le poignet – Ce sera notre sous-spécialité en vedette en 2019! COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

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Appel à la participation : Nous avons besoin de vous! À peine 18 % des répondants ont assisté à la séance Coup d’œil sur l’ACO (séance de travail) de la Réunion annuelle de Victoria; par contre, 97 % des personnes qui y ont assisté avaient l’impression de mieux savoir ce que l’ACO fait au nom du milieu de l’orthopédie au Canada après celle-ci. • La séance Coup d’œil sur l’ACO est une occasion importante de prendre part aux activités de votre association; venez voter, exprimer votre opinion et en apprendre davantage sur les initiatives de l’ACO et son orientation! Saviez-vous que vous pouvez ENCORE remplir les formulaires d’évaluation de la Réunion annuelle et recevoir vos crédits d’éducation médicale continue (ÉMC)? Cliquez ici pour les remplir.

Développements à suivre : Merci pour les suggestions! • « Vous pourriez inclure une séance finale résumant les meilleurs précis soumis, toutes catégories confondues. » • Nous allons aussi continuer de chercher à améliorer : • les services audiovisuels pendant les activités; • l’emplacement des affiches; • le moment choisi pour les séances et les pauses, et l’horaire en général.

LES TROIS GRANDES RAISONS D’ASSISTER À LA RÉUNION ANNUELLE 2019, À MONTRÉAL, DU 19 AU 22 JUIN

Nº

Première réunion tenue conjointement avec le congrès des ICORS! • Attendez-vous à une foule de séances sur la recherche de pointe en orthopédie.

Nº

Programme exhaustif regorgeant de symposiums, de conférences d’enseignement et de laboratoires! • Votre rétroaction montre à quel point la Réunion annuelle de l’ACO est une expérience d’apprentissage exceptionnelle pour tous les participants. Nous continuerons de viser l’excellence.

Nº

Réseautage, collaboration et communauté • Vous l’avez dit vous-mêmes, la Réunion annuelle est une occasion en or de renouer avec des collègues et de tisser des liens avec des orthopédistes et d’autres professionnels de la santé de tout le Canada!

La planification de la prochaine réunion annuelle, qui aura lieu à Montréal du 19 au 22 juin, va déjà bon train. Attendez-vous à un programme scientifique dynamique et stimulant, agrémenté d’activités sociales amusantes et, bien entendu, de la possibilité d’assister aux séances du congrès des ICORS, le tout au cœur de l’une des villes canadiennes les plus cosmopolites! Consultez souvent le site Web de la Réunion annuelle, à www.2019icors.org, pour obtenir des renseignements à jour sur la manifestation.

COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

Writing a Kids’ Book and Living with Intentionality in Orthopaedics Carrie Kollias, M.D., FRCSC Orthopaedic Surgeon Lethbridge, AB

Dr. Carrie Kollias, author of Maria’s Marvelous Bones

“Did you always plan on becoming a children’s author?”

his was a question recently posed to me by a group of teachers and librarians. We were discussing my recently published children’s book, Maria’s Marvelous Bones.

The short answer was “No”, but the real answer is much more complex. Ten years ago, as an orthopaedic resident, I got the idea to write a kids’ book to help explain fractures. But other priorities came first: I finished residency, the Royal College exam, fellowships, and started community practice. I had two kids. I became involved in health advocacy where I experienced some victories but many frustrations, often due to the health-care bureaucracy that demoralizes many of us over time. About 18 months ago, I decided to finally write that kids’ book. By then, my own kids were asking questions about my job. With celebrated UK illustrator Gill Guile, we featured a group of health-care professionals diverse in both gender and ethnicity. Since the book’s publication, readers have told me how it’s changing kids’ perceptions: a 10-year-old girl who snuck anatomy books to bed at night to read with a flashlight; a boy who approached his treatment with confidence after breaking his leg; a girl who declared she wanted to be an “astronaut surgeon,” and a boy who now eats broccoli because it is good for his bones. Small but meaningful victories. Fortunately, Maria’s Marvelous Bones made the top of the fiction best seller list in Calgary. So yes, bones really ARE cool! This project has fulfilled me both personally and professionally. This, we know, is important: the physician health literature indicates that spending at least 20% of our time doing high meaning professional activity is associated with lower rates of burnout1. This means that if your highest meaning activity is teaching, or administration, or research, or even performing a specific surgery, you should aim to allocate a minimum of 20% of your work schedule to that area. What goals do you have in the next 18 months? This may mean pioneering a surgery nationally or in your centre, stepping up for a leadership role, focusing on your own health, mentoring a colleague, building a marriage or learning to surf. Many of us however, exist on a professional hamster wheel day to day, spinning along with little intentionality. We mindlessly grind through patient waitlists. Sometimes it feels like we have no choice in a system where resources and patient access can be scarce. Large personal financial commitments can force us to run along at too rapid a pace. For others, we are living a version of ‘malignant’ intentionality: single-mindedly climbing ladders COA Bulletin ACO - Winter / Hiver 2018

of power and influence with not enough regard for the wellbeing of our family, our colleagues, or our own health. I often think of my colleague, Spencer McLean, M.D., FRCSC, who passed away with aggressive kidney cancer in 2013 at the end of his orthopaedic surgery residency in Calgary. Spencer lived intentionally: with kindness, appreciation, generosity, love for family, nature and orthopaedics. On the day of Spencer’s funeral, I recall sitting across the table from my colleague; we were absolutely shell-shocked. We were early in our careers, with the sacrifices of residency still fresh in our minds. We talked about how to honour our colleague’s memory. We hung a picture of Spencer, given to us by his wife Christina, in our office. In this way, Spencer continues to inspire us to pursue a life that is deliberate. We remember that each day is a gift. As surgeons, we go through seasons professionally and personally. Along the way, it is important to critically evaluate: does the way we are living and practicing align with our personal values? For those of us who have never explored this, online tools are available2. For those of us who already know what our values are, we may need a reminder. Living with intentionality can require uncomfortable choices like sacrificing income, prestige, or even ego. It might mean writing a kids’ book, collaborating more with colleagues, or reconciling with others. As any health-care professional knows, we have no guarantee of good health, nor of the years we will get. We need to think about how to make every one of them count. Special thanks to Christina Frangou

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References 1. Shanafelt T.D., West C.P., Sloan J.A., et al. Career fit and burnout among academic faculty. Arch Intern Med. 2009;169(10): 990-995.

2. Personal Values Assessment https://www.valuescentre. com/our-products/products-individuals/personal-valuesassessment-pva

Refined and Redefined

Canadian Orthopaedic Research Society Launches Three-year Strategic Plan Paul E. Beaulé, M.D., FRCSC President, Canadian Orthopaedic Research Society (CORS) Ottawa, ON

With the process now completed, I am pleased to share the CORS Vision, Mission and brief summary of our three-year strategic plan.

Vision To be the leading musculoskeletal research society in Canada.

ounded in 1966 by key leaders of our Canadian orthopaedic community, the Canadian Orthopaedic Research Society (CORS) has been at the forefront of key advances in musculoskeletal care. Since then, the field of MSK science has expanded tremendously with several new societies being established within the ever-expanding scientific community including the Canadian Biomaterials Society, the Canadian Society for Biomechanics, and the Canadian Connective Tissue Society. The importance of our basic science community was recognized early on by CORS, where in 1998, the CORS presidency began alternating between basic scientists and clinician scientists reflecting our core value of fostering collaboration to advance the field of MSK science. As the 51st President of CORS, and supported by the society’s Executive, I felt it was appropriate to establish a three-year strategic plan to meet the challenges of our growing role both at the national and international level. Over the last year and half, our CORS Executive conducted a SWOT analysis as well as survey of our Canadian sister societies (listed above) to better understand the position/role of CORS both within the COA, and in our larger MSK science community, as well as how we can best serve our members and advance the field.

Mission VISIBILITY Champion musculoskeletal research through peerreviewed publications, scientific meetings, technology development and multimedia initiatives. COLLABORATION Facilitate and support interdisciplinary collaborative research between scientists and clinicians in related fields of orthopaedics such as biomaterials, biomechanics, biomedical engineering, developmental and stem cell biology. Foster strong relationships with other musculoskeletal research societies in Canada, and orthopaedic research societies worldwide. EXCELLENCE Support excellence in musculoskeletal research through recognition, knowledge translation and funding initiatives. INSPIRE Inspire the pursuit of musculoskeletal research in scientists and clinicians in training.

2018-2019 CORS Executive Committee (from l to r: President, Dr. Paul E. Beaulé; Past President, Dr. Fackson Mwale; Program Chair, Dr. Rizhi Wang; Secretary, Dr. Simon Kelley; Member at Large, Dr. Mario Lamontage) COA Bulletin ACO - Winter / Hiver 2018

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Strategic Plan Fosters a Stronger Research Society Over the summer, the CORS Executive extensively reviewed feedback obtained through surveys and discussions held over the past year throughout the analysis and assessment process. A strategic plan is now in place that will guide CORS through its development over the next three years. The first year of the strategic plan will focus on developing a CORS membership structure, formalizing its awards selection criteria, and increasing the Society’s profile within the COA community. In the second year, focus will be placed on expanding the CORS Annual Meeting program and establishing stronger liaisons and collaborations with sister societies in Canadian research. Year three will pursue further expansion of the CORS membership, as well as grant funding opportunities. One of the key goals this year is to define the value of being a CORS member. Many of you may not realize that under the current governance structure, being a COA member automatically makes you a CORS member. Although this facilitates participation in the CORS Annual Meeting, it may not provide the level

COA Mentor for a Day Program

Are you a practicing orthopaedic surgeon with insight to share?

ublished literature attests to the numerous benefits of formal mentorship in orthopaedics. For the first time this year, the COA will offer a Mentor for a Day program at our 2019 Annual Meeting. The inauguration of this program is part of our commitment to foster the professional development, career planning needs, and personal satisfaction of junior members. We seek commitments from a diverse group of orthopaedic surgeons willing to be matched with a resident or fellow Mentee for a single day.

of engagement needed to enhance our MSK research community and foster collaborations with affiliate societies. In the next few weeks, the CORS Executive will be conducting a survey of COA and CORS members to seek your opinion on how to best frame the CORS membership structure. Please take a moment to participate and provide your feedback. CORS, along with the COA, is honoured to be hosting the International Combined Orthopaedic Research Societies (ICORS) meeting in Montréal from June 19-22. This opportunity will allow us to showcase the best in Canadian orthopaedic research on an international stage. Finally, I am truly honoured to serve as the third CORS President from the University of Ottawa preceded by Drs. Jacques Robichon (’71), Hans Uhthoff (’77) and Merv Letts(’79). For more information, contact cors@canorth.org or visit: http://coa-aco.org/research-cors/

Programme Mentor d’un jour de l’ACO

Vous êtes un orthopédiste d’expérience qui a un savoir à transmettre?

elon la littérature, le mentorat officiel en orthopédie comporte de nombreux avantages. Pour la première fois, l’ACO offrira à la Réunion annuelle 2019 un programme de mentor d’un jour. Le lancement de ce programme fait partie de notre engagement à favoriser le perfectionnement, la planification de carrière et la satisfaction personnelle des jeunes membres. Nous cherchons donc des orthopédistes de différents milieux qui seraient prêts à encadrer un résident ou fellow pendant une journée.

To become a Mentor for a Day, you need to be: • A member in good standing at the COA with more than three years of work experience • Attending the 2019 COA Annual Meeting in Montréal (June 19-22) • Available on Friday, June 21, 2019 and willing to have a resident or fellow join you at meeting sessions, including academic and networking opportunities

Pour devenir mentor d’un jour, vous devez satisfaire aux critères suivants : • Être membre en bonne et due forme de l’ACO et avoir plus de trois ans d’expérience professionnelle. • Assister à la Réunion annuelle 2019 de l’ACO, à Montréal, du 19 au 22 juin. • Être disponible le vendredi 21 juin 2019 et prêt à être accompagné d’un résident ou fellow à des séances, y compris à des possibilités de formation et de réseautage.

Our trainees need you! For more information or to become a Mentor, please contact Trinity Wittman @ trinity@canorth.org.

Nos résidents et fellows ont besoin de vous! Pour obtenir de plus amples renseignements ou pour devenir mentor, communiquez avec Trinity Wittman, à trinity@canorth.org.

COA Bulletin ACO - Winter / Hiver 2018

Your COA / Votre association

Inspirational Speakers, Conférenciers inspirants, Breathtaking Views, Culture vues à couper le souffle, and Flavours: culture et saveurs Get the best of Montréal through the Annual Meeting social program

Voyez le meilleur de Montréal grâce au programme social de la Réunion annuelle

he COA and ICORS Annual Meeting offers a dynamic social program rich with culture, history, sightseeing and tastes of the city. Get the most out of the Annual Meeting experience by participating in the social events being offered next year from June 19-22.

a Réunion annuelle de l’ACO et le congrès annuel des International Combined Orthopaedic Research Societies (ICORS) proposent un programme social dynamique où la culture, l’histoire, les visites guidées et les saveurs de la ville sont à l’honneur. Tirez le maximum de votre expérience de congressiste en participant aux activités sociales proposées du 19 au 22 juin prochain.

Opening Ceremonies and President’s Welcome Reception

Cérémonies d’ouverture et Réception de bienvenue du président

The Opening Ceremonies is open to all registered attendees and kicks off the Annual Meeting with Presidential Guest Speaker, Dr. Roberta Bondar. Join COA President, Dr. John Antoniou, and the Executive Committee at the President’s Welcome Reception immediately following in the exhibit hall.

Tous les participants dûment inscrits sont les bienvenus aux cérémonies d’ouverture, qui lancent la Réunion annuelle avec la conférencière invitée par le président, la Dre Roberta Bondar. Ensuite, retrouvez le Dr John Antoniou, président de l’ACO, et le Comité de direction à la Réception de bienvenue du président, qui a lieu immédiatement après les cérémonies d’ouverture, dans la salle d’exposition.

Register and purchase tickets for the following events when you register for the Annual Meeting online. Pricing and complete descriptions can be found at

Inscrivez-vous aux activités suivantes et achetez vos billets en vous inscrivant en ligne à la Réunion annuelle. Les prix et les descriptions complètes des activités sont fournis à

Wednesday, June 19 - 17:30

Le mercredi 19 juin, à 17 h 30

www.2019icors.org City Tour of Montréal and au Sommet Place Ville Marie Thursday, June 20 - 9:00-13:00 Pre-registration and ticket required

On this tour, you’ll have the opportunity to see how culturally diverse Montréal is, as well as visit landmarks and new developments that are so very important in making Montréal such a unique and wonderful city. The tour includes a stop at the Mont-Royal for a panoramic view of the city, a visit of the Notre-Dame Basilica and a visit to the Au Sommet Place Ville Marie, an observatory located in the heart of downtown Montréal.

Tour de Ville et au Sommet Place Ville Marie Le jeudi 20 juin, de 9 h à 13 h Inscription préalable et billet obligatoires

Pendant ce tour de ville, vous aurez l’occasion de constater la diversité culturelle de Montréal, ainsi que de visiter des points d’intérêt et de nouveaux développements qui en font une ville si unique et merveilleuse. Cette visite inclut un arrêt au parc Mont-Royal pour admirer le panorama sur la ville, une visite de la basilique Notre-Dame et une visite de l’Observatoire Place Ville Marie, situé au cœur du centre-ville de Montréal. COA Bulletin ACO - Winter / Hiver 2018

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Tour of the Golden Square Mile and Visit the Museum of Fine Arts

Visite du Mile Carré Doré et du Musée des beaux-arts de Montréal

Situated on the slopes of Mount Royal, the Square Mile has a lovely view of the city and the river. This downtown historic district contains elaborate turnof-the-century mansions, as well as the McGill University campus. See some of the prestigious houses such as Mount Stephen Club, the Lady Meredith Hall and Ravenscrag, a huge property built by shipping magnate Sir Hugh Allen. Included in this tour is a visit to the Montréal Museum of Fine arts, one of the first museums in North America to build up an encyclopedic collection worthy of the name. It now numbers over 41,000 works from Antiquity to today, making it unique in Canada. It comprises paintings, sculptures, graphic arts, photographs and decorative art objects displayed in four pavilions.

Situé sur le versant du mont Royal, le Mile Carré Doré offre une magnifique vue de la ville et du fleuve. Ce quartier historique du centre-ville contient des demeures au style recherché du tournant du siècle, ainsi que le campus de l’Université McGill. Voyez certaines de ces demeures prestigieuses, comme Le Mount Stephen Hôtel, la Maison LadyMeredith et la maison Ravenscrag, un vaste domaine bâti par le magnat du commerce maritime sir Hugh Allen. Le tour de ville comprend une visite au Musée des beaux-arts de Montréal, l’un des premiers établissements muséaux en Amérique du Nord à former une collection encyclopédique digne de ce nom. Cette dernière compte plus de 41 000 œuvres, de l’Antiquité à nos jours, ce qui la rend unique au Canada. Elle comprend des peintures, des sculptures, des œuvres graphiques, des photographies et des objets d’arts décoratifs, déployés dans quatre pavillons.

MTL by Night: Closing Gala

Montréal la nuit : Réception de clôture

Friday, June 21 - 13:00-17:00 Pre-registration and ticket required

Friday June 21 - 19:00 Room 710 and rooftop terrace, Palais des congrès Join your colleagues for an evening of dinner and dancing the Quartier International de Montréal. Enjoy spectacular views of the cityscape over cocktails on the rooftop terrace, followed by dinner, a live band (Squidjigger will be back by popular demand) and dancing.

Flavours and Aromas of Old Montréal Saturday, June 22 - 10:00-12:30 Pre-registration and ticket required

This walking tour will allow you to discover the cultural and historic culinary charms of the oldest district of Montréal. As you follow the narrow and winding streets of Old Montréal, your professional tour guide will feed your hunger for knowledge on the history of Montréal and its many culinary pleasures. You will learn how the native people have influenced Canadian food habits and how the World Fair Expo 67 brought exotic food to our tables.

COA Bulletin ACO - Winter / Hiver 2018

Le vendredi 21 juin, de 13 h à 17 h Inscription préalable et billet obligatoires

Le vendredi 21 juin, à 19 h Salle 710 et belvédère, Palais des congrès

Vous êtes invité à vous joindre à vos collègues à l’occasion d’un souperréception dans le Quartier international de Montréal. Profitez de la vue spectaculaire sur la ville pendant le cocktail au belvédère, qui sera suivi du souper, du spectacle des Squidjigger (de retour à la demande générale) et de quelques pas sur la piste de danse.

Saveurs et arômes du Vieux-Montréal Le samedi 22 juin, de 10 h à 12 h 30 Inscription préalable et billet obligatoires

Cette balade à pied vous fera découvrir les charmes culinaires, culturels et historiques du plus ancien quartier de Montréal. Tout au long de votre parcours dans les rues étroites et sinueuses du Vieux-Montréal, vous serez en compagnie d’un guide professionnel qui vous nourrira de commentaires historiques et gastronomiques. Vous apprendrez également la façon dont les Autochtones ont influencé les habitudes alimentaires des Canadiens et dont l’Exposition universelle de 1967 nous a fait découvrir des aliments exotiques.

Your COA / Votre association

Dr. Ihor Mayba

May 23, 1931 – October 25, 2018

eacefully on October 25, 2018, Dr. Ihor Mayba fell asleep in the Lord at Holy Family Home, where he had resided and received loving and compassionate care over the past year. Celebrating his earthly life, and cherishing his memory are his wife of sixty years, Helen; son Paul; and, son John and his wife Natalie, together with their four children Julia, Katherine, Andrew and Alexander. Ihor was the son of Ukrainian immigrants who came to Canada from Krywychy, Ukraine, during the second wave of immigration to Canada from Eastern Europe and Ukraine. He was the youngest of five children born to the Very Reverend Ivan Mayba and Sophia Yuschysyn. He was predeceased by both his parents: Rev. Ivan in 1983, his mother, Sophia, in 1965; as well as by his siblings – brother William in 2000, sister Gloria Pawlyshyn in 2006, sister Nadia in 2011, and his brother Bohdan in March 2018. Born on May 23, 1931 in Vegreville, Alberta, where his father served the local Ukrainian Orthodox parish, Ihor moved several times throughout rural Saskatchewan, namely living in the communities of Wakaw, Arran and North Battleford, all of which were parishes served by his father. It was in these small towns where he received his early education. Following his graduation from North Battleford Collegiate Institute, Ihor moved to Winnipeg in 1949 and studied at the University of Manitoba, completing his Bachelor of Science degree in 1952, and his Doctor of Medicine in 1957. He completed his internship at St. Boniface Hospital, and his postgraduate work in surgical training at the Colonel Belcher Veteran’s Hospital in Calgary, Alberta. On August 9, 1958, Ihor married Helen Dolynchuk, and shortly after the newlyweds were off to Swift Current, Saskatchewan and Brandon, Manitoba, where he started a general office practice. Returning to Winnipeg, Ihor entered the General Surgery program at the University of Manitoba receiving his diploma in surgery in 1962 and commencing his practice in this field at the Manitoba Clinic. It was at the clinic that Ihor worked in association with orthopaedic surgeon Dr. Elmer James who mentored this young surgeon and influenced his decision to pursue further training in Orthopaedic Surgery. Working with Dr. James and being certified by the American Board of General Surgery (1963), in 1965, he embarked upon his orthopaedic training at the Royal Victoria Hospital in Montréal, obtaining his fellowship in 1967. Returning to Winnipeg in 1967 he re-established his medical practice at the Manitoba Clinic, now as an orthopaedic surgeon. For the next fifty years he would have a profound effect on orthopaedic surgery, including performing the first total hip and knee joint replacements at the Misericordia Hospital in the 1970s, as head of orthopaedics. He also held staff appointments at the Health Sciences Centre, Children’s Hospital, as well as the Rehabilitation Hospital and the Shriners’ Hospital; served as an examiner with the Canadian Board for Certification of Prosthetists and Orthotists and as an assistant professor in Orthopaedic Surgery at the University of Manitoba. Service, generosity, passion and family were the pillars upon which Ihor lived his life – service to his country as a lieutenant in the Royal Canadian Army Medical Corps and later as a pilot officer in the Royal Canadian Air Force. He was generous with the time he dedicated to his patients, his willingness to do house calls and seeing people after hours at his office or on weekends. Whenever they needed him, he gave of his time – values and principles of a man of medicine from an earlier time. Ihor had many passions – love of his Ukrainian heritage, love of community, love of history and love of his family. Ihor undertook his first of eight trips to Ukraine in 1992. These trips were important to him as he saw first-hand the homeland of his forbearers, which gave him the energy to write with passion and insight regular newspaper columns for the Winnipeg Sun Ukrainian page and various local Ukrainian

newspapers and magazines. There he showcased the Ukrainian community with historical figures, customs, holidays and events. His involvement with the Manitoba Historical and Scientific Society, the Manitoba History of Medicine Society, the Canadian and Manitoba Orthopaedic Societies, the Advisory Board of the Holy Family Nursing Home, the Sherlock Holmes Society, the Arthur Conan Doyle Society, the Intrepid Society, the Ukrainian Professional Business Club, the Ukrainian National Home Association, the Ukrainian Fraternal Society and Trident Press; serving as President of many of these organizations, as well as President and board member of the Manitoba Clinic, provided an example for his family and friends of the importance of giving back to the community in a tangible way. Ihor authored two books: one about the history of orthopaedic surgeons in Manitoba and the other being a book about the Manitoba Clinic. He had no greater passion than for his family. Whether taking his three-year old son John to Expo 67; or taking his boys John and Paul to see the WHA Winnipeg Jets, as well as the 1972 and 1974 Canada/Russia hockey games; or trips together as a family throughout North America; or other special events too numerous to mention, the importance of family was at the core of his being. An ardent supporter of any and all of his sons’ activities, and the significant contributions made to the community by his wife Helen as a school trustee for so many years, one only had to stop by his office to see his pride reflected in the pictures and newspaper articles which graced his office walls. This pride of family flourished when it came to his four grandchildren. One of his greatest joys was following and supporting their activities and witnessing their accomplishments, especially their musical activities. However, it was in those quiet times when he would simply ask how they were doing and listen to their stories that you saw his beaming face and the true love of a grandfather shine through. A lifelong member of the Ukrainian Orthodox Church of Canada, as a member of St. Michael’s Heritage parish for the last seventeen years, he actively participated in the Sacraments of the church throughout his life. The family thanks Reverend Statkevych for his pastoral care. We acknowledge with deep appreciation the volunteers and staff of Holy Family Home for the loving care and respect shown to him over the past year. We especially thank Drs. Andrea Babick and Terry Babick for their compassionate medical and spiritual care. Finally, we thank the many friends who over the past few years, at his home on Melness Bay or at Holy Family, took the time to remember him and visit with him – we sincerely appreciate these gestures. The family also acknowledges and extends their thanks to Cropo Funeral Chapel for their support and consideration. As per Ihor’s wishes, a private funeral service has taken place. Donations in Ihor’s memory can be made to Holy Family Home, 165 Aberdeen Avenue, Winnipeg, Manitoba, R2W 1T9 or St. Michael’s Ukrainian Orthodox Heritage Church, 110 Disraeli Street, Winnipeg, Manitoba, R2W 3J5 “You can shed a tear that he is gone, or you can smile because he has lived. You can close your eyes and pray that he’ll come back, or you can open your eyes and see all he’s left. You can turn your back on tomorrow and live yesterday or you can be happy for tomorrow because of yesterday. You can remember him and only that he’s gone or you can cherish his memory and let it live on.”

COA Bulletin ACO - Winter / Hiver 2018

INTRODUCING

TRIATHLON TRITANIUM ®

Orthopaedics

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

FONT: Helvetica with bell curve

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

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

The Use of Intra-wound Vancomycin for Spinal Surgery: An Introduction to this Edition’s Debate

ften a critical portion of the “time-out” discussion we typically have prior to surgery concerns the administration of preoperative antibiotics. The prevention of a postoperative infection is certainly important to every surgeon. In spine surgery, the prevention of this complication is paramount given the grave consequences it may have or the patient. Perhaps routine administration of intra-wound

vancomycin may solve this potential problem? In this debate, experts from the University of Toronto and UBC discuss this intervention. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

The Use of Intra-wound Vancomycin Powder for Spinal Surgery: The Pro Argument Hananel Yashuv, M.D.1 Frank Lyons, M.D., PhD1 Chris Small, M.D., FRCSC1 Jeremie Larouche, M.D., MSC, FRCSC2 Spine Fellow, Sunnybrook Health Sciences Centre Toronto, ON 2 Staff Surgeon, Sunnybrook Health Sciences Centre Toronto, ON 1

Introduction urgical Site Infection (SSI) remains an important cause of morbidity and even mortality following spinal surgery. In order to determine how large of a burden this complication presents, Patel et al. have reviewed over 161 studies and determined that the pooled rate of spinal SSIs in North America, Europe, and Asia is 1.9%1. This rate increased to approximately 3.8% in instrumented spinal fusion cases. Conversely, in series looking a larger thoracolumbar surgeries including deformity corrections and osteotomies, the rate has been documented to be as high as 15%2. Staphylococcus Aureus continues to account for approximately 50% of all spinal SSIs.

The postoperative environment following posterior spinal surgery presents a challenge for conventional administration of IV antibiotics. Hematoma and seroma formation are the norm in the weeks and months following larger posterior spinal operations and may significantly lower the effectiveness of intravenous antibiotic administration (see Figure 1). This has led physicians to pursue other strategies to mitigate SSIs, including the use of local antibiotic application. Mechanism of Action and Possible Complications Vancomycin was first extracted from the soil of Borneo in 1953. It was named after a derivative of the word “vanquish” due to its impressive ability to kill penicillin-resistant Staphylococcus Aureus3. It acts as a bactericidal agent by inhibiting cell wall synthesis in most gram-positive bacteria but has little effect in gram-negative bacteria due to the difference in amino acid composition found within their cell walls.

Systemic uptake from local application of vancomycin powder is negligible. Murphy et al. reviewed serum levels of vancomycin 6, 12, and 24 hours following subfascial application of 1g and 2g of antibiotic powder in 24 and 28 patients, respectively4. In the 1g group, only one patient reached detectable levels. In the 2g group, four patients reached detectable levels, but all remained below the therapeutic threshold. Ghobrial et al. further examined the rate of complications with the use of Figure 1 intra-wound vancomy- MRI obtained six weeks following a L3 vertebral column resection and T10 to cin application in spine pelvis instrumented fusion in a 55-year2 surgery . Their pooled old female. Aspiration of the collection analysis included 9721 was negative for beta-2 transferrin, and patients, with a total of there were no dural tears encountered 23 complications. These during the operation. Multiple cultures included nephropa- were negative, and this was diagnosed as thy (one patient), tran- a postoperative seroma. sient ototoxicity (two patients), supratherapeutic levels (one patient) and culturenegative seroma formation (19 patients). Overall, their conclusion was that the rate of complications associated with intrawound vancomycin powder was 0.3%, and that this technique was both safe and effective. Evidence in Spine Surgery Since 2014, there have now been seven meta-analysis looking at the efficacy of intra-wound vancomycin application for spine surgery2,5,6,7,8. Every one of these has found a statistically sigCOA Bulletin ACO - Winter / Hiver 2018

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nificant improvement in SSI rates with the use of intra-wound application of vancomycin, with the odds ratio ranging from 0.11 to 0.439. Of the above-mentioned studies, the one by Ghobrial et al. stands out for its analysis of 9721 patients. They found the mean rate of SSI between control and vancomycintreated patients to be 7.47% and 1.36%, respectively. More recently, Devin et al. have carried out a large, prospective multicentre observational study enrolling over 2056 patients10. Intrawound vancomycin was used in 47% of procedures. They found that the risk of SSI was higher in patients with no vancomycin use (5.1%) as compared to those who received vancomycin (2.2%) (relative risk (RR) -2.5, P < 0.001). Chotai et al. performed a similar study, but also sought to determine if the use of vancomycin promoted vancomycin-resistant organisms. In their study of 2802 patients, the use of vancomycin significantly reduced infection (1.6% vs. 2.5%), but did not promote vancomycin resistance as determined by the minimal inhibitory concentration (MIC) of organisms cultured from wounds treated with vancomycin powder11. Only one prospective randomized control trial to date has been performed in India in 907 consecutive patients. Their study failed to demonstrate any statistically significant advantage to the local use of vancomycin powder but had an infection rate in both groups of only 1.68% (control) and 1.61% (study). Evidence in Other Fields The use of vancomycin powder is not limited to spine surgery. It has been demonstrated to be efficacious in reducing SSIs following sternotomies12, craniotomies13, total joint arthroplasty14, foot and ankle surgery15, and upper extremity surgery16. There were no major complications associated with its use in all of the above studies. Cost Effectiveness Prior to determining whether an intervention should be adopted, it is important to weigh the supposed benefit against its cost. Theologist et al. looked at their experience with 215 patients undergoing long-segment posterior thoracolumbar surgery with an average fusion of 10 motion segments17. Following the implementation of local Vancomycin powder to their wound, their 90-day rate of SSI not only went from 10.9% to 2.6%, but they aggregated an estimated cost savings of $2,444.02 USD per thoracolumbar fusion case. Emohare et al. reported similar outcomes in their study of 303 patients undergoing spinal surgery18. In the cohort of 96 patients receiving intra-wound vancomycin, none required a return to the operating room. In comparison, a total of $573,897 was spent in treating infections in the group that did not receive vancomycin.

infections. While an opportunity exists to refine our understanding of the use of this tool, the current data supports its regular use in patients who do not possess an absolute contraindication, such as anaphylaxis. It is the authors’ opinion that the benefit of using vancomycin powder may be greater in instrumented cases, in surgical exposures involving a greater number of spinal segments, and with patients whom possess an elevated baseline risk of SSI to begin with, however these theories require further clinical evaluation with properly constructed studies in the future. References 1. Patel H., Khoury H., Girgenti D., Welner S., Yu H. Burden of Surgical Site Infections Associated with Select Spine Operations and Involvement of Staphylococcus aureus. Surg Infect (Larchmt). 2017;18(4):461-473. doi:10.1089/sur.2016.186. 2. Ghobrial G.M., Cadotte D.W., Williams K., Fehlings M.G., Harrop J.S. Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. Neurosurg Focus. 2015;39(4):E11. doi:10.3171/2015.7.FOCUS15258. 3. Abdullah K.G., Chen H.I., Lucas T.H. Safety of topical vancomycin powder in neurosurgery. Surg Neurol Int. 2016;7(Suppl 39):S919-S926. doi:10.4103/2152-7806.195227. 4. Murphy E.P., Curtin M., Shafqat A., Byrne F., Jadaan M., Rahall E. A review of the application of vancomycin powder to posterior spinal fusion wounds with a focus on side effects and infection. A prospective study. European Journal of Orthopaedic Surgery & Traumatology. 2017;27(2):187-191. doi:10.1007/s00590-016-1878-4. 5. Xiong L., Pan Q., Jin G., Xu Y., Hirche C. Topical intrawound application of vancomycin powder in addition to intravenous administration of antibiotics: A meta-analysis on the deep infection after spinal surgeries. Orthopaedics & Traumatology: Surgery & Research. 2014;100(7):785-789. doi:10.1016/j.otsr.2014.05.022. 6. Bakhsheshian J., Dahdaleh N.S., Lam S.K., Savage J.W., Smith Z.A. The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. World Neurosurg. 2015;83(5):816-823. doi:10.1016/j. wneu.2014.12.033. 7. Chiang H.-Y., Herwaldt L.A., Blevins A.E., Cho E., Schweizer M.L. Effectiveness of local vancomycin powder to decrease surgical site infections: a meta-analysis. Spine J. 2014;14(3):397407. doi:10.1016/j.spinee.2013.10.012.

While Canadian-specific cost data is currently not available, we were able to price the cost of one gram of vancomycin powder in Vancouver, British Columbia (for the benefit of our coauthors in this debate) which has been assessed at $21.25 CAD.

8. Evaniew N., Khan M., Drew B., Peterson D., Bhandari M., Ghert M. Intrawound vancomycin to prevent infections after spine surgery: a systematic review and meta-analysis. Eur Spine J. 2015;24(3):533-542. doi:10.1007/s00586-014-3357-0.

Conclusion There is an abundance of evidence to demonstrate that the application of intra-wound vancomycin in spine surgery is safe, inexpensive, and leads to a significant decrease in surgical site

9. Fleischman A.N., Austin M.S. Local Intra-wound Administration of Powdered Antibiotics in Orthopaedic Surgery. J Bone Jt Infect. 2017;2(1):23-28. doi:10.7150/jbji.16649.

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10. Devin C.J., Chotai S., McGirt M.J., et al. Intrawound Vancomycin Decreases the Risk of Surgical Site Infection After Posterior Spine Surgery: A Multicenter Analysis. Spine. 2018;43(1):6571. doi:10.1097/BRS.0000000000001371. 11. Chotai S., Wright P.W., Hale A.T., et al. Does Intrawound Vancomycin Application During Spine Surgery Create Vancomycin-Resistant Organism? Neurosurgery. 2017;80(5):746-753. doi:10.1093/neuros/nyw097. 12. Lazar H.L., Ketchedjian A., Haime M., Karlson K., Cabral H. Topical vancomycin in combination with perioperative antibiotics and tight glycemic control helps to eliminate sternal wound infections. J Thorac Cardiovasc Surg. 2014;148(3):1035–8– 1038–40. doi:10.1016/j.jtcvs.2014.06.045. 13. Ravikumar V., Ho A.L., Pendhakar A.V., Sussman E.S., KwongHon Chow K., Li G. The Use of Vancomycin Powder for Surgical Prophylaxis Following Craniotomy. Neurosurgery. 2017;80(5):754-758. doi:10.1093/neuros/nyw127. 14. Otte J.E., Politi J.R., Chambers B., Smith C.A. Intrawound Vancomycin Powder Reduces Early Prosthetic Joint Infections in Revision Hip and Knee Arthroplasty. Surg Technol Int. 2017;30:284-289.

15. Wukich D.K., Dikis J.W., Monaco S.J., Strannigan K., Suder N.C., Rosario B.L. Topically Applied Vancomycin Powder Reduces the Rate of Surgical Site Infection in Diabetic Patients Undergoing Foot and Ankle Surgery. Foot Ankle Int. 2015;36(9):10171024. doi:10.1177/1071100715586567. 16. Yan H., He J., Chen S., Yu S., Fan C. Intrawound application of vancomycin reduces wound infection after open release of post-traumatic stiff elbows: a retrospective comparative study. J Shoulder Elbow Surg. 2014;23(5):686-692. doi:10.1016/j. jse.2014.01.049. 17. Theologis A.A., Demirkiran G., Callahan M., Pekmezci M., Ames C., Deviren V. Local intrawound vancomycin powder decreases the risk of surgical site infections in complex adult deformity reconstruction: a cost analysis. Spine. 2014;39(22):1875-1880. doi:10.1097/BRS.0000000000000533. 18. Emohare O., Ledonio C.G., Hill B.W., Davis R.A., Polly D.W., Kang M.M. Cost savings analysis of intrawound vancomycin powder in posterior spinal surgery. Spine J. 2014;14(11):27102715. doi:10.1016/j.spinee.2014.03.011.

Lack of Evidence Behind the Use of Intra-wound Vancomycin for Spine Surgery Tom Inglis, MBChB, FRACS Clinical Fellow, Adult Spine Surgery, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, BC Daniel Banaszek, M.D., FRCSC Clinical Fellow, Adult Spine Surgery, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, BC Nicolas Dea, M.D., MSc, FRCSC Clinical Associate Professor of Neurosurgery, Combined Neurosurgical and Orthopaedic Spine Program, University of British Columbia, Vancouver, BC

Introduction he use of intra-wound vancomycin powder has gained popularity among spine surgeons in an attempt to reduce the rate of postoperative surgical site infections (SSIs). It is an attractive proposition, as postoperative surgical site infections in spine surgery are associated with significant morbidity, mortality, and cost1. Although rates vary in the published literature, SSIs occur in up to 10% of cases and can lead to a prolonged treatment course involving long-term intravenous antibiotics, the need for further wound irrigation and debride-

ment, complex wound management, and morbid revision procedures. Ultimately, the presence of a wound infection may take a significant toll on a patients quality of life2,3,4. Discussion Recently published adult and paediatric guidelines recommend the consideration of intra-wound vancomycin for cases with planned spinal instrumentation, increased operative time, or patients with significant pre-surgical comorbidities5. To date, Intraoperative picture showing usage approximately 24% of of intra-wound vancomycin in spine paediatric spine surgeons surgery. are routinely using intrawound vancomycin6. Multiple groups have reported on experiences with the use of intra-wound vancomycin powder as a cost-effective practice with good safety and side-effect profiles7,8. Reported complications include the risk of potential pseudarthrosis, renal toxicity, and anaphylaxis9,10,11.

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Despite promising results, however, high-quality evidence for the use of intra-wound vancomycin powder is currently lacking. Observational studies, despite inherent limitations, currently account for an overwhelming majority of published literature. The only published randomized control trial (RCT)12 on this topic has failed to show any benefit for intra-wound vancomycin powder as routine practice. There is also a lack of consistency in vancomycin dosing within treatment groups, with reports ranging from 0.5-2g per patient. Furthermore, the aforementioned observational studies are underpowered in terms of subject numbers. With only 16 infections in a total of 1933 patients (i.e. a rate of 0.83%), any conclusions based on these findings may be difficult to interpret. The RCT by Tubaki et al. identified seven infections in 433 patients (1.6%) in the treatment group, and eight infections in 474 patients (1.7%) in the control group, once again rendering interpretation difficult. Several systematic reviews have attempted to quantify the currently available evidence13,14. The first by Bakhsheshian et al.13 concluded that pooled clinical data supported the use of vancomycin to prevent SSIs in adult spine surgeries. This study was based primarily on heterogeneous level III evidence, including modalities other than spine surgery. Specific limitations in terms of the level of evidence were not addressed. Xie et al. reviewed 19 retrospective cohort studies and one prospective case series with a total of 2803 patients and reported 2.83 times lower odds of SSI with the use of vancomycin powder compared to standard-treatment controls15. Evaniew et al.14 looked at eight retrospective cohort studies and one RCT. The reviewers rated the evidence from the observational studies as being of low quality on the basis of study design, having significant risk of bias, and risk of imprecision. Evidence from the single RCT was also graded as low quality due to the few outcome events and unclear risk of bias. This group concluded that the study heterogeneity and methodological weaknesses limited the validity of the study results. Due to diversity in techniques, the optimal vancomycin dosing regimen and mode of application remains unknown. Most authors report doses between 0.5-2g per surgical incision, based on institutional experience (Figure 1). In their systematic review and metanalysis, Xie et al. found a benefit of 2g vs. 1g when the powder was applied directly to all layers of the wound15. This effect was not measureable, however, when this practice was not employed. In a review of 2,394 patients, Xie et al. found dose-dependent differences in SSI microbiology16. Gram-negative bacteria seemed to predominate at doses of 1g, vs. primarily gram-positive bacteria at 2g dosing. Once again, the authors acknowledged heterogeneity in practices, cautioning readers about study conclusions. The practice of intra-wound vancomycin powder has shown acceptable safety profiles in most studies. In a population of 1,398 paediatric scoliosis cases, only a single adverse event was reported as a result of pharmacotoxicity17. Nonetheless, severe adverse outcomes including renal failure10, and severe circulatory compromise18 have been reported in the literature. A recent systematic review yielded a total of 23 adverse events including nephropathy (one patient), ototoxicity resulting in transient hearing loss (two patients), and culture-negative seroma formation (19 patients)9. Basic science studies have COA Bulletin ACO - Winter / Hiver 2018

shown vancomycin can inhibit osteoblast function9,19 which may increase the risk for the development of non-union and pseudarthrosis. Despite low complication rates, the use of vancomycin in surgical wounds is not benign. Conclusion Despite acceptance by many surgeons and centres for use in surgical spine wounds, evidence to support the widespread use of vancomycin as standard of care is distinctly lacking. The current literature is limited by low-quality evidence. Many prior instances of medical practices instituted as a result of observational studies can have undiscovered associated harms20, with treatment efficacy later debunked by high-quality randomized trials21. Furthermore, one must consider the ethical principle of “first, do no harm,” while risking the use of a product without proven benefit. Whether this practice should become commonplace is undetermined calling for a high-quality, multicentered trial. References 1. Kirkland K.B., Briggs J.P., Trivette S.L., Wilkinson W.E., Sexton D.J. The impact of surgical-site infections in the 1990s: attributable mortality, excess length of hospitalization, and extra costs. Infect Control Hosp Epidemiol. 1999 Nov;20(11):725– 30. 2. Sasso R.C., Garrido BJ. Postoperative spinal wound infections. J Am Acad Orthop Surg. 2008 Jun;16(6):330–7. 3. Pull ter Gunne A.F., Cohen D.B. Incidence, prevalence, and analysis of risk factors for surgical site infection following adult spinal surgery. Spine. 2009 Jun 1;34(13):1422–8. 4. Gerometta A., Olaverri J.C.R., Bitan F. Infections in spinal instrumentation. Int Orthop. 2012 Feb;36(2):457–64. 5. Vitale M.G., Riedel M.D., Glotzbecker M.P., Matsumoto H., Roye D.P., Akbarnia B.A., et al. Building consensus: development of a Best Practice Guideline (BPG) for surgical site infection (SSI) prevention in high-risk pediatric spine surgery. J Pediatr Orthop. 2013 Aug;33(5):471–8. 6. Glotzbecker M.P., Riedel M.D., Vitale M.G., Matsumoto H., Roye D.P., Erickson M., et al. What’s the evidence? Systematic literature review of risk factors and preventive strategies for surgical site infection following pediatric spine surgery. J Pediatr Orthop. 2013 Aug;33(5):479–87. 7. Godil S.S., Parker S.L., O’Neill K.R., Devin C.J., McGirt M.J. Comparative effectiveness and cost-benefit analysis of local application of vancomycin powder in posterior spinal fusion for spine trauma: clinical article. J Neurosurg Spine. 2013 Sep;19(3):331–5. 8. Gans I., Dormans J.P., Spiegel D.A., Flynn J.M., Sankar W.N., Campbell R.M., et al. Adjunctive vancomycin powder in pediatric spine surgery is safe. Spine. 2013 Sep 1;38(19):1703–7.

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9. Ghobrial G.M., Cadotte D.W., Williams K., Fehlings M.G., Harrop J.S. Complications from the use of intrawound vancomycin in lumbar spinal surgery: a systematic review. Neurosurg Focus. 2015 Oct 1;39(4):E11.

15. Xie L.-L., Zhu J., Yang M.-S., Yang C.-Y., Luo S.-H., Xie Y., et al. Effect of Intra-wound Vancomycin for Spinal Surgery: A Systematic Review and Meta-analysis. Orthop Surg. 2017 Nov;9(4):350–8.

10. Patrick B.N., Rivey M.P., Allington D.R. Acute renal failure associated with vancomycin- and tobramycin-laden cement in total hip arthroplasty. Ann Pharmacother. 2006 Nov;40(11):2037– 42.

16. Xie L., Zhu J., Luo S., Xie Y., Pu D. Do Dose-Dependent Microbial Changes Occur during Spine Surgery as a Result of Applying Intrawound Vancomycin Powder?: A Systematic Literature Review. Asian Spine J. 2018 Feb;12(1):162–70.

11. Rathbone C.R., Cross J.D., Brown K.V., Murray C.K., Wenke J.C. Effect of various concentrations of antibiotics on osteogenic cell viability and activity. J Orthop Res Off Publ Orthop Res Soc. 2011 Jul;29(7):1070–4.

17. DeFrancesco C.J., Flynn J.M., Smith J.T., Luhmann S.J., Sawyer J.R., Glotzbecker M., et al. Clinically apparent adverse reactions to intra-wound vancomycin powder in early onset scoliosis are rare. J Child Orthop. 2017 Dec 1;11(6):414–8.

12. Tubaki V.R., Rajasekaran S., Shetty A.P. Effects of using intravenous antibiotic only versus local intrawound vancomycin antibiotic powder application in addition to intravenous antibiotics on postoperative infection in spine surgery in 907 patients. Spine. 2013 Dec 1;38(25):2149–55.

18. Mariappan R., Manninen P., Massicotte E.M., Bhatia A. Circulatory collapse after topical application of vancomycin powder during spine surgery. J Neurosurg Spine. 2013 Sep;19(3):381–3.

13. Bakhsheshian J., Dahdaleh N.S., Lam S.K., Savage J.W., Smith Z.A. The use of vancomycin powder in modern spine surgery: systematic review and meta-analysis of the clinical evidence. World Neurosurg. 2015 May;83(5):816–23. 14. Evaniew N., Khan M., Drew B., Peterson D., Bhandari M., Ghert M. Intrawound vancomycin to prevent infections after spine surgery: a systematic review and meta-analysis. Eur Spine J Off Publ Eur Spine Soc Eur Spinal Deform Soc Eur Sect Cerv Spine Res Soc. 2015 Mar;24(3):533–42.

19. Edin M.L., Miclau T., Lester G.E., Lindsey R.W., Dahners L.E. Effect of cefazolin and vancomycin on osteoblasts in vitro. Clin Orthop. 1996 Dec;(333):245–51. 20. Moore, T. Deadly Medicine: Why Tens of Thousands of Heart Patients Died in America’s Worst Drug Disaster. Simon & Schuster; 1995. 21. Devereaux P.J., Yusuf S. The evolution of the randomized controlled trial and its role in evidence-based decision making. J Intern Med. 2003 Aug;254(2):105–13.

Acute Scaphoid Fracture Management: Best Practices Nina Suh M.D., FRCSC Ruby Grewal M.D., MSc, FRCSC Roth I McFarlane Hand & Upper Limb Centre, St. Joseph’s Hospital University of Western Ontario London, ON

caphoid fractures are the most common carpal bone fracture, predominantly affecting young, active males in their economically productive years1. The mechanism of injury is most often an axial load on a radial deviated and extended wrist that commonly causes fractures of the waist2. Early identification and management are critical as non-union and subsequent degenerative arthritis may ensue, leading to long-term pain and disability. Despite scaphoid fractures being common injuries, their diagnosis can be difficult to establish, and their treatment remains controversial. The classic physical finding of snuffbox tenderness should alert the clinician to the possibility of a scaphoid fracture. Wrist radiographs should be performed, with dedicated views (PA, PA with ulnar deviation, lateral, and semi-pronated oblique views) of the scaphoid. Although radiographs are known to be unreliable with poor sensitivity, they have a high specificity3.

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. In the Horizons articles, thought leaders from various subspecialties will provide insights based on their extensive clinical experience and ongoing research. The goal of this feature is to “shed some light” on the best way forward. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin COA Bulletin ACO - Winter / Hiver 2018

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Consequently, it is not uncommon to be faced with a clinical situation of positive snuffbox tenderness yet normal radiographs. The traditional treatment approach for this clinical scenario is immobilization in a short arm thumb spica cast with a repeat clinical and radiographic assessment in 10 to 14 days. However, with a reported prevalence of scaphoid fractures being 5-10% in this situation, this approach often results in an unnecessary period of immobilization. Given the morbidity associated with unnecessary immobilization, recent literature suggests that clinical scaphoid fractures should be further investigated with advanced imaging such as CT or MRI to urgently obtain a definitive diagnosis to decrease the morbidity of unnecessary casting4. In addition, this treatment strategy has been shown to be cost-effective, reducing both direct and indirect costs associated with unnecessary casting and repeat assessment5,6. Much research focus has been expended investigating the optimal treatment for scaphoid fractures with consensus still not attained. Most commonly, treatment has been directed by fracture location as well as fracture displacement. Nonoperative management using a thumb spica cast with the interphalangeal joint free has classically been recommended for all undisplaced scaphoid fractures irrespective of fracture location (distal, proximal, and waist); however, this has not been proven to be necessary with studies showing that union rates were independent of cast type7,8. With the significant improvement in patient functionality and comparable union rates without thumb immobilization, some authors advocate for routine Colles-type casting for scaphoid fractures. However, a CT to confirm stability before opting for casting and a CT to confirm union before cast discontinuation is imperative.

Figure 1 Radiographs demonstrating a scaphoid waist fracture pre- and post-ORIF.

Operative intervention is traditionally reserved for proximal pole fractures, open fractures, or those fractures with displacement. The traditional definition of unstable scaphoid fractures include ≥1 mm displacement, lateral intrascaphoid angle ≥35 degrees, scapholunate angle ≥60 degrees, radiolunate angle ≥15 degrees, bone loss or comminution, perilunate fracturedislocation, or dorsal intercalated segmental instability alignment9. Multiple techniques have been described for scaphoid fracture open reduction internal fixation such as open or percutaneous volar, open or percutaneous dorsal, and arthroscopicassisted approaches with no approach showing superiority over the other. The most common fixation method is a single headless compression screw perpendicular to the fracture line; however, less commonly used, but currently commercially available, is a volar variable-angle plate that may have utility for significantly comminuted fracture patterns10,11.

Cost analysis studies do not support ORIF as a cost-saving measure for all patients compared to casting. However, prolonged work disability for manual labourers was found with casting, whereas casting was found to be more cost-effective for office workers21. Consequently, patient factors should be taken into account when assessing for cost-effectiveness of each treatment choice offered.

In recent years, indications for operative management have expanded. More surgeons are advocating open reduction internal fixation for undisplaced scaphoid fractures to facilitate earlier return to work, potentially quicker time to union, and avoiding complications of prolonged immobilization9,12-14. Please see Figure 1. Multiple radiographic-based case series have supported these claims; however, other more recent CT-based studies show casting has comparable union rates and time to union without the surgical risks8,15. This is a growing area of controversy that has yet to be fully examined as there are concerns for long-term scapho-trapezio-trapezoidal (STT) arthritis with ORIF14, 16-19.

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If surgery is chosen for undisplaced fractures, percutaneous methods would be supported with the volar approach being preferred for distal fractures and dorsal being preferred for proximal fractures20. Waist fractures are amenable to either approach. The technical demands of these minimally invasive techniques should not be underestimated and surgeons should choose the approach most reliable in their hands. Technical errors such as screw malposition or scaphoid fracture malreduction are potentially devastating complications that may be avoided with a traditional open approach.

Another area of controversy regarding scaphoid fracture management is the use of adjunctive modalities such as pulsed electromagnetic fields and low intensity pulsed ultrasound. Both modalities are not proven to accelerate union in the literature but their use is clinically supported to potentially accelerate scaphoid fracture union with no significant harm reported22-24. Unfortunately, significant weaknesses exist in the literature. The heterogeneity of management algorithms creates significant confounding factors when comparing studies and the majority of published studies are retrospective case series with few randomized studies. Radiographic assessment of union has been established to be unreliable yet it is the principle method to assess union in most publications. Given that union rates and time to union are the principle outcome measures, previous studies using only radiographs may be underestimating the progression of union and needlessly causing patients to be placed in casts for an extended period of time. The lack of standardization in imaging also affects the ability to discern whether the definition of

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displacement or fracture instability varies amongst different authors. These inconsistencies may affect the primary outcome measures of union as well as assessment of risk factors for nonunion. Despite the continued deficiencies in the literature regarding scaphoid fracture management, current best practices would advocate the use of early advanced imaging for assessment of fracture stability and progression of union, percutaneous approaches for the surgical management of undisplaced fractures, and consideration of the fracture characteristics and patient circumstances to determine whether non-operative or operative measures should be selected. References 1. Hove L.M. Epidemiology of scaphoid fractures in Bergen, Norway. Scand J Plast Reconstr Surg Hand Surg. 1999, 33: 423-6. 2. Hickey B., Hak P., Logan A. Review of treatment of acute scaphoid fractures: R1. ANZ J Surg. 2012, 82: 118-21. 3. Behzadi C., Karul M., Henes F.O. et al. Comparison of conventional radiography and mdct in suspected scaphoid fractures. World J Radiol. 2015, 7: 22-7. 4. Carpenter C.R., Pines J.M., Schuur J.D., Muir M., Calfee R.P., Raja A.S. Adult scaphoid fracture. Acad Emerg Med. 2014, 21: 101-21. 5. Bergh T.H., Steen K., Lindau T. et al. Costs analysis and comparison of usefulness of acute mri and 2 weeks of cast immobilization for clinically suspected scaphoid fractures. Acta Orthop. 2015, 86: 303-9. 6. Karl J.W., Swart E., Strauch R.J. Diagnosis of occult scaphoid fractures: A cost-effectiveness analysis. J Bone Joint Surg Am. 2015, 97: 1860-8. 7. Clay N.R., Dias J.J., Costigan P.S., Gregg P.J., Barton N.J. Need the thumb be immobilised in scaphoid fractures? A randomised prospective trial. J Bone Joint Surg Br. 1991, 73: 828-32. 8. Buijze G.A., Goslings J.C., Rhemrev S.J. et al. Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: A multicenter, randomized, controlled trial. J Hand Surg Am. 2014, 39: 621-7. 9. Tait M.A., Bracey J.W., Gaston R.G. Acute scaphoid fractures: A critical analysis review. JBJS Rev. 2016, 4. 10. Heinzelmann A.D., Archer G., Bindra R.R. Anthropometry of the human scaphoid. J Hand Surg Am. 2007, 32: 1005-8. 11. Beutel B.G., Melamed E., Hinds R.M., Gottschalk M.B., Capo J.T. Mechanical evaluation of four internal fixation constructs for scaphoid fractures. Hand (N Y). 2016, 11: 72-7.

12. Adolfsson L., Lindau T., Arner M. Acutrak screw fixation versus cast immobilisation for undisplaced scaphoid waist fractures. J Hand Surg Br. 2001, 26: 192-5. 13. McQueen M.M., Gelbke M.K., Wakefield A., Will E.M., Gaebler C. Percutaneous screw fixation versus conservative treatment for fractures of the waist of the scaphoid: A prospective randomised study. J Bone Joint Surg Br. 2008, 90: 66-71. 14. Saeden B., Tornkvist H., Ponzer S., Hoglund M. Fracture of the carpal scaphoid. A prospective, randomised 12-year followup comparing operative and conservative treatment. J Bone Joint Surg Br. 2001, 83: 230-4. 15. Alnaeem H., Aldekhayel S., Kanevsky J., Neel O.F. A systematic review and meta-analysis examining the differences between nonsurgical management and percutaneous fixation of minimally and nondisplaced scaphoid fractures. J Hand Surg Am. 2016, 41: 1135-44 e1. 16. Dias J.J., Dhukaram V., Abhinav A., Bhowal B., Wildin C.J. Clinical and radiological outcome of cast immobilisation versus surgical treatment of acute scaphoid fractures at a mean followup of 93 months. J Bone Joint Surg Br. 2008, 90: 899-905. 17. Geurts G., van Riet R., Meermans G., Verstreken F. Incidence of scaphotrapezial arthritis following volar percutaneous fixation of nondisplaced scaphoid waist fractures using a transtrapezial approach. J Hand Surg Am. 2011, 36: 1753-8. 18. Kehoe N.J., Hackney R.G., Barton N.J. Incidence of osteoarthritis in the scapho-trapezial joint after herbert screw fixation of the scaphoid. J Hand Surg Br. 2003, 28: 496-9. 19. Nicholl J.E., Buckland-Wright J.C. Degenerative changes at the scaphotrapezial joint following herbert screw insertion: A radiographic study comparing patients with scaphoid fracture and primary hand arthritis. J Hand Surg Br. 2000, 25: 422-6. 20. Jeon I.H., Micic I.D., Oh C.W., Park B.C., Kim P.T. Percutaneous screw fixation for scaphoid fracture: A comparison between the dorsal and the volar approaches. J Hand Surg Am. 2009, 34: 228-36 e1. 21. Vinnars B., Ekenstam F.A., Gerdin B. Comparison of direct and indirect costs of internal fixation and cast treatment in acute scaphoid fractures: A randomized trial involving 52 patients. Acta Orthop. 2007, 78: 672-9. 22. Farkash U., Bain O., Gam A., Nyska M., Sagiv P. Low-intensity pulsed ultrasound for treating delayed union scaphoid fractures: Case series. J Orthop Surg Res. 2015, 10: 72. 23. Hannemann P.F., Essers B.A., Schots J.P., Dullaert K., Poeze M., Brink P.R. Functional outcome and cost-effectiveness of pulsed electromagnetic fields in the treatment of acute scaphoid fractures: A cost-utility analysis. BMC Musculoskelet Disord. 2015, 16: 84. 24. Mayr E., Rudzki M.M., Rudzki M., Borchardt B., Hausser H., Ruter A. [does low intensity, pulsed ultrasound speed healing of scaphoid fractures?]. Handchir Mikrochir Plast Chir. 2000, 32: 115-22. COA Bulletin ACO - Winter / Hiver 2018

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

Thromboprophylaxis in Trauma Patients: Is There Consensus?

he development and sequelae of venous thromboembolism can be devastating for the patient and very concerning for the orthopaedic surgeon. Nevertheless, there is a growing amount of evidence suggesting that thromboprophylaxis in its various forms can be effective and preventative. Despite this, there is no universally accepted preventative strategy.

In this feature, experts from across the country review the best strategies for thromboprophylaxis in the setting of lower extremity injuries. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

Antecedent Anticoagulation in Hip Fractures

Perioperative Management of Patients on Anticoagulants Pre-injury Tina L. Samuel, MBBS Neil J. White, M.D., FRCSC Division of Orthopaedic Trauma, Department of Surgery University of Calgary Calgary, AB

n the acute trauma setting, one of the gravest critical barriers in surgical practice is the growing and widespread use of irreversible oral anticoagulant therapy. In patients with atrial fibrillation, thromboembolic burden or valvular disease, direct oral anticoagulation therapy (DOACs) offers several advantages, such as more manageable dosing schedules, sustainable anticoagulation status with minimal supervision, and minimal drug or dietary interactions5. Unfortunately, at present many of these convenient agents cannot be reversed. Orthopaedic surgeons and specialized surgical care teams are often left with the decision to proceed with emergency surgery despite anticoagulation status, pharmacologically reverse anticoagulant therapy, and/or delay surgery.

comes. Medical centres continue to evolve and challenge their standard practice to advocate for surgery within 36-72 hours based on this emerging evidence3,4,7. A recent meta-analysis of observational studies on timing from injury to surgery showed decreased mortality when surgery was performed in less than 24 hours3,6, which is becoming a new benchmark standard among centres. Hip fracture patients on anticoagulant therapy are often delayed for surgery due to their complex comorbidity status, requirement for pharmacological reversal, drug clearance, or internal medicine and/or anaesthesia consults. To date, there continues to be no evidence to suggest delaying hip fracture repair is beneficial in patients on any type of anticoagulation. Practice variability continues to grow amongst clinicians due to lack of consensus and evidence-based clinical practice guidelines for anticoagulant reversal in the presence of urgent and emergent orthopaedic surgery.

With the increasing incidence of hip fractures requiring surgery annually, it has become clear that decreasing the time from injury to surgery yields decreased morbidity and mortality7. Approximately, 4 to 12% of hip fracture patients are on anticoagulation and the use of DOACs has superseded the use of more traditional forms of anticoagulation worldwide2,10. Not only is surgical delay potentially life-threatening, but the surgeon also has to manage the concealed blood loss that occurs from the time of injury to time of surgery. Although these difficult decisions are made with clinical judgment and multidisciplinary collaboration and discretion; it may hinder the patients’ access to care, increase the overall injury burden and/or lead to poorer clinical outcomes4,8. These decisions are becoming more arduous with the introduction and heavy push towards the use of DOACs.

During 2018, the South Campus Research Unit for Bone & Soft Tissue (SCRUBS) in Calgary, Alberta conducted a national survey to identify treatment preferences and heterogeneity among orthopaedic surgeons in the preoperative management of patients on anticoagulants. Participants completed a survey containing 16 questions about their own preoperative preference of managing anticoagulated patients. A total of 280 board-certified orthopaedic clinicians with varying years of clinical practice and expertise participated in this cohort from various community and academic medical centres across Canada. These participating clinicians reported operating on a median of 20 to 50 hip fractures per year (58.6%). Based on the attained responses, the majority of respondents did not believe that there are adequate clinical guidelines in place to inform the surgical management of patients on anticoagulant therapy (74.0%). Most of these clinicians also perceived that the anaesthesia and/or internal medicine teams have a greater influence on the timing of surgery than the attending orthopaedic surgeon (64.0%).

National guidelines for hip fracture care have transformed remarkably over the past ten years. Current clinical evidence highlights that early definitive surgery for most elderly hip fracture patients has favourable clinical and functional out-

These surgeons were asked if they would advocate for immediate versus delayed surgery when presented with a patient on either Vitamin-K antagonist (VKA, i.e. Coumadin) or DOAC medications. We found that while 45.0% of respondents would

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advocate expedited surgery in the VKA group, only 23.0% would do the same in the setting of DOACs. When stratified based on the demographic characteristics such as years in practice, the region of practice, and fellowship training we found no significant difference in whether they would advocate for immediate or delayed surgery if a patient is on VKAs or DOACs. A significant difference was found when evaluating participants based on membership status with the Canadian Orthopaedic Trauma Society (COTS). Members of this society were more likely to advocate for immediate surgery if a patient was on VKAs or DOACS than the non-members (p < 0.05). As evidenced, there is tremendous practice heterogeneity across the nation. However, the question we should start asking ourselves is if this wait for surgery is necessary in order to treat our patients. At present, the answer is not clear and in fact, is limited by the available data which may suggest that we need to be more aggressive in our centres. More importantly, the current literature clearly supports the use of evidence-based protocols for managing these patients1. Thus, it is time for us to manage our hip fracture anticoagulated patients by using and prospectively evaluating regional, provincial and/or nationally available protocols and clinical care pathways. These guidelines should recommend early definitive surgery in most patients regardless of their anticoagulation status and must include guidance about when reversal agents should be used (i.e. avoid in patients with renal impairment)9. Protocols, whether written at regional, provincial and/or national level should be prospectively evaluated and rigorously compared to the current literature base. References 1. Ahmed I., Khan M. A., Nayak V., and Mohsen A.. An evidencebased warfarin managment protocol reduces surgical delay in hip fracture patients. Journal of Orthopaedic Traumatology 15 (2014): 21-27.

2. Buecking B., et al. Effectiveness of vitamin K in anticoagulation reversal for hip fracture surgery - A prospective observational study. Thrombosis Research, no. 133 (2014): 42-47. 3. Franklin N. A., Ali A. H., Hurley R.K. , Mir H.R., Beltran M.J. Outcomes of early surgical intervention in geriatric proximal femure fractures among patients receiving direct oral anticoagulation. Journal of Orthopaedic Trauma 32, no. 6 (2018): 269-273. 4. Kanis J. A., et al. A systematic review of hip fracture incidence and probability of fracture worldwide. Osetoporos Int 23, no. 9 (2012): 2239-2256. 5. Loo, Simone Y, Sophie Dell’Aneillo, Laetitia Huiart, and Christel Renoux. Trends in the prescription of noval oral anticoagulants in UK primary care. Br J Clin Pharmacol 83, no. 9 (2017): 2096-2106. 6. Mullins B., Akehurst H., Slattery D., and Chesser T. Should surgery be delayed in patients taking direct oral anticoagulants who suffer a hip fractre? A retrospective, case-controlled observational study at a UK major trauma centre. BMJ Open 8, no. e020625 (2018). 7. Simunovic N., et al. Effects of early surgery after hip fracture on mortality and complications: Systematic review and metaanalysis. CMAJ 182, no. 15 (2010): 1609-1616. 8. Tarride J. E., et al. The burden of illness of osteoporosis in Canada. Osteoporos Int 23, no. 11 (2012): 2591-2600. 9. White S. M., Griffiths R., Holloway J., and Shannon A. Anaesthesia for proximal femoral fracture in the UK: first report from the NHS Hip Fracture Anaesthesia Network. Anaesthesia 65, no. 3 (2009): 243-248. 10. Yassa R., Khalfaoui M.Y., Ihab Hujazi I., Hannah Sevenoaks H., Dunkow P.. Management of anticoagulation in hip fractures: A pragmatic approach. Efort Open Reviews 2, no. 9 (2017): 394-402.

DVT Prophylaxis in Orthopaedic Trauma Patients Simplify Your Life and Follow Guidelines! Steven Papp, M.D., FRCSC Karl-André Lalonde, M.D., FRCSC Alan Liew, M.D., FRCSC Wade Gofton, M.D., FRCSC David Saliken, M.D., FRCSC University of Ottawa Ottawa, ON

Canadian Orthopaedic Surgeons are Simply Not Following DVT Guidelines enous Thromboembolism (DVT) can result in mortality and morbidity after trauma. The reported incidence of DVT following trauma varies widely depending on several factors including: method of detection, location of thrombus, use of prophylaxis, isolated vs. multiple injuries, hip fracture vs.

ankle fracture, patient age, comorbidities. Due to these factors, the rate of DVT ranges from 3% to 58% of patients. Prevention of DVT (and ultimately a clinically important pulmonary embolism) is the main goal of DVT prophylaxis. • Which of our patients should receive prophylaxis? • Should we offer DVT prophylaxis to all trauma patients? • Should we offer DVT prophylaxis to patients with a pelvic or acetabular fracture? • What about our patients with a hip fracture or tibia fracture? As outlined in the other articles in this edition of the COA Bulletin, there is a significant body of literature to support DVT prophylaxis treatment for some but not all of these injuries. Guidelines are important. They exist to help us follow common treatments so we can get it RIGHT! COA Bulletin ACO - Winter / Hiver 2018

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What Would the Ideal Guideline Contain? The model guideline should be designed around the following principles: for those with a demonstrable risk of thrombosis, thromboprophylaxis should be started with an effective dose as close to the thrombogenic insult as possible, without introducing an equal or greater risk of complication, and continued until the risk of thrombosis has decreased to a clinically negligible rate, with due consideration to cost and practicality3. Why Are Guidelines Not Followed? There are several reasons surgeons don’t follow guidelines. First, there are some reasonable considerations why guidelines do not receive immediate uptake. Practicality of the guidelines, expense, slow uptake by your institution, perception bias, concern over bleeding risk, and conflicting data in studies may all be good reasons. However, this is not the usual case. Rather, there is a simple lack of awareness of treatment guidelines. Secondly, personality of the surgeon may be a factor. Some surgeons may feel that the use of guidelines would interfere with their perceived right to determine their own practice based upon their own personal experience and interpretation of the evidence. They may feel that each individual patient is so different that their personal practice cannot be constrained by a prescriptive guideline3. What Guidelines Exist? Several guidelines exist in the literature. In trauma, we find the OTA guidelines offer reasonable and comprehensive recommendations2. Other guidelines (CHEST, EAST, NICE, etc.) exist but most are similar with only small variations. Why Guidelines Should be Followed In several studies, standardized screening programs based on current guidelines can not only help reduce variability, but decrease DVT events. In one study, a computerized alert program was set up to identify any hospitalized patients with > 4 of 8 risk factors for thromboembolic disease1. In this study, an “alarm” went off if certain criteria were met and patients were started on DVT prophylaxis. Twenty-four percent of patients during the study period received treatment in comparison to 13% in the control group. The DVT and PE rate was reduced by 41%. Although a computerized program may not be necessary, a standardized program will most likely help reduce the incidence of DVT. DVT serves as a significant source of medicolegal cases. During the six-year period from 2006 to 2011, the CMPA had 242 medico-legal cases involving venous thromboembolism. Many of the medico-legal problems in these cases were the result of allegations that the physician failed to diagnose and treat venous thromboembolism. The CMPA offers sound advice. In particular, they state: 1) physicians should be aware of their institution’s guidelines for VTE prophylaxis, and 2) physicians should consider a careful evaluation of each patient’s history for risks of venous thromboembolism and bleeding when making decisions about VTE prophylaxis. And finally, our friends at CMPA wisely state: evidence-based guidelines from authoritative sources should be consulted.

COA Bulletin ACO - Winter / Hiver 2018

Figure 1

Are We Following Them In Canada? NO! Recently, we surveyed all members of the COA practicing in Canada to find out their practices in the treatment of DVT prophylaxis4. This short article cannot cover the entire survey results. When asking surgeons about their current practice regarding usage in single extremity injuries, multiple trauma patients, stratifying for risk factors and institutional protocols, the results were quite disappointing (Figure 1). a) When asking surgeons when they start anticoagulation after surgery – 49% did not follow guidelines. b) When asking surgeons how long they anticoagulated patients for (when indicated) 63% did not follow guidelines. c) When asking surgeons if they use risk factors to help decide which patients to anticoagulate – most surgeons were unaware of appropriate risk factors. d) When asking surgeons if they and their colleagues in their institution follow an institutional protocol ->80% of respondents stated they do not have an institutional guideline.

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This survey will hopefully serve as a reminder that DVT guidelines are well established, relatively easy to follow, help prevent complications, and help avoid medical legal issues but are commonly NOT being implemented. As a physician leader in your hospital, we recommend all surgeons and the institution ensure that you review your current practices and make sure they are up to date. Secondly, we recommend that all orthopaedic surgeons in each institution follow the SAME guidelines. We have done this at our institution and have found this simplification alone to be a huge advantage. This consistency amongst the entire group leads to improved ease of communication, less prescriptions errors, less confusion amongst our nurses and residents. A consistent approach amongst your entire group to follow guidelines will simplify your life and keep you out of trouble.

References 1. Kucher, N., Koo, S., Quiroz, R., Cooper, J. M., Paterno, M. D., Soukonnikov, B., & Goldhaber, S. Z. (2005). Electronic alerts to prevent venous thromboembolism among hospitalized patients. The New England Journal of Medicine, 352(10), 969–977. http://doi.org/10.1056/NEJMoa041533 2. Sagi, H. C., Ahn, J., Ciesla, D., Collinge, C., Molina, C., Obremskey, W. T., et al. (2015). Venous Thromboembolism Prophylaxis in Orthopaedic Trauma Patients: A Survey of OTA Member Practice Patterns and OTA Expert Panel Recommendations. Journal of Orthopaedic Trauma, 29(10), e355–62. http://doi.org/10.1097/BOT.0000000000000387 3. Warwick, D., Dahl, O. E., bone, W. F. T. J. O., 2008. (n.d.). Orthopaedic thromboprophylaxis: limitations of current guidelines. Online.Boneandjoint.org.Uk. http://doi. org/10.1302/0301-620X.90B2 4. Saliken D., Lalonde K., Gofton W., Liew A., Papp S. Current Standards of Venous Thromboembolism Prophylaxis in Canadian Orthopedic Trauma; A Survey of COA

Thromboprophylaxis for Patients with Pelvic and Acetabular Fractures Bill Ristevski M.D., MSc, FRCSC Associate Professor, Orthopaedic Surgery McMaster University Hamilton, ON Dale Williams M.D., FRCSC Associate Professor, Orthopaedic Surgery McMaster University Hamilton, ON

atients who have sustained pelvic and/or acetabular fractures are at high risk for venothromboembolism (VTE) events, with the most devastating VTEs being fatal pulmonary emboli (PE). Unfortunately, there is a paucity of level I evidence on VTEs to guide thromboprophylactic treatment. Balancing the risk of bleeding versus VTE events remains the biggest concern and controversy in patients with pelvic and acetabular fractures. Despite our best efforts, combined with diligent and timely care, VTEs and their sequelae remain a major source of morbidity and mortality in this population of trauma patients1. In studies using sensitive means to detect deep vein thromboses (DVTs), 61% of patients demonstrated a DVT with 29% of patients having proximal DVTs2. It is important to note that about half of proximal thrombi will be in the pelvic veins, rather than the lower extremities1. Pelvic DVTs can be harder to diagnose and may be more likely to result in a PE. Although the majority of patients with pelvic trauma will have a DVT of some type, it has been reported that only 1-3% of patients are

actually symptomatic3. PE rates vary from approximately 2-10%, with fatal PEs ranging from 0.5%-2%4-7. Bleeding risk is inherently linked to thromboprophylaxis in patients with pelvic and acetabular fractures. This is especially poignant as many of these patients are polytraumatized, raising the potential risk of Figure 1 hemorrhage if treat- Pelvic X-ray of an 80-year-old patient who had a fall from standing height, demoned with anticoagu- strating right-sided pelvic rami fractures. lants. Distinguishing This patient has osteoporosis and previbetween “low” and ously had hip fractures managed surgically. “high” energy trauma can be helpful in assessing bleeding risk and guiding treatment. For instance, Figure 1 shows a pelvic X-ray of an 80-year-old patient who previously required interventions for hip fractures. She presented to hospital with minimally displaced pelvic fractures after a trip and fall. This fall, from standing height, would be classified as low energy. Based on her injury and overall medical history, her bleeding risk was determined to be low. Despite multi-modal analgesic treatment, the pain stopped her from mobilizing immediately, placing her at increased risk for VTE. COA Bulletin ACO - Winter / Hiver 2018

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

Figure 2 (A, B, C) is a computed tomography scan of a pelvis from an 18-year-old patient who sustained a pelvic injury after crashing a motor vehicle at speeds greater than 100km/ hr. This patient sustained a concomitant closed head injury with intracranial bleed and presented in shock, requiring multiple blood transfusions. These two patients clearly have substantially different risk profiles for B C the potential use of anti-coag- A ulants to prevent VTEs. The two Figure 2 A, B, C scenarios elucidate the fact that CT 3D reconstruction of the pelvis of an 18-year-old patient demonstrating a pelvic fracture involving the right differential methods of throm- sacrum and anterior pelvic ring. In addition, this patient had a left sacro-iliac joint dissociation. boprophylaxis are required. The options for VTE prophylaxis in these types of trauma patients can broadly be broken down into three categories:

Patients in Category 2 would be given compression stockings and a LMWH (the author’s choice was Enoxaparin).

1. Static (anti-embolic stockings) or pneumatic compression devices 2. Chemoprophylaxis 3. Retrievable inferior vena cava filters (rIVCFs)

Patients in Category 3 would be given compression stockings, LMWH, and a pneumatic compression device.

A study of Canadian trauma surgeons demonstrated that all surgeons prefer low-molecular-weight heparin (LMWH) as a first line prophylaxis to VTE in a trauma population. When LMWH was contraindicated; 79% of respondents preferred pneumatic compression devices while 21% preferred a rIVCF8. Certainly, the patient whose X-ray is shown in Figure 1 would receive LMWH (+/- anti-embolic stockings) due to her injury and subsequent immobility to protect against VTE. The patient whose images are shown in Figure 2 had contraindications to the use of immediate anti-coagulants, due to the large hemorrhage causing hemodynamic instability and the intracranial bleeding. Anti-embolic stockings and a pneumatic compression device were employed followed by LMWH once the patient was stable from a hemodynamic perspective. El-Daly et al. in 2013 proposed a recommendation for VTE prophylaxis in trauma patients with pelvic and acetabular fractures9. The below points are adapted from this proposed framework. Trauma patients were divided into three categories based on mobility: • Category 1: Mobile; patients that can walk freely with no walking aids • Category 2: Semi-mobile; patients requiring a stick, frame or crutches to mobilize • Category 3: Immobile; patients bound to bed/chair Classifying patients into a mobility category determined their treatment algorithm. Patients in Category 1 would be given compression stockings alone and no further prophylaxis.

COA Bulletin ACO - Winter / Hiver 2018

In addition to the above, placement of a rIVCF would be strongly considered in Category 3 patients if they didn’t receive anticoagulation for > 48 hours, particularly the first 48 hours (i.e. missed doses on admission) plus expected immobility to last >72 hours. Placement of a rIVCF, if completed, was done with an anticipated removal prior to the patient being discharged from hospital. Despite this recommendation, there isn’t any compelling data for the use of prophylactic rIVCFs10,11 in patients with pelvic and acetabular fractures. The majority of Canadian trauma surgeons surveyed (65%) felt that the risks outweighed the benefit of rIVCF, but most acknowledged a need for further research8. Certainly, rIVCF placement has risks including, but not limited to, implant fracture/failure, migration, caval wall tears, vena cava thrombosis, increased DVT risk, inability to retrieve, failure to stop a PE from occurring, amongst other complications noted in the literature12. The lack of robust data has left physicians with undefined indications for implanting prophylactic rIVCFs. Therefore, treatment variability as well as regional differences in the use of rIVCFs exists. Due to these discrepancies, consultation with a thrombosis expert is of enormous value if one is considering prophylactic rIVCF for a high-risk patient. Even with early aggressive prophylactic treatment of VTE in patients with pelvic and acetabular fractures, VTE events still occur. We rely on a hyper-coagulable state to heal and survive from a major trauma. Therefore, completely eliminating the negative aspects of clotting is likely an unobtainable goal. However, the risks of VTE can be reduced with the liberal use of static and pneumatic compression devices, along with early use of chemoprophylaxis once the bleeding risks are tempered. Currently, there is not compelling evidence for the prophylactic use of rIVCFs to stop PEs in high-risk trauma patients that have pelvic and/or acetabular fractures. Judicious use of rIVCFs on a patient by patient basis, preferably with consultation of a thrombosis expert is a reasonable approach.

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References 1. Montgomery K.D., Geerts W.H., Potter H.G., Helfet D.L. Thromboembolic complications in patients with pelvic trauma. Clin Orthop Relat Res. 1996 Aug;(329):68–87. 2. Geerts W.H., Code K.I., Jay R.M., Chen E., Szalai J.P. A prospective study of venous thromboembolism after major trauma. N Engl J Med. 1994 Dec;331(24):1601–6. 3. Poole G.V., Ward E.F., Griswold J.A., Muakkassa F.F., Hsu H.S. Complications of pelvic fractures from blunt trauma. Am Surg. 1992 Apr;58(4):225–31. 4. Judet R., Judet J., Letournel E. Fractures of the Acetabulum: Classification and Surgical Approaches for Open Reduction. Preliminary Report. J Bone Joint Surg Am. 1964 Dec;46:1615– 46. 5. O’Malley K.F., Ross S.E. Pulmonary embolism in major trauma patients. J Trauma. 1990 Jun;30(6):748–50. 6. Webb L.X., Rush P.T., Fuller S.B., Meredith J.W. Greenfield filter prophylaxis of pulmonary embolism in patients undergoing surgery for acetabular fracture. J Orthop Trauma. 1992;6(2):139–45.

7. Ostrowka C., Bonhomme S., Jouffroy P., Riouallon G. Evaluation of venous thromboembolic complications in patients operated on for pelvic fracture. Orthop Traumatol Surg Res. 2018 Oct;104(6):917–21. 8. Curtis R.M., Vogt K., Leeper W.R., Mujoomdar A., Kribs S., Parry N., et al. A national survey of thromboprophylaxis strategies in high risk trauma patients. J Trauma Crit Care [Internet]. 2018;2(1). Available from: http://www.alliedacademies.org/ articles/a-national-survey-of-thromboprophylaxis-strategies-in-high-risk-trauma-patients-9151.html 9. El-Daly I., Reidy J., Culpan P., Bates P. Thromboprophylaxis in patients with pelvic and acetabular fractures: A short review and recommendations. Injury. 2013 Dec;44(12):1710–20. 10. Slobogean G.P., Lefaivre K.A., Nicolaou S., O’Brien P.J. A systematic review of thromboprophylaxis for pelvic and acetabular fractures. J Orthop Trauma. 2009;23(5):379–84. 11. Geerts W, Selby R. Inferior vena cava filter use and patient safety: legacy or science? Hematol Am Soc Hematol Educ Progr. 2017 Dec;2017(1):686–92. 12. Ayad M.T., Gillespie D.L. Long-term complications of inferior vena cava filters. J Vasc surgery Venous Lymphat Disord. 2018 Aug;

Thromboprophylaxis for Hip Fracture Surgery Henry Broekhuyse, M.D., FRCSC Vancouver, BC

Summary of VTE Prophylaxis Recommendations for Patients with a Hip Fracture

Role for early surgical treatment. Delayed surgical management is a significant risk factor for VTE. Even with use of preoperative chemoprophylaxis, a delay in surgical intervention more than 48 hours post injury has been shown to increase the prevalence of preoperative DVT to 62%.8

he American College of Chest Physicians (ACCP) puts hip fracture surgery in the highest risk category for venous thromboembolism (VTE). Without thromboprophylaxis in this patient population, the incidence of deep venous thrombosis (DVT) is approximately 50%1. With thromboprophylaxis, the incidence of symptomatic VTE can be reduced to one to two percent2. The large number of hip fracture patients at high risk for VTE, and the serious consequences of VTE in these patients, have prompted the publication of clinical practice guidelines (CPGs) based on the large body of clinical evidence published on this topic. Guidelines in most common usage have been developed by the American College of Chest Physicians (ACCP)2, the American Academy of Orthopaedic Surgeons (AAOS)4, the National Institute for Health and Clinical Excellence (NICE)5, and the Scottish Intercollegiate Guidelines Network (SIGN)6. The recommendations of these CPGs are similar but not identical as a result of differences in methodology used during development of each organization’s guidelines. For example, the AAOS guidelines do not recognize either symptomatic or asymptomatic DVT as a surrogate marker for more serious outcomes such as pulmonary emboli7.

Low-molecular-weight heparin (LMWH). Use of LMWH is supported by all CPGs, and many studies favour LMWH over all other pharmacologic agents for VTE prophylaxis. All CPGs recommend that LMWH administration begin immediately following patient admission to hospital, stopping 12h prior to surgery, and restarting 6-12 hours after surgery. LMWH should be continued until 28-35 days after surgery. Intermittent pneumatic compression devices (IPCDs). All CPGs recognize that IPCDs are effective as a prophylaxis for VTE associated with hip fractures, but specify that IPCDs must be used in combination with pharmacologic therapy. Fondaparinux. All CPGs support use of Fondaparinux, but due to its long half-life and slow onset of action, it is not recommended for use preoperatively. Administration should begin six to eight hours postoperatively and should be continued until 28-35 days after surgery.

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

Acetylsalicylic Acid (Aspirin). There is considerable evidence that aspirin is an effective, inexpensive, and safe pharmacologic agent for VTE prophylaxis in patients with a hip fracture9. However, since other pharmacologic agents are more effective than aspirin alone for reduction of VTE risk10, some CPGs (such as the ACCP) indicate a preference for use of LMWH over aspirin. CPGs (such as the SIGN guidelines) recommend that if aspirin is used as the thromboprophylactic agent, it should be used as part of a multimodal approach which includes use of an intermittent pneumatic compression device (IPCD) from the time of patient admission to hospital, until the patient no longer has significantly reduced mobility following surgical management. Evidence indicates that a low dose of aspirin (81mg BID) is not inferior to a higher dose of aspirin (325mg BID) taken for four weeks following surgery. Warfarin. All CPGs recognize the effectiveness of Warfarin as a thromboprophylactic agent. However, there are many disadvantages associated with its use including a slow onset of action, long half-life (which also precludes preoperative administration), interactions with food and other medications, and monitoring to establish and maintain safe dosing. For these reasons, routine use of warfarin is not recommended by NICE and SIGN guidelines. Summary A substantial amount of published evidence has established that there is a high risk of VTE in patients who have sustained a hip fracture. The importance of reducing this risk is key to improving outcomes of treatment for hip fracture given the relative effectiveness of options for providing thromboprophylaxis. Clinical practice guidelines have been developed for reduction of VTE risk in patients with a hip fracture, and in many practice environments, it is mandatory to follow CPG recommendations as a standard of care. In addition to early surgical management, all CPGs recommend use of pharmacologic prophylaxis for VTE in all patients with a hip fracture. References

2. Falck-Ytter U.Y., Francis C., Johanson N., et al. Prevention of VTE in orthopedic surger patients: antithrombotic therapy and prevention of thrombosis, 9th edition. American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012; 141:e278S-e325S 3. American Academy of Orthopaedic Surgeons. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. Evidence based guidelines and evidence report. September 24, 2011. https://www. aaos.org/research/guidelines/vte/vte_full_guideline.pdf 4. National Institute for Health and Clinical Excellence. Venous thromboembolism in over 16s: reducing the risk of hospital-acquired deep vein thrombosis or pulmonary embolism. NICE guideline NG89, published date March 2018. https://www.nice.org.uk/guidance/ng89 5. Scottish Intercollegiate Guidelines Network. Management of hip fractures in older people: A national clinical guideline. 2009 June. https://www.sign.ac.uk/assets/sign111.pdf 6. Stewart D.W., Freshour J.E. Aspirin for the prophylaxis of venous thromboembolic events in orthopaedic surgery patients: A comparison of the AAOS and ACCP guidelines with review of the evidence. The Annals of Pharmacotherapy. 2013 Jan, Vol 47, 63-74. 7. Zahn H.R., Skinner J.A., Porteous M.J. The preoperative prevalence of deep vein thrombosis in patients with femoral neck fractures and delayed operation. Injury 1999; 30(9) 605-7 8. Azboy I., Barrack R., Thomas A.M., Haddad F.S., Parvizi J. Aspirin and the prevention of venous thromboembolism following total joint arthroplasty. Bone Joint J. 2017 nov; 99-B(11): 1420-1430. 9. Gent M., Hirsh J., Ginsberg J.S., et al. Low molecular weight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation. 1996;93:80-4

1. Geerts W.H., Pineo G.F., Heit J.A. Bergqvist D., Lassen M.R., Colwell C.W. et al. Prevention of venous thromboembolism: the Seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest 2004; 126:S338-400

CORA Resident Abstract Deadline: January 31 The 2019 CORA Annual Meeting will be held on Wednesday, June 19 in Montréal. New this year: the CORA meeting will include a session made up of 6-minute Feature Talks, as well as 2-minute Lighting Talks at the podium. This is a short and dynamic way to pack more research into the meeting. Orthopaedic residents from a Canadian training program are encouraged to submit one abstract per person ahead of the January 31 deadline. Click here for abstract submission details.

COA Bulletin ACO - Winter / Hiver 2018

Date limite de soumission des précis à l’ACRO : Le 31 janvier La Réunion annuelle 2019 de l’ACRO aura lieu à Montréal, le mercredi 19 juin. Une nouveauté cette année : la Réunion comprend une séance alternant entre des présentations-vedettes de 6 minutes et des présentations éclair de 2 minutes au podium. Il s’agit d’une façon rapide et dynamique de présenter davantage de recherche pendant la Réunion. On invite les résidents inscrits à un programme canadien de formation en orthopédie à soumettre un précis avant le 31 janvier. Limite d’un précis par résident. Cliquez ici pour les détails.

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

Thromboprophylaxis for Patients with Injury Below the Hip and Knee Chad P. Coles, M.D., FRCSC Associate Professor, Dalhousie University Halifax, NS

hile there is reasonable consensus for “major” orthopaedic procedures including arthroplasty, hip fractures and polytrauma, much controversy exists in the prophylaxis of venous thromboembolism for isolated injury below the hip and knee. While not as frequent as with these higherrisk procedures, VTE does occur in these patients with isolated injuries, sometimes with fatal results. Most of the literature to date has focused on foot and ankle injuries and surgery, and injuries requiring lower-extremity immobilization. Large database reviews of foot and ankle injuries by Jameson et al.1 in 2011 of the English National Health Service (NHS) database including 45,949 patients, and by Shibuya et al.2 in 2012 of the US National Trauma database of 75,664 patients both reported a combined risk of DVT and symptomatic PE of less than 0.5%. Lapidus et al.3 in 2013 reported a much higher incidence of DVT/PE risk of 3.6% following ankle fracture fixation and 7.2% following Achilles tendon repair in a review of 45,968 consecutive patients. More recently, a 2016 metaanalysis by Calder et al.4 including 43,381 patients reported a 1% VTE incidence overall, and 7% with Achilles tendon surgery. Earlier this year, a US quality improvement database review by Huntley et al.5 including 23,212 patients reported an overall VTE incidence of 0.6%. Wang et al.6, in a prospective review of lower extremity fractures, reported even higher incidence rates of 14.5% for femoral shaft and 4.5% for tibial shaft or plateau fractures. These studies suggest the overall incidence of VTE is approximately 1% for foot and ankle surgery, 7% for Achilles tendon repair in particular, and up to 15% for more proximal extremity fractures. Most studies addressing VTE prophylaxis in this patient population have looked at the use of low-molecular-weight heparin (LMWH). A 2006 meta-analysis by Ettema et al.7 including 1,456 patients showed a reduction in VTE incidence from 17.1% to 9.6% with no increased bleeding risk. A 2017 Cochrane review by Zee et al.8 determined there was moderate-quality evidence showing a benefit of LMWH for VTE prophylaxis for lowerextremity injuries requiring immobilization. A more recent 2018 meta-analysis by Hickey et al.9 included over 800 patients and confirmed the protective effect of LMWH, but indicated that 86 patients needed to be treated in order to prevent one VTE event. Certainly LMWH has been shown to be effective, but can we be more selective in our recommendation of who needs prophylaxis? The American College of Chest Physicians clinical practice guideline published in CHEST 201210 recommended against routine prophylaxis of isolated lower-extremity injuries requiring immobilization. Since that time, there has been increasing interest in identifying risk factors associated with the develop-

Figure 1 National Health Service Plymouth Hospitals Risk-Stratification Tool12.

ment of VTE in patients with isolated lower-extremity injuries. Factors including advanced age, obesity, diabetes, and multiple medical comorbidities have all been associated with an increased risk of VTE1,2,11. More recent prophylaxis guidelines have recommended screening patients for factors which place them at increased risk. The use of LMWH is recommended for VTE prophylaxis in these high-risk patients12-14. A sample screening tool from the UK National Health Service is shown in Figure 112. Haque et al.15 demonstrated the use of a similar riskstratification tool (Figure 2) to be safe and effective in a small prospective study of 150 patients. However, Watson et al.16 critically evaluated the accuracy of five risk-assessment models, and only found them to be accurate about 50% of the time.

COA Bulletin ACO - Winter / Hiver 2018

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

Figure 2 Kettering Hospital VTE Risk-Stratification Tool15.

Venous thromboembolism is a real problem that potentially threatens our patients with isolated lower-extremity injuries. Low-molecular-weight heparin has been proven effective in decreasing this risk, however widespread treatment of every patient is likely not necessary or cost-effective. The use of a riskstratification approach may be more appropriate in identifying those patients most at risk, and offering VTE prophylaxis to this select cohort of patients. Further research in this area and the development of clear prophylaxis guidelines are needed to better direct optimal care in this patient population. References 1. Jameson S.S., Augustine A., James P., Serrano-Pedraza I., Oliver K., Townshend D., Reed M.R. Venous thromboembolic events following foot and ankle surgery in the English National Health Service. J Bone Joint Surg Br. 2011;93(4):490-7. 2. Shibuya N., Frost C.H., Campbell J.D., Davis M.L., Jupiter D.C. Incidence of acute deep vein thrombosis and pulmonary embolism in foot and ankle trauma: analysis of the National Trauma Data Bank. J Foot Ankle Surg. 2012 JanFeb;51(1):63-8. COA Bulletin ACO - Winter / Hiver 2018

3. Lapidus L.J., Ponzer S., Pettersson H., de Bri E. Symptomatic venous thromboembolism and mortality in orthopaedic surgery - an observational study of 45 968 consecutive procedures. BMC Musculoskelet Disord. 2013;4;14:177. 4. Calder J.D., Freeman R., Domeij-Arverud E., van Dijk C.N., Ackermann P.W. Meta-analysis and suggested guidelines for prevention of venous thromboembolism (VTE) in foot and ankle surgery. Knee Surg Sports Traumatol Arthrosc. 2016;24(4):1409-20. 5. Huntley S.R., Abyar E., Lehtonen E.J., Patel H.A., Naranje S., Shah A. Incidence of and Risk Factors for Venous Thromboembolism After Foot and Ankle Surgery. Foot Ankle Spec. 2018 Apr 1:1938640018769740. doi: 10.1177/1938640018769740. [Epub ahead of print] 6. Wang H., Kandemir U., Liu P., Zhang H., Wang P.F., Zhang B.F., Shang K., Fu Y.H., Ke C., Zhuang Y., Wei X., Li Z., Zhang K. Perioperative incidence and locations of deep vein thrombosis following specific isolated lower extremity fractures. Injury. 2018 May 22. pii: S0020-1383(18)30261-4. doi: 10.1016/j. injury.2018.05.018. [Epub ahead of print]

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 40)

7. Ettema H.B., Kollen B.J., Verheyen C.C., Büller H.R. Prevention of venous thromboembolism in patients with immobilization of the lower extremities: a meta-analysis of randomized controlled trials. J Thromb Haemost. 2008 Jul;6(7):1093-8. 8. Zee A.A., van Lieshout K., van der Heide M., Janssen L., Janzing H.M. Low molecular weight heparin for prevention of venous thromboembolism in patients with lower-limb immobilization. Cochrane Database Syst Rev. 2017 Aug 6;8:CD006681. 9. Hickey B.A., Watson U., Cleves A., Alikhan R., Pugh N., Nokes L., Perera A. Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis. Foot Ankle Surg. 2018;24(1):19-27. 10. Falck-Ytter Y., Francis C.W., Johanson N.A., Curley C., Dahl O.E., Schulman S., Ortel T.L., Pauker S.G., Colwell C.W. Jr. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians EvidenceBased Clinical Practice Guidelines. Chest. 2012 Feb;141(2 Suppl):e278S-e325S. 11. Park S.J., Kim C.K., Park Y.S., Moon Y.W., Lim S.J., Kim S.M. Incidence and Factors Predicting Venous Thromboembolism After Surgical Treatment of Fractures Below the Hip. J Orthop Trauma. 2015 Oct;29(10):e349-54.

12. Keenan J., Nokes T., Gale T. Guidelines for Venous Thromboembolism (VTE) Prophylaxis in Orthopaedics and Trauma V3. Plymouth Hospitals NHS Trust. http://w w w.plymouthhospitals.nhs.uk/download. cfm?doc=docm93jijm4n2870.pdf&ver=6605. (Accessed 5/11/2018). 13. Roberts C., Horner D., Coleman G., Maitland L., Curl-Roper T., Smith R., Wood E., Mackway-Jones K. Guidelines in Emergency Medicine Network (GEMNet): guideline for the use of thromboprophylaxis in ambulatory trauma patients requiring temporary limb immobilisation. Emerg Med J. 2013 Nov;30(11):968-82. 14. National Institute for Health and Care Excellence. Venous Thromboembolism in over 16s. NICE Guideline NG89 (Volume 1). March 2018. https://www.nice.org.uk/guidance/ng89. (Accessed 5/11/2018). 15. Haque S., Bishnoi A., Khairandish H., Menon D. Thromboprophylaxis in Ambulatory Trauma Patients With Foot and Ankle Fractures: Prospective Study Using a Risk Scoring System. Foot Ankle Spec. 2016 Oct;9(5):388-93. 16. Hickey B.A., Watson U., Cleves A., Alikhan R., Pugh N., Nokes L., Perera A. Does thromboprophylaxis reduce symptomatic venous thromboembolism in patients with below knee cast treatment for foot and ankle trauma? A systematic review and meta-analysis. Foot Ankle Surg. 2018 Feb;24(1):19-27.

Annual Meeting Housing: Did you reserve a hotel room in Montréal yet?

Hébergement pour la Réunion annuelle 2019 : Avez-vous réservé votre chambre à Montréal?

Don’t wait! When it comes to booking your Annual Meeting accommodations – keep this tip in mind! Montréal is a popular destination in June with its many summer festivals and events. We are also expecting a larger number of participants as we welcome our international colleagues and research associates participating in the ICORS meeting. Make sure your accommodations are booked well in advance.

Ne tardez pas! Quand il s’agit de réserver sa chambre pour la Réunion annuelle, voilà un conseil qui vaut son pesant d’or! Montréal est une destination populaire en juin, avec ses nombreux festivals et activités qui viennent marquer le début de l’été. Nous attendons également nos collègues et chercheurs de l’étranger en grand nombre vu la tenue conjointe du congrès annuel des International Combined Orthopaedic Research Societies (ICORS). Il serait donc bon de vous assurer de réserver votre chambre bien à l’avance.

The COA and ICORS have conference room blocks at the InterContinental Hotel Montréal, le Westin Montréal and the Embassy Suites by Hilton which are all nearby the Palais des congrès convention centre.

L’ACO et les ICORS ont réservé des blocs de chambres à l’Hôtel InterContinental Montréal, au Westin Montréal et à l’Embassy Suites by Hilton Montréal, qui sont tous situés à proximité du Palais des congrès.

Don’t wait for registration to open – go ahead and book your accommodations now!

N’attendez pas que la période d’inscription soit commencée : réservez votre chambre dès aujourd’hui!

To reserve a room, please visit www.2019icors.org and click on the Housing tab.

Rendez-vous à www.2019icors.org, puis cliquez sur l’onglet « Hébergement » pour réserver une chambre.

Need help? Contact meetings@canorth.org

Besoin d’aide? Écrivez à meetings@canorth.org.

COA Bulletin ACO - Winter / Hiver 2018

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

Opioid Use in Orthopaedics: The Need for Orthopaedic Surgeon Stewardship Raja Rampersaud M.D., FRCSC Professor of Surgery, University Health Network, University of Toronto Toronto, ON

espite growing evidence of poor efficacy of opioids for pain management of both low back pain and knee osteoarthritis, there is continued significant use of opioids for degenerative orthopaedic conditions1,2. In a recent study by the Canadian Primary Care Sentinel Surveillance Network, 33% of osteoarthritis patients where prescribed opioid medications for pain management3. While the degree of direct and indirect contribution of musculoskeletal pain management to the opioid epidemic has not been clearly defined, the increase risk of adverse events associated with opioid use, including the risk of dependency is clear4. Orthopaedic surgeons need to consider our roles and practices in contributing to and going forward mitigating the opioid crisis. The following is a summary of our research to date that supports potential mechanisms to positively impact the opioid crisis and encourage orthopaedic surgeons to be stewards in the fight against opioid overuse and availability. A. The impact of an upstream shared-care interprofessional model of care for low-back pain to minimize chronic opioid use for low back conditions. Intervention: With funding from the Ontario Ministry of Health and Long-Term Care the Inter-Professional Spine Assessment and Education Clinic (ISAEC, www.ISAEC.org) was established in Ontario (pilot sites in Toronto, Hamilton, and Thunder Bay) in November 2012. The goal of ISAEC is to enable shared care management of low back pain (LBP) by employing a network structure between primary care providers (PCPs: medical doctors and nurse practitioners), advanced practice clinicians (APCs, specially trained physiotherapists and chiropractors) and specialists to deliver timely access to evidence-based LBP assessment, risk stratification, care recommendations, education, and support to enable patient self-management. In a review of 4746 patients, more than half were at moderate to high risk of having chronic persistent LBP. At first visit, 20% of patients reported using at least one opioid medication, with nearly one in five of these individuals characterized (using the Opioid Risk Tool) as being at moderate or high risk of opioid abuse compared to one in eight of those not using opioids. In a sub-group of patients enrolled in a longitudinal study (n=2272), 18% of opioid users at initial ISAEC assessment were not using them six months after participating in the ISAEC program. Independent predictors of ongoing opioid use at six months included smoking, previous history of LBP, and high pain-related disability at the initial visit. A current master’s project (Eric Crawford MD, MSc Candidate, Supervisors: Peter Coyte, PhD, Health Economist and Raja Rampersaud, MD) using ISAEC data

has shown that opioid use does not improve outcomes and was associated with increased health-care costs and possibly work absenteeism. Key Point: Upstream shared-care interprofessional management provides a mechanism to optimize non-pharmacological management and reduce initiation or downstream escalation of opioid use in the management of LBP. B. The impact of preoperative opioid use on patient reported outcomes following elective spine surgery. Study: The objective of this national study5 was to assess the influence of preoperative opioid use on patient-reported pain and disability one year after elective spine surgery. We retrospectively reviewed data from eight provinces using the Canadian Spine Society, Canadian Spine Outcomes and Research Network (CSORN) registry. In a cohort of 1931 subjects with degenerative spinal pathology, 50% (32% daily users) where on opioids preoperatively. In multivariable linear regression models, preoperative daily opioid use was independently associated with worse self-reported pain (β=0.48; p=0.003) and disability (β=4.83; p<0.0001) at one-year post-surgery as compared to patients not using opioids. Intermittent use was associated with worse disability (β=2.44; p<0.042) but not pain. Opioid use was also independently associated with increased length of hospital stay (β=1.4; p<0.05). Key point: Preoperative use of opioids in elective spinal surgery patients is independently associated with greater pain and disability at one-year post-surgery. Preoperative mitigation of daily opioid use using multidisciplinary pain teams is recommended. C. Increasing the health-care provider role in education and facilitating the safe storage/disposal of prescription opioids. Study: Nonmedical opioid users, including children, most often obtain prescription opioid drugs from their own home, or that of a friend. Unused prescription opioids are often (more than 50% of the time) left in the home following orthopaedic surgery or acute orthopaedic injury. Orthopaedic surgeons are among the top three prescribers of opioids6. In a needs survey undertaken in our ambulatory orthopaedic/fracture clinics (University Health Network, Toronto Western Hospital), 653 patients reported the following: The majority of respondents (78%) reported use of prescription opioid medication: 55% reported former COA Bulletin ACO - Winter / Hiver 2018

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

(continued from page 43)

use and 23% current use. A large proportion of ever-users reported that they did not receive (or did not recall receiving) instructions on safe handling practices from a pharmacist or health-care provider (56% for safe storage practices, and 44% for safe disposal practices). Unsafe practices were common. Thirty percent of all respondents and 36% of ever-users had unused opioids at home. Two in three everusers reported storing opioid medications in an unsecure location; among this group, 41% reported having children, teenagers, or young adults in the household. A considerable proportion (43%) of ever-users reported that they would use an unsafe disposal method (e.g., flushing pills down the toilet or throwing them in the garbage), or did not intend to dispose of unused medication. Six percent of ever-users and 10% of ever-users with unused medication at home reported sharing their prescription opioids with another person. Key point: There exists a significant opportunity to effect safer opioid storage, and disposal by orthopaedic surgeon stewardship. We have recently begun (September 2018) an intervention study (Title: Evaluation of a Patient Education Program Promoting Safe Handling of Opioids After Orthopaedic Surgery) at our centre. The objective of this project is to assess the impact of an education program aimed at enabling our orthopaedic surgeons, orthopaedic trainees, frontline clinical staff (e.g. nurses and technicians) and clerical staff to promote safe use, storage, and disposal of prescription opioids among our patients, including facilitating the return of unused opioids. The ultimate goal of this study is to reduce the possible number of prescribed opioids pills that could make it to the street or unintended users.

References 1. Foster N.E., Anema J.R., Cherkin D., Chou R., Cohen S.P., Gross D.P., et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet. 2018. 2. Krebs E.E., Gravely A., Nugent S., Jensen A.C., DeRonne B., Goldsmith E.S., Kroenke K., Bair M.J., Noorbaloochi S. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients with Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872-882. 3. Birtwhistle R., Morkem R., Peat G., Williamson T., Green M.E., Khan S., Jordan K.P. Prevalence and management of osteoarthritis in primary care: an epidemiologic cohort study from the Canadian Primary Care Sentinel Surveillance Network. CMAJ Open. 2015 Jul 17;3(3):E270-5. 4. Mouravska N., Zielinski L., Bhatt M., Sanger N., Bawor M., Dennis B., et al. Adverse outcomes associated with opioid prescription for acute low back pain: a systematic review protocol. 2017;6(1):163. 5. Murray J.C., Canizares M., Power J.D., Perruccio A.V., Rampersaud Y.R., on behalf of the Canadian Spine Outcomes and Research Network (CSORN). The influence of preoperative opioid use on self-reported pain and disability one year after elective spine surgery. Manuscript in preparation (2018). 6. Thiels C.A., Anderson S.S., Ubl D.S., et al. Wide Variation and Over prescription of Opioids After Elective Surgery. Ann Surg. July 2017.

COA Position Statement on Opioids and Orthopaedic Surgical Practice Jeff Gollish, M.D., FRCSC, Toronto, ON Trinity Wittman, MSc, COA, Manager of Development and Advocacy

s the annual number of deaths attributed to opioid overdose in Canada continues to rise, there is increasing attention on the availability of opioids, whether obtained through prescription or illicit acquisition. The COA encourages all orthopaedic surgeons to have an in-depth understanding of their own role in safe and effective pain management, including the role of prescription opioids in the spectrum of pharmaceutical and non-pharmaceutical options for pain management.

COA Bulletin ACO - Winter / Hiver 2018

Why Should Surgeons Beef Up Their Opioids Knowledge? Surgeons are responsible for writing 60% of “new start” opioid prescriptions1. The risk of a new start patient becoming a chronic opioid user is estimated to be five percent2. Given the alarming combination of unacceptably long wait times coupled with rampant opioid use and dependence, it is incumbent on us (as the national society) to acknowledge that for many members, our medical training lacked the appropriate depth into safe pain management required to effectively do our part to combat the opioid tragedies taking place across the country. In the October 2018 edition of AAOS Now, Dr. Megan Conti Mica from Chicago shared a personal story from her own practice on the ‘quintessential student athlete’, who did not use a single opioid pill post hand surgery, but who attempted suicide with unused hydrocodone following an assault which took place three months after the operation.

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 44)

We can and we must do better at collectively encouraging optimal pain management and eliminating diversion of prescribed opioids. Pain Management Survey Results As a preliminary step, the Standards Committee, under the leadership of Dr. Jeff Gollish, surveyed members in 2017 about their approaches to pain management. The survey questions refer to surgical procedures or trauma that would be expected to result in moderate to severe pain (7/10 or greater on the VAS Scale). Key Findings: • There is wide variation in choice of narcotic medication and number of pills prescribed. • The majority of respondents supported limiting the initial post-discharge opioid prescription to a maximum of two weeks, even for highly painful procedures. • Large variability in the number of pills prescribed at discharge and willingness to prescribe long-acting opioids. • Dosing and duration guidelines are a particular challenge in orthopaedics, given the broad spectrum of conditions managed under the orthopaedic umbrella. • This wide diversity of practices reinforced that members would benefit from some direction for prescribing and discussing with patients. Position Statement Founded upon a thorough literature review and survey results, the Standards Committee set out to develop a tool to assist members in discussions with patients. The COA Position statement on Opioids and Orthopaedic Surgical Practice was published in June 2018, touching on numerous points including the consideration of evidence-based non-pharmacological treatments and adjuvant medications, as well as medical interactions. Key Messages √ The COA supports “The 2017 Canadian Guideline for Opioids for Chronic Non-Cancer Pain”, recently published in the CMAJ3. No similar guidelines for acute pain currently exist to our knowledge. √ Avoid prescribing an initial post-discharge opioid prescription exceeding two weeks in duration, even for procedures anticipated to be associated with severe pain (except in extreme cases). √ Ensure that in situations in which a patient continues to report pain of significant severity beyond the anticipated timeframe of pain subsidence, re-assessment of the patient by the surgeon or general practitioner is considered, particularly if the first routine post-surgical follow-up visit is not imminent. √ Consult with the hospital Acute Pain Service (APS), where available, for assistance with multimodal analgesia and in prescribing post-discharge medications, especially in patients who are not narcotic naïve. √ Ensure that all patients who are prescribed opioids are advised about the risks of taking opioids and the potential for withdrawal symptoms.

COA Bulletin ACO - Winter / Hiver 2018

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

(continued from page 45)

√ Minimize diversion of opioid medications and risks of accidental or deliberate overdose, especially related to children and seniors, by advising patients and family members regarding: • Safe storage, including child-proof container and location. • Proper handling of unused medication, which should be returned to the pharmacy for disposal at the earliest convenience following discontinuation of use. Click here to view the full COA Position statement on Opioids and Orthopaedic Surgical Practice.

Comments? E-mail policy@canorth.org

References 1. Health Quality Ontario. Starting on Opioids: Opioid prescribing patterns in Ontario by family doctors, surgeons, and dentists, for people starting to take opioids. Toronto: Queen’s Printer for Ontario; 2018 [cited 2018 June 13]. Available from: http://www.hqontario.ca/SystemPerformance/Specialized-Reports/Starting-on-Opioids-inOntario 2. Goesling J., Moser S.E., Zaidi B., Hassett A.L., Hilliard P., Hallstrom B., et al. Trends and predictors of opioid use after total knee and total hip arthroplasty. Pain [Internet]. 2016 June [cited 2018 June 13]; 157(6): 12591265. Available from: https://insights.ovid.com/cros sref?an=00006396-201606000-00012 DOI: 10.1097/j. pain.0000000000000516. 3. Busse J.W., Craigie S., Juurlink D.N., Buckley D.N., Wang L., Couban R.J., et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ [Internet]. 2017 May 08 [cited 2018 June 13];189 (18):E659-E666. Available from http://www. cmaj.ca/content/189/18/E659 DOI: https://doi.org/10.1503/ cmaj.170363

Énoncé de position de l’ACO : Les opioïdes et la chirurgie orthopédique Jeff Gollish, MD, FRCSC Toronto, Ont. Trinity Wittman, M.Sc. Directrice du développement et des activités de défense des droits de l’ACO

lors que le nombre annuel de décès dus à une surdose d’opioïdes au Canada ne cesse de croître, on s’intéresse de plus en plus à la disponibilité des opioïdes, qu’ils soient obtenus sous ordonnance ou de façon illicite. L’ACO incite tous les orthopédistes à bien comprendre leur rôle dans la gestion sûre et efficace de la douleur, ce qui comprend leur recours aux opioïdes parmi toutes les options, pharmacologiques et autres, qui s’offrent à eux pour la gestion de la douleur. Pourquoi les orthopédistes devraient-ils renforcer leurs connaissances sur les opioïdes? Les chirurgiens rédigent 60 % des « ordonnances nouvelles » d’opioïdes.1 Les risques qu’un patient qui reçoit une ordonnance nouvelle devienne un consommateur chronique d’opioïdes sont évalués à 5 %.2 La combinaison des temps d’attente inacceptables et du recours et de la dépendance aux opioïdes – qui atteignent des proportions endémiques – est inquiétante; il nous incombe donc, en tant que société nationale, de reconnaître que la formation médicale de bien des membres n’approfondissait pas COA Bulletin ACO - Winter / Hiver 2018

suffisamment la question de la gestion sécuritaire de la douleur pour que nous puissions participer de manière efficace à la lutte contre la crise des opioïdes qui a cours au pays. Dans le numéro d’octobre 2018 d’AAOS Now, la Dre Megan Conti Mica, de Chicago, raconte un cas tiré de sa propre pratique, l’histoire de « la quintessence de l’athlète étudiante », qui n’a pas consommé un seul comprimé d’opioïde après une chirurgie à la main, mais qui a tenté de s’enlever la vie en avalant les comprimés d’hydrocodone non utilisés à la suite d’une agression trois mois après l’opération. Nous pouvons et devons faire mieux, collectivement, pour favoriser une gestion optimale de la douleur et éliminer le détournement des ordonnances d’opioïdes. Résultats du Sondage sur les opioïdes et pratiques de gestion de la douleur À titre préliminaire, en 2017, le Comité sur les normes nationales de l’ACO, présidé par le Dr Jeff Gollish, a sondé les membres à propos de leurs pratiques de gestion de la douleur. Les questions du sondage portaient sur la gestion de la douleur à la suite de procédures chirurgicales ou de traumatismes qui devraient générer une douleur modérée à aiguë (d’au moins 7/10 sur l’échelle visuelle analogique).

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Principales constatations • Les narcotiques et le nombre de comprimés prescrits varient considérablement. • La majorité des répondants étaient en faveur d’une première ordonnance d’opioïdes d’au plus deux semaines après l’obtention du congé, même si la procédure est associée à des douleurs aiguës. • Il y a une grande variabilité dans le nombre de comprimés prescrits au congé et dans la volonté de prescrire des opioïdes à action prolongée. • L’établissement de lignes directrices pour la posologie et la durée s’avère particulièrement complexe en orthopédie, vu le large spectre de troubles traités. • La grande diversité dans les pratiques vient confirmer que les membres bénéficieraient de lignes directrices pour la prescription ainsi que les discussions avec leurs patients. Énoncé de position En se fondant sur un examen rigoureux de la littérature et les résultats du sondage, le Comité sur les normes nationales a entrepris de concevoir un outil afin de faciliter les discussions des membres avec leurs patients. L’Énoncé de position de l’ACO : Les opioïdes et la chirurgie orthopédique, publié en juin 2018, aborde une série de points, y compris la considération de traitements non pharmacologiques éprouvés, du recours aux adjuvants, de même que des interactions médicamenteuses. Messages clés √ L’ACO appuie les Recommandations canadiennes 2017 sur l’utilisation des opioïdes pour le traitement de la douleur chronique non cancéreuse, publiées récemment dans le Journal de l’Association médicale canadienne.3 À notre connaissance, il n’existe pas de lignes directrices semblables pour la gestion de la douleur aiguë actuellement. √ Éviter toute ordonnance nouvelle d’opioïdes de plus de deux semaines après l’obtention du congé, même si la procédure est associée à des douleurs aiguës, sauf dans des circonstances extrêmes. √ Veiller à ce qu’un patient qui continue de rapporter des douleurs aiguës au-delà des délais habituels soit réévalué par le chirurgien ou un généraliste, surtout si le premier suivi postopératoire n’est pas imminent. √ Consulter le service de contrôle de la douleur aiguë de l’hôpital, le cas échéant, pour obtenir de l’aide à propos de l’analgésie multimodale et de la prescription de médicaments après l’obtention du congé, surtout pour les patients ayant une tolérance aux opioïdes. √ Veiller à ce que tous les patients qui reçoivent une ordonnance d’opioïdes soient avisés des risques inhérents à ces médicaments et des symptômes de sevrage possibles.

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√ Minimiser le détournement des ordonnances d’opioïdes et les risques de surdoses accidentelles ou délibérées, particulièrement en ce qui a trait aux enfants et aux personnes âgées, en informant les patients et les membres de la famille sur ce qui suit : • Entreposage sécuritaire des médicaments, y compris les contenants et les endroits à l’épreuve des enfants • Traitement adéquat des médicaments non utilisés, soit leur retour dès que possible à la pharmacie, où ils sont détruits Cliquez ici pour lire l’Énoncé de position de l’ACO : Les opioïdes et la chirurgie orthopédique.

Vous avez des commentaires à formuler? Écrivez à policy@canorth.org

Références 1. QUALITÉ DES SERVICES DE SANTÉ ONTARIO. Ordonnances nouvelles d’opioïdes : Tendances en matière de prescription d’ordonnances nouvelles d’opioïdes par les médecins de famille, les chirurgiens et les dentistes ontariens, Imprimeur de la Reine pour l’Ontario, Toronto, 2018. Internet (consulté le 13 juin 2018) : www.hqontario.ca/Rendementdu-système/Rapports-spécialisés/Ordonnances-nouvellesdopioïdes-en-Ontario 2. GOESLING, J., S.E. MOSER, B. ZAIDI, A.L. HASSETT, P. HILLIARD, B. HALLSTROM et al. « Trends and predictors of opioid use after total knee and total hip arthroplasty », Pain, vol. 157, no 6 (juin 2016), p. 1259-1265. Internet (consulté le 13 juin 2018) : https://insights.ovid.com/cro ssref?an=00006396-201606000-00012. DOI : 10.1097/j. pain.0000000000000516 3. BUSSE, J.W., S. CRAIGIE, D.N. JUURLINK, D.N. BUCKLEY, L. WANG, R.J. COUBAN et al. « Guideline for opioid therapy and chronic noncancer pain », Journal de l’Association médicale canadienne, vol. 189, no 18 (8 mai 2017), p. E659-E666. Internet (consulté le 13 juin 2018) : www.cmaj.ca/content/189/18/E659. DOI : https://doi.org/10.1503/ cmaj.170363

Regional Orthopaedic Program Supports Equitable Access to Care The RAC is governed by Thunder Bay Regional Health Sciences Centre’s Regional Orthopaedic Program (ROP) and combines the Regional Joint Assessment Centre (hip and knee) and InterProfessional Spine Assessment and Education (ISAEC low back pain) clinic. Created in partnership with the North West LHIN, the clinic has proven benefits to both patients and providers, including:

Caroline Fanti, MHM, BSc (PT), BSc (HK) Program Director, Regional Orthopaedic Program David Puskas, M.D., MSc, FRCSC Medical Director of Musculoskeletal Health Thunder Bay, ON

ntario’s North West Local Health Integration Network (LHIN) has a land mass the size of France with a population of approximately 230,000 people. Recruitment and retention of specialists and access to specialist care across this vast geography have been long-standing historical problems until now. An interprofessional orthopaedic team has developed an innovative hub and spoke model of care to address this issue.

The COA invites members to feature innovative orthopaedic care pathways from across the country. If you would like to submit your model of care for publication in the Bulletin, please contact Trinity Wittman at policy@canorth.org.

The Rapid Access Clinic (RAC) is improving patient experiences and making wait times more equitable for musculoskeletal patients across Northwestern Ontario. The RAC has been designated by the Ministry of Health and Long-Term Care as a Musculoskeletal Program of Excellence.

COA Bulletin ACO - Winter / Hiver 2018

• Improved access to care for musculoskeletal patients and streamlined referral process • Closer-to-home care for more patients in the region • Reduced costs to the system • Reduced wait times • Improved health outcomes Key components to the clinic’s success include regional integration, advanced technology and cohesive, collaborative orthopaedic team members who work together to provide consultative and surgical services across four surgical sites in the North West LHIN.

At the heart of the program is the new PRO-cedure Management Information System (PROMIS) digital health system co-developed by the ROP to create a single point of

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access for referrers. It links together existing systems such as the regional referral system, hospital information system (HIS), and Cancer Care Ontario’s Wait Time Information System (CCO-WTIS). PROMIS delivers centralized e-booking capabilities with real time clinic and operating room scheduling at all four sites in order to transparently manage wait times for surgeons, track wait time and other performance metrics, and help standardize preoperative processes.

Dr. David Puskas and Ms. Caroline uses Fanti, founders of the Regional Orthopaedic Program.

The program also technology such as Ontario Telemedicine Network’s videoconferencing capabilities and actively introduces new services such as Home Video Visits to the program as they become available. This allows regional patients to access the care they need without having to travel.

Outcomes Evidence-based, standardized models of care have been proven to reduce length of hospital stays, reduce the number and severity of complications, improve health outcomes, and provide more equitable outcomes throughout the region – improving care while reducing costs. The Regional Orthopaedics Program has realized several impacts to indicators of quality such as: • Reduced wait times for all MSK appointments including hip and knee surgeries • Reduced costs to the system • Improved resource use across the region, both in terms of financial and human resources Continuing advantages to the patient and the system include: • Decreased intensity and frequency of care • Decreased ED visits • Decreased Primary Care repeat visits • Decreased imaging procedures by eliminating duplication • Decreased risk of narcotic use and dependence • Decreased risk of depression secondary to chronic pain • Decreased lost time off work

How Does the Regional Orthopaedic Program (ROP) Model of Care Work? The ROP provides onsite consultation and surgery at four facilities in the North West LHIN: Thunder Bay Regional Health Sciences Centre, Dryden Regional Health Centre, Lake of the Woods District Hospital and Riverside Health Care. It functions as a “hub and spoke model” to streamline the referral process from primary care, to referral for consultation and possible surgery, to recovery and rehabilitation. The result is more equitable access to care, improved health outcomes, and an increase in the overall quality of care provided to orthopaedic patients across the region. The ROP is a highly integrated system focused on improving access to specialists through continuous engagement of its partners, implementation of clinical care standards and best practices, and investment in capacity to support improved services. The unified vision of all our regional partners at hospitals and the LHIN (including administrators, leaders, surgeons, clinicians and patients) has allowed the program to transition from four separate hospitals operating in silos, to four sites with a one-model of care program with the following benefits: • • • •

Streamlined referral patterns and care pathway More efficient use of resources Standardized Care Meeting the needs of patients living in urban, rural and remote areas of the North West LHIN

There are other opportunities to leverage advanced technology to overcome geographical barriers and improve access to care within this program as well. For example, the ROP is investigating new service delivery methods for patients living in remote First Nations in the North West LHIN to improve outcomes and reduce morbidity related to lower access to care (prevent amputations, disability from inappropriate practice and delays, etc.).

Multidisciplinary team at the Rapid Access Clinic

The streamlined ROP reduces system costs in a number of ways: • Maximized resources and efficiency – increased surgical throughput in regional facilities from 2-3 total joint replacement surgeries/day to 4-6 (50% reduction in cost per case) • Reduced travel grants – savings of 90 travel grants per visit to the region. At 30 visits per year, that is 2,700 travel grants • Optimized telemedicine consults – 120 consults and follow-ups per week or 1,440 per year • Decreased diagnostic imaging costs due to prioritization at the Central Intake and timely access to care

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Efficiency is also improved through the maximization and use of existing resources within the system, while also demonstrating effectiveness through the matching of care and science. For example: • Reverse hub and spoke model of care which brings a team to each regional site • Increasing OR utilization • Preventing over-booking and under-booking of the OR • Driving volumes by site and by provider to decrease complication risks as supported by research These efficiency improvements in a constrained fiscal environment have also coincided with improvements in wait time information, clinical care standards, access to specialists and capacity planning.

The sustainability of the program is evidenced by the ability to link with other programs including rheumatology, self-management and chronic low back pain programs in our communities, as well as local and provincial support for the expansion of these initiatives. The expansion also presents the opportunity to test acute and post-acute upstream bundled care payments for Quality Based Procedures – including the preoperative assessment and postoperative follow-up. The ROP is a flexible but standardized framework that can be used as a template for any clinical and/or community program. We are a navigational beacon to all other surgical services on how to improve patient care and health system efficiencies. For more information or questions, please contact Caroline Fanti at fantic@tbh.net.

“Lack of Access to Justice, Lack of Access to Care” Brian Day, M.D., FRCSC Vancouver, BC

t the heart of our ongoing constitutional challenge is patient suffering (physical, mental and economic) while waiting for treatment, combined with the irreversible harms suffered afterwards. Governments and opposing intervenors in our case continue a strategy of referencing it as the ‘Cambie Case’, or personalizing it to me, and ignore five patient plaintiffs and the irreversible harms they suffered. “We certainly acknowledge that there are patients who are waiting longer than they should and there are patients who are experiencing pain and discomfort while they’re waiting”, confessed a government lawyer during our trial. Showing disdain for patient suffering, he disclosed the government’s strategy in the case: “I’ll get into this a little bit later, but it’s not that the waiting list didn’t cause the harm; it’s that the legislation didn’t cause the harm.” Further into the trial, we have come to understand the meaning of that concession. Harm is admitted, but government strategy is to assign blame to the health authorities or doctors. Government conveniently ignores the fact that they appoint and control hospital boards and they control funding and ration patient care. A few years ago I debated “Health and the Constitution” with Lorne Sossin, Dean of Osgoode Hall Law School. He argued it was the role of governments, rather than the courts, to change the law. He faced admonishment from an attending senior Ontario judge for underestimating the court’s responsibility to enforce constitutional rights and make governments accountable. That criticism was consistent with many rulings of the Supreme Court of Canada. I believe the 81% of residents, which polls show support our case, deserve such accountability. After the debate, Dean Sossin, who has co-authored a book called “Access to Justice, Access to Care”, conceded that he was “agnostic” rather than opposed to private medical insurance. We ended by agreeing to consider co-authorship of a book, COA Bulletin ACO - Winter / Hiver 2018

“Lack of Access to Care, Lack of Access to Justice”. Twenty years ago, I had been scheduled for a similar live debate on CBC television with Andrew Petter, former Dean of Law and BC Minister of Health. Petter withdrew at the last minute because he had “not been adequately briefed” to debate health law with an orthopaedic surgeon. Our current constitutional challenge would fit in nicely as an introductory chapter in the book. We have faced a prolonged filibuster mounted by government lawyers who appear to believe that they cannot defend their case based on factual evidence. They have conspired to make the legal process as onerous and costly for us as possible. I was recently on the witness stand. In cross examination, I was questioned only on billings, legers, payments, and profit margins. Not a single question related to wait lists, harm to patients, or rationing of care. The same lawyer had spent endless days of court time arguing to exclude any such references from my affidavit. The government has fought tooth and nail to exclude their own data on wait lists and harms. We had to call a hostile government witness in order to get that data into evidence. I believe their strategy is to needlessly prolong the trial, hoping that funding constraints will force us to abandon our efforts. That strategy will fail.

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 50)

A question uppermost in my mind, as we approach 2019, is whether the Canadian Charter of Rights and Freedoms has any value for a citizen whose rights are violated? Our action was launched in 2009, and the trial began over two years ago. The Chaoulli case lasted six weeks. We have raised several million dollars (and taken out a new mortgage) during this period, but our opponent has unlimited tax dollars with which to oppose us. How can any ordinary citizen ever afford to fight for their rights? An opposing lawyer (Joe Arvay) in our case has previously made this point when he said: “I believe that if we are going to have an equal playing field when we are litigating the Charter, the government should be required to pay the cost of not only the government lawyers but the lawyers on the other side of the case, because one of the greatest impediments to justice or the access to justice in Canada is our legal costs.” “Governments don’t have any problems finding the money to defend laws when they are being challenged, but citizens have a huge amount of difficulty.” In practical terms, our Charter offers no more protection of individual rights than those living in oppressive and authoritarian regimes. Last year, the Canadian Constitution Foundation (https://www.yourhealthcantwait.ca/news) which is supporting our challenge, filed a freedom of information request after the BC Government refused to disclose its expenditures in fighting to deny patients access to timely care. The Privacy Commissioner ordered the government to divulge costs by September 26, 2018. The day before the deadline, the government filed a petition in BC Supreme Court to have the Commissioner’s order quashed, so generating another costly court battle aimed at limiting transparency. Government documents confirm that BC fails to meet its own maximum wait times, beyond which patients are harmed, with only 12% of patients with hip arthritis in “severe pain, unable to self-care, and at risk of serious harm” being treated within that period. For lung cancer it’s 31%, and for bladder cancer “with high risk of progression” only 13%. There are thousands of similar shameful examples. Government is dismissive of patients lacking access to a GP, mental health services, cancer treatment, or those languishing on ER stretchers for days.

children) – are significantly underestimated. This new finding, combined with existing evidence at trial of a physician being ordered to stop seeing patients, in order to make waits seem shorter, and to reclassify patients designated in a “moderate” pain category of prioritization to a “mild” category, illustrate an almost fanatical effort aimed at hiding the truth. The Canadian Institute for Health Information reports that the number of patients waiting over four months for elective surgery in Canada is nine times that in France; four and half times that in Holland; three times that in Switzerland; and over 18 times that in Germany. Federal and provincial governments are responsible for such poor performance, and exacerbate the suffering as they outlaw an individual’s right to care for their own bodies. Proposed new BC government fines of $20,000 per patient undergoing private MRIs or surgery have now been successfully challenged in court, with the granting of an injunction against the BC government. Had we failed, the rights’ violations would have escalated to new heights as wait lists would have risen dramatically. The only possible rationale for such fines was to eliminate competition and choice in order to preserve an underperforming monopoly. The independent judge granting the injunction ruled in a manner that is extremely rare in Canadian legal history. She also ruled that patients were being harmed, and that we, the plaintiffs, had “established irreparable harm in the context of a constitutional case”. Governments continue to mandate that patients wait and suffer despite our Canadian Charter of Rights. Such laws do not exist anywhere in the world. Groups in Canada historically exempted from such “government ownership” of their bodies have included the RCMP, Canadian Armed Forces, Workers’ Compensation Boards, federal employees and prisoners. Such exemptions also appear to violate Article 7 of the Universal Declaration of Human Rights which states, “All are equal before the law and are entitled without any discrimination to equal protection of the law.” Surely, it is not unreasonable to have a court declare that Canadians who are not in jail be granted the same rights and freedoms as those who are?

We have recently discovered that original data is being manipulated and that wait times in children (three of the plaintiffs were

Click here to read the court’s November 23 decision to grant the Cambie Surgeries Corporation et al. an injunction to prevent the BC government to bring certain provisions of the Medicare Protection Amendment Act pending a final determination of the constitutional issues raised in Dr. Day’s action is dismissed.

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 - Winter / Hiver 2018

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

Choosing Wisely Canada: Advancing Conversations about Overuse in Orthopaedics Eric Bohm, M.D., MSc, FRCSC Professor, University of Manitoba Co-lead for Choosing Wisely Manitoba Winnipeg, MB Karen Born, PhD Knowledge Translation Lead, Choosing Wisely Canada Assistant Professor, Institute for Health Policy, Management & Evaluation, Faculty of Medicine, University of Toronto Toronto, ON

common orthopaedic conditions, and are intended to facilitate informed decision making by surgeons and their patients. 1. Do not use arthroscopic debridement as a primary treatment in the management of osteoarthritis of the knee.

hoosing Wisely Canada is the national voice on overuse in Canada. The campaign launched in 2014 in partnership with the Canadian Medical Association and more than 50 national clinician societies. The Canadian Orthopaedic Association (COA), the Canadian Arthroplasty Society (CAS) and Arthroscopy Association of Canada (AAC) are campaign partners. National clinician societies are the heart of the campaign, and their members have formed working groups to develop lists of recommendations of tests, treatments and procedures that clinicians and patients should question. These lists serve as the basis for which national, regional and local activities are centered. Lists are evidence-based, and developed in a transparent fashion. They target common tests, treatments and procedures within a specialty which are overused, there is strong evidence that they confer no benefit, and may event cause harm. The lists are intended to be the basis for conversations, both within the profession and specialty, but also with patients about the harms and risks of unnecessary tests, treatments and procedures. It can be challenging to explain to patients that commonly offered medical tests and treatments can sometimes offer no benefit, and might even be harmful. The campaign has developed plain language information for patients and the public to help share the message that sometimes more is not always better. This information has taken shape as op-eds in national media, as well as posters distributed to physician offices, medical labs and hospitals which share this information and messaging. Most Recent Orthopaedic Recommendations The lists are living documents and are updated each year. This year, the COA, CAS and AAC added a number of new recommendations to the list of existing recommendations related to orthopaedic surgery. These reflect an ongoing commitment to ensuring that the lists represent the most up to date and high-quality evidence. The recommendations relate to COA Bulletin ACO - Winter / Hiver 2018

Several recent meta-analyses1-4 have culminated in clinical practice guidelines recommending against the use of arthroscopic debridement for the treatment of degenerative knee arthritis and meniscal tears in patients over the age of 35, as it appears there is no maintained benefit of arthroscopic surgery over conservative management (exercise therapy, injections, drugs)5. However, this does not preclude the judicious use of arthroscopic surgery when indicated to manage symptomatic coexisting pathology in the presence of osteoarthritis or degeneration6.

2. Don’t order a knee MRI when weight-bearing X-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis, as the MRI rarely adds useful information to guide diagnosis or treatment.

The diagnosis of knee osteoarthritis can be effectively made based upon the patient’s history, physical examination and plain radiography consisting of weightbearing posterior-anterior, lateral and skyline views7-9. Ordering MRI scans incurs further waiting times for patients, can cause unnecessary anxiety while waiting for specialist consultation, and can delay MRI imaging for appropriate patients.

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 52)

3. Do not order a hip MRI when X-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis, as they rarely add useful information to guide diagnosis or treatment.

The diagnosis of hip osteoarthritis can be effectively made based upon the patient’s history, physical examination and plain radiography7,9. Ordering MRI scans incurs further waiting times for patients, can cause unnecessary anxiety while waiting for specialist consultation, and can delay MRI imaging for appropriate patients.

4. Do not prescribe opioids for management of osteoarthritis before optimizing the use of non-opioid approaches to pain management.

The use of opioids in chronic non-cancer pain is associated with significant risks. Optimization of non-opioid pharmacotherapy and non-pharmacologic therapy is strongly recommended. Treatment with opioids is not superior to treatment with non-opioid medications in improving pain-related function over 12 months in patients with moderate to severe hip, knee or back pain due to osteoarthritis10,11.

5. Do not routinely request pathological examination of tissue from uncomplicated primary hip and knee replacement surgery undertaken for degenerative arthritis.

Several large reviews including thousands of patients have demonstrated that routine pathological examination of operative specimens from uncomplicated primary hip and knee arthroplasty surgeries does not alter patient management or outcome12-15.

Implementation of the Campaign While the lists are at the centre of the Choosing Wisely Canada campaign, there are increasing efforts from coast to coast to ‘go beyond the list’. This has included regionally-coordinated efforts to implement campaign recommendations into practice. An example of this relevant to orthopaedic surgery are efforts to revise order sets, pre-surgical guidelines and form templates to reduce unnecessary preoperative testing for our patients. Commonly-ordered preoperative tests such as chest X-rays, ECGs and blood work for healthy patients undergoing minor orthopaedic procedures can cause harm, including further invasive and unnecessary tests from false positive or borderline results, as well as delaying surgery. These waste health-system resources, and cause physical and psychological stress to patients.

Choosing Wisely Recommendations are intended to support evidence-based decisions by providers and their patients about tests, treatments and procedures. These current recommendations will directly affect common practice patterns, however by incorporating new evidence into practice; our specialty can play a role in redirecting resources from low to high value care, and in reducing potential harm and stress for patients. References 1. Brignardello-Petersen R., Guyatt G.H., Buchbinder R., Poolman R.W., Schandelmaier S., Chang Y., et al. Knee arthroscopy versus conservative management in patients with degenerative knee disease: a systematic review. BMJ Open. 2017;7(5):e016114. 2. Khan M., Evaniew N., Bedi A., Ayeni O.R., Bhandari M. Arthroscopic surgery for degenerative tears of the meniscus: a systematic review and meta-analysis. CMAJ. 2014;186(14):1057-64. 3. Laupattarakasem W., Laopaiboon M., Laupattarakasem P., Sumananont C. Arthroscopic debridement for knee osteoarthritis. Cochrane Database Syst Rev. 2008(1):CD005118. 4. Thorlund J.B., Juhl C.B., Roos E.M., Lohmander L.S. Arthroscopic surgery for degenerative knee: systematic review and metaanalysis of benefits and harms. BMJ. 2015;350:h2747. 5. Siemieniuk R.A.C., Harris I.A., Agoritsas T., Poolman R.W., Brignardello-Petersen R., Van de Velde S., et al. Arthroscopic surgery for degenerative knee arthritis and meniscal tears: a clinical practice guideline. BMJ. 2017;357:j1982.

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6. Arthroscopy Association of Canada. Position Statement of Arthroscopy Association of Canada (AAC) Concerning Arthroscopy of the Knee Joint - September 2017. Available from: http://coa-aco.org/wp-content/uploads/2017/09/ AAC-position-statement-Knee-Arthroscopy-2017Sept.pdf.

11. Krebs E.E., Gravely A., Nugent S., Jensen A.C., DeRonne B., Goldsmith E.S., et al. Effect of Opioid vs Nonopioid Medications on Pain-Related Function in Patients With Chronic Back Pain or Hip or Knee Osteoarthritis Pain: The SPACE Randomized Clinical Trial. JAMA. 2018;319(9):872-82.

7. Menashe L., Hirko K., Losina E., Kloppenburg M., Zhang W., Li L., et al. The diagnostic performance of MRI in osteoarthritis: a systematic review and meta-analysis. Osteoarthritis Cartilage. 2012;20(1):13-21.

12. Campbell M.L., Gregory A.M., Mauerhan D.R. Collection of surgical specimens in total joint arthroplasty. Is routine pathology cost effective? J Arthroplasty. 1997;12(1):60-3.

8. Zhang W., Doherty M., Peat G., Bierma-Zeinstra M.A., Arden N.K., Bresnihan B., et al. EULAR evidence-based recommendations for the diagnosis of knee osteoarthritis. Ann Rheum Dis. 2010;69(3):483-9.

13. Kocher M.S., Erens G., Thornhill T.S., Ready J.E. Cost and effectiveness of routine pathological examination of operative specimens obtained during primary total hip and knee replacement in patients with osteoarthritis. J Bone Joint Surg Am. 2000;82-A(11):1531-5.

9. Sakellariou G., Conaghan P.G., Zhang W., Bijlsma J.W.J, Boyesen P., D’Agostino M.A., et al. EULAR recommendations for the use of imaging in the clinical management of peripheral joint osteoarthritis. Ann Rheum Dis. 2017;76(9):1484-94.

14. Lin M.M., Goldsmith J.D., Resch S.C., DeAngelis J.P., Ramappa A.J. Histologic examinations of arthroplasty specimens are not cost-effective: a retrospective cohort study. Clin Orthop Relat Res. 2012;470(5):1452-60.

10. Busse J.W., Craigie S., Juurlink D.N., Buckley D.N., Wang L., Couban R.J., et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ. 2017;189(18):E659-E66.

15. Meding J.B., Ritter M.A., Jones N.L., Keating E.M., Faris P.M. Determining the necessity for routine pathologic examinations in uncomplicated total hip and total knee arthroplasties. J Arthroplasty. 2000;15(1):69-71.

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

Your COA, Coast to Coast

L’ACO, d’un bout à l’autre du pays

he COA values its strong and thriving partnerships with provincial and subspecialty societies, working with them to position the collective skill and expertise in orthopaedics to government, the media and other MSK health-care providers. The opportunity to support the provincial societies is critical to our efforts in advocating for improved access to MSK care. We would like to thank the Atlantic Provinces, Ontario, Quebec, and Manitoba, provincial societies for involving the COA in various capacities of their meeting programs over the past year. Diversity, Advocacy and Engagement Executive members, Drs. Kevin Orrell and Laurie Hiemstra presented a comprehensive update on the Association’s various initiatives in advocacy, employment, and diversity at the Atlantic Provinces Orthopaedic Society (APOS) meeting in September 2018. In her closing remarks at the Quebec Orthopaedic Association meeting in Lévis, Nominating Committee Member (Quebec Representative), Dr. Monika Volesky, encouraged engagement by inviting participation in the COA COA Executive members, Annual Meeting in Montréal next Drs. Kevin Orrell and June 2019. Also, a specific call was Laurie Hiemstra with 2018 made to provincial members to APOS Program Co-Chair, be involved in a committee or Dr. Brendan Sheehan. leadership position. Notably, Quebec has the largest proportion of female orthopaedic surgeons in the country, and Dr. Volesky highlighted some of the gender and diversity programs that the COA is currently pursuing.

’ACO tient à ses partenariats forts et florissants avec les associations provinciales et les sociétés de sous-spécialité; elle travaille avec elles de sorte à faire valoir nos compétences et notre savoir-faire collectifs en orthopédie auprès des gouvernements, des médias et des autres fournisseurs de soins de l’appareil locomoteur. La possibilité de soutenir les associations provinciales est essentielle à nos efforts en vue de l’amélioration de l’accès aux soins de l’appareil locomoteur. Nous aimerions remercier les associations des provinces de l’Atlantique, de l’Ontario, du Québec et du Manitoba d’avoir intégré l’ACO à divers degrés dans le programme de leur congrès cette année. Diversité, défense des droits et intérêts et participation Les Drs Kevin Orrell et Laurie Hiemstra, membres du Comité de direction de l’ACO, ont présenté une mise à jour exhaustive sur les initiatives de l’ACO en matière de défense des droits et intérêts, d’emploi et de diversité au congrès de l’Atlantic Provinces Orthopaedic Society (APOS), en septembre 2018. Dans son mot de la fin au congrès de l’Association d’orthopédie du Québec à Lévis, la Dre Monika Volesky, représentante du Québec au sein du Comité des candidatures de l’ACO, a invité les congressistes à participer à la Réunion annuelle de l’ACO à Montréal, en juin 2019. De même, on a invité les membres québécois à siéger à un comité ou à assumer un rôle de leadership au sein de l’ACO. Il importe de souligner que c’est au Québec qu’on trouve la plus forte proportion de femmes orthopédistes au pays; la Dre Volesky en a profité pour mentionner certains des programmes axés sur le sexe et la diversité actuellement élaborés par l’ACO. Opioïdes et pratiques de gestion de la douleur Au congrès annuel de l’Ontario Orthopaedic Association, en novembre, le Dr Bheeshma Ravi, membre actif de l’ACO, a fait le résumé de l’Énoncé de position de l’ACO : Les opioïdes et la chirurgie orthopédique pendant un symposium sur la crise des opioïdes et le cannabis médicinal comme solution de rechange.

Opioids and Pain Management COA Active member, Dr. Bheeshma Ravi, summarized the COA’s Position Statement on Opioids and Orthopaedic Surgical Practice during a symposium on the opioid crisis and medical cannabis alternatives held at the Ontario Orthopaedic Association (OOA) Annual Meeting Dr. Bheeshma Ravi presents a summary of the COA’s opioids in November 2018.

L’Annual Manitoba Orthopaedic Symposium comprenait un exposé du Dr Ryan Amadeo, de la Pan Am Pain Management Clinic,

position statement at the OOA Annual Meeting.

The Manitoba Orthopaedic Symposium included a talk on the opioid crisis by Dr. Ryan Amadeo from Winnipeg’s Pan Am Pain Management Clinic. Dr. Amadeo referenced the COA’s Position Statement during his presentation and informed provincial members how they can access this resource through the COA. If the COA could assist or contribute your provincial or local orthopaedic meeting, please contact Cynthia Vezina: cynthia@canorth.org.

à Winnipeg, sur la crise des opioïdes. Le Dr Amadeo a cité l’énoncé de position de l’ACO pendant son exposé, en plus d’indiquer aux participants où ils pouvaient le trouver. Si l’ACO peut contribuer de quelque façon que ce soit à une de vos activités provinciales ou locales en orthopédie, veuillez communiquer avec Cynthia Vezina, à cynthia@canorth.org.

COA Bulletin ACO - Winter / Hiver 2018

FAW systems with HEPA filters don’t improve surgical infection risk. Read the evidence for yourself. 3M™ Bair Hugger™ Normothermia System is the world’s leading forced-air warming (FAW) system, providing safe and effective warming therapy to surgical patients. Visit BairHugger.com/Filtration or contact your 3M Sales Representative to learn more.

Some forced-air warming manufacturers have suggested that their systems are safer because they use HEPA filtration. There is no scientific evidence that supports these claims. In fact, a retrospective review of patients who underwent total joint arthroplasty (TJA) at the Cleveland Clinic, and two high-volume arthroplasty regional hospitals, found that the Bair Hugger system was not associated to a higher risk of infection during TJA when compared to devices with HEPA filters.1

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Curtis, G.L., Faour, M., George, J., Klika, A.K., Barsoum, W.K., Higuera, C.A. High efficiency particulate air filters do not affect acute infection rates during primary total joint arthroplasty using forced air warmers. J. Arthroplasty. 2018 Feb. 5. Pii: S0883-5403(18)30107-4. doi: 10.1016/j.arth.2018.01.069. ; [Epub ahead of print] PMID: 29572038.

Foundation / Fondation

COF Presents Two Community Innovation Awards

he Canadian Orthopaedic Foundation announced the approval of two awards under its Community Innovation Awards competition in October 2018. The awards celebrate community-based surgeons and research studies dedicated to improving patient care or musculoskeletal health in their community. The two new projects are described here. Using patient-reported outcomes and mobility monitoring to optimize hospital care for patients undergoing knee arthroplasty – Dr. Scott Wiens, Dr. Wynand Wessels, Dr. Elroy Campbell, Dr. Jean Gelinas, Grande Prairie, Alberta Perioperative physicians have historically not had the means to systematically understand how patients do postoperatively. Next generation electronic medical records, EMRs (ie. Connect Care in Alberta) will provide some of the tools that will make the gathering of patient-centric data much easier. These tools, if used wisely, could finally enable clinicians to have Dr. Scott Wiens a better understanding of the incidence of things like postoperative nausea, pain, sleep disturbances and general patient satisfaction. We also believe that having a better understanding of individual patient’s pre and postoperative mobility would add valuable information to optimally manage postoperative pain, nausea and sleep disturbances. Optimal postoperative management of pain, nausea and sleep disturbances must take into account patient mobility. Our current study will examine the relationship between the timed up and go test (TUG test), which is a marker of frailty, and correlate it to self-evaluation of distance walked, sensor evaluated mobility and discharge times. Using sensor derived mobility data, we are able to track a patient’s progress before and after knee arthroplasty in an objective manner, which will hopefully allow us to understand the patient’s postoperative recovery and thus better understand and plan discharge readiness. Collating such data will hopefully create a basic framework for future research opportunities.

Smoking Cessation prior to Elective Surgery: Quality Improvement in a Centralized Intake Clinic Model Assessment to Implementation - Dr. James McInnes, Victoria, BC Hip and knee arthroplasty, together, represent the second most common in-patient surgeries in Canada and therefore represent an ideal target for surgical optimization in orthopaedic surgery. Smoking is a recognized modifiable risk factor in pre-surgical patients which can lead to increased peri and postoperative complications. Surgery itself represents an incentive for smoking cessation and existing wait times, though decreasing, may be viewed as providing an opportunity for optimization interventions. We plan to approach the issue of smoking in pre-arthroplasty patients in our local clinic and arthroplasty hospital through the application of described quality improvement tools. The project will encompass Dr. James McInnes initial assessment of the current model and focus on identifying and, later correcting, root causes and care gaps through an iterative series of change ideas directed at improving rates of preoperative smoking cessation. If successful, the improved process will ideally be expanded to involve all elective orthopaedic patients in our central intake clinic, and possibly other surgical specialties. 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 on the community, that would benefit from some much-needed funding. Dr. Rick Buckley, Chair of the COF Research Committee, says, “This competition enables us to fund some community-level research that otherwise might not be funded. The COF is filling a gap in the orthopaedic research environment with this competition, and we’re pleased to be able to fund these projects, which will have a direct impact on patients.” The COF’s research program is supported by industry partners in the Powering Pain Free Movement campaign: Zimmer Biomet, DePuy Synthes Canada, and Wright Medical Technology Inc.; and by orthopaedic surgeons and patients across the country.

COA Bulletin ACO - Winter / Hiver 2018

Foundation / Fondation

La Fondation Canadienne d’Orthopédie remet deux prix d’innovation communautaire

a Fondation Canadienne d’Orthopédie a annoncé la remise du Prix d’innovation communautaire à deux lauréats en octobre 2018. 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. Les deux projets primés sont décrits ci-après. Using patient reported outcomes and mobility monitoring to optimize hospital care for patients undergoing knee arthroplasty – Drs Scott Wiens, Wynand Wessels, Elroy Campbell et Jean Gélinas, Grande Prairie (Alberta) Les médecins assurant les services périopératoires n’ont traditionnellement pas de moyens pour comprendre de façon systématique le rétablissement postopératoire du patient. Les dossiers médicaux électroniques de nouvelle génération (Connect Care, en Alberta) leur donneront des outils qui faciliteront grandement la collecte de données sur les patients. Une utilisation Dr Scott Wiens judicieuse de ces outils pourrait enfin permettre aux cliniciens de mieux comprendre l’incidence, entre autres, des nausées, douleurs et troubles du sommeil postopératoires de même que de la satisfaction globale des patients. Nous sommes également d’avis que la gestion des douleurs, nausées et troubles du sommeil postopératoires pourrait être optimisée grâce à une meilleure compréhension de la mobilité du patient avant et après l’intervention. La gestion optimale des douleurs, nausées et troubles du sommeil postopératoires doit tenir compte de la mobilité du patient. Notre étude porte sur la relation entre le test chronométré du lever de chaise de Mathias (Timed Up and Go), qui est un marqueur de fragilité, et l’autoévaluation de la distance franchie, la mobilité évaluée grâce à des capteurs inertiels et la durée de l’hospitalisation. À l’aide des données sur la mobilité tirées des capteurs, nous sommes en mesure de suivre de façon objective la progression du patient avant et après son arthroplastie du genou, ce qui, nous l’espérons, nous permettra de comprendre le rétablissement postopératoire et ainsi de mieux cerner quand un patient peut obtenir son congé et de mieux le planifier. En colligeant ces données, nous espérons créer un cadre de recherche sur lequel s’appuieront de futurs travaux.

COA Bulletin ACO - Winter / Hiver 2018

Smoking Cessation prior to Elective Surgery: Quality Improvement in a Centralized Intake Clinic Model – Assessment to Implementation – Dr James McInnes, Victoria (Colombie-Britannique) Ensemble, les arthroplasties de la hanche et du genou arrivent au deuxième rang des interventions chirurgicales avec hospitalisation les plus répandues au Canada; il s’agit donc d’une cible d’optimisation chirurgicale idéale en orthopédie. Le tabagisme est un facteur de risque modifiable reconnu chez les patients en attente d’une chirurgie, et il peut augmenter les risques de complications périopératoires et postopératoires. La chirurgie en soi est un incitatif à la renonciation au tabac, et les temps d’attente, même s’ils sont en baisse, peuvent être vus comme une occasion d’intervention d’optimisation. Nous souhaitons aborder la question du tabagisme chez les patients qui doivent subir une arthroplastie dans notre clinique locale et établissement hospitalier grâce aux outils d’amélioration de la qualité établis. Le projet comprend Dr James McInnes l’évaluation initiale du modèle actuel et met l’accent sur l’établissement, puis la correction, des causes fondamentales et des écarts dans les soins grâce à un processus itératif axé sur des idées de changement qui vise l’amélioration du taux de renonciation au tabac avant l’intervention chirurgicale. S’il s’avère concluant, le processus amélioré sera idéalement appliqué à tous les patients en attente d’une chirurgie orthopédique non urgente dans notre clinique centrale d’admission et, peut-être, à d’autres spécialités chirurgicales. En remettant le Prix d’innovation communautaire, la Fondation Canadienne d’Orthopédie 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 Fondation : « Ce prix nous permet de financer des projets de recherche à l’échelle communautaire qui ne le seraient peut-être pas autrement. La Fondation vient ainsi combler une lacune dans le milieu de la recherche orthopédique, et est heureuse de pouvoir financer de tels projets, qui auront une incidence directe sur les patients. » Le programme de financement de la recherche de la Fondation est propulsé par ses partenaires de l’industrie qui appuient sa campagne Misons sur une vie sans douleur, soit Zimmer Biomet, DePuy Synthes Canada et Wright Medical Technology Inc., sans oublier des orthopédistes et patients de partout au pays.

More possibilities

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

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

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

Using the CanMEDS Roles in Your Practice

The Health Advocate Role: A Crucial Component of Expert Care Wade Gofton, M.D., MEd, FRCSC Director of Education, University of Ottawa Ottawa, ON Tyson Gofton, PhD Kevin Smit, M.D., FRCSC Assistant Professor, University of Ottawa The Children’s Hospital of Eastern Ontario Ottawa, ON

a wide range of choices for maintaining points. For example, time spent addressing medical-professional administrative or systems-related questions, including time spent on certain committees or developing clinical practice guidelines (Section 2) can be counted towards maintenance requirements. Reviewing and reflecting on results from an MCC 360 or other work-place appraisals may also be counted as HA maintenance points (Section 3).

s orthopaedic surgeons, we may be temptTeaching HA ed to think that our work is defined by what Trainees may have misconceptions about the HA takes place in the operating room. Even role. Initially, some trainees may be unclear about if surgery is central to the identity and practice of their role in patient-physician relationships. The orthopaedic surgery and its subspecialties, excellent approach to care delivery promoted by the CanMEDS Copyright © 2015 care requires that surgeons collaboframework encourages physicians to rate with patients. Communication, The Royal College of Physicians and Surgeons of Canada. take on a coaching role when working Reproduced with permission. collaboration, facilitation, planning, with patients, helping the patient to implementation and follow-up are identify goals of care and collaborating all key competencies of the Health in decisions about care options and the The CanMEDS framework is a tool used for teaching Advocate (HA) role and are essential development of care plans. Advocacy and for our continuing medical education. It is to supporting excellent care inside and is not about working for the patient, well established, benefits our profession and has outside of the operating room. but with them to reach common goals. been integrated into the Royal College’s programs Trainees may also initially confuse activincluding Maintenance of Certification. The seven HA in Practice ism and advocacy. While physicians roles of the CanMEDS are: Competence in HA is about more than may at times work to make systemic providing general health-care advice changes, HA is about collaboration with • Medical Expert (the integrating role) or preoperative consultation. Above the patient to achieve common goals. • Communicator all, HA is about working with patients. Many physicians will identify with the Since patients are individuals and have agency of the health services provider • Collaborator different values, expert care requires to advance patient health goals and • Leader close cooperation with patients to promote health equity. Finally, trainees • Health Advocate understand their priorities and supmay be unsure of how to balance HA • Scholar port them in realizing their health with the need for resource stewardship. • Professional goals. Excellent medical care also goes For example, a 63-year-old patient with beyond medical intervention to include notable radiographic OA and a menisThe Health Advocate role now wraps up this series disease prevention, health protection cal tear may feel that an arthroscopy is in the COA Bulletin. To review articles on each of and the promotion of health equity. in their best interests, while surgery is the CanMEDS roles featured in past editions, click The HA role closely supports the role not justified by the literature and may through the various roles listed above. Thank you to of Medical Expert, especially in helping place an unnecessary burden on scarce all of the contributors who provided guidelines on patients determine when and whether resources. how to use the CanMEDS roles to their full advantage surgery is an appropriate intervention. in your orthopaedic practice. – Ed. As an advocate, the surgeon also proWhen providing training in HA, it may vides expertise and care to support be helpful to think of HA as a process. the patient beyond the clinical context as they prepare for Initially, HA focuses on communicating with the patient to and recover from surgery by facilitating access to the services clarify values and health goals. Start by providing explicit of the health-care team and the broader care context, includorientation to trainees around common health, access and ing external health promotion agencies. HA in practice is also equity issues. For example, older patients receiving total hip evident when we, as orthopaedic surgeons, advocate for the arthroplasty may be at higher risk of falls and benefit from care of those whose voice may not be heard, as in the case of preoperative referral to a physiotherapist for balance exercises non-accidental trauma in children or the elderly. and occupational therapy for a home assessment. Preoperative consultations may also be rushed, leaving trainees with little Developing competency in HA is an important component opportunity to develop skills in understanding patient prioriof continuous medical education (CME). The Royal College ties and developing care plans. Provide trainees with guidance allows the distribution of maintenance points across roles and for starting conversations around common HA concerns, such COA Bulletin ACO - Winter / Hiver 2018

Training & Practice Management / Formation et gestion d’une pratique (continued from page 60)

as values in postoperative recovery, or common care decisions. Advocacy then takes the form of facilitation with allied health care. Demonstrate HA to trainees by picking up the phone to ensure patient needs are met in a timely fashion, especially if their issue is time-sensitive. The HA role then collaboratively develops in an action plan with the patient and the health-care team, such as the development of a postoperative return-tohome and rehabilitation plan. Once a plan has been developed, the HA role leads to the practical implementation of the care plan. In the operating room, HA helps the surgeon consider patient values and goals of care even when direct consultation is not possible. Finally, the surgeon maintains communication with the patient, ensuring optimal recovery at home and through access to broader health-care services. Keep in mind that you can always help trainees see HA at work by modeling it in your own practice and signposting advocacy throughout contact

with patients. This may take the form of pointing out “system” issues that commonly affect patients and health equity, such as wait times and access to uninsured services, and mechanisms that may address these issues. The Health Advocate Dilemma As a physician your role is to be the health advocate for your patient. At times this may be in conflict with advocacy that focuses on cost containment to meet societal needs. There are no easy answers for these dilemmas, but one should consider each option based on its merit and best available evidence and include your patient where possible in reaching a decision. But when you believe a particular treatment is in your patient’s best interests, advocate for them to the best of your ability. References CanMEDS Teaching and Assessment Tool Guide. Royal College of Physicians and Surgeons of Canada.

Leading by Example: What is Our Role in Injury Prevention?

r. Merv Letts is a surgeon whose kindness, compassion and advocacy for the safety of children go above and beyond his duties as an orthopaedic surgeon. As such, he is a role model to us all. As we spend our days repairing broken bodies, we should consider what could have prevented the injuries we are treating. Personally, as I amputate diabetic limbs, I think about the role I should play in preventing the damage the first place. Dr. Letts can rest assured that his public advocacy has worked towards saving thousands of children’s limbs and lives, and many more than he could possibly have fixed during his career. We should all follow his example and work towards pre-

vention. The insight we receive as orthopaedic surgeons gives us a unique role in society to advocate towards change. Letters to the newspapers, social media, presentations to school groups and representation on committees are all mechanisms by which we can effect change. Dr. Letts will be providing us with his most successful methods of advocacy in future editions of the COA Bulletin. This first article gives us insight into his experience with machine injuries. Stay tuned for more! Alastair Younger, MB ChB, MSc, ChM, FRCSC Editor in Chief, COA Bulletin

Machinery Trauma in Children Merv Letts, M.D., FRCSC Ottawa, ON

Part 1 of a special COA Bulletin series

hildren traumatized by machinery accidents are always stressful to the family, patient, the staff and surgeon. We, as surgeons, all learn how to cope with the treatment and technical issues but must learn how to deal with the family’s stress as well. This is sometimes more difficult than keeping our own concerns and vigilance under control. I always tell families under these circumstances that “you have the best team available looking after your son or daughter and we’re all going to do our absolute best for him/her!” I also always add, “Children are remarkable healers and your child will amaze us

with his/her healing powers! We must all be patient and await the work of Mother Nature.” I occasionally use the word “God” in place of Mother Nature, if I know the family is very religious, but I prefer using Mother Nature. The use of “God” borders too much on Amboise Pare’s pronouncement “I treats ‘em and God heals ‘em!” Second Opinions Good communication with families is the most important way to avoid lawsuits and repeated requests for second opinions. Be sure you take adequate time necessary to discuss the child’s care with their family. Most times that’s enough, though sometimes it isn’t and families will insist on getting a second opinions. If there is enough time in a trauma case, I always obtain a second opinion if the family requests one or if I need one myself. The more on board, the merrier as they say! It’s COA Bulletin ACO - Winter / Hiver 2018

Training & Practice Management / Formation et gestion d’une pratique (continued from page 61)

called “spreading the trauma around!” Never try to talk a family out of a second opinion. It’s sure to come back and haunt you. If you are the requested second opinion, and you agree with your colleague’s recommended action, inform the family and emphasize your support of their surgeon. If you disagree, tell the family you have a couple of suggestions that you will be discussing with their surgeon. The second opinion is the family’s “peace of mind”. Beware of using the Internet for a second opinion although parents often will present you with reams of print outs from Google search results for you to review. These are time consuming but should always be treated with respect, reviewed seriously and commented on briefly. You may be surprised to find one of your own quotes they found online in the bundle! If you find yourself practising in a remote area, telehealth links can provide very credible consults and second opinions, having used it myself in both remote areas of Churchill, Manitoba and Iqaluit, Nunavut. Effects of Trauma on the PediPod Coping with severe injury is challenging at the best of times but doing so with children is particularly difficult. As paediatric orthopaedic surgeons, we can all expect to become members of trauma teams. Some surgeons, although they are good and competent ones, just never get used to trauma. They probably should never have become orthopaedic or general surgeons. I often would counsel students that the next important decision to be made after deciding to enter the medical field is whether you are “medical” or “surgical”. The worst decision one can make is to pursue a surgical career when you are not inherently cut out to be a surgeon. Like the coward, you will die a thousand deaths during your career. You will usually know deep down which you are by fourth year medical school. DON’T FIGHT IT! Just go with the flow and pursue a psychiatric or medical career rather than getting locked into a surgical career in which you will never be comfortable. The issue of PTSD is only just becoming defined. In that regard we are all different. Trauma, per se, never bothered me psychologically but the effects of trauma on the child and family did. Having said that, and assuming you have made the right decision for your career involving trauma and are comfortable as an orthopaedic surgeon and a PediPod, you will encounter horrendous trauma situations during your career secondary to machinery accidents. I will describe a few of mine to you and hope against hope you will not have to deal with similar ones. Wringer Washer Injuries The first machinery trauma case I would like to share involved none other than myself. I grew up in the “40’s” on the Prairies Figure 1 when wringer washers The Wringer Washing Machine COA Bulletin ACO - Winter / Hiver 2018

were ubiquitous, and my parents had one in their house. This is one of my earliest memories. Shortly after our move to Minnedosa, Manitoba in the latter part of 1942, I was “helping” my mother do the washing in the basement when it happened. Our washing machine, at that time, was a typical powered wringer washer whereby the dirty clothes were put into the washing cylinder, water and soap added, and the agitator turned on for a half hour or so. This was the boring part of washing from a three-year-old’s perspective but following the rinse cycle things got much more interesting! The clothes were then inserted into the wringer which wrung out most of the water and they dropped into a wash tub ready to be taken to hanging on the line to dry. It was here that my assistance was “pivotal” as I directed the clothes from the wringer into the wash tub with, of course, a little assistance from gravity. On this particular day, it obviously dawned on me that gravity could do this job quite efficiently without my assistance, so I moved my chair to the other side of the machine to help feed the clothes into the wringer under the watchful eye of my mother. Our phone rang, two long and one short, which indicated the call was for the Letts family and not the other three families on the party line. My mother ran upstairs to answer the phone, the last piece of clothing having gone through the wringer. Instead of waiting for her return, I scooped some clothes out of the washer and began to thread them through the wringer. The next thing I knew, my fingers were in the wringer and my arm followed quickly up to the shoulder. Since it crossed my mind that I might go right through entirely, I hollered bloody murder, following which I remember the bang of the wringer release as my mom’s fist hit the release button on the top of the machine. Amazingly, other than some skin burns in my axilla where the rollers had been turning on my stuck shoulder, I seemed to have sustained no major trauma despite what was indeed a major traumatic episode! This was later brought home to me during my orthopaedic residency training. I treated similar children who had been caught in a wringer but whose mothers did not immediately release the wringers, or the wringers had been tightened for thinner clothing. They suffered axillary skin loss usually requiring skin grafting, as well as the development of deadly “compartment syndromes” in their arms. The wringer rollers could be tightened or loosened depending on the thickness of the clothes. Since my mother and I were washing towels and bedsheets, the wringers were a little looser and as they say, “There but for the grace of God go I”. I was also most fortunate that my mother was close by, that I had a very loud voice for my small size, and that the release on the wringers actually worked as that was the first time (and last time) it was ever used to release the wringers for a child’s arm! Wringer washers caused, and are still causing (though to a lesser extent), considerable trauma, primarily to young children who become entangled in the clothes, being pulled into the electrically-powered wringers, similar to the mechanism of farm machinery injuries. However, children were not exclusively traumatized, as there are many reports of the hair, hands and even breasts of the operators becoming entangled in the rollers. At least one death of a young child whose clothing became entangled in the wringer resulting in strangulation has been reported. As with so many pieces of machinery, one must retain respect for the machine. Once it is taken for granted and

Training & Practice Management / Formation et gestion d’une pratique (continued from page 62)

disrespected, whether it be a wringer washer, a lawn mower, a snowmobile or a grain auger... tragedies happen! This is one of the most common reasons for farm machinery accidents on the Prairies - losing respect for the power of the machine and cutting safety corners. As an orthopaedic surgeon, I saw a lot of farm machinery trauma resulting from disrespect for the machine as the prominent cause. Part II in the next edition of the COA Bulletin will address various types of machinery injuries sustained by children in a farming environment, most of which were preventable. Educating children on the dangers of various pieces of farm equipment plays a major role in prevention. Safety devices, proper training, common sense and good judgement on the part of parents are other essential ancillary preventative measures as well.

Figure 2 A wringer injury to an arm requiring compartment release.

Now Available: National Data Collection Standards on PROMs for Hip and Knee Arthroplasty Nicole De Guia, Sunita Karmakar-Hore, Shannon Weir-Seeley, and Ellis Chow Canadian Institute for Health Information (CIHI) Toronto, ON

ince 2015, the Canadian Institute for Health Information (CIHI) has been working with a broad range of stakeholders to develop a common approach to collecting and reporting on hip and knee arthroplasty PROMs across Canada. Under the leadership of CIHI’s PROMs Hip and Knee Replacements Working Group, chaired by Dr. Eric Bohm, and the CJRR Advisory Committee, co-chaired by Drs. Eric Bohm and Michael Dunbar, standards including recommended PROMs instruments, a minimum data set (MDS) and survey time points have been developed for these clinical areas. The EQ-5D-5L, Oxford Hip Score (OHS), and Oxford Knee Score (OKS) were identified as the recommended PROMs instruments for the national standards. National survey time points were identified as up to four weeks preoperatively and at one year postoperatively. These standards are now available in the June 2018 publication PROMs Data Collection Manual: Hip and Knee Arthroplasty and on the CIHI web site www.cihi.ca/proms. CIHI has acquired national licences for the EQ-5D-5L, OHS and OKS for use in routine care, and can sub-licence these tools to regions and hospitals for this use (note that for research use, additional permission is required from licensors). A number of hospitals are already being licenced for pilots in Ontario and Nova Scotia. COA Bulletin ACO - Winter / Hiver 2018

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

(continued from page 63)

CIHI continues to progress on other PROMs initiatives for hip and knee arthroplasty, including project work for Ontario and internationally. CIHI is co-executing Ontario’s hip and knee PROMs pilot project with Cancer Care Ontario (CCO) and the Ontario Ministry of Health and Long-Term-Care. The Ontario PROMs pilot project aims to improve patient care through the use of patient-generated data, test the collection of PROMs, and establish a mechanism for on-going PROMs collection. Additionally, CIHI continues to chair the international Working Group on Patient-Reported Indicators for Hip and Knee Replacement Surgery, in partnership with the Organisation for Economic Co-operation and Development (OECD); this initiative aims to use existing PROMs programs to

pilot international comparable reporting in OECD’s Health at a Glance 2019 report, and to develop new international data collection standards for hip and knee arthroplasty PROMs. Canadian data will be sourced from Alberta (via Alberta Bone and Joint Health Institute) and Manitoba, and others as available as part of this project. If you have questions about these projects or if you would like to have a routine care licence to utilize any of the above PROMs tools, please contact us at proms@cihi.ca or visit our web site at www.cihi.ca/proms.

Creating Your Own Defined Benefit Pension Adam O’Neill, CFP®, CLU®, CHS™, IMBA, BSc Special to the COA Bulletin

Individual Pension Plan (IPP) ne of the few remaining tax sheltering tools available to incorporated surgeons in Canada is the Individual Pension Plan. An IPP can allow you to significantly improve your tax-assisted retirement savings over the alternate of an RRSP.

IPP contributions must be set assuming a prescribed rate of return of 7.5% per annum. RSP accumulations are shown above at 7.5% and 5% investment returns for comparison purposes. Additional tax-deductible contributions to the IPP may be required if investment returns fall short of the 7.5% expectation. Contributions to the IPP are made by your company are and fully tax-deductible. It is possible for you to recognize the years of past service you have had with your company, as long as you transfer a portion of your RSP into the IPP, remove some unused RSP deduction room, or a combination of the two. Individual Pension Plan An Individual Pension Plan (IPP) is a defined benefit pension plan that is registered with the Canada Revenue Agency (CRA) and depending on the applicable provincial law, with the provincial pension regulator. The primary purpose (singleness of purpose) of a pension plan is to provide periodic payments to members after retirement and until death, for service as employees of the corporation(s) that participate (participating employer) in the pension plan. Corporations generally offer participation in an IPP to employees that meet the definition under the Income Tax Act as Specified Individuals, which requires that they satisfy either of the requirements below: COA Bulletin ACO - Winter / Hiver 2018

• A Connected Person(s) – director in direct owner of at least of 10% of any class of shares of the corporation or is a person who does not deal at arm’s length with the corporation, as may be the case with a spouse, parent, child and other related family members. • A High-Paid Employee(s) – employee with Pensionable Earnings of at least 2.5 times the YMPE (as defined under the Canada Pension Plan), for the year 2018 the earnings threshold is $147,222. We note that IPPs are more complex than RRSPs, and while there are significant corporate tax advantages, and the opportunity to manage and grow the assets to achieve improved benefits, there are stringent regulatory controls that govern the administration of these plans.

Training & Practice Management / Formation et gestion d’une pratique (continued from page 64)

An IPP has start-up costs associated with establishing the plan and meeting registration requirements. The plan also has to comply with pension regulations, which include the submission of an initial and subsequent triennial actuarial valuation reports and filing of documents on an annual basis. However, the tax deferral opportunity and security of a retirement income that flow from the IPP quickly outweigh the additional costs. Key Benefits • Tax savings / fee deductions • Catch-up contributions • Larger (25-70%) contributions than an RRSP • Potential to purchase optional Past Service back to 1991 • Increase retirement income • Pension income splitting • Additional funding at retirement • Estate Planning and opportunity to rollover to children (in some circumstances) • Assets are secured from creditors • Members own any plan surplus • Compliance and monitoring by experts IPP Advantage – Retirement: Earlier than Age 65 or Later? While the normal retirement age is 65, there is the opportunity to commence retirement as early as age of 55 (age 50 in Alberta) on a very favourable basis. In most cases, this could present a significant tax-deductible opportunity for the corporation if a final contribution (top-up) is allowed at retirement. Retirement may also be extended to anytime up to the end of the year in which the member attains age 71. Between age 65 and 71 contribution room and pensionable service continue to accrue. The benefits that accrue in an IPP are based on service earned as an employee. The plan will, in return, guarantee a level of pension benefits at retirement. Unlike an RRSP, the guarantee of a pension permits the corporation to make additional taxdeductible contributions if the investment performance of the plan is less than the prescribed rate of 7.5%. In addition, should the plan member retire before age 65, an additional contribution to the IPP may be allowed. This terminal funding could amount to as much as 50% of the accumulated assets in the plan.

IPP Advantage - Retirement at Age 65 or Later Options at Retirement and Death Benefits Pension assets may be applied to provide a lifetime retirement pension under any of these retirement options: • A guaranteed life annuity from a Licensed Insurance Company. The form of lifetime pension is to be materially similar to that of the IPP, which includes providing the guarantee of a minimum number of payments, joint payment with your spouse and indexing payments to inflation of up to 4% per year. • The assets maybe transferred (up to a limit) to a Lockedin Retirement Account (LIRA), Life Income Fund (LIF) or a Locked-in RIF (LRIF). These options are similar to a normal RRIF with annual income withdrawals but are subject to prescribed minimums and maximums each year. Similar to a normal RRIF, the investments remain under the control of the member and any assets remaining at death will be passed to the spouse, designated beneficiary or estate. • Receive Pension Directly from the IPP. Under this option the IPP continues to exist and the assets are used to pay a pension. Any asset, including surplus, remaining at death are passed to the surviving spouse and if none, to the designated beneficiary or estate. By continuing the IPP, pension benefits maybe further enhanced as additional contributions are permitted to reduce any deficiency in the performance deficiency. Current Service Contributions Contributions to the IPP are determined by the actuary and must be deposited each year. The amount may be expressed as a percentage of compensation, and will respond to periods of low earnings by reducing the required contribution in each of those years.

COA Bulletin ACO - Winter / Hiver 2018

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

(continued from page 65)

Investments Allowable investments for an IPP are similar to those permitted for RRSPs. The IPP “fund holder” maybe a Life Insurance Company or a trust administered by three individual Trustees or a Corporate Trustee. As with RRSPs, the plan administrator, through the Trustees or Life Insurance Company, may make the investment decisions or delegate them to a professional fund manager. Deductibility of Fees As an IPP is a registered pension plan, all fees relating to the plan’s operation are fully tax-deductible. Actuarial and set up fees are always deductible. The IPP fund’s investment management fees, which are not tax-deductible for RRSPs, are deductible when paid directly by the plan sponsor. In other words, the investment management fees are not deductible when paid from the IPP fund.

Let’s consider a 45 year-old surgeon who has 15 years of work experience with annual salary of $150,000 (from their professional corporation) with $600,000 in current RRSP accounts. More Information While the above information may be attractive, IPPs are a complex strategy which will not be appropriate for all physicians. To explore if this strategy is right for you or to get a quote, please reach out to your Certified Financial Planner, your accountant, or contact COAplan through the Membership Benefits bar of the COA web site, or send an email to info@COAplan.ca. The information in the article has been provided to the COA by O’Neill Financial Inc. and COAplan Inc. It is always recommended to seek independent advice related to your particular circumstances as necessary.

17th Annual Canadian Orthopaedic Resident Forum (CORF) - Register Now!

he CORF course is an annual “finishing school” course to prepare PGY5 residents for the Royal College exam. Join us from April 5-8, 2019 at the Fairmont Palliser Hotel in Calgary, AB. Early bird registration ends January 25, 2019. Download the registration form here: http://coa-aco.org/residents-cora/residents-cora-news-info/

Questions? E-mail corfcalgary@gmail.com.

Upcoming COA/CORS/CORA Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO 2019

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