COA Bulletin #115 - Winter 2016-17 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Winter / Hiver 2016/2017 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

115

e M i o e m r i H chez u a b m E Patients Continue to Wait…

and Orthopaedic Surgeons Continue to Languish in Unemployment – The Status of Orthopaedic Unemployment in Canada............ See page 30

Les patients continuent d’attendre…

et les orthopédistes de rêver d’un emploi – Aperçu du chômage chez les orthopédistes canadiens........................................................ Page 32 Aperçu de systèmes de santé à l’étranger � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5 Outpatient Hip and Knee Replacements in the Canadian Health-care System � � � 20 Higher Survival of Hip Fracture Patients Treated in Larger Hospitals � � � � � � � � � � � � � � � 28 Engage, Network, Listen: Twitter Tips and Tricks for Canadian Surgeons � � � � � � � � � � 41

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Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 115 - Winter / Hiver 2016/2017 COA / ACO Peter B. MacDonald 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.

ADVERTISING SPACE AVAILABLE The COA Bulletin, the official journal of the Canadian Orthopaedic Association, has been declared by our membership as one of the most valuable membership services. By placing your advertisement in the COA Bulletin, you will be communicating with the largest number of Canada’s leading orthopaedic specialists. Don’t miss out on this kind of opportunity! Become a part of our publication cycle by contacting Cynthia Vezina at the COA Office - Tel: (514) 874-9003 ext. 3 or e‑mail: cynthia@canorth.org and details will be forwarded to you.

ESPACE PUBLICITAIRE Le Bulletin, publication officielle de l’Association Canadienne d’Orthopédie (ACO), a été désigné par nos membres comme l’un des services les plus utiles que nous leur offrons. Placer une annonce dans le Bulletin de l’ACO assure une visibilité inégalée auprès des orthopédistes les plus influents au pays. Ne manquez pas cette occasion! Pour faire partie de notre cycle de publication, communiquez avec Cynthia Vezina, au bureau de l’ACO, au 514-874-9003, poste 3, ou à cynthia@canorth.org.

A Taste of Health-care Systems Abroad Peter B. MacDonald, M.D., FRCSC President, Canadian Orthopaedic Association

s COA President I was lucky enough to travel to the British Orthopaedic Association (BOA) Meeting in Belfast in September, followed by the Combined Australian Orthopaedic Association (AOA) and New Zealand Orthopaedic Association (NZOA) Meeting in Cairns, Australia in October. Both were fulfilling experiences and gave me a glimpse of other medical systems who share some of the same challenges that we face, yet have different approaches in other areas.

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 2016/2017

Your COA / Votre association

(continued from page 3)

The BOA Annual Meeting in Belfast took place despite threats of a junior doctors’ strike only the week before, which could have cancelled the meeting. The junior doctors apparently have not received a pay increase in several years - if they would have walked out, the senior staff and consultants within the National Health Service of Great Britain would have had to take up the slack and perform their duties. The National Health Service (NHS) used to be a model that other health-care systems around the world aspired to. It now seems like the NHS is headed for turmoil in future years due to underfunding. Although Canada spends in the neighborhood of 10% of GDP on health care; the NHS spends roughly 8.5% of GDP. This is forecasted to drop to 7.6% by 2020. This creates an atmosphere of crisis management amongst the health-care service where it is no longer possible to meet their wait-time targets. This is obviously going to push more and more people into the private sector of the health-care service in Britain. On the positive side, the BOA held a very strong Annual Meeting, steeped in tradition thanks to its long, rich history and its many leaders in the profession. Industries are extremely well-developed in Great Britain and individual surgeons receive regular feedback. They have good control of their implant cost and have recently begun to publicly disclose what each trust area pays for their implants. In most areas they have moved to a single hip or knee implant for a regional trust. In speaking with Australian orthopaedic surgeons at the Combined Meeting, I learned how much they value their two-tiered system that seems to be working well in terms of patient access and the ease of which professionals can practice. Specifically, approximately 50% of Australians have private insurance which can be used in the private health-care system if the patient chooses to take this direction. However, even within a robust public system (they spend approximately 10% of GDP similar to Canada), the wait list seemed to be under control and reasonable for all procedures. All in all, the system seems to be working well in both Australia and New Zealand and may be models for us in the future if we find that our present system is unsustainable. I also learned that the Australian registry does not only cover hip and knee arthroplasty. It also includes shoulder and ankle arthroplasty, as well as osteotomies and ACL reconstructions. There was a national levy placed on each implant which allows the AOA to collect enough money from industry to support all of these registries. Registries are published on the Australian Orthopaedic Association web site and are reported very well. Something else common to the BOA, the AOA and the NZOA is how strong their member attendance is at their Annual Meetings. The support for all three of these Associations is obviously very well-entrenched. Annual membership dues for the BOA and for the NZOA are comparable to what we pay here in Canada, although the Australians actually pay quite a bit more annually because their dues do not include their Annual Meeting registration fee. Their staff offices are quite a bit more robust than the COA’s in terms of the number of full-time staff, and their associations are also more involved with maintenance of certification and administering the training programs.

COA Bulletin ACO - Winter / Hiver 2016/2017

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 18 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 30 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 40

I am very grateful to Mr. Tim Wilton, the former President of the BOA, Andreas Loefert from Australia and Jean-Claude Theis from New Zealand who were excellent hosts and clearly demonstrated why they were chosen as leaders in their respective countries. After a situational analysis and very thorough review of the strategic issues that need to be confronted by the COA, our CEO, Doug Thomson, has restructured some of the staff roles at the COA office. As such, Cynthia Vezina will be promoted and her duties expanded, very deservingly. An additional staff member will be hired to offset Cynthia’s previous duties to allow her to focus on more high-level management and strategic initiatives. We are very fortunate to have such dedicated and hardworking staff in our office. It is important that we support our Association and recognize it as the only common voice for orthopaedic surgeons across the country. Political advocacy has never been more important. Trinity Wittman, our Manager of Development and Advocacy, has assembled a comprehensive catalogue of successful models of care from our members. We plan to take these models of care to federal and provincial governments to expand ideas for efficiency in our health-care system. The most important thing that we can instill is better access to care for our patients. We look forward to updating the membership about our meetings with government in the next edition of the COA Bulletin. We invite your comments to policy@canorth.org.

Your COA / Votre association

Aperçu de systèmes de santé à l’étranger Peter B. MacDonald, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

n tant que président de l’ACO, j’ai eu la chance d’assister au congrès de la British Orthopaedic Association (BOA) à Belfast, en septembre, puis au congrès conjoint de l’Australian Orthopaedic Association (AOA) et de la New Zealand Orthopaedic Association (NZOA) à Cairns, en Australie, en octobre. Dans les deux cas, l’expérience a été enrichissante; elle m’a permis d’obtenir un aperçu d’autres systèmes médicaux confrontés à des défis semblables aux nôtres, mais ayant une approche différente à certains égards. Le congrès annuel de la BOA à Belfast s’est déroulé malgré les menaces de grève des internes des hôpitaux lancées la semaine précédente, dont la concrétisation aurait pu entraîner l’annulation du congrès. Il semble que les internes n’ont pas obtenu de hausse salariale depuis plusieurs années; s’ils avaient déclenché la grève, le personnel supérieur et les consultants du National Health Service (NHS) britannique auraient dû prendre la relève. Le NHS a déjà été un modèle pour les autres systèmes de santé dans le monde, mais son sous-financement semble maintenant présager des années de tourmente. Le Canada consacre environ 10 % de son PIB à la santé, mais en Grande-Bretagne, les dépenses du NHS correspondent à peu près à 8,5 % du PIB, et elles devraient passer à 7,6 % du PIB d’ici 2020. Cela crée un climat de gestion de crise, où on ne peut plus atteindre les cibles en matière de temps d’attente, et poussera vraisemblablement de plus en plus de personnes vers le secteur privé. Passons aux points positifs : la BOA a organisé un excellent congrès, bien ancré dans la tradition grâce à sa longue et riche histoire et à ses nombreuses figures marquantes de la profession. L’industrie est extrêmement bien développée en Grande-Bretagne, et les orthopédistes en reçoivent régulièrement des nouvelles. Ils exercent un bon contrôle sur le coût des prothèses, et ont récemment commencé à rendre public ce que chaque groupe paie pour ses prothèses. Dans la plupart des cas, on est passé à une seule prothèse pour la hanche ou le genou par groupe régional. Au congrès conjoint à Cairns, j’ai pu constater en discutant avec des orthopédistes australiens l’importance qu’ils accordent à leur système à deux paliers, qui semble bien fonctionner sur les plans de l’accès aux soins et de la convivialité de leur prestation. Environ la moitié des Australiens ont une assurance privée, qu’ils peuvent utiliser au sein du système de santé privé s’ils le souhaitent. Par contre, même au sein du système public, qui est robuste (dépenses correspondant à environ 10 % du PIB, comme au Canada), les temps d’attente semblent limités et raisonnables pour toutes les procédures. En gros, les systèmes australien et néo-zélandais semblent bien fonctionner et pourraient nous servir de modèles si nous constatons que le nôtre n’est plus viable.

De plus, j’ai appris que les registres australiens ne se limitent pas aux arthroplasties de la hanche et du genou, mais qu’ils comprennent aussi les arthroplasties de l’épaule et de la cheville, les ostéotomies et les reconstructions du ligament croisé antérieur (LCA) du genou. À l’échelle nationale, un montant est prélevé pour chaque prothèse, ce qui permet à l’AOA d’obtenir de l’industrie les fonds nécessaires à la gestion de tous ces registres. Les registres sont également publiés sur le site Web de l’AOA et très bien tenus. La BOA, l’AOA et la NZOA ont aussi en commun une très forte participation de leurs membres à leur congrès annuel. Le soutien pour ces trois associations est manifestement bien enraciné. Les cotisations annuelles à la BOA et à la NZOA sont comparables aux cotisations au Canada, même si les Australiens paient en fait pas mal plus chaque année, puisque leur cotisation n’inclut pas les droits d’inscription à leur congrès annuel. En outre, leurs bureaux comptent bien plus d’effectifs à temps plein que les nôtres, et leur association nationale participe davantage au maintien des certificats d’exercice et à l’administration des programmes de formation. Je suis très reconnaissant à M. Tim Wilton, ancien président de la BOA, à Andreas Loefert, en Australie, et à Jean-Claude Theis, en Nouvelle-Zélande, qui ont été d’excellents hôtes et m’ont clairement montré pourquoi ils sont devenus des leaders dans leur pays. Enfin, après une analyse de la situation et un examen très approfondi des questions stratégiques auxquelles nous sommes confrontés, Doug Thomson, directeur de l’ACO, a procédé à la restructuration de certains des rôles du personnel. Ainsi, Cynthia Vezina bénéficiera d’une promotion bien méritée, et ses tâches seront élargies. Pour lui permettre de se concentrer sur une gestion de niveau supérieur et des initiatives stratégiques, on embauchera quelqu’un pour effectuer une partie de ses tâches actuelles. Nous sommes très chanceux d’avoir des gens aussi dévoués et travaillants dans nos bureaux. Il est important de soutenir notre association et de reconnaître qu’elle est la seule voix commune des orthopédistes de tout le pays. Les démarches politiques n’ont jamais été aussi importantes. Trinity Wittman, directrice du développement et des activités de défense des droits de l’ACO, a dressé, grâce aux membres, un catalogue exhaustif des modèles de soins efficaces. Nous comptons présenter ces modèles de soins aux gouvernements fédéral et provinciaux afin de diversifier les idées d’optimisation de notre système de santé. Et la chose la plus importante que nous puissions inspirer, c’est l’amélioration de l’accès aux soins pour nos patients. Nous avons hâte de vous communiquer les résultats de nos démarches auprès des gouvernements dans le prochain numéro du Bulletin de l’ACO. N’hésitez pas à nous faire part de vos commentaires, en écrivant à policy@canorth.org.

COA Bulletin ACO - Winter / Hiver 2016/2017

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 produc uct. 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. 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

Your COA / Votre association

You Asked….We Listened

2017 Annual Meeting better caters to ALL COA members Cynthia Vezina Executive Director, Strategic Initiatives Canadian Orthopaedic Association

he COA’s Program Committee, Continuing Professional Development Committee, Executive and Staff have carefully reviewed your comments and feedback provided through last year’s Annual Meeting evaluation surveys as well as through the discussions that took place during the strategic focus group session also held last June. Although member satisfaction with the Annual Meeting is very high, there is definitely room for improvement to meet the needs of our entire membership regardless of their practice setting. We are taking several of your suggestions into consideration and will be making a few modifications to the 2017 event being held next June in Ottawa. • Later start to morning sessions Sessions will begin at 7:50am on Friday and Saturday, and 8:00am on Sunday morning. This may sound like a simple change but we think that it will be WELL received by all attendees (sessions previously started at 7:00am or earlier!). • ICLs all day Instructional Course Lectures (ICLs) will be offered throughout the entire day of programming – not only first thing in the morning as they were in the past. • No more added fees The additional fees involved with registering for an ICL or Fireside Chat session ($50 and $25 respectively) are no more! Pre-registration is still required to attend an ICL or Fireside Chat session due to limited seating; however, these sessions are now free of charge during the preregistration period (fees apply when registering on site). Be sure to pre-register for the ICLs and Fireside Chats of your choice when you register online. • Less concurrent sessions One of the Annual Meeting’s biggest criticisms for many years has been that there are too many concurrent sessions - members simply can’t attend everything they wanted to because too much is scheduled at the same time. We have restructured this year’s program so that there are less conflicting sessions.

• Sessions for community and academic surgeons New sessions have been added to the 2017 meeting program that will be of interest to surgeons practicing in either a community or an academic setting. Look for sessions highlighting successful models of care, patient outcome measures as well as a two-part session using an interactive audience response system on how to manage and avoid complications in both upper and lower extremity fractures. • More networking time One of the most enjoyable parts of the COA meeting is catching up with colleagues and friends that you don’t have the opportunity to see throughout the year. On Friday evening, cash bars will be set up in the exhibit hall’s poster area for a ‘Poster Pub’ where you can enjoy a drink with colleagues while having designated time to view the poster presentations. We have extended the lunch hour by an extra thirty minutes to allow for additional networking and down time. A huge perk for local surgeons who may still need to tend to real life during the meeting dates. • Learn more about your membership services During an education-based symposium, Bone & Joint Journal Editor in Chief, Professor Fares Haddad, will offer tips on how to prepare your research for publication and a representative from OrthoEvidence will highlight how www.myorthoevidence.com can be used in your practice and CME. Subscription access to both of these educational resources is available through your COA membership. • Be sure to attend the now streamlined COA Business Meeting on Friday morning to find out what initiatives the COA’s Board of Directors and various committees are working on. We are reformatting and modernizing our Business Meeting to better communicate important COA news and programs to our membership. These are only some of the changes and improvements that you will experience at the 2017 COA, CORS and CORA Annual Meeting next June. Look for more information about the program, guest speakers and social events in the next edition of the COA Bulletin or by visiting www.coaannualmeeting.ca.

COA Bulletin ACO - Winter / Hiver 2016/2017

Your COA / Votre association

Nous sommes à votre écoute

La Réunion annuelle 2017 plaira davantage à TOUS les membres de l’ACO Cynthia Vezina Directrice générale, Initiatives stratégiques Association Canadienne d’Orthopédie

e Comité responsable du programme, le Comité de perfectionnement professionnel (CPP), le Comité de direction et le personnel de l’ACO étudient attentivement la rétroaction que vous avez formulée dans les formulaires d’évaluation de la dernière Réunion annuelle, ainsi que pendant la séance du Groupe de discussion sur la planification stratégique, en juin dernier. Même si vous êtes très satisfaits de la Réunion annuelle, elle peut certainement être améliorée de sorte à mieux répondre aux besoins de l’ensemble des membres, peu importe leur milieu d’exercice. Nous étudions plusieurs de vos suggestions en vue d’apporter quelques modifications à la Réunion annuelle 2017, qui aura lieu en juin, à Ottawa : • Un début plus tardif des séances matinales Les séances commenceront à 7 h 50 les vendredi et samedi, et à 8 h le dimanche. Ce changement peut sembler simple, mais nous croyons qu’il sera TRÈS BIEN accueilli par tous les participants (les séances commençaient auparavant dès 7 h, voire plus tôt!). • Des conférences d’enseignement toute la journée Des conférences d’enseignement seront offertes pendant toute la journée, et non plus en début de matinée seulement, comme c’était le cas jusqu’ici. • Finis les frais supplémentaires Les frais supplémentaires associés à l’inscription à une conférence d’enseignement ou à une séance « Discussions au coin du feu » (50 $ et 25 $, respectivement) sont choses du passé! L’inscription à l’avance reste obligatoire en raison des places limitées, mais elle est désormais offerte sans frais pendant la période de préinscription (des frais s’appliquent à l’inscription sur place). N’oubliez donc pas de sélectionner les conférences d’enseignement et séances « Discussions au coin du feu » qui vous intéressent lorsque vous vous inscrirez à l’avance à la Réunion annuelle. • Moins de séances concurrentes L’une des critiques les plus récurrentes depuis nombre d’années est qu’il y a trop de séances en même temps, ce qui vous empêche d’assister à toutes celles qui vous intéressent. Cette année, nous avons donc restructuré le programme de sorte qu’il y ait moins de séances concurrentes. COA Bulletin ACO - Winter / Hiver 2016/2017

• Des séances pour les orthopédistes en milieu communautaire et universitaire Le programme 2017 comprend de nouvelles séances qui sauront intéresser à la fois les orthopédistes en milieu communautaire et universitaire. Ne manquez pas les séances sur les modèles de soins efficaces et les indicateurs des résultats pour les patients, ainsi que la séance en deux volets sur la prévention et la gestion des complications dans le traitement des fractures aux membres supérieurs et inférieurs, lors de laquelle on mettra à profit un système de réponse de l’auditoire. • Plus de temps pour réseauter La possibilité de renouer avec amis et collègues qu’on ne voit pas souvent est l’un des aspects les plus agréables de la Réunion annuelle de l’ACO. Le vendredi soir, des bars payants seront aménagés dans la zone de présentation des affiches de la salle d’exposition. Le « Pub des affiches » vous permettra de prendre un verre avec vos collègues tout en jetant un coup d’œil aux affiches présentées. Nous avons en outre prolongé le dîner d’une demi-heure de sorte à vous donner plus de temps pour réseauter et vous reposer, un grand avantage pour les orthopédistes locaux qui doivent continuer de vaquer à leurs occupations pendant la manifestation. • Une séance sur les abonnements offerts aux membres À l’occasion d’un symposium d’information, le Pr Fares Haddad, rédacteur en chef du Bone & Joint Journal, vous offrira des conseils sur la préparation à la publication de travaux de recherche, et un représentant d’OrthoEvidence (www.myorthoevidence.com) vous expliquera de quelle façon tirer profit de cet outil dans votre exercice et obtenir des crédits d’éducation médicale continue (ÉMC). La cotisation à l’ACO inclut l’abonnement à ces ressources. • Le vendredi matin, découvrez les initiatives sur lesquelles travaillent notre conseil d’administration et nos comités à la Séance de travail de l’ACO, qui a subi une cure de rajeunissement. Nous en modernisons le format afin de mieux vous communiquer les nouvelles et programmes importants de l’ACO. Ce ne sont là que quelques-unes des améliorations que vous pourrez constater à la Réunion annuelle 2017 de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO), en juin prochain. Pour en savoir davantage sur le programme, les conférenciers invités et les activités sociales, consultez le prochain numéro du Bulletin de l’ACO ou rendez-vous à www.coaannualmeeting.ca.

Your COA / Votre association

Refining Membership Value

New mandate for long-time COA staffer

e are very pleased to announce the promotion of Cynthia Vezina as our new Executive Director for Strategic Initiatives. Cynthia is the COA’s longest serving employee having started in March of 1999. Over the past 17 years she has taken on increasing levels of responsibility and has been an invaluable member of our staff.

the Annual Meeting, refining the COA’s membership offerings and communications to strengthen and expand our membership base, diversify our revenue opportunities, seek new opportunities to better engage members and manage the COA’s expansion into improved strategic planning and advocacy.

Cynthia has brought tremendous levels of innovation to our organization that have always been focused on delivering increasing value to our members. Her new role is an exceptionally important one as the COA seeks to tackle increasingly important strategic issues that are critical to the growth of the Association: improved use of technology to allow a more sophisticated approach to serving the needs of our members, initiatives to expand our core mission beyond

To ensure that Cynthia is able to achieve these important objectives, the COA has hired an additional staff member to coordinate membership services and affiliate programs. We look forward to introducing you to the newest member of our team in the next edition of the COA Bulletin. Cynthia can continue to be reached at: cynthia@canorth.org or 514 874-9003 x 3.

Optimiser la valeur de l’adhésion

Un nouveau mandat pour une employée de longue date de l’ACO

ous avons l’immense plaisir d’annoncer la promotion de Cynthia Vezina au tout nouveau poste de directrice générale, Initiatives stratégiques. Cynthia est l’employée de l’ACO qui a accumulé le plus d’ancienneté : elle œuvre au sein de notre organisation depuis mars 1999. Depuis 17 ans, elle assume progressivement de plus en plus de responsabilités et s’est avérée un atout inestimable.

mentale de l’ACO au-delà des réunions annuelles; parfaire les services et communications aux membres de sorte à renforcer et augmenter l’adhésion; diversifier les sources de revenus; chercher de nouvelles occasions de stimuler la participation des membres; et gérer l’expansion de l’ACO grâce à une planification stratégique et à des activités de défense des droits et intérêts améliorées.

Cynthia a apporté beaucoup d’innovations au sein de notre organisation, toujours de sorte à accroître la valeur de l’adhésion. Son nouveau rôle revêt une importance majeure, car l’ACO souhaite aborder des questions stratégiques d’une incidence de plus en plus grande et qui sont essentielles à sa croissance : améliorer l’utilisation de la technologie afin d’adopter une approche plus recherchée dans la réponse aux besoins des membres; élaborer des initiatives pour élargir la mission fonda-

Pour permettre à Cynthia d’atteindre ces objectifs importants, l’ACO a embauché une nouvelle coordonnatrice des services aux membres et programmes affiliés. Nous avons hâte de vous présenter notre nouvelle recrue dans le prochain numéro du Bulletin de l’ACO. Vous pouvez toujours joindre Cynthia à cynthia@canorth.org ou au 514-874-9003, poste 3.

Tour Diary from the 2016 Austrian-Swiss-German (ASG) Fellowship 2016 ASG Fellows: Eric W. Edmonds, M.D. San Diego, CA Simon C. Mears, M.D., PhD Little Rock, AR Mathew Sewell BSc(Hons), MB ChB(Hons), FRCS(Tr & Orth) Middlesbrough, United Kingdom Andrea Veljkovic, M.D., MPH Vancouver, BC

rom our initial meeting it was clear that a special international friendship had begun which continued throughout four weeks of travelling together through Austria, Switzerland and Germany. Mr. Mathew Sewell is from Middleborough, England, specializing in paediatric spine deformity. A paediatric orthopaedic surgeon, Dr. Eric Edmonds, is from San Diego focusing on arthroscopy and trauma. Dr. Simon Mears is from Little Rock, Arkansas specializing in geriatric orthopaedics and arthroplasty. Hailing from Vancouver, Dr. Andrea Veljkovic specializes in sports, trauma, and foot & ankle surgery. No doubt these early days set the tone for the remainder of the trip, and the remainder of our lives. COA Bulletin ACO - Winter / Hiver 2016/2017

Your COA / Votre association

(continued from page 9)

We were initiated into the ASG fellowship with a lovely visit to the home of Prof. Rüdiger Krauspe. We visited university centres in Dusseldorf, Cologne, Essen, Bonn, Frankfurt, Heidelberg and Mainz – all within the first week. Each local host was generous and thoughtful of our time and interests. Of course it seemed like a whirlwind tour through the Rhine Valley watching surgery, touring hospitals, giving our lectures, and listening to amazing research at each facility. Not everything was business thankfully, and we were able to tour the Cologne Cathedral, as well as see the heart of industrial Germany with a tour of the Zollverein coal mine. Our hosts took wonderful care of us with spectacular meals. On the first weekend, we had an ASG Symposium near Trier. We stayed at a winery owned by the uncle of Christoph Zilkens (one of last years ASG fellows), Claude Piedmont. We sampled his extensive collection of Riesling wine and learned the subtleties of the wines of the Mosel and Saar valleys. The symposium was a grand success because for the first time, it brought together last year’s ASG fellows with this years’ fellow class.

We visited two private centres in Zurich and Basel, Switzerland that were beautiful well-organized facilities. Professor Anke Eckhardt took us to Luzerne where we saw the breathtaking beauty of the Alps and visited an extensive Picasso collection. The tour concluded in Baden Baden, where we attended the VSOU meeting. There, we rekindled our friendships with many of the local hosts from the past month. We look forward to future international collaboration, not only through the travels of future ASG fellows, but also in research projects and medical mission trips that are currently in the making with our new friends. We would like to thank our local hosts for all the time and energy that they put into our education and professional development. Call for applications for the 2018 ASG tour will open in the Spring of 2017. Eligible COA members are encouraged to apply for this opportunity. See the COA web site for details. – Ed.

Week two brought us to former East Germany, where we meet Christoph Lohmann in Magdeburg. There was a distinct difference in the facilities (construction, food, roads and layout); and yet, patient care was unparalleled. We then visited the famous Charité Klinik in Berlin and were engaged academically with talks about innovative translational research. This then led into our second weekend, which was highlighted by dinner at the Tausend (Bar 1000). The restaurant was one of a kind from our perspective, particularly since one had to enter through an unmarked door hiding under a bridge! Week three started with an enjoyable eight-hour train ride to Innsbruck, Austria. Here we saw a great hospital and team, and watched amazing surgery. Subsequently, we were led on a hike to the top of the snow-covered Nordkette where we engaged in an all for none snowball fight! We then travelled to Vienna and were hosted by Philipp Funovics, one of last year’s ASG fellows. We visited both the university hospital as well as the all-orthopaedic Speising Clinic. We were treated to the Vienna Opera and evening entertainment hosted by both chairmen from the two hospitals.

The fellows meet on their first night at the home of Prof. Rüdiger Krauspe in Dusseldorf. COA Bulletin ACO - Winter / Hiver 2016/2017

Ass. Prof. Philipp Funovics graciously took us to the Vienna Opera to see Don Pasquale.

A picturesque day with Prof. Anke Eckardt in Luzerne.

Your COA / Votre association

(continued from page 10)

Casino night at the VSOU conference in Baden Baden.

The ASG fellows from 2015 and 2016 at the annual “spargel” luncheon.

Active Members - It’s Time to Renew Your COA Membership

Oyez membres actifs : Avez-vous payé votre cotisation à l’ACO?

017 COA membership dues invoices for Active and Overseas members are ready for payment by logging in to the COA web site: www.coa-aco.org with your e-mail address and password. Pay your dues online after log in through our secure payment server, or print out a remittance form to submit with a cheque payment if you prefer. Associate (resident/fellow), Senior (retired) and Research Affiliate (CORS) members are not required to pay membership dues. Annual renewal is automatic.

es membres actifs ou outre-mer de l’ACO peuvent régler dès maintenant leur cotisation de 2017 en ouvrant une session sur le site Web de l’ACO, à www.coa-aco.org, à l’aide de leurs courriel et mot de passe. Vous pouvez ensuite régler votre cotisation en ligne grâce à notre système de paiement sécurisé ou imprimer un formulaire afin de payer par chèque. Les membres associés (résidents et boursiers), les membres seniors (à la retraite) et les membres affiliés du milieu de la recherche (SROC) n’ont pas à payer de cotisation annuelle. Le renouvellement de leur adhésion se fait automatiquement.

COA Bulletin ACO - Winter / Hiver 2016/2017

Your COA / Votre association

Where Are You Sleeping? Are your Ottawa Annual Meeting accommodations booked?

Avez-vous réservé votre chambre pour la Réunion annuelle d’Ottawa?

onsidering the large number of visitors Ottawa will be receiving this June for the celebrations surrounding Canada’s 150 years of Confederation, we encourage COA members to make their Annual Meeting hotel reservations as soon as possible.

u le grand nombre de visiteurs attendus à Ottawa en juin en raison des célébrations du 150e anniversaire de la Confédération du Canada, nous recommandons aux membres de l’ACO de réserver leur chambre pour la Réunion annuelle le plus tôt possible.

To reserve a room in the COA’s room block at the Westin Hotel (where the Annual Meeting will be held), please visit www.coaannualmeeting.ca and click on the Hotels tab on the homepage.

Pour réserver une chambre dans le bloc de chambres de l’ACO à l’hôtel The Westin (où aura lieu la Réunion annuelle), rendezvous à www.coaannualmeeting.ca, puis cliquez sur l’onglet « Hôtels ».

Inquiries? Contact meetings@canorth.org

Vous avez des questions? Écrivez à meetings@canorth.org.

2017 Ottawa Annual Meeting Web Site

Site Web de la Réunion annuelle d’Ottawa

Make regular visits to www.coaannualmeeting.ca for complete information, including registration, about the 2017 Annual Meeting being held from June 15-18, 2017 in Ottawa.

Consultez régulièrement le site www.coaannualmeeting. ca pour obtenir tous les renseignements sur la Réunion annuelle (y compris sur l’inscription), qui aura lieu du 15 au 18 juin 2017, à Ottawa.

COA Bulletin ACO - Winter / Hiver 2016/2017

Your COA / Votre association

Resident Experiences in the Uganda Sustainable Trauma Orthopaedic Program (USTOP)

STOP was founded in 2007 by Drs. Peter J. O’Brien and Piotr Blachut in partnership with Makerere University in Kampala, Uganda. Its aim has been to reduce the burden of disability due to neglected orthopaedic trauma by addressing trauma systems, capacity, and policy through training, partnership and research. Bi-annual two-week visits occur in partnership with McMaster University, and consist of large multidisciplinary teams including surgeons, residents, physiotherapists, nurses, and engineers. Three UBC residents joined the USTOP team on recent trips to Uganda; the following are short stories that exemplify their resident experiences in global surgery. To learn more about USTOP, please visit http://ustop.orthopaedics.med.ubc.ca/. An Ordinary Day Amar Cheema, PGY-2, UBC (travelled October 2016) Landing in Entebbe, not knowing what to expect, I am immediately struck by a distinct aroma of clay and smoke. We have travelled for nearly two days, but striking Uganda’s red earth makes my visit now real. We arrive at night, eager to begin our clinical duties. Jet lag is non-existent as excitement and curiosity drive us. The juxtaposition of Vancouver General Hospital and the Mulago National Referral Centre is stark. Rather than rooms, there are halls full of stretchers. Surrounding each stretcher, the patient’s family members are tasked with providing care, including feeding, clothing and providing medication for their loved one. I am shocked to learn that analgaesics are not stocked within the hospital, but rather a prescription is filled and brought back to the ward. We stroll through a narrow hallway that doubles as the “preanaesthetic unit” and the “post-anaesthetic unit.” I am eager for our first case. Physical radiographs lie at the bedside without a light box. We hold the films up to the bright sun. The first case is a both bone forearm fracture in a young man. What we are not told until we have scrubbed for the case, is that the fracture is four weeks old. The patient’s tourniquet is a glove wrapped around the arm and secured with a clamp. The surgical area is prepped using alcohol poured out of a Nalgene bottle. The drapes are made of sterile wrappings and towels fashioned like a puzzle over the patient. I am told there is no cautery or suction, and throughout these discoveries, I am in awe. We move on to our surgery and find the fracture has essentially healed with significant angular deformity and shortened by over two centimetres. It requires the effort of four surgeons to achieve an anatomic reduction. All the while, I am thinking how much better off this young man would have been if treated the next day, as would be customary back home. We proceed with the case, lacking basic technology which I have taken for granted during my entire training, a C-arm. We persevere, the fixation is in place and it is time to close.

Piotr Blachut and Mwayafu Danwald (AKA Dr. Piotr and Dr. Dan) attempt to fix the C-arm by following instructions found online.

We leave the OR and I am left thinking of the countless differences between Canadian and developing health-care systems. I am humbled by the Ugandans’ dedication to providing adequate orthopaedic care despite countless obstacles and scarce resources, and I am ever more appreciative of the training and technology provided by our education system at home. Basic Principles, Creatively Applied David Stockton, PGY-3, UBC (travelled September 2015) The first morning after landing in Uganda, I joined the Makerere University orthopaedic residents and officers on morning rounds in Mulago Hospital, on the “casualty ward”, which receives all musculoskeletal trauma cases. Patients were crammed side-to-side like sardines, family members were acting as nurses for sick relatives, and open fractures had been left unsplinted and open to the environment for days. It was a shock to say the least. The level of need and the scarcity of resources was difficult for me to reconcile. Over the next few weeks I witnessed how this paucity of basic supplies bred a sense of creativity amongst the orthopaedic staff. The residents had the knowledge base and educational resources to treat basic musculoskeletal injuries, but they lacked access to many of the resources called for by their textbooks. Splints and back slabs were fashioned out of cardboard boxes and tape, and skin traction was MacGyver’d using gauze COA Bulletin ACO - Winter / Hiver 2016/2017

Your COA / Votre association

(continued from page 13)

wrap tied around the ankle and connected with a piece of string to the nearest available rock, suspended over the end of the stretcher. Borne out of the scarce resources in Uganda, a unique partnership developed between USTOP and the UBC Engineers in Scrubs (EiS) program. Engineering students have been tasked with assessing challenges inherent in orthopaedic care in Uganda and proposing solutions, much like the Ugandan staff must do on a daily basis. This initiative led to the development of the Sterile Drill Cover, an autoclaveable cover allowing commercial drills to be used in austere environments. Often, hospitals in low- and middle-income countries receive donated surgical equipment which may be incomplete or unuseable in surgery. For example, many of the bone screws are too long or impractical, which led to another invention called the Screw Cutter, a lever device that can shorten any screw and add a rudimentary pointed tip to it. We were fortunate to have access to these innovations daily in the operating room, and we were moved by the gratitude of the Ugandan surgeons, as their capacity to treat fractures was sustainably improved, thanks to a strong partnership and the spirit of creativity. A Sustainable Resource Ben Jong, PGY-4, UBC (travelled October 2016) One of the main reasons I signed on with USTOP was for the word “sustainable”. I believe that for doctors, charity is easy. We are fortunate to be in the position to give to people in need, whether a donation of money or equipment, or even just our time. The real challenge is eliminating the need for charity by creating sustainable, permanent resources. In Uganda, I witnessed this challenge first hand. At the risk of sounding dramatic, the hospital sites we visited were a graveyard of good intentions. One of the most striking memories I have of Mulago Hospital in Kampala was a C-arm sitting outside the orthopaedic office, protected from the rain by the building’s awning, but covered in red dust from the road. It was donated by one of the many groups that have visited Uganda, and used until it was broken. Then, with no one available to repair it, it found its way outside. The situation in Mbale was slightly better, where the C-arm there was idle in the theatre. It was clean, but it had not taken an X-ray in about two years. The same problem again – no one available to fix it. As I spoke to the local residents, surgeons, and other staff, I started to understand that this was a common

Casualty Ward in Mulago Hospital, Kampala. COA Bulletin ACO - Winter / Hiver 2016/2017

Members of USTOP pose with Dr. Dan outside Mbale Hospital. From left to right: Mathilde Marcy (site coordinator), Lana Leeson (physiotherapist), Ben Jong (UBC resident), Mwayafu Danwald (Ugandan orthopaedic surgeon), Maureen Duggan (physiotherapist), Audrey Hiebert (nurse), Piotr Blachut (UBC orthopaedic surgeon).

occurrence – equipment was donated, and then used until it malfunctioned or “disappeared”. It seemed that the donations helped for a while, but not sustainably. When I participated in teaching the Bioskills course to the Ugandan residents, I recognized a different approach. We were not there to take over cases, or to donate equipment. We were there to teach. We taught basic AO principles to the residents, and I was impressed with how much they threw themselves into the course. In Mbale, I had the pleasure of meeting a Ugandan resident who previously worked with USTOP, and was now a staff surgeon at the local hospital. “Dr. Dan” was an example of how this program can work. He was an advocate for good orthopaedics in Uganda that adhered to the principles of AO trauma, and he was fighting hard for change. I learned also that he regularly sent X-rays to Dr. Blachut in Vancouver for critique and advice. Dr. Dan himself was the sustainable resource that USTOP had helped create. I am proud to have worked with Dr. Dan, and I am confident he will improve orthopaedics in Uganda, with little risk of being left outside to collect red dust. The COA Global Surgery (COAGS) Committee is pleased to share Canadian global health initiatives. If you are interested in COAGS featuring your organization in the Bulletin, please contact trinity@canorth.org.

Patients prefer our knee while going down stairs. How do your patients feel? A staged bilateral TKA study using different designs showed that patients were more satisfied with the ACL-PCL Substituting Knee design: 76% preferred it over PS and CR designs, and 61% preferred it over mobile-bearing designs. Fast Forward™ to patient satisfaction.

For more information about our patient satisfaction studies, visit www.ortho.microport.com/index.cfm/products/clinical-data/clinical-data ™

The ACL-PCL Substituting Knee

Every patient is different, and individual results will vary. There are risks associated with surgery. Pritchett JW. Patients prefer a bi-cruciate-retaining or the medial-pivot total knee prosthesis. J Arthroplasty. 2011;26(2):224-8. Trademarks and Registered marks of MicroPort Orthopedics. ©2015 MicroPort Orthopedics Inc. All rights reserved. 010687

Your COA / Votre association

Attention University of Toronto Orthopaedic Program Alumni!

he Division of Orthopaedic Surgery at the University of Toronto is in the process of assembling a list of alumni from its residency program. Unfortunately the university has little information on surgeons who have graduated from the program prior to 1992. If you are a graduate of the University of Toronto’s orthopaedic training program, they would like to reconnect with you! They are developing some exciting alumni initiatives in the coming few years and would like to ensure that all of the alumni are included. Please contact the UofT with the following information if possible: 1) Full name 2) E-mail address 3) Year of graduation from UofT residency training program 4) Names of other individuals who graduated in your year Please forward the requested information to Dr. Peter Ferguson at orthopaedics.chairman@utoronto.ca and to Dan Stojimirovic at orthopaedics.admin@utoronto.ca.

Alvin H. McKenzie

B.Sc., M.D, M.Ch.Orth., FRCSC, FACS, FICS

assed away peacefully at home on November 20, 2016. He faced many ailments, but fought them bravely to the end with his great medical knowledge, strength of will and the heroic support of his wife, Phyl, and the help of family and friends. Born in Lethbridge, October 19, 1926, to Leonard and Lila McKenzie, he shared many adventures with family and friends from the Lethbridge area, including his dear friend, Bill Matheson, before enlisting for service in WWII and later enrolling in medicine at the U of A. After specializing in orthopaedics in Liverpool, England, he returned to Edmonton where he practiced medicine for over six decades! A full-time surgeon by day and full-time rancher the rest, for over 25 years, he, his wife, Phyl, and their family, raised some of the finest Maine Anjou cattle the breed has ever seen. Dolanakaal Ranch, located on a beautiful spot on the Sturgeon River, was his favourite place to be. A skilled surgeon, he helped many overcome illness and injuries, some becoming close friends. After leaving active surgery, he spent the last chapter of his career as a medical legal orthopaedic consultant. His thirst for knowledge and desire to contribute never slowed. As a surgeon, he pioneered new methods of spinal surgery and, as a consultant, he found new links between spinal injuries and concussions. Sadly, like some, he died just months after he retired; the difference being he retired at 89! Medicine was truly one of his greatest passions. COA Bulletin ACO - Winter / Hiver 2016/2017

He read everything from classics to the news and had boundless intellectual curiosity. He had the heart of a lion and the soul of a poet. An avid sportsman, he always enjoyed watching a good game. Everyone knew his keen sense of humour. He respected many great men, particularly Winston Churchill, and was a long-time member of the local Churchill Society. He had a keen interest in his family tree and loved trips to Scotland with family. Always ready to share a “wee dram” of fine single malt, he loved sharing time with friends and family. He was a true patriarch, mentor, advocate and our strongest supporter. He led by example and was always willing to help when we needed it most. He was a family man in the fullest sense and we will miss him more than words can say. He is survived by his devoted wife, Phyl; his children, Doug, Laurie (Clayton Elliott), Nancy (Ray Cone), Kathryn, Alan; grandchildren, Dillon, Brandon and Kristyn Elliott, Scotty, Amanda, Cera, Elena and Namieka Macaro; and great-grandchildren, Makaya, Colin and Nigella Elliott. He was predeceased by his parents, Lila (McCaugherty) and Leonard McKenzie, brothers, Donald and Leonard, and first wife, Sheila (McCully). Donations may be made to the Salvation Army, Edmonton Humane Society or the charity of your choice.

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 +

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COA Bulletin ACO - Winter / Hiver 2016/2017

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

Update from the Canadian Joint Replacement Registry The Canadian Joint Replacement Registry (CJRR) is Canada’s only pan-Canadian medical device registry. It was launched in 2001 in collaboration with the Canadian Orthopaedic Association and is managed by the Canadian Institute for Health Information (CIHI). Information on the CJRR can be found at www.cihi.ca/cjrr. CJRR Coverage IHI captures all acute, inpatient hip and knee replacement procedures across Canada through the Discharge Abstract Database (DAD) and the Hospital Morbidity Database (HMDB). Some provinces also send data on day surgery procedures to CIHI. CJRR captures additional prosthesis and other clinical information. Data for almost 84,000 hip and knee procedures were submitted to the CJRR for fiscal year 2015-2016. This represented 72% of all hip and knee replacements performed in hospitals in Canada. As shown in Figure 1, coverage varied by province with some provinces mandating reporting to the registry. Prior to the first provinces mandating collection in 2012, CJRR’s coverage was less than 50%.

Our goal is to reach greater than 90% coverage across Canada. Mandatory submissions from all jurisdictions is the most effective way to ensure a comprehensive capture of prosthesis and other clinical information for the country, in order to inform surveillance of device safety, inform procurement functions, and improve outcomes for hip and knee replacement patients.

As of April 1st, 2018, CIHI will be accepting CJRR data through the DAD. This transition is an opportunity for all Ministries of Health to expand CJRR data collection across each jurisdiction, and through these discussions, Ministries are seeking input and support from clinical orthopaedic leaders. This integration will enable prosthesis information to be linked directly to the patient-level hospitalization data. More information will be provided to current CJRR data providers on this transition. Other Activities With guidance from the CJRR Advisory Committee (chaired by Dr. Eric Bohm and co-chair Dr. Michael Dunbar) and CJRR Scientific Working Group, the CJRR team is developing revision risk curves for publication in the upcoming CJRR Annual Report. CIHI is also coordinating national efforts to advance a common approach for patient-reported outcome measures (PROMs) data collection and reporting in routine care, with hip and knee replacements being one of the initial areas of focus. A PROMs Hip and Knee Working Group has been established, also chaired by Dr. Eric Bohm, to provide input and recommendations on collection and use of PROMs in hip and knee arthroplasty, including PROMs tools and administration guidelines for pan-Canadian use. CIHI is also acquiring data sets from existing PROMs programs to help inform the national efforts. For more information or to contact the CJRR team, please email cjrr@cihi.ca.

Figure 1 CJRR Coverage, 2015-2016

COA Bulletin ACO - Winter / Hiver 2016/2017

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

Horizons

A new COA Bulletin feature

he 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 are excited to introduce this new 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 new feature is to “shed some light” on the best way forward. I would thank to thank Dr. Brent Lanting from Western University for contributing to this edition’s Horizons feature. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

Outpatient Hip and Knee Replacements in the Canadian Health-care System Brent A. Lanting, M.D., FRCSC Assistant Professor, Western University London, ON

Consented in clinic. Eligible for outpa5ent

otal hip replacements (THR) and total knee replacements (TKR) are the standard of care treatment for end stage arthropathy. Excellent patient outcomes with low complication rates are expected due to continuous rigorous innovation and dedication to optimal patient care1,2. As the population ages, a growth in demand is expected3. However, the budgetary effect of THR and TKR is increasingly an area of attention due to the limits in health-care funding. An additional reality in our health-care system is the challenge of bed management. Enhanced recovery patient-care pathways, including outpatient arthroplasty, have gained additional attention as they may respond to these needs as well as provide the potential for an improved patient experience.

In/Out pa5ent decision

Surgeon: SoF 5ssue management, hemostasis

Pre-Opera5ve Holding Area

OR Anesthesia: hydra5on, mul5modal pain control

To be successful with an outpatient arthroplasty program, all patients undergoing an outpatient joint replacement need to have preoperative, intraoperative, and postoperative care parameters clearly understood by all stakeholders in this clinical pathway. A consistent, clear message needs to be delivered by the clinicians, clinical support staff and physical therapists to ensure both the patient and the caregiver understands each step of the pathway. Patients must understand appropriate goals and expectations to ensure an appropriate outcome.

PT: Standard discharge criteria PACU

Day Surgery

RN: Hgb, Hemodynamic stability

MD: ensure appropriate for discharge

COA Bulletin ACO - Winter / Hiver 2016/2017

NP/ Medicine/ Anesthesia

PT: Screen, educate

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

Analgesia, nausea prevention, and the provision of appropriate volume resuscitation is important immediately postoperatively. When the patient is hemodynamically stable and postoperative symptoms of nausea and hypotension are controlled, physical therapy is initiated. It is critical that standards of care which have been built and adhered to for patients that have a standard of care THA or TKA must not be arbitrarily amended or altered to potentiate a shortened length of stay without careful consideration. Patients should only be cleared for discharge once they have appropriately completed standard physical therapy discharge criteria and are medically stable.

on the health-care provider and their administrative staff to guide patients through outpatient arthroplasty are generally not supported. There are additional demands on the caregivers regarding early care and associated anxiety with that, which often requires additional education and support to alleviate. If home care nursing and monitoring is part of the care pathway, who bears these additional costs is unclear, as the hospital often does not have home care support mechanisms. This may result in other patient or tax payer programs having additional costs. The gait aids and home physio needs will be very similar to other enhanced recovery care pathways.

Patient safety is of paramount importance whenever a healthcare innovation is proposed. A recent systematic review has demonstrated that patient safety can be achieved with an outpatient THA and TKA care pathway4. To successfully achieve outpatient arthroplasty surgeries, each aspect of the surgical care pathway needs to be reviewed. Minimized muscle damage, hemostasis, intraoperative hydration, multi-modal pain control, preoperative patient education, and comprehensive physical therapy are all important to potentiate outpatient care1,2. Selecting appropriate patients to be considered for outpatient THA and TKA is also very important. Successful patient cohorts in current literature typically have highly selected patient groups, which highlights the importance of choosing patients and caregivers that are amenable to this care pathway. Using a multi-disciplinary approach, these procedures can be safely performed in an outpatient setting.

Outpatient arthroplasty represents a paradigm shift from the current standard of care, but in carefully selected patients it may be appropriate. In a small number of Canadian centres, outpatient THA and TKA is already being practiced. With a carefully developed multimodal treatment plan involving all stakeholders, it can be implemented while maintaining patient safety. Greater discussion between health-care providers, administrators, and policy makers is required prior to adopting this innovation. The cost savings inherent to conducting THA or TKA as an outpatient suggest further evaluation should be conducted.

One of the benefits of the movement towards outpatient joint replacements is the potential for considerable cost savings. In literature, reported cost reductions of $8,527 at two years follow-up5, $2,5006 and $6,9783 have been demonstrated compared to inpatient groups. Although these outcomes may not be directly transferable to the Canadian health-care system, a significant reduction in budgetary impact was demonstrated in each paper. As length of stay is a major component of the cost of a THA, if a portion of these cases were done as an outpatient procedure, the potential for cost reduction is significant given 50,000 THAs are performed annually in Canada. Patient satisfaction and reported outcomes are an important measure of the success or potential downsides to the patient’s experiences and response to a new care pathway. Patient autonomy is an important factor in patient satisfaction. In-spite of the greater patient autonomy inherent to outpatient arthroplasty, no differences in clinical outcomes between inpatient or outpatient groups have been reported3,6. Although the early outpatient THA or TKA results in literature have demonstrated cost savings and appropriate patient safety, it is unclear how this paradigm shift translates to the Canadian health-care system. Provincial billing regulations, budgetary management, re-imbursement of the hospital and the health-care provider varies region to region. Where there isn’t provincial remuneration for outpatient arthroplasty, the hospital may not be supportive of creating an outpatient THA or TKA program. As quality of care markers may include readmission rates, provider stakeholders may also have significant trepidation in providing this patient care pathway. It is also notable that there may be a dis-incentive for the surgeon to provide this care pathway, as the additional demands placed

References 1. Berger R.A. A comprehensive approach to outpatient total hip arthroplasty. American Journal Of Orthopedics-Belle Mead-. 2007;36(9):4. 2. Berger raaw, S. M. Outpatient Total Knee Arthroplasty: Pathways and Protocols. Techniques in Knee Surgery. 2009;8(2):115-118. 3. Aynardi M., Post Z, Ong A., Orozco F, Sukin D.C. Outpatient Surgery as a Means of Cost Reduction in Total Hip Arthroplasty: A Case-Control Study. HSS Journal®. 2014;10(3):252-255. 4. Pollock M., Somerville L., Firth A., Lanting B. Outpatient Total Hip Arthroplasty, Total Knee Arthroplasty, and Unicompartmental Knee Arthroplasty – A Systematic Review of the Literature. JBJS Reviews. 2016. 5. Lovald S..T, Ong K.L., Malkani A.L., et al. Complications, mortality, and costs for outpatient and short-stay total knee arthroplasty patients in comparison to standard-stay patients. The Journal of arthroplasty. 2014;29(3):510-515. 6. Bertin K.C. Minimally invasive outpatient total hip arthroplasty: a financial analysis. Clinical orthopaedics and related research. 2005;435:154-163.

COA Bulletin ACO - Winter / Hiver 2016/2017

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

Paediatric ACL Reconstruction An introduction to this edition’s debate

nee injuries in the paediatric population are being progressively diagnosed and treated. Due to increased early sports specialization and more intense training, injuries such as anterior cruciate ligament (ACL) ruptures are being sustained by younger patients. Consequently, determining the best surgical technique to stabilize the knee while preserving normal growth potential is important. In this edition’s

debate, experts from the University of Toronto and McMaster University discuss the best surgical strategies for ACL reconstruction in the paediatric population. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

Transphyseal Anterior Cruciate Ligament Reconstruction in Skeletally Immature Patients Ryan O’Shea, M.D. Clinical Fellow Hospital for Sick Children University of Toronto Lucas Murnaghan, M.D., MEd, FRCSC Fellowship Program Director, Division of Orthopaedics Assistant Professor, Department of Surgery Hospital for Sick Children and Women’s College Hospital University of Toronto Toronto, ON

anagement of anterior cruciate ligament (ACL) injuries in patients with open physes is challenging and raises the concern of growth disturbance. It is important to note that not all paediatric ACL injuries are created equal; as patients with more growth remaining generate greater concern for a potential growth disruption. In skeletally immature patients, the surgeon must consider the physiologic age of the patient to select the appropriate surgical reconstruction technique with minimal complications.

Physeal-sparing techniques are usually reserved for younger patients (Tanner stages 1-2) and include the Micheli-Kocher and the all-epiphyseal ACL reconstruction techniques7,8. The Micheli-Kocher method uses the iliotibial band for combined intra- and extra-articular reconstruction9, and the all-epiphyseal reconstruction method involves drilling bone tunnels confined to the epiphysis10. Alternatively, the transphyseal technique involves drilling across the femoral and tibial physes11. A partial transphyseal technique is a hybrid of physeal-sparing and transphyseal approaches and involves drilling across either the distal femoral or proximal tibial physis on one side and using a physeal-sparing technique on the opposite side7. Consider this scenario: A 12-year-old female presents to the clinic with a one-year history of symptomatic knee instability after a non-contact soccer injury. She is healthy, premenarchal, and her mother explains she hasn’t yet hit her “growth spurt.” On physical exam, she has full range of motion, a positive pivot shift, and a positive Lachman. Radiographs demonstrate open physes and an MRI reveals a complete ACL tear in conjunction with a posterior horn medial meniscus tear (Figure 1).

Historically, paediatric patients with ACL injuries were initially treated nonoperatively with management focused on activity modification, bracing, and physiotherapy. Nonoperative management has now largely fallen out of favour due to the risk of recurrent instability1,2, secondary meniscal tears1,3, chondral injuries3,4, and cessation of sport participation5. Multiple studies have demonstrated a superior clinical result with surgical treatment of ACL injuries in the skeletally immature population2,5,6. The treatment paradigm for ACL ruptures in skeletally immature patients has now shifted toward operative intervention to restore knee stability, prevent secondary intra-articular injury, and facilitate return to sport. Various techniques for ACL reconstruction in the paediatric population have been described and are generally categorized as: physeal-sparing, partial transphyseal, or complete transphyseal techniques.

COA Bulletin ACO - Winter / Hiver 2016/2017

Figure 1 A, B: Radiographs of a 12-year-old female with an ACL injury and open physes. C, D: Representative coronal and sagittal MRI slices demonstrating an ACL injury.

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

The case example above demonstrates a patient who is a good candidate for a transphyseal ACL reconstruction with certain modifications to protect the physes. This type of reconstruction differs from the approach typically used in adults in that we utilize hamstring autograft with metaphyseal suspensory fixation, no fixation nor bone block is placed across the physis, and tunnel diameter is limited to less than nine millimetres. In a survey of the Herodicus Society and the ACL Study Group, Kocher et al. surveyed members in an attempt to identify cases of growth disturbance in skeletally immature patients undergoing ACL reconstruction. Reported cases included: hardware fixation spanning the physis, placement of bone blocks across the physis, use of large bone tunnels (> 12 mm), lateral extraarticular tenodesis, dissection in proximity to the perichondral ring of LaCroix, and suturing near the tibial tubercle8,13. In a separate study, increased tunnel diameter in relation to physeal diameter, overtensioning of the graft, inadequate filling of the tunnels with graft material, and tunnel malposition were also associated with growth disturbance14. It should be noted that many of these scenarios are avoidable by surgical technique and may explain why clinical results for transphyseal ACL reconstructions have not demonstrated high rates of growth disturbance. A recent meta-analysis of ACL reconstructions included 55 studies and 935 skeletally immature patients; the rate of leg-length discrepancy (greater than one centimetre) or axis deviation (greater than three degrees) was found to be 1.9%. In this particular study, the authors note that transphyseal techniques were associated with a lower risk of leg length discrepancy or axis deviation than were physeal-sparing procedures (1.9% compared to 5.8%)15. In a separate study, Fauno et al. attempted to quantify the degree of growth disturbance after transphyseal ACL reconstruction in 33 children by comparing the operative leg to the nonoperative side. Each patient’s subjective outcome, functional level, and objective knee stability were assessed upon follow-up and full extremity radiographs were obtained. The authors revealed that transphyseal ACL reconstruction in children results in minor length growth disturbances in 24% of patients (no greater than two centimetres); additionally, the authors noted a subtle surgically-induced distal femoral valgus angulation that was counterbalanced by a nearly equally subtle proximal tibial varus angulation. Overall, the authors concluded transphyseal ACL reconstruction has satisfactory clinical outcomes, with good subjective outcomes, function level, and knee stability despite minor changes induced by transphyseal drilling16. These studies demonstrate not only low rates of growth disturbance with transphyseal reconstruction, but alert us to the fact that physeal-sparing options are not without risk. When considering physeal-sparing or all-epiphyseal techniques, the theoretical advantage is to avoid the risk of growth disturbance. Unfortunately, this perceived advantage has not been borne out in the literature. Recently, a systematic review of 27 studies by Pierce et al. compared the incidence of growth disturbance between transphyseal and physeal-sparing techniques. Both cohorts showed similar rates of leg length discrepancy and angular deformity, and the authors concluded that these surgical techniques have no difference in the incidence

of growth disturbances17. Another recent systematic review by Collins et al. revealed that limb overgrowth may actually account for a majority of leg length discrepancies after ACL reconstruction. More interestingly, physeal-sparing techniques account for nearly half of leg length discrepancies and a quarter of angular deformities17. On the basis of these studies, we are comfortable concluding that while the growth plate must be considered, it should not be feared. When considering a transphyseal reconstruction, certain technical recommendations should be heeded. We recommend a soft tissue graft with complete fill of the femoral and tibial tunnels. These tunnels should be oriented in such a way as to minimize the cross-sectional area across the physis. Fixation of the graft should be remote from the physis and should stay within the metaphyseal bone on both the femoral and tibial sides. In conclusion, the transphyseal ACL reconstruction with technical modifications to respect the physis is our preferred technique in the operative management of children and adolescents with ACL injuries. References 1. Kannus P., Jarvinen M. Knee ligament injuries in adolescents: eight-year follow-up of conservative management. J Bone Joint Surg Br. 1988;70(5):772–776. 2. McCarroll J.R., Shelbourne K.D., Porter D.A., Rettig A.C., Murray S. Patellar tendon graft reconstruction for midsubstance anterior cruciate ligament rupture in junior high school athletes. Am J Sports Med.1994;22:478–483. 3. Lawrence J.T., Argawal N., Ganley T.J. Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: Is there harm in delay of treatment? Am J Sports Med 2011; 39(12):2582-2587. 4. Vavken P., Murray M.M. Treating anterior cruciate ligament tears in skeletally immature patients. Arthroscopy. 2010;27(5):704-716. 5. Ramski D.E., Kani W.W., Franklin C.C., Baldwin K.D., Ganley T.J. Anterior cruciate ligament tears in children and adolescents: a meta-anaylsis of nonoperative versus operative treatment. Am J Sports Med. 2014;42:2769-2776. 6. Streich N.A., Barie A., Gotterbarm T., Keil M., Holger S. Transphyseal reconstruction of the anterior cruciate ligament in prepubescent athletes. Knee Surg Sports Traumatol Arthrosc. 2010;18:1481-1486. 7. Pennock A., Murphy M.M., Wu M. Anterior cruciate ligament reconstruction in skeletally immature patients. Curr Rev Muscloskelet Med. Sept 2016. 8. Frank J.S., Gambacirta P.L. Anterior Cruciate Ligament Injuries in the Skeletally Immature Athlete: Diagnosis and Management. J Am Acad Orthop Surg 2013;21:78-87

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

9. Kocher M.S., Sumeet G., Michelli L.J. Physeal sparing reconstruction of the anterior cruciate ligament in skeletally immature prepubescent children and adolescents. J Bone Joint Surg Am. 2005;87a(11)2371-2379. 10. Anderson A.F. Transepiphyseal replacement of the anterior cruciate ligament in skeletally immature patients. A preliminary report. J Bone Joint Surg Am. 2003;85-A:1255–1263. 11. Cruz A.I., Fabricant P.D., McGraw M., Rozell J.C., Ganley T.J., Wells L. All-ephysieal ACL reconstruction in children: a review of safety and early complications. J Pediatr Orthop. 2015;0(0);1-6. 12. Kocher M.S. et al. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and the ACL Study Group. J Pediatr Orthop. 2002;22(4):452–7. 13. Kocher M.S., Saxon H.S., Hovis W.D., Hawkins R.J. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop. 2002 Jul-Aug;22(4):452-7.

14. Hudgens J.L., Dahm D.L. Treatment of anterior cruciate ligament injury in skeletally immature patients. Int J Pediatrics. 2012;1-6. 15. Frosch K.H., Stengel D., Brodhun T., Stietencron I., Holsten D., Jung C., Reister D., Voigt C., Niemeyer P., Maier M., Hertel P., Jagodzinski M., Lill H. Outcomes and risks of operative treatment of rupture of the anterior cruciate ligament in children and adolescents. Arthroscopy. 2010 Nov;26(11):153950. 16. Faunø P., Rømer L., Nielsen T., Lind M. The Risk of Transphyseal Drilling in Skeletally Immature Patients With Anterior Cruciate Ligament Injury. Orthop J Sports Med. 2016 Sep;4(9):2325967116664685. 17. Pierce T.P., Issa K., Festa A., Scillia A.J., McInerney V.K. Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of Transphyseal Versus Physeal-Sparing Techniques. Am J Sports Med. 2016 Apr 4. 18. Collins M.J., Arns T.A., Leroux T., Black A., Mascarenhas R., Bach B.R., Forsythe B. Growth Abnormalities Following Anterior Cruciate Ligament Reconstruction in the Skeletally Immature Patient: A Systematic Review. Arthroscopy. 2016 Aug;32(8):1714-23.

Extraphyseal Paediatric Anterior Cruciate Ligament Reconstruction Kayode O. Oduwole, M.D., MCh, FRCSC Devin C. Peterson M.D., FRCSC, Dip. Sport Med. Division of Orthopedic Surgery, McMaster University Hospital Hamilton, ON

he incidence of anterior cruciate ligament (ACL) injury in skeletally immature individuals appears to be increasing1. Delays in surgical management may lead to recurrent instability with secondary chondral and meniscal injuries, degenerative joint disease and decreased functional outcome measures2–4. Unfortunately, ACL reconstruction (ACLR) in this population is challenging, given the potential risk of physeal damage and growth arrest as well as potential non-compliance to postoperative instructions. Although the etiology of physeal damage is multifactorial5, animal studies have shown that a physeal defect greater than 7% of the femoral physeal crosssectional area and 4% of the tibial physeal cross-sectional area is enough to cause growth arrest6,7. This quantiﬁable and modiﬁable risk factor can be capitalized upon to reduce this risk and its consequences by avoiding physeal disruption beyond the aforementioned dimensions. Although many surgeons feel transphyseal techniques are safe in this vulnerable population, recent literature suggests that this approach also has potential risks to the future growth of these patients.

COA Bulletin ACO - Winter / Hiver 2016/2017

The distal femur and proximal tibia physis contribute 37% and 28% respectively to the overall growth of the lower extremity. During the last few years of growth, the distal femoral physis contributes to roughly ten millimetres of growth per year and the proximal tibial physis to six millimetres8. The significant amount of growth potential around the knee has led to the development of physeal-sparing and partial transphyseal ACLR, due to concerns that traditional ACLR involving drilling across the physis may have a higher potential risk of growth disturbance and angular deformity. However, a meta-analysis by Frosch et al.9 found significant differences in the overall rate of leg length differences or axis deviation to be 5.8% with physeal-sparing techniques and only 1.9% with transphyseal techniques, using a very judicious value of one centimetre for leg length and greater than three degrees for angular deformity9. These findings would appear to favour transphyseal over physeal-sparing ACLR in an effort to lessen the chances of growth arrest. They proposed that heat damage to the physis caused by tangential drilling and graft transport out of the joint with fixation distal to tibia growth plate in physeal-sparing techniques can lead to growth arrest and angular deformity. Unfortunately, the low level of evidence in the eligible studies (Level IV), and the heterogeneity of techniques make it very difficult to interpret the findings and make definitive recommendations. Furthermore, the documentation of growth disturbance was not standardized between studies and only a few used long-leg radiographs.

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

A recent review of the outcomes of paediatric ACLR revealed concerning failure rates as high as 15–25% and growth disturbances being uncommon but now reported within almost every technical category10. Table 1 outlines the demographics of current publications on paediatric ACLR along with their failure rates and documented growth disturbances. Although the majority of the studies did not report the existence of any leg length or angular abnormalities in their patients, this data looks different when criteria similar to Frosch is applied in these same publications where raw data is available (Table 2)9. The raw data in some of the studies suggests a higher incidence of growth abnormality than the authors reported. High failure rates as well as growth disturbances can now be seen within each surgical category.

Proponents for transphyseal ACLR are directed toward recent studies with troubling findings for growth arrest using this procedure even in almost skeletally mature patients. Shifflett et al. reported on four patients who underwent transphyseal ACLR with hamstring autograft at a mean age of 14.2 years (range, 13.5 y - 14.8 y)11, an age when many surgeons are comfortable ignoring the physis due to the limited amount of growth remaining. These patients were treated with endobutton fixation on the femur and biointerference screw in the tibial tunnel backed up with a screw/washer construct. They presented with clinically significant growth arrest with two cases of tibial recurvatum and two cases of genu valgum. Fauno et al. reported results of transphyseal ACLR using hamstring autograft without intraosseous-placed fixation implants in 33 patients with a mean age of 11.7 years (range, 9.0-14.0 y) and a mean follow-up of 68 months12. They found more than ten millimeTable 1: Study Demographics and Complications tres of shortening of the operated leg in 24%, and a change in anatomic femoral Surgical Author/ No Age of Pts yrs Follow-up Re-rupture rates Author’s reported axis in 82% of the patients. Importantly, technique YOP of Pts (range) mos (range) No (%) LLD and AD these findings were not found to be age PhysealNawabi 15 Mn 13.6 Mn 21 mos None None dependent. sparing 201420 (11-15) (12-39) Koizum 15 Md 14 Md 38 mos 2 (13.3%) None Although a theoretical advantage of 201321 (13-16) (25-48) transphyseal techniques is that they may Partial Demange 12 Mn 10.7 Minimum 3 (25%) None allow for a more “anatomic” reconstruc22 Transphyseal 2014 (8.3-12.4) 15years tion and intraosseous tunnels enabling Cassard 28 Mn 13 Mn 2.8 yrs 2 (7%) None better graft incorporation, a recent sys23 2014 (9-15) (2-5) tematic review comparing transphyseal Nawabi 8 Mn 14.5 Mn 14 mos None None and physeal-sparing techniques showed 20 2014 (13.5-16) (12-18) a higher re-rupture rate of 6.2% in the Transphyseal Calvo 27 Mn 13 Mn 10.6 yrs 4 (15%) None transphyseal group versus 3.1% in the 201524 (12-16) (10-13) physeal-sparing group, although these numbers did not reach significance13. Kohl 15 Mn 12.8 Mn 4.1yrs None LLD in 3 pts (13%) 201325 (6.2-15.8) (1.9-9.7) AD in 1 pt (6%) Similarly, the meta-analysis by Frosch et al. reported higher re-rupture rate of Schmale 29 Mn 14 Mn 4years 4 (14%) 4.2% in transphyseal ACLR compared to 201426 (2-8) YOP=Year of publication, No=number, pts=patients, yrs=years, mos=months, RRR=re-rupture rate, LLD=Leg length discrepancy, a rate of 1.4% in physeal sparing ACLR (RR,2.91; 95% CI, 0.70 to 12.12)9. AD=angular deformity, Mn=mean, Md = median Table 2: Leg Length Discrepancy and Angular Deformity

Surgical technique Physeal Sparing

Author/ YOP Nawabi 2014 Koizum 2013 Partial Demange Transphyseal 2014 Cassar 2014

No Author’s reported of Pts LLD and AD 15 None 15

None

Raw data re-analysed using: LLD > 10mm AD > 3 degrees LLD 1 pt (6.6%), No AD No raw data available

None

No raw data available

None

LLD 9 pts (32%) AD 5 pts (18%s)

Nawabi 2014 Transphyseal Calvo 2015 Kohl 2013 Schmale 2014

None

No raw data available

AD 1 pt (6%t)

LLD 3 pts (13%) AD 1 pt (6%t) No reoperations for growth abnormalities No raw data available No angular malalignments

YOP=Year of publication, No=number, pts=patients, LLD=Leg length discrepancy, AD=angular deformity

This recent evidence would suggest that transphyseal ACLR with a soft tissue graft is not as benign as was previously thought, and this technique may not necessarily lead to superior outcomes compared to physeal-sparing techniques. Our current treatment for the skeletally immature patient with an ACL tear is to perform a partial physeal ACLR incorporating many of the principles discussed in the article by Peterson and Ayeni10. Swami et al. reported a mean vertical epiphyseal height (difference between the physeal plate and the tibial articular surface) of only 15.9 mm in an adolescent group (11–15 years) and 15.1 mm in a preadolescent group (six to ten years)14. Subsequently, concern over the small safe zone between the tunnel and either the physis or the articular surface has resulted in our use of a docking COA Bulletin ACO - Winter / Hiver 2016/2017

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

technique using retrograde drilling, which results in a small tunnel crossing the physis and a larger tunnel in the epiphysis for the graft (Figure 1). Several physeal protecting principles have also been incorporated into our practice. A more vertically oriented tibial tunnel (55o) is used as this reduces physeal damage15, care is taken to avoid the tibial tubercle apophysis16, and a slower drilling speed is used to prevent thermal injury to the physis17. An all epiphyseal femoral tunnel is slowly drilled and a hamstring autograft is passed with button fixation for both the tibial and femoral side (Figure 2); thus, preventing placement of bone or hardware across the physis which has been shown to be a cause of growth arrest18. Finally, excessive tensioning of the graft (tenoepipysiodesis) is avoided as this may also be a potential cause of growth arrest, although the amount of tension required to cause growth arrest is currently unknown19. Conclusion The incidence of ACL injury in the skeletally immature patient appears to be increasing, presumably due to the earlier age of participation and more intensive involvement in sporting activity. Early surgical reconstruction is recommended to avoid irreparable damage that can occur with recurrent instability. Nevertheless, proper patient education is important due to the potential for high failure rates and growth arrest. Although there is no definitive reconstructive gold standard, at a minimum we recommend soft tissue graft selection, more vertically oriented tibial and possibly femoral tunnels, slow drilling speed (e.g. using a manual drill) to avoid thermal injury, fixation that does not cross the physis, and avoidance of excessive tension. We are currently more comfortable with avoiding the femoral physis altogether and performing minimal drilling across the tibial physis, especially in our patients with more than two years of growth remaining.

Figure 1 (AP X-ray) - A retrograde drilling technique allows a large tunnel in the epiphysis but a much smaller one through the physis

References 1. Gottschalk A.W., Andrish J.T. Epidemiology of sports injury in pediatric athletes. Sports Med Arthrosc. 2011;19(1):26. doi:10.1097/JSA.0b013e31820b95fc\r00132585201103000-00002 [pii]. 2. Henry J., Chotel F., Chouteau J., Fessy M.H., BĂŠrard J., Moyen B. Rupture of the anterior cruciate ligament in children: Early reconstruction with open physes or delayed reconstruction to skeletal maturity? Knee Surgery, Sport Traumatol Arthrosc. 2009;17(7):748-755. doi:10.1007/s00167-009-0741-0. 3. Millett P.J., Willis A.A., Warren R.F. Associated injuries in pediatric and adolescent anterior cruciate ligament tears: Does a delay in treatment increase the risk of meniscal tear? Arthroscopy. 2002;18(9):955-959. doi:10.1053/ jars.2002.36114. 4. Lawrence J.T., Argawal N., Ganley T.J. Degeneration of the knee joint in skeletally immature patients with a diagnosis of an anterior cruciate ligament tear: is there harm in delay of treatment? Am J Sport Med. 2011;39(12):2582-2587. doi:10.1177/0363546511420818.

COA Bulletin ACO - Winter / Hiver 2016/2017

Figure 2 (AP X-Ray) - Button fixation on both femur and tibia

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 26)

5. Frank J.S., Gambacorta P.L. Anterior cruciate ligament injuries in the skeletally immature athlete: diagnosis and management. J Am Acad Orthop Surg. 2013;21(2):78-87. doi:10.5435/JAAOS-21-02-78.

16. Shea K.G., Carey J.L., Richmond J., et al. The American Academy of Orthopaedic Surgeons Evidence-Based Guideline on Management of Anterior Cruciate Ligament Injuries. Summ Guidel. 2015:672-674.

6. Makela E.A., Vainionpaa S., Vihtonen K., Mero M., Rokkanen P. The effect of trauma to the lower femoral epiphyseal plate. An experimental study in rabbits. J Bone Jt Surg Br. 1988;70(2):187-191. doi:10.1097/01241398-19880900000104.

17. Meller R., Kendoff D., Hankemeier S., et al. Hindlimb growth after a transphyseal reconstruction of the anterior cruciate ligament: a study in skeletally immature sheep with wideopen physes. Am J Sports Med. 2008;36(12):2437-2443. doi:10.1177/0363546508322884.

7. Guzzanti V., Falciglia F., Gigante A., Fabbriciani C. The effect of intra-articular ACL reconstruction on the growth plates of rabbits. J Bone Joint Surg Br. 1994;76(6):960-963. http:// www.ncbi.nlm.nih.gov/pubmed/7983128.

18. Kocher M., Saxon H., Hovis W., Hawkins R. Management and complications of anterior cruciate ligament injuries in skeletally immature patients: survey of the Herodicus Society and The ACL Study Group. J Pediatr Orthop. 2002;22(4):452-457.

8. Mosley C. Leg Length Discrepancy. In: Lovell and Winter’s Pediatric Orthopaedics. 5th ed. Philadelphia: Lippincott Wiliams & Wilkins; 2001:1111-11127.

19. Stadelmaier D.M., Arnoczky S.P., Dodds J., Ross H. The effect of drilling and soft tissue grafting across open growth plates. A histologic study. Am J Sports Med. 1995;23(4):431-435. doi:10.1177/036354659502300410.

9. Frosch K.-H., Stengel D., Brodhun T., et al. Outcomes and Risks of Operative Treatment of Rupture of the Anterior Cruciate Ligament in Children and Adolescents. Arthrosc J Arthrosc Relat Surg. 2010;26(11):1539-1550. doi:10.1016/j. arthro.2010.04.077. 10. Peterson D.C., Ayeni O.R. Pediatric anterior cruciate ligament reconstruction outcomes. Curr Rev Musculoskelet Med. 2016;9(4):339-347. doi:10.1007/s12178-016-9358-3. 11. Shifflett G.D., Green D.W., Widmann R.F., Marx R.G. Growth Arrest Following ACL Reconstruction With Hamstring Autograft in Skeletally Immature Patients: A Review of 4 Cases. J Pediatr Orthop. 2015;36(4):355-361. doi:10.1097/ BPO.0000000000000466. 12. Faunø P., Lund B., Christiansen S.E., Gjøderum O., Lind M. Analgesic effect of hamstring block after anterior cruciate ligament reconstruction compared with placebo: a prospective randomized trial. Arthroscopy. 2015;31(1):63-68. doi:10.1016/j.arthro.2014.07.024. 13. Pierce T.P., Issa K., Festa A., Scillia A.J., McInerney V.K. Pediatric Anterior Cruciate Ligament Reconstruction: A Systematic Review of Transphyseal Versus Physeal-Sparing Techniques. Am J Sports Med. 2016:0363546516638079-. doi:10.1177/0363546516638079. 14. Swami V.G., Mabee M., Hui C., Jaremko J.L. MRI Anatomy of the Tibial ACL Attachment and Proximal Epiphysis in a Large Population of Skeletally Immature Knees: Reference Parameters for Planning Anatomic Physeal-Sparing ACL Reconstruction. Am J Sports Med. 2014;42(7):1644-1651. doi:10.1177/0363546514530293. 15. Kercher J., Xerogeanes J., Tannenbaum A., Al-Hakim R., Black J.C., Zhao J. Anterior cruciate ligament reconstruction in the skeletally immature: an anatomical study utilizing 3-dimensional magnetic resonance imaging reconstructions. J Pediatr Orthop. 2009;29(2):124-129. doi:10.1097/ BPO.0b013e3181982228.

20. Nawabi D.H., Jones K.J., Lurie B., Potter H.G., Green D.W., Cordasco F.A. All-inside, physeal-sparing anterior cruciate ligament reconstruction does not significantly compromise the physis in skeletally immature athletes: a postoperative physeal magnetic resonance imaging analysis. Am J Sports Med. 2014;42(12):2933-2940. doi:10.1177/0363546514552994. 21. Koizumi H., Kimura M., Kamimura T., Hagiwara K., Takagishi K. The outcomes after anterior cruciate ligament reconstruction in adolescents with open physes. Knee Surgery, Sport Traumatol Arthrosc. 2013;21(4):950-956. doi:10.1007/ s00167-012-2051-1. 22. Demange M.K., Camanho G.L. Nonanatomic anterior cruciate ligament reconstruction with double-stranded semitendinosus grafts in children with open physes: minimum 15-year follow-up. Am J Sport Med. 2014;42(12):2926-2932. doi:10.1177/0363546514550981. 23. Cassard X., Cavaignac E., Maubisson L., Bowen M. Anterior cruciate ligament reconstruction in children with a quadrupled semitendinosus graft: preliminary results with minimum 2 years of follow-up. J Pediatr Orthop. 2014;34(1):70-77. doi:10.1097/BPO.0b013e3182a008b6. 24. Calvo R., Figueroa D., Gili F., et al. Transphyseal anterior cruciate ligament reconstruction in patients with open physes: 10-year follow-up study. Am J Sports Med. 2015;43(2):289294. doi:10.1177/0363546514557939. 25. Kohl S., Stutz C., Decker S., et al. Mid-term results of transphyseal anterior cruciate ligament reconstruction in children and adolescents. Knee. 2014;21(1):80-85. doi:10.1016/j. knee.2013.07.004. 26. Schmale G.A., Kweon C., Larson R.V., Bompadre V. High satisfaction yet decreased activity 4 years after transphyseal ACL reconstruction. Clin Orthop Relat Res. 2014;472(7):21682174. doi:10.1007/s11999-014-3561-6.

COA Bulletin ACO - Winter / Hiver 2016/2017

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

Higher Survival of Hip Fracture Patients Treated in Larger Hospitals Boris Sobolev, PhD Professor and Head Division of Health Services and Policy, School of Population and Public Health The University of British Columbia Pierre Guy, MDCM, MBA, FRCSC Associate Professor and Head of Division of Orthopedic Trauma Department of Orthopedics The University of British Columbia, Katie Sheehan, PT, PhD Lecturer Department of Physiotherapy Division of Health and Social Care Research, King’s College London

A recent article reports variation in survival after hip fracture by place of treatment. Sheehan K.J. et al., for the Canadian Collaborative Study of Hip Fractures. In-hospital mortality after hip fracture by treatment setting. CMAJ 2016; 188 (18). The burden of breaking a hip very year, 25,000 older Canadians face disability, dependence and death after breaking a hip. In fact, hip fractures occur as frequently as common cancers resulting in severely worse outcomes: 25% never walk again, 22% never live independently, and 30% die within a year1-4. These figures have not changed in the past 15 years, and little is known about how to reduce a difference in death rates between the injured and the general population. With an aging population and people living longer lives, these figures pose a major challenge to health-care systems in Canada.

In-hospital mortality after hip fracture by treatment setting For older men and women, withstanding the double stress of the injury and a major surgery could be an uphill battle that carries a significant risk of death even during the hospital stay5. What treatment and why it was chosen have been studied extensively in hip fracture care. We believe that in order to understand variation in outcomes of hip fracture care, we need also to consider where treatment is provided, who provides it and when it is provided. It is well established that survival after hip fracture surgery depends on age, sex, health status, characteristics of fracture and type of surgery. But the roles of the where, who and when of hip fracture care remain largely unknown. Our recent CMAJ article shows that where a person receives their treatment determines survival after hip fracture: people with broken hips were more likely to be discharged alive from a teaching hospital and a large community hospital than a small or mediumsized community hospital.

COA Bulletin ACO - Winter / Hiver 2016/2017

120

No. of deaths per 1000 admissions

Teaching Community – large Community – medium Community – small

No. of inpatient days

Figure 1 Cumulative incidence of in-hospital death by inpatient days across treatment settings among all patients admitted with first hip fracture. Reproduced with permission from CMAJ.

The study used data from the Canadian Institute for Health Information to look at people 65 years or older who were admitted to hospitals in Canada for treatment of hip fracture over the period 2004–2012. We compared how often patients died during hospitalization across 165 hospitals varying by type and size6. We accounted for difference in length of stay by treatment setting. Teaching hospitals were defined as hospitals with full membership in the Association of Canadian Academic Healthcare Organizations, now part of HealthCareCAN. Community hospitals were categorized by size: large hospitals had 200 or more beds, medium hospitals had 50 to 199 beds, and small hospitals had fewer than 50 beds. For every 1000 patients with hip fracture, we found 14 and 43 fewer survivors among those admitted to medium and small community hospitals compared with teaching hospitals (Figure 1). The majority of patients had surgery to repair their fracture at the admitting hospital or after transfer to another hospital. For every 1000 patients treated surgically, we found 11 fewer survivors among those treated at medium community hospitals compared with teaching hospitals. Previous research suggests that the higher risk of death may be the result of less timely care because smaller hospitals have fewer beds, fewer staff members, or less readily available equipment. The Canadian Collaborative Study of Hip Fractures Health services research guides changes in policy and practice by revealing variations in care outcomes that cannot be explained by illness level, known benefit or patient preference. The Canadian Collaborative Study of Hip Fractures brings

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

together experts in surgery, health-care research, economics, data science, policy, knowledge translation and patient engagement to evaluate hip fracture care in Canada. Funded by the Canadian Institutes of Health Research, we are looking at whether expedited access to surgery, a higher level of care intensity and enhanced organization of care delivery improve survival in these vulnerable patients. In particular, we are studying morbidity and mortality among patients treated at various times after admission with hip fracture to Canadian acute care hospitals. We estimate timing and results of surgery across the entire country. Using a standardized method for defining index admission and care episodes, we test whether postoperative complications and deaths were more frequent among patients with longer waiting times. We will identify groups of patients who would benefit from expedited access to hip fracture surgery, in terms of fewer complications and deaths. Members of this collaborative study include Eric Bohm, Lauren Beaupre, Michael Dunbar, Donald Griesdale, Pierre Guy, Edward Harvey, Erik Hellsten, Susan Jaglal, Hans Kreder, Lisa Kuramoto, Adrian Levy, Suzanne N. Morin, Katie J. Sheehan, Boris Sobolev, Jason M. Sutherland and James Waddell. The collaborative has already published several articles in leading orthopaedic journals on constructing an episode of care (Journal of Orthopaedic Research) and on variation in hospital stay after hip fracture in Canada (Archives of Osteoporosis). Forthcoming articles will report on the incidence of surgical complications and time trends in death rates after hip fracture.

Free Pre-registration Deadline for Active & Associate Members Closes on April 28

ctive* and Associate members of the COA are reminded to register for the upcoming COA, CORS and CORA Annual Meeting by April 28 in order to benefit from the waived registration fees. Reduced rates for our Active members practicing in the US, for Senior and Research Affiliate members are in effect until April 28 as well. Visit www.coaannualmeeting.ca to register today. If you are a presenter (poster or podium), moderator or speaker, you also must register before the June 9 online registration cut-off date.

References 1. Public Health Agency of Canada. Chronic Disease and Injury Indicator Framework. Chronic Disease Infobase 2014. 2. Lund C.A., Moller A.M., Wetterslev J., Lundstrom L.H. Organizational factors and long-term mortality after hip fracture surgery. A cohort study of 6143 consecutive patients undergoing hip fracture surgery. PLoS One 2014; 9(6):e99308. 3. Magaziner J., Fredman L., Hawkes W., Hebel J.R., Zimmerman S., Orwig D.L. et al. Changes in functional status attributable to hip fracture: a comparison of hip fracture patients to community-dwelling aged. Am J Epidemiol 2003; 157(11):10231031. 4. Nikitovic M., Wodchis W.P., Krahn M.D., Cadarette S.M. Direct health-care costs attributed to hip fractures among seniors: a matched cohort study. Osteoporos Int 2013; 24(2):659-669. 5. Sobolev B., Guy P., Sheehan K.J., Kuramoto L., Bohm E., Beaupre L. et al. Time trends in hospital stay after hip fracture in Canada, 2004-2012: Database study. Archives of Osteoporosis 2016; 11(1):13. 6. Canadian Institute for Health Information. Peer Groups in the Electronic Discharge Abstract Database Reports. 2015.

Les membres actifs et associés peuvent s’inscrire gratuitement jusqu’au 28 avril

n rappelle aux membres actifs* et associés de l’ACO qu’ils doivent s’inscrire à la Réunion annuelle de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO) d’ici le 28 avril pour profiter de l’annulation de leurs droits d’inscription. Les réductions sur l’inscription offertes aux membres actifs qui exercent aux ÉtatsUnis, aux membres seniors et aux membres affiliés du milieu de la recherche sont également en vigueur jusqu’au 28 avril. Rendez-vous à www.coaannualmeeting.ca et inscrivez-vous dès aujourd’hui!

See you in Ottawa!

Si vous présentez une affiche ou un exposé, êtes modérateur ou conférencier, vous devez aussi vous inscrire en ligne avant le 9 juin.

*practicing in Canada

Au plaisir de vous voir à Ottawa! * Les membres actifs exerçant au Canada. COA Bulletin ACO - Winter / Hiver 2016/2017

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

Patients Continue to Wait…and Orthopaedic Surgeons Continue to Languish in Unemployment – The Status of Orthopaedic Unemployment in Canada Peter B. MacDonald, M.D., FRCSC, COA President Emil Schemitsch, M.D., FRCSC, COA Human Resources Committee Chair Trinity Wittman, MSc, COA Development and Advocacy Manager

“…this is a horrible spot to be in, $150K of educational debt and no job prospects!!!” “...extremely discouraging to have gone through 15 years of post-secondary education and not to have full-time employment” “I am frustrated by job postings that are …a formality…successful applicants have already been chosen…” “was told that I was not a viable candidate for a community job because I did not have two fellowships…it is an appalling job market” “we will downgrade our profession if we continue this” “…many, if not all, full-time jobs appear to be pre-determined and not open to other candidates…” “extremely disappointed…no job in the field I am so passionate about… extremely difficult for me, my spouse, our children…likely have to relocate from the country and province we call home” “I still don’t understand why the COA allowed excess residents to be trained” “please stop training so many new grads” “our system is TOTALLY broken” “I personally would not have chosen my specialty had I known the sad state my “staff” colleagues have left the job market” “I am terrified about unemployment following completion of my training” “the COA should do more to help me find a job” “…took a job in the US as there were no jobs in my specialty in Canada” “…hope to practice in Canada…but likely will not have that option” “I have little to no hope I will ever get a job in orthopaedics”

hese are just a few of the comments the COA received from Canadian-trained orthopaedic graduates when surveyed recently about employment. They reflect some of the hurt, frustration and even anger that is being felt by the almost 200 unemployed graduates in the country right now. Canada’s unacceptably high rate of unemployment among orthopaedic graduates poses a serious threat to the quality of patient care and to surgeons’ personal and professional wellbeing. The ever-increasing number of graduates unable to find employment in Canada are faced with chronic locum experiences and serial fellowships, and many are turning to job opportunities abroad. Members have shared stories of financial and emotional burden which cannot be ignored. The COA Bulletin ACO - Winter / Hiver 2016/2017

COA Board of Directors would like graduates to know that your voice is being heard. A number of initiatives are underway: Data collection: The COA Board identified a lack of accurate data around surgical unemployment, and has invested significant resources in detailed collection of underemployment data, offering the needed tools to advocate for further resources with various levels of government. For some of the latest statistics, see the Orthopaedic Unemployment Fact Sheet (opposite page). Education: The COA urges members at all stages of their career to educate themselves about the unemployment crisis and to take steps to help manage this situation. For the Board’s complete list of recommendations, please refer to the Orthopaedic Graduate Unemployment Position Statement. Reduction in residency spots: The COA has encouraged all orthopaedic programs to consider temporary, but immediate reductions in residency spots. As a result, the number of R1 residency positions nationwide decreased from 81 in 2011 to 64 in 2016. Given the lengthy training process required to recruit and train orthopaedic surgeons, this recommendation must be closely monitored as long wait times are persistent, and Canada’s aging population will call for more specialists in coming years. Despite these facts, however, we expect the limiting factor will continue to be public funding to invest in new permanent orthopaedic positions, as well as the hospital-based resources required to support them. COA Job Board: The password-protected membership portal offers a Canadian orthopaedic Job Board, where surgeons can post and seek available positions at no charge. We encourage all hospitals to maintain a transparent hiring process whereby jobs are widely circulated for equal opportunity to all graduates seeking employment. Help us out! If you hear of an orthopaedic job opening, please send a note to cynthia@canorth.org. We will follow up directly with the orthopaedic centre in hopes of posting the position on our site. Free Services: COA membership is offered free of charge to residents, fellows and job seekers (including those doing locums and part time work). Newly-hired surgeons are offered a 50% rebate on their membership dues for the first year in practice. This initiative translates to 6-10 years of free membership benefits. The COA Membership Committee is sensitive to the challenges our new surgeons are facing, and this is one way we could offer support. Click here to see some of benefits offered to COA members. Late Career Transition Planning and Job Sharing: Traditional definitions of a full-time position should be reconsidered with a focus on late-career practice changes. We strongly encourage

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

senior surgeons to plan for job-sharing when moving towards retirement in order to allow younger surgeons to transition smoothly into full-time positions. Decreased surgical activities could be linked to meaningful participation in other aspects of surgical practice, including patient assessment, mentoring, assisting, teaching, research and administration. Hospital resource utilization by individual surgeons should be linked to on-call responsibilities and both should decrease in a planned and orderly fashion when transitioning towards the end of career. The COA encourages the addition of a new orthopaedic surgeon to a group practice where possible, including mentoring and resource-sharing. Please refer to the COA Guidelines for Late Career Transition. Government Advocacy: The COA believes governments and hospitals, which together fund and manage the health-care system, should allocate hospitalbased resources more effectively to better serve Canadian patients. Board members continue to advocate accordingly at various levels of government. The Access to Care Steering Committee, struck in 2016 to build on the COA Position Statement on Access to Orthopaedic Care in Canada, called on COA members to share innovative models of surgical care which have improved access to timely, appropriate orthopaedic care. Through your responses, the Committee gained an understanding of the constructive solutions that you believe would positively impact orthopaedic patients and systems. COA President Dr. Peter MacDonald will meet with Health Canada policy advisors in January 2017, drawing on themes and commonalities among innovative strategies, advocating for more efficient use of resources, which in turn will lead to improved patient care and ultimately, increased hiring of surgeons.

Seeking Feedback: The COA Executive recognizes the frustration that affected members are feeling on this critical issue. Given the limitations in our ability to intervene directly in finding jobs for graduates, what more do you see the COA doing to address the employment situation in Canada? We want to hear from you. If you have a suggestion, or would like to speak with an Executive member, please contact policy@canorth.org. Underemployment of our colleagues is likely the most challenging issue that our profession has ever faced and the COA will continue to seek ways to best serve our members.

CANADIAN ORTHOPAEDIC SURGEONS LOOKING FOR WORK FACT SHEET

June 2016 – COA Orthopaedic Human Resources Committee

The COA Orthopaedic Human Resources Committee surveyed the 17 Canadian Program Directors to determine the number of recent orthopaedic graduates currently seeking full-time orthopaedic employment. Current Orthopaedic Unemployment Data Snapshot (Captured June 2016) Training Region Atlantic Quebec Ontario Prairies British Columbia TOTAL

Ortho grads 2010-2016 44 134 223 113 40

IMG / Military 7 16 3 8 0

Full-Time Job Canada 23 85 98 57 19

International Job 2 14 39 4 2

Seeking Full-Time (FT) Position* 12 19 88 44 19

559

282

182

*Includes orthopaedic surgeons in the market for full-time orthopaedic positions in Canada (currently completing locums, fellowships, research)

Quebec-trained surgeons have the highest success rate of finding FT employment in Canada (63.4%) Ontario-trained surgeons have the lowest success rate of finding FT employment in Canada (43.9%)

More than 50% of grads trained in BC and Ontario in the last seven years have not found full-time positions in Canada The number of Canadian grads seeking full-time employment outside Canada (US or international) has doubled in the last two years

Currently, 182 recently-graduated Canadian orthopaedic surgeons are seeking full-time employment.

CANADIAN ORTHOPAEDIC ASSOCIATION / ASSOCIATION CANADIENNE D’ORTHOPÉDIE

policy@canorth.org

COA Bulletin ACO - Winter / Hiver 2016/2017

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

Les patients continuent d’attendre… et les orthopédistes de rêver d’un emploi – Aperçu du chômage chez les orthopédistes canadiens Peter B. MacDonald, MD, FRCSC, président de l’ACO Emil Schemitsch, MD, FRCSC, président du Comité sur les ressources humaines en orthopédie de l’ACO Trinity Wittman, M.Sc., directrice du développement et des activités de défense des droits

« …c’est une position horrible : une dette d’études de 150 000 $ et aucune perspective d’emploi! » « ...c’est extrêmement décourageant d’être passé à travers 15 années d’études postsecondaires et de ne pas avoir d’emploi à temps plein. » « C’est exaspérant, ces offres d’emploi qui ne sont… qu’une formalité… parce que les candidats sont déjà choisis… » « On m’a dit que ma candidature n’est pas viable en milieu communautaire parce que je n’ai pas deux formations spécialisées… le marché du travail est consternant. » « Nous allons dévaloriser notre profession si nous continuons comme ça. » « …beaucoup des postes à temps plein, pour ne pas dire tous, semblent préattribués et non ouverts à d’autres candidats… » « C’est une immense déception… pas de travail dans le domaine qui me passionne tellement… c’est extrêmement difficile pour ma famille et moi… nous devrons probablement quitter notre pays et notre province. » « Je ne comprends pas encore pourquoi l’ACO a permis qu’on forme des résidents en trop. » « S’il vous plaît, arrêtez de former autant de diplômés. » « Notre système est COMPLÈTEMENT détraqué. » « Personnellement, je n’aurais pas choisi ma spécialisation si j’avais su dans quel état mes collègues “titulaires” laissent le marché du travail. » « Les risques de chômage à la fin de ma formation me terrifient. » « L’ACO devrait faire davantage pour m’aider à trouver un emploi. » « …j’ai accepté un poste aux États-Unis parce qu’il n’y avait pas d’emploi dans ma spécialité au Canada. » « …j’aimerais exercer au Canada… mais ce ne sera probablement pas possible. » « Je n’ai que peu ou pas d’espoir de trouver un emploi en orthopédie un jour. »

l ne s’agit là que de quelques-uns des commentaires que l’ACO a obtenus dans le cadre d’un sondage sur l’emploi mené récemment auprès de diplômés de programmes d’orthopédie canadiens. Ils reflètent en partie toute la peine et la frustration, voire la colère, que ressentent les quelque 200 diplômés canadiens qui n’ont pas d’emploi en ce moment. Le taux élevé de chômage chez les diplômés en orthopédie est inacceptable; il compromet fortement la qualité des soins ainsi que le bien-être personnel et professionnel des orthopédistes. Un nombre sans cesse croissant de diplômés sont incapables COA Bulletin ACO - Winter / Hiver 2016/2017

de trouver un emploi au pays et enfilent les formations spécialisées et les suppléances; beaucoup se tournent vers les emplois offerts à l’étranger. Des membres ont partagé leur fardeau financier et émotionnel, et on ne peut pas fermer les yeux sur leur histoire. Le conseil d’administration de l’ACO tient à dire aux diplômés qu’il est à l’écoute. Un certain nombre d’initiatives sont d’ailleurs en cours : Collecte de données – Le conseil d’administration de l’ACO a cerné un manque de données fiables sur le chômage des orthopédistes; il investit des ressources considérables dans la collecte de données détaillées sur le sous-emploi, question d’avoir les outils nécessaires pour demander davantage de ressources aux différents ordres de gouvernement. Pour des statistiques récentes, consultez la fiche d’information sur le sous-emploi en orthopédie (ci-contre). Formation – L’ACO incite tous ses membres, peu importe l’étape de leur carrière, à s’informer sur cette crise de l’emploi et à prendre les mesures nécessaires pour aider à gérer la situation. Pour connaître les recommandations du conseil d’administration, consultez l’énoncé de position de l’ACO sur le sous-emploi des diplômés en orthopédie. Réduction du nombre de résidences – L’ACO a recommandé à tous les programmes d’orthopédie de considérer une réduction temporaire, mais immédiate du nombre de résidences. Il s’en est suivi une baisse nationale du nombre de places en première année de résidence, de 81 places en 2011 à 64 en 2016. Vu la durée du processus de recrutement et de formation des orthopédistes, il faut assurer une surveillance étroite du nombre de résidences, car les temps d’attente continuent d’être considérables et que la population canadienne est vieillissante, ce qui entraînera une hausse de la demande pour les spécialistes dans les prochaines années. Malgré cela, nous nous attendons à ce que les fonds publics alloués au financement de nouveaux postes permanents en orthopédie et des ressources de soutien en milieu hospitalier connexes demeurent le facteur limitant à cet égard. Babillard des possibilités d’emploi de l’ACO – Le portail des services aux membres, auquel ces derniers accèdent par mot de passe, propose un babillard des possibilités d’emploi en orthopédie au Canada. Les orthopédistes peuvent y afficher les postes offerts et y chercher un emploi gratuitement. Nous recommandons à tous les hôpitaux de maintenir un processus d’embauche transparent, grâce auquel les possibilités d’emploi sont largement diffusées de sorte à offrir les mêmes chances à tous les diplômés en recherche d’emploi. Aideznous! Si vous entendez parler d’un poste vacant en orthopédie, écrivez à cynthia@canorth.org pour nous en aviser. Nous communiquerons directement avec le centre orthopédique pour lui offrir d’afficher la possibilité d’emploi sur notre site. Services gratuits – L’adhésion à l’ACO est gratuite pour les résidents, boursiers et chercheurs d’emploi (y compris ceux qui font des suppléances et travaillent à temps partiel). De plus,

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

les orthopédistes qui viennent d’obtenir un poste bénéficient d’un rabais de 50 % sur la cotisation pour leur première année d’exercice. Grâce à cette initiative, il est possible de profiter des avantages offerts aux membres gratuitement pendant six à dix ans. Le Comité d’admission de l’ACO est sensible aux défis que doivent relever les jeunes orthopédistes, et c’est l’une des façons dont nous pouvons leur donner un coup de main. Cliquez ici pour voir une partie des avantages offerts aux membres de l’ACO.

points communs dans les stratégies novatrices, en plus de militer pour une utilisation plus efficace des ressources, ce qui entraînera une amélioration des soins et, en fin de compte, une augmentation de l’embauche d’orthopédistes. Rétroaction – Le Comité de direction de l’ACO reconnaît la frustration ressentie par les membres touchés par cette question cruciale. En tenant compte de sa capacité limitée à intervenir directement dans les efforts de recherche d’emploi des diplômés, l’ACO aimerait savoir ce qu’elle devrait faire, selon vous, pour améliorer la situation d’emploi au Canada? Nous voulons connaître votre avis. Si vous avez des suggestions ou souhaitez parler à un membre du Comité de direction, écrivez à policy@canorth.org. Le sous-emploi de nos collègues est assurément l’enjeu le plus difficile auquel notre profession a été confrontée à ce jour. L’ACO continuera de chercher des moyens de mieux servir ses membres.

Planification de la transition en fin de carrière et partage des tâches – Les définitions traditionnelles d’un poste à temps plein doivent être revues en mettant l’accent sur les changements de pratique en fin de carrière. Nous incitons fortement les orthopédistes chevronnés à planifier un partage des tâches dans leur transition vers la retraite afin de permettre à leurs cadets d’intégrer graduellement des postes à temps plein. Une diminution des activités chirurgicales pourrait être associée à une participation significative à d’autres aspects de l’exercice de la profession, dont l’évaluation des patients, le ORTHOPÉDISTES CANADIENS EN RECHERCHE D’EMPLOI mentorat, l’entraide, l’enseignement, la FICHE D’INFORMATION Juin 2016 – Comité sur les ressources humaines en orthopédie de l’ACO recherche et l’administration. L’utilisation des ressources hospitalières par chaque orthopédiste devrait être associée aux Le Comité sur les ressources humaines en orthopédie de l’ACO a sondé les dix-sept directeurs de programmes responsabilités en matière de temps de canadiens afin d’établir le nombre de jeunes diplômés actuellement à la recherche d’un poste à temps plein garde; tant les ressources que ces responen orthopédie. sabilités devraient diminuer de manière planifiée et calculée pendant la transition Aperçu des données actuelles sur le chômage en orthopédie (juin 2016) en fin de carrière. L’ACO favorise l’intégraRégion de Diplômés de Diplômés internationaux en Poste à t. plein Poste à À la recherche d’un formation 2010 à 2016 médecine/forces armées au Canada l’étranger poste à t. plein* tion d’un nouvel orthopédiste à un groupe Atlantique 44 7 23 2 12 de pratique, quand c’est possible, y comQuébec 134 16 85 14 19 pris grâce au mentorat et au partage des Ontario 223 3 98 39 88 ressources. Pour en savoir plus, consultez Prairies 113 8 57 4 44 les lignes directrices sur la transition en Colombie-Britannique 40 0 19 2 19 fin de carrière de l’ACO. TOTAL 559 34 282 61 182 Relations gouvernementales – L’ACO croit que les gouvernements et hôpitaux, qui financent et gèrent ensemble le système de santé, doivent veiller à une allocation plus efficace des ressources hospitalières afin de mieux répondre aux besoins de la population canadienne. Les membres du conseil d’administration continuent de militer en conséquence auprès de différents ordres de gouvernement. Le comité directeur de l’ACO sur l’accès aux soins orthopédiques, créé en 2016 dans la foulée de la publication de l’énoncé de position de l’ACO sur l’accès aux soins orthopédiques au Canada, a invité les membres de l’ACO à lui faire part des modèles de soins novateurs qui ont permis d’améliorer l’accès en temps opportun aux soins orthopédiques pertinents. Grâce à leurs réponses, le comité directeur a pu mieux comprendre les solutions constructives qui pourraient avoir une incidence positive sur les patients et systèmes en orthopédie. Le Dr Peter B. MacDonald, président de l’ACO, rencontrera des conseillers en politiques de Santé Canada en janvier 2017. Il misera sur les thèmes et

* Comprend les orthopédistes à la recherche d’un poste à temps plein en orthopédie au Canada (effectuant actuellement des suppléances, une formation spécialisée ou de la recherche).

Les orthopédistes formés au Québec ont le taux d’emploi à temps plein le plus élevé au Canada (63,4 %). Les orthopédistes formés en Ontario ont le taux d’emploi à temps plein le plus faible au Canada (43,9 %).

Plus de 50 % des diplômés formés en ColombieBritannique et en Ontario au cours des 7 dernières années n’ont pas de poste à temps plein au Canada. Le nombre de diplômés canadiens à la recherche d’un poste à temps plein à l’extérieur du Canada (aux États-Unis ou ailleurs) a doublé au cours des deux dernières années.

Il y a actuellement 182 jeunes diplômés canadiens à la recherche d’un poste à temps plein en orthopédie.

CANADIAN ORTHOPAEDIC ASSOCIATION / ASSOCIATION CANADIENNE D’ORTHOPÉDIE

policy@canorth.org

COA Bulletin ACO - Winter / Hiver 2016/2017

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

Trials and Tribulations Brian Day, MRCP, FRCS, FRCSC Vancouver, BC

In upcoming editions of the COA Bulletin, Dr. Brian Day will be contributing trial updates from the Constitutional Challenge to B.C.’s ban on the purchase of private health insurance for medically necessary services that are already covered by the public system, led by the Cambie Surgery Centre. Access to orthopaedic care in Canada remains a huge issue to our patients, and care is limited by funding. If this challenge is successful, it will allow benefits to be used to fund surgery and prevent the loss of employment of Canadians who are unable to work while waiting for care. While health care in the Canadian model should be funded by taxes, it is unlikely that adequate funding will reach health care, and even more unlikely that an investment will be made in orthopaedic care. We therefore need a financial model that more directly links our patients to the funding of care. The outcome of this trial is important to orthopaedic surgeons across Canada as the decision in British Columbia will likely set a precedent for other provinces. Improving access will be beneficial to patients, to the economy of Canada, is compassionate, and will provide resources so that our orthopaedic graduates will have jobs in the future. Regardless of how you feel about the trial and its outcome, the debate on access and funding of care is critical to the future care of our patients – Ed.

n September of 2016 – after a near eight-year delay - we began the process that puts medicare on trial. By anyone’s definition, our health-care system is not working. In Canada, the worst outcomes and access occur in lower socioeconomic groups. That’s not how it was supposed to be. The plaintiffs’ long opening statement at trial offers a detailed review of the current state of medicare1. In early 2016, I debated health and the constitution with Lorne Sossin, Dean of Osgoode Hall Law School. Lorne has co-authored a book called Access to Justice, Access to Care. At the end of the debate, he accepted my invitation to co-author another book called Lack of Access to Justice, Lack of Access to Care. Twenty years ago, I was scheduled for a similar live debate on CBC television with Andrew Petter, former Dean of Law and BC Minister of Health. He withdrew at the last minute because he had “not been adequately briefed” to debate health law with an orthopaedic surgeon. During the first three months of the current trial, I have observed repeated legal manoeuverings by government that seem aimed at prolonging the hearing. This is consistent with the shenanigans that delayed the case for so long. The plaintiffs (including six patients, two of whom died waiting) are challenging a system that treats Canadians as subjects under authoritarian control, where governments rule rather than serve. Our case asks two simple questions:

COA Bulletin ACO - Winter / Hiver 2016/2017

1. In a free democracy, who has ownership of one’s body the state or the citizen? 2. Should Canadians outside Quebec have the same protection under the Charter of Rights and Freedoms that were granted to Quebeckers by the Supreme Court of Canada? Health and legal bureaucracies appear committed to a crusade of self-preservation. Canada has 11 public health bureaucrats for every one that Germany has. Is it a coincidence that patients in the German public health system do not experience long waits for access? During the current litigation I have observed a legal bureaucracy paralleling that of their health counterparts. This is evidenced by our lone lawyer often facing eight opposing government lawyers. In the 2005 Supreme Court of Canada Chaoulli judgement (in which the COA and CMA intervened as patient advocates against government), it was held that Canadians were suffering and dying on wait lists. It follows that governments, their trial witnesses, and their surrogates are willing to sacrifice Canadian lives in pursuit of their goals. Government strategies so far appear focused on blocking as much information as possible from being presented in court. Some ancient court rules shackle the ability of witnesses to describe their experiences and discuss their knowledge. I have observed lay witnesses lose their natural train of thought when challenged in mid-sentence because they mention “hearsay”. Imagine if a 911 operator dismissed as hearsay a frantic child reporting her father was complaining of breathlessness and severe chest pain. Doctors are trained to elicit as much information as possible and then filter and grade its importance. If we, or 911 operators, dismissed hearsay evidence it could cost a limb or a life.

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 34)

Unless “qualified” as an expert, witnesses are severely restricted as to what they can say in court. An experienced eye surgeon was prevented from defining glaucoma because he was not qualified as an “expert witness”. Rules require that experts swear to a non-advocacy role. However, experts do have opinions and tend to advocate for the side that retains them. A battle of experts begins as credibility is judged. When experts disagree, the court may choose to believe one, or the other, or neither. Experts are often wrong. Decca records rejected the Beatles: “We don’t like their sound, and guitar music is on the way out.” In the silent movie era, Warner Brothers’ chief opined, “Who the hell wants to hear actors talk?” How many experts believed that Donald Trump would become President of the United States? Experts may allow beliefs to become prejudices. FBI agent Ali Soufan (involved in the hunt for Osama Bin Laden), described his frustration with so-called experts saying: “There is a difference between a desk (couch) expert and a field expert.” Government experts in this trial are mostly couch experts, often proclaiming more knowledge than exists as they prepare to tell the court more than they know. Most have minimal or no direct involvement in patient care. Our witnesses are nearly all field experts or witnesses. The views of doctor witnesses may be inadmissible because they are ethically required to advocate for patients. Most government experts lack such constraints. If evidence on Buddhism

COA Response to the Constitutional Challenge to B.C.’s Ban on Private Health Insurance led by the Cambie Surgery Centre

he publicly-funded Canadian health-care system has historically offered reasonable solutions to patients, but the COA is concerned that the current model is not effectively meeting certain benchmarks for musculoskeletal care in this country, including long wait times for orthopaedic consultation and surgery. The COA Position Statement on Access to Orthopaedic Care in Canada states that all Canadians should have timely access to orthopaedic care. The COA supports evidence-based practice, responsible use of resources, and a serious and open dialogue about health-care delivery in this country, specifically adopting innovative models of care that will make significant improvements to patients’ access to health services.

were presented by Buddha, or Roman Catholicism by the Pope, or the theory of relativity by Einstein, their advocacy/beliefs would invalidate their qualification as experts on their topics. I am optimistic that the court will assign appropriate weight to the facts and evidence presented. We are not yet halfway through the trial, but witnesses have presented powerful evidence of government neglect of the health system. It is regrettable that the responsibility for needed reforms has again been delegated to the courts. Previously, in Chaoulli, the COA and CMA intervened as patient advocates against government. Our case was recently described in an Italian journal as a “strange case”, with the lawyer/author stating, “The Canadian health system appears designed for very rich people who can travel to the US when they need care”2. It is a strange case. References 1. h t t p s : / / d 3 n 8 a 8 p r o 7 v h m x . c l o u d f r o n t . n e t / bchealthcoalition/pages/234/attachments/ original/1473905437/2016_09_06-Opening-Statement-ofthe-Plaintiffs.pdf?1473905437 2. http://www.academia.edu/29782039/Lo_strano_caso_ del_dottor_Brian_Day._Pubblico_e_privato_nella_ sanit%C3%A0_canadese_alla_ricerca_di_un_equilibrio

Réaction de l’ACO à la contestation constitutionnelle de l’interdiction des assurances-santé privées en Colombie-Britannique par le Cambie Surgery Centre

epuis sa création, le système de santé public canadien offre des solutions raisonnables aux patients, mais l’Association Canadienne d’Orthopédie (ACO) craint que, sous sa forme actuelle, il ne soit pas en mesure de respecter certaines balises en matière de soins de l’appareil locomoteur, entre autres en raison de ses longues listes d’attente pour les consultations et interventions en orthopédie. L’énoncé de position de l’ACO intitulé Accès aux soins orthopédiques au Canada stipule que toute la population canadienne devrait avoir accès à des soins orthopédiques en temps opportun. L’ACO appuie les principes de l’exercice fondé sur des données probantes, l’utilisation responsable des ressources, ainsi qu’un dialogue sérieux et ouvert sur la prestation des soins de santé au pays, plus particulièrement sur l’adoption de modèles de soins novateurs qui amélioreront de façon marquée l’accès aux soins. COA Bulletin ACO - Winter / Hiver 2016/2017

THE LARGEST GATHERING OF CANADA’S ORTHOPAEDIC COMMUNITY. JOIN US IN OTTAWA DURING CANADA’S 150TH ANNIVERSARY CELEBRATIONS.

LE PLUS GRAND RASSEMBLEMENT DE LA COMMUNAUTÉ ORTHOPÉDIQUE DU CANADA. JOIGNEZ-VOUS À NOUS À OTTAWA LORS DES CÉLÉBRATIONS DU 150E ANNIVERSAIRE DU CANADA.

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Foundation / Fondation

Orthopaedic Projects Across Canada to be Supported with Hip Hip Hooray! Funds

rthopaedic surgeons and their colleagues raised more than $50,000 in the Fall 2016 Hip Hip Hooray! fundraising program organized by the Canadian Orthopaedic Foundation. Through the program, funds raised are shared between the COF for its national programs of research, education and care, and initiatives identified by the local surgeons’ teams. Six surgeons participated in a live walk event held on October 1 in Saskatoon. Drs. Jeffrey McKerrell, Geoffrey Johnston, Ian Lutz, Bill Dust, Tony King and Trevor Loback invited their patients to join them for the one kilometre walk celebrating pain free movement. More than 50 people attended the event which raised $19,370, with top fundraising honours going to Dr. Jeffrey McKerrell. Funds raised support the following project: Multicentre trial for cortical locking screws and other COTS studies These funds contribute to ongoing participation in Canadian Orthopaedic Trauma Society studies. Five surgeons led teams in the Pedometer Challenge, a virtual walk in which participants tracked their steps from October 17 – 21, raising a total of $33,740 through pledges collected from their patients, colleagues and friends. There was a friendly competition to see which team could log the most steps and who could raise the most money. Team MacOrtho Research logged the most steps at 910,203 (with 15 teammates); and No Bones About It from St. Michael’s Hospital raised the most money at $14,720. Dr. Mohit Bhandari’s MacOrtho Research team from McMaster Health Sciences elected to have all their funds raised donated to the COF to support its national programs. Other participating teams are using their share of funds to support the following projects:

Arthroscopic Repair of Chronic Two-Tendon Rotator Cuff Tears by Human Dermal Allograft Augmentation – Dr. Ivan Wong, Halifax Sports Medicine Team The objective of this study is to determine the effect on pain, strength and function of performing a bridging rotator cuff reconstruction with an acellular human dermal allograft implant compared with the gold standard treatment of arthroscopic debridement with partial repair of large and massive, chronic, two-tendon (supraspinatus and infi’aspinatus) tears of the rotator cuff. Addressing the Educational Needs of Patients in the Holland MSK Program – Toronto, Holland Orthopaedic Centre, Dr. Stewart Wright’s Bone to Pick team Funds raised will support the production of new educational material for patients who attend the Bayview Campus Fracture Clinic, in addition to making the clinic’s core Hip and Knee Replacement guide web accessible. Osteoporosis Screening in the Cast Room – Foothills Medical Centre, Calgary, Dr. Rick Buckley This study attempts to determine whether or not patients who present with a fracture are in the process of being treated for osteoporosis. Since many of the patients have fragility fractures, they are already in the age and risk group for osteoporosis and may be already receiving treatment. If they are not already getting treatment – why not? Salary Support for Orthopaedic Clinical Research in Joint Replacement Surgery – St. Michael’s Hospital, Toronto, Dr. James Waddell’s No Bones About It Team Funds from Hip Hip Hooray! will enable continued support of the important clinical arthroplasty research being done at St. Michael’s Hospital. The COF is pleased to be able to contribute to orthopaedic programs across Canada through its fundraising program. New challenge events are being investigated for 2017. Any surgeon interested in participating can contact the Foundation at hhh@canorth.org.

SAVE THE DATE: Monday, June 26, 2017

COF Bassin Bad to the Bone Golf Tournament at Wooden Sticks golf course, near Toronto.

Reserve the date for a great day of golf with hockey stars, industry leaders, surgeons and others. Registration and sponsorship details will follow soon. COA Bulletin ACO - Winter / Hiver 2016/2017

Foundation / Fondation

Hip Hip Hourra! finance des projets en orthopédie partout au Canada

l’automne 2016, des orthopédistes et leurs collègues ont recueilli plus de 50 000 $ grâce à la campagne de collecte de fonds Hip Hip Hourra! de la Fondation Canadienne d’Orthopédie. Les fonds recueillis servent à soutenir les programmes nationaux de recherche, de sensibilisation et de soins de la Fondation, de même que des initiatives locales des équipes d’orthopédistes participantes. Six orthopédistes ont participé à la marche organisée le 1er octobre à Saskatoon : les Drs Jeffrey McKerrell, Geoffrey Johnston, Ian Lutz, Bill Dust, Tony King et Trevor Loback avaient invité leurs patients à venir marcher un kilomètre avec eux afin de célébrer le retour à une mobilité sans douleur. Plus de 50 personnes ont pris part à l’activité, qui a permis de recueillir 19 370 $. C’est le Dr Jeffrey McKerrell qui a levé le plus de fonds. Les fonds étaient recueillis au profit du projet suivant : « Multicentre trial for cortical locking screws and other COTS studies » Les fonds recueillis contribuent à la participation continue à des études de la Société canadienne d’orthopédie traumatologique (COTS). Cinq orthopédistes ont en outre formé des équipes afin de relever le Défi podomètre, une marche virtuelle organisée du 17 au 21 octobre. Les participants, qui comptaient leurs pas à l’aide d’un podomètre, ont recueilli 33 740 $ au total en promesses de don auprès de leurs patients, collègues et amis. Une compétition amicale s’était installée entre les équipes, à savoir laquelle accumulerait le plus de pas et laquelle recueillerait le plus de fonds. Finalement, c’est l’équipe MacOrtho Research qui a fait le plus de pas, soit 910 203 (au total pour les 15 participants), tandis que l’équipe No Bones About It, du St. Michael’s Hospital, est celle qui a amassé le plus de fonds, soit 14 720 $. Le Dr Mohit Bhandari et son équipe, MacOrtho Research, de la faculté des sciences de la santé de l’Université McMaster, avaient choisi de remettre tous les fonds recueillis à la Fondation Canadienne d’Orthopédie, pour le financement de ses programmes nationaux. Les autres équipes utilisent leur part des fonds recueillis pour appuyer les projets suivants :

« Arthroscopic Repair of Chronic Two-Tendon Rotator Cuff Tears by Human Dermal Allograft Augmentation » – Dr Ivan Wong, équipe de médecine sportive de Halifax L’objectif de cette étude est de déterminer l’incidence sur la douleur, la force et la fonction de la reconstruction sous arthroscopie par allogreffe dermique acellulaire d’origine humaine en pont comparativement au traitement standard par débridement arthroscopique avec réparation partielle des déchirures chroniques massives de deux tendons (supraépineux et infraépineux) de la coiffe des rotateurs. « Ressources d’information pour les patients du programme de soins musculosquelettiques du Holland » – Dr Stewart Wright, équipe Bone to Pick du Holland Orthopaedic & Arthritic Centre, à Toronto Les fonds servent à soutenir la production de nouvelles ressources d’information pour les patients de la clinique de traitement des fractures du campus Bayview, en plus de rendre son guide principal sur les arthroplasties de la hanche et du genou accessible sur le Web. « Osteoporosis Screening in the Cast Room » – Dr Rick Buckley, équipe du Centre médical Foothills, à Calgary Cette étude cherche à déterminer si les patients ayant une fracture reçoivent un traitement pour l’ostéoporose. Comme beaucoup des patients ont subi une fracture de fragilisation, ils font déjà partie du groupe d’âge à risque d’ostéoporose et peuvent déjà être traités en ce sens. Sinon, pourquoi ne le sont-ils pas? « Aide salariale pour la recherche clinique en arthroplastie » – Dr James Waddell, équipe No Bones About It du St. Michael’s Hospital, à Toronto Les fonds provenant de la campagne Hip Hip Hourra! servent au soutien continu des importants travaux de recherche clinique en arthroplastie menés au St. Michael’s Hospital. La Fondation Canadienne d’Orthopédie est heureuse de pouvoir contribuer à des programmes d’orthopédie partout au pays grâce à ses activités de collecte de fonds. On envisage la création de nouveaux défis pour 2017. Tout orthopédiste intéressé peut communiquer avec la Fondation, en écrivant à hhh@canorth.org.

FAITES UNE CROIX À VOTRE CALENDRIER!

La classique de golf Sherry Bassin Bad to the Bone, de la Fondation Canadienne d’Orthopédie, aura lieu le lundi 26 juin 2017, au club de golf Wooden Sticks, près de Toronto.

Mettez à votre calendrier cette belle journée de golf en compagnie de leaders de l’industrie, de vedettes du hockey et d’orthopédistes, entre autres. Les détails sur l’inscription et les commandites seront diffusés sous peu. COA Bulletin ACO - Winter / Hiver 2016/2017

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

Calendar of Events / Calendrier des événements CSES Annual Shoulder & Elbow Course February 1-3 février Calgary, AB E-mail/Courriel : cses@canorth.org Web Site/Site Int. : http://coa-aco.org/cses/cses-meetings/ Canadian Orthopedic Foot and Ankle Society Foot & Ankle Symposium Februrary 2-4 février Fairmont Chateau Whistler Whistler, BC Web Site/Site Int. : http://ubccpd.ca/course/cofas2017 30th St. Justine Paediatric Review Course (SPORC) / 30e Cours de mise à jour en orthopédie pédiatrique March 8-10 mars Montreal, QC E-mail/Courriel : joelle.fortier.hsj@ssss.gouv.qc.ca Web Site/Site Int. : http://saac.chu-sainte-justine.org/sporc2017.html

The 15th Annual Canadian Orthopaedic Resident Forum (CORF) April 7-10 avril Calgary, AB Contact(er) : Stephanie Abt Phone: 403 210-9636 Registration E-mail/Courriel : corf@ucalgary.ca 40th CONA National Conference Fact, fiction or fantasy May 28-31 mai Toronto, ON Web Site/Site Int. : http://www.cona-nurse.org/ 2017 CORA Annual Meeting June 15 juin Ottawa, ON E-mail/Courriel : coraweb@canorth.org Web Site/Site Int. : www.coraweb.org

AAOS 2017 Annual Meeting March 14-18 mars COA RECEPTION = THURSDAY, MARCH 16 @ 18:00 RECEPTION DE L’ACO = LE JEUDI 16 MARS @ 18 H San Diego Convention Centre San Diego, CA Web Site/Site Int. : www.aaos.org

Upcoming COA/CORS/CORA Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO 2018

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

2017

June 15-18 juin CORA Meeting/ Réunion de l’ACRO June 15 juin Ottawa, ON

COA Bulletin ACO - Winter / Hiver 2016/2017

2019

Combined with the 2nd ICORS Meeting June 19-22 juin CORA Meeting/Réunion de l’ACRO June 19 juin Montréal, QC www.2019icors.org

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

Engage, Network, Listen: Twitter Tips and Tricks for Canadian Surgeons Adrian Huang, MB BCh BAO, FRCSC Orthopaedic Trauma Fellow The Orthopaedic Trauma Institute, University of California San Francisco, CA William M. Weiss, M.D., MSc, FRCSC Assistant Professor Sports Medicine, Reconstruction & Trauma Department of Orthopedic Surgery & Rehabilitation Texas Tech University Health Sciences Centre El Paso, TX

he COA’s Communications Committee will be reviewing various social media platforms and providing advice, how tos, and tips for members through a series of upcoming articles featured in the COA Bulletin. First up, Drs. Adrian Huang and Bill Weiss, members of the Communications Committee, will be discussing Twitter. #enjoy! – Ed.

It’s always important to consider appropriate online content. If you feel yourself getting stuck in a Twitter tirade, saying nothing at all is okay too. Medical conferences provide a perfect opportunity for getting started, and often have a #hashtag of their own, so you can search for colleagues’ comments about the meeting. Use #COAOttawa2017 at the COA Annual Meeting next June! For beginners, the idea of making a statement in one click may be overwhelming, so here are 10 Tips and Tricks for the rookie Twitter user (each in 140 characters or less, which is the maximum length of a tweet!).

1 COA @CdnOrthoAssoc

What’s all this buzz about Twitter? Social media has become a powerful tool for personal and professional real-time news and communication, and you may not want to be left behind. Whether you’re interested in best surgical practices, the public-private health-care debate or your local community events, it’s all being shared, discussed and debated in social media circles.

2 COA

Twitter is a social media web site which allows you to “tweet” (send) brief statements (maximum of 140 characters), to your followers. These messages may include photos, videos or web site links. By ‘following’ thought leaders and health-care organizations, you create a customized and interactive list of news items and articles that your peers find most relevant. Physicians have the opportunity to network and share updates with colleagues across the globe, to access medical education resources, and to offer an opinion on current hot topics. Not to mention, it’s a convenient way to stay connected with friends, family and colleagues on a personal level. Getting Started Create your Twitter account by clicking ‘Sign up’ at https://twitter.com/. To use Twitter on your mobile device, you will need to download the Twitter app. If anonymity is important to you, you may prefer to stay out of the limelight, and choose a user name that does not identify you publicly. You will need to decide if your account will be accessible to all Twitter users, or if you prefer to approve each follower individually before they can read your tweets. The Twitter Help Centre offers quick answers for many common questions.

Follow & be followed! Friends, organizations, sports, news, & more! e.g, @AAOSmembers @janephilpott @CBCHealth @CdnOrthoAssoc @BoneJointJ

@CdnOrthoAssoc

Your Twitter feed can be organized into lists, allowing you to find information more quickly.

3 COA @CdnOrthoAssoc

Remember: Once online, it’s there forever. A good rule of thumb: Think twice, and don’t post what you wouldn’t want heard at your trial!

COA Bulletin ACO - Winter / Hiver 2016/2017

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

(continued from page 41)

COA

@CdnOrthoAssoc

Mentions: You can interact with, and tweet to, another user by adding “@“ followed by the user’s Twitter handle. Right on, @bill_weiss !

If you like what someone else has to say, click on the heart icon to show some love.

COA

@CdnOrthoAssoc

You can send a direct message, akin to an email, to another user if you prefer a private conversation.

If you want someone else’s tweet to appear on your news feed, Retweet by clicking on the , with or without adding a comment.

COA

@CdnOrthoAssoc

Hashtags (#) draw attention to tweets, linking them to a topic, like a keyword. e.g. #COAGlobalSx or #canadianhealthcare. No spaces!

7 COA @CdnOrthoAssoc

Web links always account for 23 characters, no matter how short or long they are.

COA Bulletin ACO - Winter / Hiver 2016/2017

To add a photo to your post, click on and attach a file from your phone or laptop.

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

The CSES 2017 Residents Course is Moving West! Aaron Bois, University of Calgary, Course Co-Chair David Sheps, University of Alberta, Course Co-Chair

or the first time, the Canadian Shoulder and Elbow Society (CSES) will be welcoming residents to Calgary for the CSES 2017 Residents Course, formerly known as the JOINTS Shoulder Course, taking place from February 1-3, 2017. Course chairmen Drs. Aaron Bois (University of Calgary) and David Sheps (University of Alberta), are excited to announce that a half-day elbow component has been added to the program. The program is packed with innovative shoulder and elbow topics by renowned faculty, as well as a number of networking/social activities.

To learn more about the transition from JOINTS Canada to the CSES, please visit the CSES web page at http://coa-aco.org/cses/cses-main/. Membership categories are available to surgeons, researchers, allied health professionals, residents and fellows with an interest in shoulder and elbow surgery. Click here to join CSES or contact cses@canorth.org for details.

Registration is available exclusively to R3, R4 and R5 residents from a Canadian orthopaedic training program as well as upper extremity fellows. This year’s course will begin at the Fairmont Palliser Hotel in downtown Calgary, moving mid-morning to the Advanced Technical Skills Simulation Laboratory (ATSSL) at the Health Research and Innovation Centre (HRIC) at the University of Calgary (Foothills Campus). A shuttle bus will be available at no cost to transport participants between the two locations. For full course programming, hotel and registration information, please visit http://cumming.ucalgary.ca/cme/event/201702-01/canadian-shoulder-and-elbow-society-2017-residentscourse. For any questions at all, do not hesitate to contact Stephanie Abt at cmeortho@ucalgary.ca.

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

Les contributions au Bulletin de l’ACO sont toujours les bienvenues! Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : cynthia@canorth.org COA Bulletin ACO - Winter / Hiver 2016/2017

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