COA Bulletin #127 - Summer 2020 by Canadian Orthopaedic Asssociation

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

BULLETIN

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Summer Été 2020

COVID-19 PANDEMIC:

IMPACT ON ORTHOPAEDIC SURGERY p. 45

PANDÉMIE DE

COVID-19 INCIDENCE SUR LA

CHIRURGIE ORTHOPÉDIQUE p. 45

127

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Farewell – A Message from Past CEO, Doug Thomson. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 8 Félicitations aux deux gagnants de notre concours de renouvellement d’adhésion à l’ACO – c’est NOUS qui payons pour 2021! . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15 Management of Proximal Humerus Fractures Debate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27 In Development of a New COA Gender Diversity Task Force. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38

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Bulletin

Contents / Sommaire

Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 127 - Summer / Été 2020

Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

COA / ACO

Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27

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

Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45

ReCOAnnected Mohit Bhandari M.D., PhD, FRCSC President, Canadian Orthopaedic Association

“When it comes to accelerating performance, there’s a paradox: If we want to have greater impact, faster, we have to slow down enough to reflect on what we’ve done and what we’re going to do.” Hagel, Seely-Brown, de Marr, Wooll Sometimes We Have to Slow Down, To Speed Up his year of shutdown forced us all to rethink how we prioritize our time, and specifically, how we use it. For many of us, the shutdown refocused our time to family, a new hobby, personal health and wellness, or simply relaxation. Whatever our focus, we all experienced changes in our priorities.

In lieu of the customary transfer of office ceremony, Dr. Bhandari had the honour of receiving the medal of office from his daughter, Kaya

I took this time to read, write, and repeat. Bill Gates had famously popularized the term “Think Week”- as a week of seclusion with a heaping pile of books across all disciplines, a pen, and a notepad. I can’t remember a recent time in my life where I consumed as much content, wrote as much content, and spoke as many people around the world week by week, day by day, and hour by hour. The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4060 St. Catherine Street West, Suite 620, Westmount, Quebec, H3Z 2Z3. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: cynthia@canorth.org

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

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

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

COA Bulletin ACO - Summer / Été 2020

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Re-envisioning My 20% The slowdown, by chance or deliberateness, forced all of us to think about what matters, and what it means to have a successful day, a successful week, a successful year, and more broadly - a successful life. I distinctly remember the moment I committed to my 20% [the 20% of things in my work and life, that give me 80% of my satisfaction and joy]. While on a short work meeting in Pune, India, a colleague and I made an impromptu decision to fly across the country to spend a day in a small Nepali village of Tumling (15 people living at an altitude of 10,000 ft) on the Nepal/India border.

Staring across a valley with Mount Kangchenjunga in sight, it was hard not to reflect. We both did. For me, it was the realization that meaningful connections, the use of data for decisions, and a mindset of creativity (arts and adventure) that are the source of 80% of my personal happiness. After the careful examination, I was able to align most of my decisions each week to one of those three items. With time, I have become more convinced that exploration of your 20% can help you move from good to great (and great to exceptional) in both work and life. Ask yourself, “Do I know my 20%?” If you’ve read this far, this may be the most important message of this article. So, let me provide three critical steps to A.C.T: 1. A sk yourself, “Do I know my 20%?” 2. C reate time. You need to find a few minutes to think, really think - no distractions and 3. T oday. Start today. Pledging Time to T.H.I.N.K. in 2020 I often create acronyms to remember ideas very important to me. An acronym becomes really powerful when the word, itself, is the focus of the actions. I urge any of you who feel this resonates to take 30 minutes (ideally a lot more than 30 minutes) and T.H.I.N.K. T ry new things. H ave fun (if you have passion and purpose, it’s always fun!) I nvest in your 20% (the 20% of the things that give you 80% of your joy). N ever fear failure-take a few risks. K now it’s okay to start again. Whether early, mid, or late career, you can reinvent yourself. COA Bulletin ACO - Summer / Été 2020

I have particularly been struck by how many times I’ve been told by a colleague, “Ah, it’s time for somebody else to take this to the next level. I’m too late now”. One word: Why? Take a look at Picasso’s trajectory, for example. It wasn’t until the latter part of his career that he discovered modernism and his brand of painting. For my younger colleagues, if you take a few risks early in your career you may just unlock new inspirations, new opportunities, and accelerate your career (especially if it’s consistent with your values and purpose). The hardest part I’ve found is to simply, “do it”. I’ve made a career of verbalizing “Saying isn’t doing, Doing is Doing!”. So, if you are still with me, reading along, begin today.

Try this Thought Experiment: “If I Had Just One More To Go?” Whether a scientist, a clinician, a trainee, or an industry professional, imagine your next endeavor as your final one. Quentin Tarantino has famously stated for years that he will only write and direct ten major motion films in his career. Having just completed his ninth film, “Once Upon A Time in Hollywood” (to great critical acclaim, I might add), he has just one more to go. Imagine the process of writing your last script for a minute - would it paralyze you, or invigorate you? It’s not entirely that different deciding on a choice of fellowship, a new job, or even a program of research. On a personal note, if my next study was my last, I would be rethinking carefully about its impact and significance – and hopefully, I might dare to risk more. If it’s the last one, why not? But that’s the point, we think very differently, attribute greater importance when we know this may be our last chance to make a difference. In the context of the Canadian Orthopaedic Association, I have spent the last few months considering the opportunities ahead. With a single year tenure, the next 12 months matter. If any year in the COA’s history should matter, this upcoming year is [yes, I’m going to say it…] an unprecedented one. For this reason, let me propose an over-arching strategy. My Promise to You in Five Key Actions Honour our HISTORY Foster EXCELLENCE Invite the WORLD to our home Create a CULTURE of engagement Always RESPECT our differences Forget the 12 Month “Maybe” Plan In Lieu of the “Daily” Plan Given the uncertainty of the months ahead, the rapidly changing landscape, and inconsistent policies I propose an alternative goal-setting tactic. By focusing on what we can change

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each day, we can realize our Five Key Actions over the year. To plan ahead with the phase “if things open up, we should be okay” is a doomed to fail strategy. Let’s consider an alternative. Let’s plan for what we know we can achieve, and take calculated, data-driven, risks when necessary to innovate. The fog will clear. The winter will end, and the COA will be positioned for whatever the future holds. In the days to come, I will work hard with the COA leadership to provide clarity on values, strategy, outcomes and deliverables. VALUES (Personal and Professional) Inform STRATEGY (Connection, Communication, Collaboration) Inform OUTCOMES (Data-driven) Inform NEXT 52 WEEKS (Daily, Weekly, Monthly) The 2020-2021 Presidential Year is About Connecting Consistent with my personal values, I hope to “Reconnect” with COA members. More specifically, reconnect with my colleagues and friends from coast to coast, cities to townships, north to south, current members and non-members, and residents to retirees. Whether face to face, or virtual, I promise to listen, learn, share insights, and act swiftly. Our Canada-wide “ReCOAnnect/ RACOnnectons-nous 2020-2021” tour will begin soon.

75 is Special Number The significance of the 75th President of the Canadian Orthopaedic Association has been profound. For the past several years, I’ve been on a personal (and public) journey to develop a creative mindset. I’ve made it a central theme in my messaging at meetings, to trainees, and to my colleagues around the world. I’ve also been drawn to the number five for a variety of reasons – too many to list, actually. We are the sum of the five people with whom we associate the most. Five years is about the time it takes to make real change as a leader (the second term is often less productive). My mantra “T.H.I.N.K” is a key five-letter word that resonates with me daily. At its core, the number five represents ‘curiosity’. The number seven is associated with “introspection’. Together, 75 has been associated with creativity. Creativity, as Mary Lou Cook describes, “is inventing, experimenting, growing, taking risks, breaking rule, making mistakes, and having fun.” Here’s to a year of creativity. Onward.

RACOnnectons-nous Mohit Bhandari, MD, Ph.D., FRCSC Président de l’Association Canadienne d’Orthopédie

« Quand il s’agit d’accélérer la performance, il existe un paradoxe : pour avoir plus d’incidence plus rapidement, il faut ralentir suffisamment pour réfléchir à ce qu’on a fait et à ce qu’on va faire. » – D’après Hagel, Seely-Brown, de Marr et Wooll Il faut parfois ralentir pour Au lieu de la traditionnelle céréaccélérer de transfert des charges, le ette année de confine- monie Dr Mohit Bhandari a eu l’honneur ment nous a obligés à de recevoir la médaille d’office des repenser la façon dont mains de sa fille, Kaya. nous priorisons, et surtout utilisons, notre temps. Le confinement a permis à beaucoup d’entre nous de recentrer notre temps sur notre famille, un nouveau hobby, notre santé et mieux-être ou, simplement, la détente. Peu importe l’objet de notre attention, nous avons tous vécu des changements de priorités.

touchant toutes les spécialités, un crayon et un bloc-notes. Je ne me rappelle pas avoir récemment consommé autant de contenu, écrit autant de contenu, et parlé à autant de gens partout dans le monde semaine après semaine, jour après jour, et heure après heure. Réimaginer mon 20 % Le ralentissement, involontaire ou non, nous a tous obligés à réfléchir à ce qui importe, et à ce que signifie avoir une bonne journée, une bonne semaine, une bonne année et, de façon plus générale, une bonne vie. Je me souviens distinctement du moment où je me suis engagé à respecter mon 20 % [le 20 % de choses, dans mon travail et ma vie, responsables de 80 % de ma satisfaction et de mon bonheur]. À Pune, en Inde, pour une

J’ai profité de ce temps pour lire et écrire, encore et encore. Bill Gates a popularisé l’expression « semaine de réflexion » (Think Week), une semaine en solitaire avec une pile de livres COA Bulletin ACO - Summer / Été 2020

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courte rencontre professionnelle, un collègue et moi avons décidé à l’improviste de prendre l’avion et de traverser le pays pour aller passer une journée dans le petit village népalais de Tumling (15 personnes vivant à 2 970 mètres d’altitude), sur la frontière indo-népalaise.

vrir de nouvelles inspirations et possibilités, et accélérer votre carrière (surtout s’ils correspondent à vos valeurs et à votre but). Le plus difficile, selon moi, est simplement d’ « agir ». J’ai fait carrière en verbalisant : « Dire n’est pas agir, agir est agir! » Donc, si vous êtes toujours ici avec moi, commencez maintenant.

En admirant le mont Kangchenjunga au-delà d’une vallée, il était difficile de ne pas se mettre à réfléchir. C’est ce que nous avons fait. De mon côté, j’ai compris que les connexions significatives, l’utilisation de données pour prendre des décisions et la créativité (arts et aventure) sont la source de 80 % de mon bonheur. Après cet examen minutieux, j’ai pu aligner la plupart de mes décisions chaque semaine sur l’un de ces trois éléments. Avec le temps, ma conviction que l’exploration de notre 20 % peut nous aider à passer de bon à excellent (et d’excellent à exceptionnel), au travail comme dans notre vie personnelle, s’est renforcée. Demandez-vous : « Est-ce que je connais mon 20 %? » Si vous avez lu jusqu’ici, c’est probablement le message le plus important de cet article. Voici trois étapes essentielles pour passer à l’acte :

Essayer cette réflexion : « Si c’était la dernière? » Que vous soyez chercheur, clinicien, résident ou fellow ou professionnel de l’industrie, imaginez que votre prochaine initiative est votre dernière. Quentin Tarantino a dit pendant des années qu’il ne scénariserait et réaliserait que dix films majeurs dans sa carrière. Comme il vient de terminer son neuvième, Il était une fois à... Hollywood (louangé par la critique, si je puis dire), il ne lui en reste qu’un seul. Imaginez un instant le processus de rédaction de votre dernier scénario – serait-il paralysant ou stimulant? Choisir un fellowship, un nouvel emploi, voire un programme de recherche, n’est pas si différent. De mon côté, si ma prochaine étude était la dernière, je repenserais soigneusement à son incidence et à sa portée et, je l’espère, je pourrais prendre davantage de risques. Si c’était la dernière, pourquoi pas? Mais c’est le but; on pense très différemment, on accorde plus d’importance à ce qu’on fait, quand on sait que ça pourrait être notre dernière occasion de changer les choses.

1. Demandez-vous : « Est-ce que je connais mon 20 %? » 2. Trouvez du temps. Il faut trouver quelques minutes pour réfléchir, vraiment, sans distractions 3. Commencez maintenant

Prendre le temps de réfléchir en 2020 Je me fais souvent des aide-mémoire pour me rappeler les idées qui me sont très importantes. J’invite ceux d’entre vous qui se retrouvent là-dedans à prendre 30 minutes (idéalement bien plus que 30 minutes) pour réfléchir à ces cinq principes : Essayez de nouvelles choses Amusez-vous (avec la passion et un but, on s’amuse toujours!) Investissez dans votre 20 % (le 20 % de choses responsables de 80 % de votre bonheur) Prenez quelques risques – ne craignez jamais l’échec Sachez qu’il n’y a rien de mal à recommencer. Que vous soyez en début, milieu ou fin de carrière, vous pouvez vous réinventer J’ai été particulièrement frappé par le nombre de fois où un collègue m’a dit : « Ah, il est temps que quelqu’un d’autre prenne le relais. Il est trop tard pour moi. » Un mot : Pourquoi? Prenez la trajectoire de Picasso, par exemple. Ce n’est que dans la dernière partie de sa carrière qu’il a découvert le modernisme et son style de peinture. Pour mes collègues plus jeunes, si vous prenez quelques risques en début de carrière, vous pourriez bien découCOA Bulletin ACO - Summer / Été 2020

En ce qui concerne l’ACO, j’ai passé les derniers mois à considérer les possibilités. Vu le mandat d’un an seulement, les douze prochains mois sont importants. Et si une année devait compter dans l’histoire de l’ACO, la prochaine année s’annonce [oui, je vais le dire…] sans précédent. Pour cette raison, j’aimerais vous proposer une stratégie globale : Ma promesse envers vous en cinq actions clés Honorer notre HISTOIRE Nourrir l’EXCELLENCE Inviter le MONDE chez nous Créer une CULTURE d’engagement Toujours RESPECTER nos différences Oublier le plan « potentiel » de douze mois, opter pour le plan « quotidien » Vu l’incertitude inhérente aux mois à venir, l’évolution rapide de la situation et les politiques changeantes, je propose une autre tactique pour l’établissement d’objectifs : en nous concentrant sur ce que nous pouvons changer au quotidien, nous pouvons concrétiser nos cinq actions clés pour l’année. Planifier en se disant « s’il y a assouplissement, ça devrait aller » est voué à l’échec. Considérons une autre stratégie : planifions en fonction de ce que nous savons pouvoir réaliser, et prenons des risques calculés, fondés sur les données, quand il faut innover. Le brouillard va s’éclaircir, l’hiver va finir, et l’ACO sera bien posi-

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tionnée, peu importe ce qui nous attend. Dans les prochains jours, je travaillerai dur avec la direction de l’ACO afin de clarifier les valeurs, la stratégie et les résultats attendus. Les VALEURS (personnelles et professionnelles) influencent la STRATÉGIE (connexion, communication, collaboration), qui influence les RÉSULTATS ATTENDUS (fondés sur les données), qui influencent les 52 PROCHAINES SEMAINES (chaque jour, semaine et mois) En 2020-2021, la présidence sera axée sur la connexion Conformément avec mes valeurs personnelles, j’espère me « reconnecter » avec les membres de l’ACO. Je souhaite plus particulièrement me reconnecter avec mes collègues et amis d’un bout à l’autre du pays, des villes aux plus petites agglomérations, du nord au sud, des membres aux non-membres, et des résidents aux retraités. Que ce soit en personne ou virtuellement, je vous promets d’écouter, d’apprendre, de partager des idées et d’agir promptement. Notre tournée pancanadienne, baptisée « ReCOAnnect/RACOnnectons-nous 2020-2021 », commencera bientôt.

Le chiffre 75 est spécial La signification de la 75e présidence de l’ACO est profonde. Ces dernières années, j’ai été en quête personnelle (et publique) d’un esprit plus créatif. J’en ai fait le thème central de mes messages aux réunions, aux résidents et fellows, et à mes collègues partout dans le monde. Je suis aussi attiré par le chiffre 5 pour un éventail de raisons – trop nombreuses pour les inclure toutes ici, en fait. Nous sommes la somme des cinq personnes avec qui nous nous associons le plus. Cinq ans, c’est environ le temps nécessaire pour apporter de véritables changements en tant que leader (le deuxième mandat est souvent moins productif ). Mon mantra, « essayez, amusez-vous, investissez, prenez et sachez », comprend cinq principes qui trouvent écho chez moi tous les jours. Fondamentalement, le chiffre 5 représente la « curiosité ». Le chiffre 7 est quant à lui associé à l’ « introspection ». Mis ensemble, 75 est associé à la créativité. Selon Mary Lou Cook : « La créativité, c’est inventer, expérimenter, grandir, prendre des risques, briser les règles, faire des erreurs et s’amuser. » Trinquons à une année de créativité. Et plus.

Reflections from the Immediate Past President Mark Glazebrook, MSc, PhD, Dip Sports Med., M.D., FRCSC Immediate Past President, Canadian Orthopaedic Association

n Friday, June 19, 2019 Dr. John Antoniou placed the COA Medal of Office around my neck with a responsibility and honour that I was both excited and apprehensive to accept. Shortly after receiving this responsibility, my friends and family gathered with me and provided the support that I required to serve as your COA president from 2019 to 2020. When I look back and assess myself in my own personal report card, I feel that though very important work was accomplished with success, more was discovered to be done. Starting the year, the biggest challenge was the Canadian orthopaedic human resources dilemma. Simply put - we live in a country with extremely long wait lists for orthopaedic care and young unemployed surgeons seeking ways to fill this need. While progress was accomplished in this area, the COVID-19 pandemic quickly put a hold on this priority. Your COA did establish a blueprint to assist with this agenda, including retirement transition, marketing/lobbying firm engagement, and increased collaboration with our Industry partners, amongst other initiatives. However, there is much more work to be done and I intend to continue to address this issue with your Association.

It is no secret that the COVID-19 pandemic disrupted the entire global civilization and in doing so, halted many COA projects. As such, a new normal has emerged that has left your leadership and the entire COA membership struggling with ways to provide timely and safe care for orthopaedic patients. For me personally, I reflect on the past year as being the most interesting year of my career. I was fortunate to represent you, the members of the COA, on the global stage and be on the front line of crisis management for member issues at the height of the COVID-19 pandemic. Looking forward, I can say with confidence that the COA membership is in good hands with its current leadership and presidential line including Drs. Mohit Bhandari, Kishore Mulpuri and Laurie Hiemstra. I am excited to continue to work for my COA, in whatever capacity that may arise. In closing, I would like to thank the COA Executive, staff, and most importantly the members, for allowing me the honour to act as your 74th president.

COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

Réflexions du président sortant Mark Glazebrook, M.Sc., Ph.D., diplôme de MSE, MD, FRCSC Président sortant de l’Association Canadienne d’Orthopédie

e vendredi 19 juin 2019 le Dr John Antoniou a mis à mon cou la médaille d’office de l’ACO, symbole d’une responsabilité et d’un honneur que j’acceptais avec un mélange d’enthousiasme et de crainte. Peu après avoir reçu cette responsabilité, mes amis et ma famille se sont réunis en ma présence et m’ont offert le soutien dont j’avais besoin pour être votre président de 2019 à 2020. Quand je regarde derrière et que j’évalue mon propre rendement, je crois que, même si j’ai réussi à accomplir du travail très important, beaucoup reste à faire. En début d’année, le principal enjeu était le dilemme des ressources humaines en orthopédie au Canada. En quelques mots : nous vivons dans un pays où les listes d’attente pour les soins orthopédiques sont extrêmement longues, et où de jeunes orthopédistes sans emploi cherchent à combler ce besoin. Bien qu’on ait réalisé des progrès à cet égard, la pandémie de COVID-19 a rapidement mis un frein aux efforts relatifs à cette priorité. Votre association a tout de même établi un plan connexe, abordant entre autres la transition vers la retraite, l’embauche d’une firme de marketing ou lobbying et une collaboration accrue avec nos partenaires de l’industrie. Il reste cependant beaucoup à faire, et j’ai l’intention de continuer d’y travailler avec votre association.

La pandémie de COVID-19 perturbe l’ensemble de la civilisation mondiale et, ce faisant, a interrompu beaucoup des projets de l’ACO – ce n’est un secret pour personne. Il en découle une nouvelle normalité qui oblige la direction et l’ensemble des membres de l’ACO à se démener pour offrir des soins orthopédiques sécuritaires et en temps opportun. Personnellement, je vois la dernière année comme la plus intéressante de ma carrière. J’ai eu la chance de vous représenter, à titre de membres de l’ACO, sur la scène mondiale et d’être en première ligne de la gestion de crise des enjeux touchant les membres en plein cœur de la pandémie de COVID-19. Quand j’envisage l’avenir, je peux dire avec confiance que les membres de l’ACO sont en bonnes mains, grâce à la direction actuelle et à l’équipe de la présidence, composée des Drs Mohit Bhandari, Kishore Mulpuri et Laurie Hiemstra. J’ai hâte de continuer de travailler pour l’ACO, peu importe à quel titre. Enfin, j’aimerais remercier le Comité de direction, le personnel et, plus important encore, les membres de l’ACO de m’avoir fait l’honneur d’être votre 74e président.

Farewell – A Message from Past CEO, Doug Thomson Thank you for the feelin’, But I think I’ve had enough For the sun came late this morning And I sure am feeling rough! C. Fred Turner, BTO 1973

delivered my final report to the COA Board of Directors last June 2019 in Montréal, and now, this will be my final Bulletin article for this amazing organization. This is my final chance to thank the members of the COA for the support they offered me. I have been treated incredibly well by the COA leadership and I know that Cynthia Vezina will also experience the same level of support that I have. My first COA Board meeting was in January 2001, hosted at the time in what was a very frigid weekend in Montréal. I had been in my new position of CEO for all of two weeks, and I truly had no idea what I was doing or what I had gotten myself into. The president in 2001 was Cecil Rorabeck, the President-elect was Clive Duncan, the Second President-elect was Bill Rennie, COA Bulletin ACO - Summer / Été 2020

Robin Richards was the COA Secretary, the Treasurer was Alain Jodoin, Finance and Audit chair was Dave Petrie, Bill Johnston was Past President and COF Chair was Hubert Labelle. Back then, I also managed the Canadian Orthopaedic Foundation (COF). The minutes for that meeting showed my report to be very short. There were no financial reports available, indeed the audit for the prior year was not completed as the COA had dismissed the previous CEO before the audit was finalized. There were

The COA received this kangaroo paw cigarette lighter back in 1964 as a gift from the Australian Orthopaedic Association. Doug put it on display at the 2005 Annual Meeting for the COA’s 60th anniversary.

Your COA / Votre association

(continued from page 8)

two action items for me coming out of the meeting; firstly, Secretary Richards requested that I look into sending member communications through electronic means rather than waiting for the Bulletin publication cycle and secondly, that I develop a reorganization plan for the COA/COF to be presented in a month’s time. This was to include my plans for closing the COA office in Montréal and combining the COA and COF offices and staff in the Toronto area. Prior to my employ at the COA, the Board had engaged a (rather expensive) consultant who had made the strong recommendation that this type of reorganization be done forthwith. I did my due diligence on this reorganization but soon concluded that this might be the craziest move the COA or COF could make. At least to me, it made no sense whatsoever. I still remember how nervous I was when I reported to the COA Executive teleconference in March 2001 that my reorganization plan looked nothing like the consultant’s well-written plan and that my recommendation was that we maintain our COA staff (which

at that time was a total of two, one of them being Cynthia) and also to maintain our presence in Montréal. Further, I rather boldly suggested that we close the very expensive COF office in Scarborough and set up the COF staff to work from their homes, as would I. Admittedly, I had no idea if the plan would work but I was quite convinced that my COA career would be coming to a crashing end anyway, barely three months after it began. Imagine my shock and surprise when the Executive Committee whole-heartedly endorsed it. This was my very first tangible demonstration of the trust that the leadership and broader membership had in me, and I never forgot it nor taken it for granted. My career at the COA has given me the great privilege to work with some of the giants in Canadian orthopaedics. What has been particularly impressive to me was that in addition to the stature that these leaders enjoyed for their clinical excellence, they were always, to a person, immersed in the effort to improve this Association and make positive changes to benefit all orthopaedic surgeons in this country. These are the names of the COA Presidents that I have had the privilege and honour to work with: • • • • • • • • • •

Cecil Rorabeck Clive Duncan Bill Rennie Bob Hollinshead Alain Jodoin Bob Bourne Brendan Lewis Marc Moreau Peter O’Brien Cy Frank

• • • • • • • • • •

Ross Leighton Emil Schemitsch Geoff Johnston Ed Harvey Bas Masri Robin Richards Peter MacDonald Kevin Orrell John Antoniou Mark Glazebrook

All smiles with Dr. Norm Schachar, Dr. Brendan Lewis (COA President 2007) and his wife, Dolores Clements in 2005.

A quiet moment with Dr. Robert McGraw (COA President 1990) at the Past President’s Dinner in 2015.

COA Treasurer, Dr. Markku Nousiainen and Doug had many discussions about the COA’s finances over these past couple years. COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

(continued from page 9)

I can honestly say that I enjoyed working with every one of these fine gentlemen (and I am so happy to see that the COA finally has elected a female second President-elect!). It has also been the absolute highlight of my career to have worked with such incredible staff – Cynthia, Trinity, Meghan, Lexie, and Schneïda (whom I have not yet met in person due to the COVID-19 craziness!). I have been truly blessed to work with

Doug Thomson’s

these dedicated people that have made this job so incredibly satisfying. I will miss the sense of belonging to a great institution of so many brilliant parts on which so much that matters depends. Thank you to the staff, members and many industry friends. As Fred Turner belted out, Thank you for the feelin’!

TOP 10 COA Memories

10 At the 2001 Annual Meeting, my first as CEO of the COA, the

graphics company we used misspelled Johnson & Johnson, my previous employer, as “Johnston & Johnston”. Several of my exwork mates at J&J good-naturedly accused me of sabotage. It was a bum rap!

9 I still remember, with absolute clarity, where I was and what

5 At the Halifax 2007 Annual Meeting, there was a scheduling mix

up with the caterers of the Past Presidents’ Dinner that resulted in over 100 people in black-tie walking into a dark and empty venue.

4 At the Edmonton meeting in 2010, our networking social night

SARS, just five days before it was to start, is something I thought about a lot in light of what happened this year.

was held at Fort Edmonton. Guests arrived by the bus load for the cocktail reception on a beautiful evening, only to be confronted by closed bars not serving alcohol. The city of Edmonton was late in delivering our liquor license to the venue and we were not allowed to serve until it arrived. I am not admitting anything here, but beer may have been served illegally for an hour or two by the COA staff. I think the Alberta Liquor Authority still has an active warrant on me.

7 Associated with #8 above, the General Manager of the Sheraton

3 At that same Edmonton meeting, I elected not to wear any suits

I was doing when Cynthia phoned me to tell me the shocking news that Dr. Cy Frank had passed away. I still think of him fondly and often.

8 Cancelling the 2003 Annual Meeting in Toronto as a result of

Centre Toronto Hotel summoned me to a meeting with her management team a week later to present me with an invoice for $350,000, plus a threatened lawsuit as a result of the cancellation. She gave me the choice to pay the bill in 30 days, or reschedule the conference for the next month (July). I told her we could not come back for 3 years later (we already had contracts in other cities until then), and as for her invoice, the COA barely had two nickels to rub together so we would have to bankrupt the Association. The result of which, all she would end up with was a couple of aged computers and some broken down desks. We instead agreed to reschedule the Toronto meeting to 2006.

6 At the rescheduled Toronto Annual Meeting in 2006, Dr. Brendan

Lewis delivered his President-Elect address whilst suffering from atrial fibrillation. He still somehow managed to get through the entire speech.

COA Bulletin ACO - Summer / Été 2020

or ties. Cynthia wrote in her post-meeting staff notes, and I quote, “Doug dressed like a homeless person. Full intervention required on his wardrobe.” End quote.

2 Dennis Jeanes and I were scheduled to meeting with some

Health Canada officials in Ottawa one morning in April of 2010. Due to my calendar entry error, we showed up exactly one week early.

1 My top memory will always be how much I enjoyed working

with such a fun, talented, and motivated staff team who are dedicated to delivering value to our members. It was the time of my life!

Your COA / Votre association

Adieu – Un message de Doug Thomson, ancien directeur général Thank you for the feelin’, But I think I’ve had enough For the sun came late this morning And I sure am feeling rough! – C. Fred Turner, BTO, 1973

’ai présenté mon rapport final au conseil d’administration de l’ACO en juin 2019, à Montréal, et voici maintenant mon dernier article pour le Bulletin de cette formidable organisation. Il s’agit pour moi d’une dernière occasion de remercier les membres de l’ACO pour leur soutien. La direction de l’ACO m’a extrêmement bien traité, et je sais que Cynthia Vezina bénéficiera du même soutien que moi. Ma première réunion du conseil de l’ACO a eu lieu en janvier 2001, lors d’une fin de semaine glaciale à Montréal. J’étais à mon nouveau poste de directeur général depuis tout juste deux semaines, et je n’avais vraiment aucune idée de ce que je faisais ni dans quoi je m’étais embarqué. En 2001, Cecil Rorabeck était président, Clive Duncan, président élu, Bill Rennie, deuxième président élu, Robin Richards, secrétaire, Alain Jodoin, trésorier, Dave Petrie, président du Comité des finances et de la vérification, et Bill Johnston, président sortant, tandis que Hubert Labelle était président du conseil d’administration de la Fondation Canadienne d’Orthopédie (FCO). À l’époque, je gérais aussi la FCO. Le procès-verbal de cette réunion montre que mon rapport était très court. Il n’y avait pas de rapport financier disponible – en effet, la vérification de l’exercice précédent n’avait pas été complétée, puisque l’ACO avait congédié mon prédécesseur avant qu’elle soit terminée. J’étais responsable de deux mesures à prendre à la suite de la réunion : premièrement, M. Richards avait demandé que j’essaie d’envoyer les communications aux membres par voie électronique plutôt que de dépendre de la

Le Comité de direction en 2015, avec les Drs Robert Turcotte (ancien président de l’AOQ) et Marc Isler (ancien président du Comité des communications).

publication du Bulletin, et deuxièmement, je devais présenter un plan de restructuration de l’ACO et de la FCO le mois suivant. Ce plan devait aborder la fermeture des bureaux de l’ACO à Montréal, et le regroupement des bureaux et du personnel de l’ACO et de la FCO dans la région de Toronto. Avant mon embauche, le conseil de l’ACO avait engagé (à grands frais) un consultant qui avait fortement recommandé de procéder à ce type de restructuration sur-le-champ. J’ai fait preuve de diligence par rapport à cette restructuration, mais j’ai vite conclu que c’était probablement la chose la plus démente que pouvait faire l’ACO ou la FCO. À mes yeux, du moins, cela n’avait aucun sens. Je me souviens encore à quel point j’étais nerveux quand j’ai annoncé, à la téléconférence du Comité de direction de l’ACO en mars 2001, que mon plan de restructuration n’avait rien à voir avec celui bien rédigé par le consultant, et que je recommandais de conserver le personnel de l’ACO (qui comprenait deux personnes, dont Cynthia) ainsi que notre présence à Montréal. De plus, j’ai eu l’audace de suggérer de fermer les bureaux très dispendieux de la FCO à Scarborough, et de faire travailler le personnel de la FCO de la maison, comme je le ferais moi-même. Je dois admettre que je n’avais aucune idée si ce plan réussirait, mais j’étais pas mal convaincu que ma carrière à l’ACO prendrait abruptement fin de toute façon, à peine trois mois après mon arrivée. Imaginez ma surprise quand le Comité de direction l’a approuvé sans réserve. C’était là une première démonstration concrète de la confiance que la direction et les membres en général m’accordaient, et je ne l’ai jamais oublié ni pris pour acquis. Au cours de ma carrière à l’ACO, j’ai eu l’immense privilège de travailler avec quelques-uns des géants de la communauté orthopédique canadienne. Ce qui m’a particulièrement impressionné, c’était que, en plus de la stature dont jouissaient ces leaders grâce à leur excellence clinique, ils se sont toujours plongés dans les efforts afin d’améliorer cette association et d’engendrer des changements positifs pour tous les orthopé-

Doug et le Dr Bas Masri (président de l’ACO en 2015) à la Réunion annuelle d’Edmonton, en 2010.

COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

(suite de la page 11)

distes au pays. Voici le nom des présidents de l’ACO avec qui j’ai eu le privilège et l’honneur de travailler : • • • • • • • • • •

Cecil Rorabeck Clive Duncan Bill Rennie Bob Hollinshead Alain Jodoin Bob Bourne Brendan Lewis Marc Moreau Peter O’Brien Cy Frank

• • • • • • • • • •

Ross Leighton Emil Schemitsch Geoff Johnston Ed Harvey Bas Masri Robin Richards Peter MacDonald Kevin Orrell John Antoniou Mark Glazebrook

En toute honnêteté, je peux dire que j’ai aimé travailler avec chacun de ces éminents messieurs (je suis d’ailleurs si heureux de voir que l’ACO a enfin une deuxième présidente élue!). Un des points forts de ma carrière a en outre été de travailler avec un personnel incroyable – Cynthia, Trinity, Meghan, Lexie et Schneïda (que je n’ai pas encore rencontrée en personne, avec toute la folie autour de la COVID-19!). Ce fut un véritable bonheur de travailler avec ces personnes dévouées qui ont rendu ce travail si gratifiant. Faire partie d’une grande institution composée de tellement de gens brillants sur qui dépendent tant de choses importantes va me manquer. Merci au personnel, aux membres et à mes nombreux amis de l’industrie. Comme le chantait Fred Turner : « Thank you for the feelin’! »

En train de rigoler avec le Dr James Waddell (président de l’ACO en 1998) à la Réunion annuelle de Vancouver, en 2015 .

En train de profiter de St. John’s, en 2011, avec les Drs Ross Leighton (président de l’ACO en 2011) et Kevin Orrell (président de l’ACO en 2018), tous deux Néo-Écossais. COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

(suite de la page 12)

Les DIX GRANDS souvenirs de Doug Thomson à l’ACO 10 À la Réunion annuelle de 2001, ma première à titre de direc-

teur général de l’ACO, le service de graphisme que nous avions retenu avait mal orthographié Johnson & Johnson, mon ancien employeur, en écrivant « Johnston & Johnston ». Plusieurs de mes anciens collègues m’avaient gentiment accusé de sabotage. Fausse accusation, votre honneur!

9 Je me rappelle encore, dans les moindres détails, où j’étais et

ce que je faisais quand Cynthia m’a téléphoné pour m’annoncer la triste nouvelle du décès du Dr Cy Frank. Je pense encore à lui affectueusement et souvent.

8 L’annulation de la Réunion annuelle de Toronto, en 2003, en rai-

son de l’épidémie de SARS, à peine cinq jours à l’avance, est un événement auquel j’ai beaucoup pensé avec ce qui s’est passé cette année.

7 En lien avec le point 8, la directrice générale de l’hôtel Sheraton

Centre Toronto m’avait convoqué à une réunion avec son équipe de direction une semaine après l’annulation afin de me remettre une facture de 350 000 $ et de me menacer de poursuites. Elle m’avait donné le choix entre payer la facture dans les 30 jours, ou remettre le congrès au moins suivant (juillet). Je lui avais dit que nous ne pouvions pas revenir avant trois ans (nous avions déjà des contrats dans d’autres villes entre-temps), et que pour la facture, l’ACO avait trois fois rien et n’aurait d’autre choix que de déclarer faillite. Le cas échéant, elle ne récupérerait que quelques vieux ordinateurs et bureaux mal en point. Nous avons plutôt convenu d’y tenir la Réunion annuelle en 2006.

6 À cette réunion annuelle de Toronto, en 2006, le Dr Brendan Lewis

avait prononcé son allocution de président élu alors qu’il était en pleine fibrillation auriculaire. Il avait tout de même réussi à faire toute son allocution.

5 À la Réunion annuelle d’Halifax, en 2007, en raison d’une erreur

de planification avec les traiteurs du souper des anciens présidents, plus de 100 personnes s’étaient présentées en smoking dans une salle noire et vide.

4 À la Réunion annuelle d’Edmonton, en 2010, notre soirée

sociale avait lieu au Parc du fort Edmonton. Par une magnifique soirée, les invités, arrivés par autocars pour le cocktail, se sont rivé le nez sur des bars fermés et aucun service d’alcool. La Ville d’Edmonton était en retard avec son permis d’alcool, et nous ne pouvions rien servir avant son arrivée sur place. Je n’avoue rien ici, mais il est possible que de la bière ait été servie illégalement pendant une heure ou deux par le personnel de l’ACO. Je crois que la régie des alcools de l’Alberta a encore un mandat contre moi.

3 À cette même réunion d’Edmonton, j’avais décidé de ne porter

ni complet ni cravate. Dans ses remarques au personnel après la Réunion, Cynthia avait écrit : « Doug était habillé comme un sans-abri. Intervention majeure requise sur sa garde-robe. » Tel quel.

2 Dennis Jeanes et moi devions rencontrer des fonctionnaires de

Santé Canada à Ottawa par un matin d’avril 2010. Parce que j’avais mal noté la date, nous nous sommes présentés sur place exactement une semaine à l’avance.

1 Mon plus beau souvenir restera le plaisir que j’ai eu à travailler

avec un personnel aussi drôle, talentueux et motivé, ayant à cœur d’accroître la valeur de l’adhésion pour nos membres. Je me suis amusé comme un fou!

Dr. William A. Silver

October 3, 1932 - May 3, 2020

ill passed away at the Palliative Care Unit in Regina after a struggle with pancreatic cancer. He was predeceased by his parents, brother, sister and two sons. Bill leaves to mourn his wife Dr. Hilary Ryan; previous wife Eunice Silver; daughter Karen Stewart; son Andrew (Kim) Silver; sister-inlaw Ellie Silver; sisters and brothers-in-law Helen and Gregg Bathgate, Christina and Derek Scansen and Patrick and Anjelica O’Ryan; many grandchildren; great-grandchildren; nieces, nephews and dear friends. Bill was an amazing surgeon, athlete and Christian and will be sorely missed. Published on May 9, 2020 – Regina Leader Post COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

Congratulations to Our Two COA Membership Giveaway Contest Winners – 2021 is on US! Lexie Bilhete COA Coordinator, Membership Services & Affiliate Programs

n behalf of the COA leadership, thank you to all our members in Canada, the U.S., and abroad, for your commitment to the Association. By being a COA member, you are also contributing to national and local initiatives that

support our collective community of orthopaedic surgeons, researchers, and trainees right here in Canada. Every COA member who settled their 2020 dues between February 4 – March 4 were automatically entered to win free 2021 COA membership and a randomized draw occurred in April. Congratulations to Drs. Marie-Eve LeBel and Brad Ashman!

Dr. Marie-Eve LeBel

Dr. Brad Ashman

“Being a member of the COA has allowed me to keep connected to friends, trainees (current and former) and colleagues across our wonderful country. The COA is a very open-minded, inclusive and supportive association to all of us and I have truly enjoyed participating to different activities and meetings under their umbrella.”

“My COA membership has been a fantastic resource for me from medical school through to my clinical practice, enabling me to advance my knowledge and skill set, present research, network with colleagues, and stay in touch with close friends.”

Dr. Marie-Eve LeBel is an Associate Professor in the Department of Surgery, Division of Orthopaedic Surgery at the Schulich School of Medicine & Dentistry at Western University, ON, since 2006. She grew up in Québec City and, following studies in physiotherapy, completed both an M.D. degree and residency in orthopaedic surgery at Laval University (QC). She then went on to pursue subspecialty training in sport medicine at the Fowler-Kennedy Sport Medicine Clinic (Western University, ON) in 2005. Dr. LeBel then worked in a community hospital in Cowansville, in Québec’s Eastern Townships for one year before being recruited to go back to an academic practice at the well-known Fowler-Kennedy Sport Medicine Clinic. In September 2012, she was recruited to join the renowned Roth|McFarlane Hand and Upper Limb Centre, specializing in the arthroscopic treatment of athletic injuries and soft tissue disorders of the shoulder. She also completed a Masters Degree in Health Professions Education at the University of Illinois at Chicago in 2014 with a special interest in simulation-based research in surgery and motor skills learning. Dr. LeBel received many research grants for the development of simulators for shoulder and knee surgery and for her work in surgical simulation research. She had the opportunity to present her research in Europe, North America and South America. “Through my COA membership, I was awarded the CFBS (CanadaFrance-Belgium-Switzerland) travelling fellowship. Myself and my co-travelling fellow were the first female Canadian CFBS fellows. I am very thankful for the COA to have allowed me to live these amazing moments and incredible experience.” COA Bulletin ACO - Summer / Été 2020

Dr. Ashman graduated from the orthopaedic surgery residency program at the University of British Columbia in 2016 where he also completed his undergraduate degree and medical school training. He then moved on to a fellowship in sport medicine at the Cincinnati SportsMedicine and Orthopaedic Centre in Cincinnati, Ohio, training with a group led by Dr. Frank Noyes. After fellowship, he worked as a locum throughout BC until being offered a full-time position in Prince George, BC, in 2018. Dr. Ashman currently works alongside a group of nine orthopaedic surgeons servicing much of northern British Columbia. He also conducts outreach clinics and surgery in nearby northern communities as well. Despite a subspecialty interest in arthroscopic and open joint preservation of the shoulder and knee, he continues to provide comprehensive orthopaedic care for patients as a general orthopaedic surgeon. “I enjoy my role as a clinical instructor for the Faculty of Medicine in the UBC Department of Orthopaedics, teaching medical students, family practice residents, and senior orthopaedic surgery residents.”

On behalf of the COA Leadership, thank you to all of our members for your ongoing participation and involvement!

Your COA / Votre association

Félicitations aux deux gagnants de notre concours de renouvellement d’adhésion à l’ACO – c’est NOUS qui payons pour 2021! Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés de l’ACO

u nom du Comité de direction, merci à tous les membres au Canada, aux États-Unis et outre-mer pour leur engagement envers l’ACO. En étant membre de l’ACO, vous contribuez à des initiatives nationales et locales en soutien à

la communauté des orthopédistes ainsi que des chercheurs, résidents et fellows en orthopédie canadiens. Chaque membre qui réglait sa cotisation entre le 4 février et le 4 mars était automatiquement inscrit au tirage de l’une des deux adhésions gratuites à l’ACO pour 2021. Le tirage au sort a eu lieu en avril. Félicitations à la Dre Marie-Ève LeBel et au Dr Brad Ashman!

Dre Marie-Ève LeBel

Dr Brad Ashman

« Être membre de l’ACO me permet de rester en contact avec mes amis, mes résidents et fellows (actuels et anciens) et mes collègues d’un bout à l’autre de notre merveilleux pays. L’ACO est une association très ouverte, inclusive et bienveillante envers chacun de nous, et j’ai vraiment aimé participer à différentes activités et réunions qu’elle a chapeautées. »

« Mon adhésion à l’ACO a été une ressource fantastique pour moi, de l’école de médecine à l’exercice clinique; elle me permet d’approfondir mes connaissances et mes compétences, de présenter mes travaux, de réseauter avec des collègues et de garder le contact avec de bons amis. »

La Dre Marie-Ève LeBel est professeure agrégée à la division de la chirurgie orthopédique du département de chirurgie de l’École de médecine et de dentisterie Schulich de l’Université Western, à London (Ontario), depuis 2006. Elle grandit à Québec et, après des études en physiothérapie, elle effectue son grade en médecine et sa résidence en orthopédie à l’Université Laval, à Québec (Québec). Elle poursuit ensuite sa formation en se spécialisant en médecine sportive à la Fowler Kennedy Sport Medicine Clinic, à l’Université Western, en 2005. La Dre LeBel travaille ensuite dans un hôpital communautaire à Cowansville, dans les Cantons de l’Est (Québec) pendant un an, avant d’obtenir un poste d’universitaire dans la réputée Fowler Kennedy Sport Medicine Clinic. En septembre 2012, elle est recrutée par le réputé Roth|McFarlane Hand and Upper Limb Centre, à London, où elle se spécialise dans le traitement par arthroscopie des blessures sportives et des troubles des tissus mous de l’épaule. Elle décroche également une maîtrise en éducation pour les professions de la santé spécialisée en recherche fondée sur la simulation chirurgicale et en apprentissage des habiletés motrices à l’université de l’Illinois, à Chicago, en 2014. La Dre LeBel a reçu de nombreux prix et bourses de recherche pour le développement de simulateurs pour la chirurgie de l’épaule et du genou, ainsi que pour ses travaux de recherche sur la simulation chirurgicale. Elle a eu l’occasion de présenter ses travaux en Europe et en Amérique du Nord et du Sud. « Grâce à mon adhésion à l’ACO, j’ai reçu la Bourse de voyage canado-franco-belge-suisse (CFBS). Ma coboursière et moi-même étions les premières lauréates canadiennes de la Bourse. Je suis très reconnaissante envers l’ACO de m’avoir permis de vivre ces moments et cette expérience incroyables. »

Le Dr Ashman termine son programme de résidence en orthopédie à l’Université de la Colombie-Britannique en 2016, après y avoir obtenu son grade de premier cycle et sa formation en médecine. Il se spécialise ensuite en médecine sportive au Cincinnati Sports Medicine and Orthopaedic Centre, à Cincinnati (Ohio), au sein d’un groupe dirigé par le Dr Frank Noyes. Après ce fellowship, il fait des suppléances un peu partout en Colombie-Britannique, jusqu’à ce qu’on lui offre un poste à temps plein à Prince George (ColombieBritannique), en 2018. Le Dr Ashman travaille actuellement au sein d’une équipe de neuf orthopédistes servant une bonne partie du Nord de la Colombie-Britannique. Il tient en outre des cliniques de sensibilisation et effectue des chirurgies dans les collectivités du Nord à proximité. Malgré sa spécialisation en chirurgie de conservation par arthroscopie et ouverte de l’épaule et du genou, il continue d’offrir des soins orthopédiques exhaustifs en tant qu’orthopédiste généraliste. « J’aime mon rôle d’enseignant clinique au département d’orthopédie de la Faculté de médecine de l’Université de la ColombieBritannique, où j’enseigne aux étudiants en médecine, aux résidents en médecine familiale et aux résidents seniors en orthopédie. »

Au nom du Comité de direction, merci à tous les membres pour leur participation continue! COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

Beyond Education and CME Cynthia Vezina CEO, Canadian Orthopaedic Association

t the time of planning the COA’s Virtual Meeting held in June, very few Canadian associations had delivered fully virtual events and those who did, had five times the resources of the COA. We suddenly found ourselves in foreign territory without a map, and had to navigate members and stakeholders through this new landscape all the while charting it for the first time ourselves. Overall, participants were very satisfied with our first virtual meeting, and quality and format of the educational program. Stay tuned for a summary of the session evaluation results in the Fall edition of the COA Bulletin. Many enjoyed the ability to access the meeting from anywhere, participate in sessions between cases if they were at the hospital, and view the recordings if they missed a session. However, participant feedback also demonstrates that everyone truly missed being together. Undeniably, the Annual Meeting experience goes far beyond education and CME. Networking and seeing colleagues from across the country, most of which you only get to see at the COA Annual Meeting, is a such vital component of the event. To many, it’s their favourite thing about the Annual Meeting. I think this is where we’ll find the true divide in satisfaction and fulfillment with virtual versus in person events. Although online conferences are evolving to include more options for virtual social activities (happy hours, scavenger hunts etc.), will these be enough to replicate the same networking experience we get from sharing physical space with each other? Or, as my son told me after his virtual Zoom prom a couple months ago, is it ‘just not the same, Mom.’ 2020 has been a lesson in adaptability and approaching things from a different angle. It’s taught us the importance of being in the best position to deal with unexpected changes. The COA remains committed to delivering quality education to its members through the best and most appropriate means. Although 2021 has its own uncertainties, the Continuous Professional Development Committee (CPD) and Executive Committee are building an educational program that will be relevant and effectively delivered in any format. Plans are still underway for an in-person event in Vancouver from June 16-19. Our Program Chair and Committee Members are working together to ensure the program’s success in any format (virtual, hybrid, in-person) in the event of an unforeseen change resulting from public health advisories. Keep up to date about the 2021 event through www.coa-aco.org. Tips for Planning Virtual Events Like any new adventure, several lessons were learned along the way as we delivered a first ever virtual COA, CORS and CORA Annual Meeting less than three months after cancelling the Halifax event. Our five tips may be helpful to many of you involved with planning virtual courses and events for your universities or specialty societies.

COA Bulletin ACO - Summer / Été 2020

Team COA were masked and distanced when hosting the Virtual Annual Meeting this past June. This was the first time we were all physically together in the office since March 17.

1) Don’t try to replicate your usual program. Virtual and in person meetings provide very different learning and teaching experiences and should be considered separate entities when planning session and program formats. This is an opportunity to innovate and try something different from what you usually offer – don’t think you have to somehow reproduce the exact same meeting or program virtually. 2) Timing is everything. Start and end your program at reasonable hours for all of your demographic’s time zones, keep sessions to a maximum of 60-90 minutes, and include breaks between sessions. Sitting in front of a computer screen feels much longer than sitting in a live audience. Consider offering extended programming that is accessible over a longer period than just the meeting dates. 3) Be ready for competition. Participating in a virtual meeting comes with added distractions, and family and work commitments. Expect disparity between actual participation numbers versus registration numbers which makes attendance and uptake difficult to forecast. 4) Get support. Similar to in person events, successful virtual meetings need an expert team to execute. Don’t assume that without the usual venue logistics to manage, there are fewer moving parts to oversee when planning and executing a virtual event. Invest in extra resources and qualified experts to ensure all aspects of your event are well-supported. 5) Your experience is only as strong as your Internet connection. Relying on a shared public signal (coffee shops, hospitals), or on your cottage WIFI is risky – especially if participating as a speaker or panelist. The bandwidth needed to stream a webinar session is far more than what you usually need for daily tasks like checking e-mails or Google searches. Verify the capacity and strength of your WIFI signal before the event.

Your COA / Votre association

Au-delà de la formation et de l’ÉMC Cynthia Vezina Directrice générale de l’Association Canadienne d’Orthopédie

orsque nous avons planifié la Réunion annuelle virtuelle de l’ACO, qui avait lieu en juin, très peu d’associations au pays avaient organisé des manifestations entièrement virtuelles, et celles qui l’avaient fait avaient cinq fois plus de ressources que l’ACO. Nous nous sommes soudainement retrouvés en territoire inconnu, sans carte, et avons dû guider les membres et autres parties concernées dans ce nouvel environnement tout en organisant nous-mêmes une telle manifestation pour la première fois. Globalement, les participants étaient très satisfaits de notre première réunion virtuelle, ainsi que de la qualité et du format du programme scientifique. Nous vous présentons un résumé des résultats de l’évaluation des séances dans le numéro automnal du Bulletin de l’ACO. Beaucoup ont apprécié de pouvoir accéder à la Réunion de n’importe où, participer aux séances entre des cas s’ils étaient à l’hôpital, et écouter l’enregistrement des séances qu’ils avaient manquées. Par contre, la rétroaction obtenue montre aussi que tout le monde a vraiment regretté de ne pas pouvoir être ensemble. Il est indéniable que la Réunion annuelle va bien au-delà de la formation et de l’éducation médicale continue (ÉMC). Le réseautage et la possibilité de voir vos collègues de tout le pays, dont vous ne voyez la plupart qu’à la Réunion annuelle de l’ACO, sont tellement une composante essentielle de la manifestation. Il s’agit pour beaucoup d’entre vous de votre aspect préféré de la Réunion annuelle. Je crois que c’est de là que vient le vrai fossé entre les activités virtuelles et en personne sur le plan de la satisfaction et du contentement. Même si les congrès en ligne évoluent de sorte à inclure plus d’options pour les activités sociales virtuelles (p. ex. cocktails ou chasses au trésor), celles-ci parviendront-elles à reproduire la même expérience de réseautage dont nous profitons en partageant un espace physique commun? Ou, comme m’a dit mon fils après son bal de finissants sur Zoom, il y a quelques mois, c’est « juste pas pareil, maman ». L’année 2020 nous aura appris à nous adapter et à aborder les choses sous un angle différent. Elle nous a enseigné l’importance d’être dans la meilleure position possible pour gérer des changements inattendus. L’ACO reste engagée à offrir de la formation de qualité à ses membres par les moyens les plus efficaces et appropriés. Même si l’incertitude demeure par rapport à la Réunion annuelle 2021, le Comité de perfectionnement professionnel et le Comité de direction conçoivent un programme scientifique à la fois pertinent et efficace, peu importe la forme qu’elle prendra. On prévoit toujours une réunion en personne à Vancouver, du 16 au 19 juin. Le président et les membres du Comité responsable du programme travaillent ensemble afin de veiller au succès du programme peu importe la forme que prendra la Réunion (virtuelle, hybride ou en personne), en cas de changement imprévu à la suite de directives des services de santé publique. Pour connaître les derniers développements quant à la Réunion annuelle 2021, consultez www.coa-aco.org/fr.

Conseils pour la planification d’activités virtuelles Comme toute nouvelle aventure, nous avons tiré plusieurs leçons au cours de l’organisation de la toute première réunion annuelle virtuelle de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO), qui a eu lieu moins de trois mois après l’annulation de la Réunion annuelle d’Halifax. Nos principaux conseils, ci-après, pourraient être utiles à beaucoup d’entre vous qui planifiez des activités et cours virtuels pour votre université ou société de sous-spécialité. 1) N’essayez pas de reproduire le programme habituel. Les réunions virtuelles et traditionnelles offrent une expérience d’apprentissage et d’enseignement très différente et devraient être considérées comme des entités distinctes dans la planification du format des séances et programmes. Il s’agit d’une occasion d’innover, et d’essayer quelque chose de différent de ce que vous proposez d’habitude – ne croyez pas que vous deviez pour une raison ou une autre reproduire parfaitement une réunion ou un programme en mode virtuel. 2) Tout repose sur les moments choisis. Commencez et terminez votre programme à des heures raisonnables dans tous les fuseaux horaires de votre public cible, proposez de limiter les séances à 60 à 90 minutes, et intégrez des pauses entre les séances. Être assis devant un écran d’ordinateur semble beaucoup plus long que d’être assis au milieu d’un public. Envisagez d’offrir un programme prolongé, accessible au-delà des dates de la réunion. 3) Soyez prêt à avoir de la compétition. Participer à une réunion virtuelle implique des distractions supplémentaires et des conflits avec les engagements familiaux et professionnels. Attendez-vous à un écart entre le nombre réel de participants et le nombre d’inscriptions, ce qui rend la participation et la mobilisation difficiles à prévoir. 4) Obtenez du soutien. Comme pour les manifestations en personne, leur pendant virtuel nécessite une équipe chevronnée à la mise en œuvre. Ne présumez pas que, sans la gestion de la logistique habituelle sur place, il y a moins d’aspects changeants à superviser dans la planification et la mise en œuvre d’une activité virtuelle. Investissez dans des ressources supplémentaires et des spécialistes afin de vous assurer de bien soutenir tous les aspects de votre activité. 5) Toute l’expérience du monde ne vaut pas une bonne connexion Internet. Il est risqué de se fier à un signal public partagé (café ou hôpital) ou au Wi-Fi de votre chalet, surtout si vous êtes conférencier ou panéliste. La bande passante requise pour diffuser un webinaire est loin de celle dont vous avez besoin au quotidien pour vérifier vos courriels ou faire des recherches sur Google, par exemple. Vérifiez la capacité et la fiabilité de votre signal avant l’activité.

COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

Diversity in the COA: Spotlight on Women in Orthopaedics Lexie Bilhete COA Coordinator, Membership Services & Affiliate Programs

he COA recognizes the strength in diversity and promotes equity across its membership, services, and all community engagement. Each edition of the COA Bulletin will feature one of the many women members of the Association, their experiences and insights, contributions to the specialty and advice for junior colleagues and students. Get to know the membership! Dr. Magdalena Tarchala completed her residency at McGill University in 2020 and is currently on fellowship at SickKids hospital in Toronto, Ontario. Afterwards, she is heading to Boston Children’s Hospital in 2021. Dr. Tarchala is excited for the next steps in her academic journey and hopes to further her experience with education in order to promote diversity within orthopaedics. She hopes to return to Canada to join a practice in paediatric orthopaedics with future goals of becoming a Program Director. 1. What drew you to orthopaedics? I always wanted to pursue a surgical specialty, but after doing my core rotations and being exposed to most of them, there was always something missing and it wasn’t all that I had envisioned it out to be. Only after my last rotation of 3rd year medical school, I encountered orthopaedic surgery. My mind was blown. The pathology was interesting, the surgical procedures were amazing, but even more so, the people and environment were everything I was looking for. I felt at home. But one thing was holding me back - I didn’t fit the stereotype and felt intimidated. It wasn’t until I met my first female mentor – an intelligent, successful academic surgeon, an amazing educator, and a mom of three. Since then, orthopaedics has always proven itself over and over again. It continues to surprise me and fulfills my professional dreams and desires, and daily reaffirms that it’s the right decision for me. 2. Can you recount a defining moment in your career thus far? I was a junior resident still trying to figure it all out, and had a medical student assigned to work with me. On the first day we worked together, I asked her, “do you know what you’re interested in?” and she immediately responded – “definitely not ortho.” This is a common response and one I hear all the time. Yet by the end of our rotation, she decided to switch her electives to orthopaedics and is currently an orthopaedic resident in Canada. When I asked what made her change her mind, she said “if you can do it – I can do it too.” 3. What does diversity mean to you? Gender, ethnicity, experiences. The more diversity you are exposed to, the more you are challenged to learn from others and your experiences. They can be applied to your career or COA Bulletin ACO - Summer / Été 2020

your personal life skills, and it will only further help you grow. In the end – we use them all together to be the best clinicians we can. The way you connect with your patients in clinic and how you empathize with them is not taught in a textbook during medical school, it’s learned from experiences during your life and being exposed to various cultures and diverse experiences. I have been extremely fortunate to have lived in a few countries around our beautiful world and am even more lucky to call Canada home and feel welcomed here. One of my biggest joys is when I’m in clinic and I can connect with a patient and their family on a personal level because of the understanding of how scared and difficult it is for them to be in a place where their health is at stake and they can’t always speak in their native tongue. Meeting people from all different upbringings and cultures has helped further diversify my training and continues to make me a better clinician. 4. What advice would you give to orthopaedic residents? Find balance and be happy in what you do. Read as much orthopaedics as you can but be happy about it. Enjoy the process of learning and growth. You are blessed to have five years to learn and challenge yourself. Make sure to take time to do something for you – workout, meditate, play PlayStation, travel – just something that helps you destress and makes you a better you. 5. What is one professional goal and one personal goal you hope to achieve in the next five years? Professional goal: Start an academic practice in paediatric orthopaedics/paediatric sports medicine and be a safe and competent surgeon. Personal goal: take my family on a safari. 6. Name one of your go-to tricks or hacks that has helped you in your day to day life? Workout - best stress reliever and study aid ever made. Call my mom. It always amazes me that no matter how old I get, the wiser I think I am – when I don’t know how to do something and am ready to give up, she always has the answer.

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Diversité au sein de l’ACO : Pleins feux sur les femmes en orthopédie Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés de l’ACO

’ACO reconnaît la force inhérente à la diversité et fait la promotion d’une culture d’équité chez ses membres ainsi qu’en ce qui a trait à ses services et à son engagement communautaire. Chaque numéro du Bulletin comprendra le portrait de l’une des nombreuses femmes membres de l’ACO. On en apprendra davantage sur son expérience et ses idées, sa contribution à la profession et ses conseils pour ses jeunes collègues et les étudiants. Apprenez à connaître vos collègues! La Dre Magdalena Tarchala a terminé sa résidence à l’Université McGill en 2020, et elle effectue actuellement sa spécialisation à l’hôpital SickKids, à Toronto (Ontario). Elle doit par la suite poursuivre sa formation au Boston Children’s Hospital, à Boston (Massachusetts), en 2021. La Dre Tarchala est emballée par les prochaines étapes de son parcours universitaire et espère approfondir son expérience en formation de sorte à promouvoir la diversité en orthopédie. Elle espère revenir au Canada et se joindre à une pratique d’orthopédie pédiatrique, et éventuellement devenir directrice de programme. 1. Qu’est-ce qui vous a amenée à choisir l’orthopédie? J’ai toujours voulu me spécialiser en chirurgie, mais après avoir effectué mes stages fondamentaux et été exposée à la plupart des spécialités, il manquait toujours quelque chose, et aucune n’était ce que j’avais imaginé. Ce n’est qu’après mon dernier stage, en troisième année de médecine, que je suis tombée sur la chirurgie orthopédique. J’étais soufflée. La pathologie était intéressante, les procédures chirurgicales étaient incroyables, mais encore mieux, les gens et le milieu étaient exactement ce que je cherchais. Je me sentais chez moi. Une seule chose me retenait : je ne correspondais pas au stéréotype et j’étais intimidée. Ce fut le cas jusqu’à ce que je rencontre ma première mentore – une orthopédiste en milieu universitaire intelligente et réputée, formatrice incroyable et mère de trois enfants. Depuis, l’orthopédie ne m’a jamais déçue. Elle continue de me surprendre et de me permettre de réaliser mes rêves professionnels, et me confirme chaque jour que j’ai pris la bonne décision. 2. Racontez-nous un moment marquant de votre carrière. J’étais résidente junior, encore en train d’essayer de tout comprendre, quand on m’a assignée une étudiante en médecine. La première journée où nous avons travaillé ensemble, je lui ai demandé : « Savez-vous ce qui vous intéresse? », et elle m’a tout de suite répondu : « Définitivement pas l’ortho. » C’est une réponse courante, et je l’entends tout le temps. Cependant, avant la fin de notre stage, elle avait décidé de changer ses stages optionnels et de les faire en orthopédie, et elle est actuellement résidente en orthopédie au Canada. Quand je lui ai demandé ce qui l’avait fait changer d’avis, elle a répondu : « Si vous pouvez le faire, je peux le faire aussi. » 3. Pour vous, que signifie la diversité? Le sexe, l’ethnicité et l’expérience. Plus on est exposé à la diversité, plus on est stimulé à apprendre des autres et de notre

expérience. Cela peut ensuite être appliqué à notre carrière ou à nos aptitudes à la vie quotidienne, et ne peut que nous aider à grandir. Au bout du compte, on s’en sert pour être les meilleurs cliniciens possible. La façon d’établir un lien avec nos patients en clinique et de comprendre ce qu’ils ressentent n’est pas enseignée dans les manuels de médecine; on l’apprend par notre expérience de vie et en étant exposé à un éventail de cultures et d’expériences. J’ai eu l’immense chance de vivre dans quelques pays sur notre belle planète, et je suis encore plus chanceuse d’habiter au Canada et de me sentir la bienvenue ici. L’une de mes plus grandes joies est de me retrouver en clinique et de pouvoir établir un lien personnel avec un patient et sa famille parce que je comprends à quel point c’est effrayant et difficile pour eux de ne pas toujours pouvoir parler dans leur langue maternelle alors que leur santé est en jeu. Rencontrer des gens à l’éducation et à la culture différentes m’a aidée à diversifier ma formation et continue de me permettre de m’améliorer comme clinicienne. 4. Quels conseils donneriez-vous aux résidents en orthopédie? Trouvez l’équilibre et soyez heureux dans ce que vous faites. Lisez autant que possible sur l’orthopédie, mais soyez-en heureux. Appréciez le processus d’apprentissage et de croissance. Vous avez le bonheur d’avoir 5 années pour apprendre et vous dépasser. Assurez-vous de prendre du temps pour vous – entraînez-vous, méditez, jouez au PlayStation, voyagez – quelque chose qui vous aide à déstresser et à être meilleur. 5. Pouvez-vous me parler d’un objectif professionnel et d’un objectif personnel que vous voulez atteindre au cours des cinq prochaines années? Objectif professionnel : Démarrer une pratique universitaire en orthopédie pédiatrique ou médecine sportive pédiatrique et être une orthopédiste fiable et compétente. Objectif personnel : Amener ma famille en safari. 6. Nommez le truc ou l’astuce que vous appliquez au quotidien pour vous faciliter la vie. M’entraîner – le meilleur moyen de détente et la meilleure aide aux études qui soient. Appeler ma mère. Cela me stupéfie de constater que, même si je vieillis et me pense avisée, quand je ne sais pas comment faire quelque chose et que je suis prête à abandonner, elle a toujours la réponse.

COA Bulletin ACO - Summer / Été 2020

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Training Orthopaedic Surgeons in Sub-Saharan Africa: The Changing Landscape and Canadian Contribution Norgrove Penny, CM, MD, FRCSC, FCS(ECSA) Victoria, BC

did so because they desired subspecialty training. If in-country training in general orthopaedics could be so successful, was it now necessary and possible to develop subspecialty training programs in the region?

hen I went to live and work in Uganda in 1996, I became the sixth practicing orthopaedic surgeon in a country with the same populaThe first such orthopaedic subtion as Canada, the only one specialty program to become The COA Global Surgery (COAGS) Committee is pleased to share focusing on children’s orthopaeorganized and accredited by Canadian global health initiatives. If you are interested in COAGS dic surgery, and the only surthe College is paediatric orthogeon outreaching the remote paedic surgery. Candidates need featuring your organization in the Bulletin, or if you are a resident and rural parts of the country to be fully accredited orthopaeand you would like to share an essay about your global surgery on a regular basis. None of my dic surgeons first, then undergo experience, please contact schneida@canorth.org for details. orthopaedic colleagues were two years of further fellowship trained indigenously; they all training before the examination had to go overseas to get their training. Today, it is thought process which gives them an FCS (paeds ortho) accreditation. that there are at least 100 orthopaedic surgeons in Uganda, The first fellows were examined in 2018 with two successful many of whom are practicing in smaller communities outside candidates. Since there were no accredited paediatric orthothe capital, and all are indigenously trained. This is a paradigm paedic surgeons in the COSECSA region, the examiners were shift, a whole new day, and a source of great wonderment to all overseas members of the College, including Dr. Howard and me personally. How did this happen, and what has been the I. At the second round of examinations in 2019, the examincontribution of Canadian orthopaedic surgeons? ing counsel included four Canadians: Drs. Andrew Howard, Norgrove Penny, Fabio Ferri-de-Baros, and Elaine Joughin. The brain drain was historically the problem throughout subSaharan African countries. Training in orthopaedic surgery The hospital I helped establish in Uganda is called CoRSU was considered subspecialized, and students went abroad to Rehabilitation Hospital, a subspecialty children’s orthopaeget their training, seldom to return. Recognizing this, a unique dic and plastic reconstructive hospital similar to a Shriner’s collaborative college of surgeons was established in 1999: hospital, now performing approximately 5000 reconstructive the College of Surgeons of East, Central and Southern Africa surgical procedures annually with an orthopaedic staff of (COSECSA), encompassing ten sub-Saharan countries. Each seven indigenously trained surgeons. We have established a country recognized that they did not individually have enough current project to get four of the surgeons fully accredited resources to establish their own college but could do so colwith their FCS (paeds ortho) designation - the purpose being laboratively. The purpose was to foster training in-country and develop an examination and accreditation system common to all the countries. It was the first college-based training as compared to university-based training in the region. Colleges of surgeons from Great Britain and Ireland mentored this fledgling organization and all participating countries ramped up their specialty training in all surgical disciplines, including orthopaedic surgery. The accreditation and examination process gave candidates a fellowship designation rather than a university degree, the FCS(ECSA), accredited in all the participating countries, which now number 14. At this writing there are now 35 orthopaedic residents training in Uganda with an annual intake of ten. Dr. Andrew Howard and I have had the privilege of being external examiners for the college on a regular basis since its inception, with other Canadian colleagues participating from time to time. Training surgeons in-country rather than sending them abroad on a scholarship has shown to be hugely successful. In his presidential address to the College in 2018, Dr. Abebe Bekele, from Ethiopia, showed that 93% of surgeons trained in Africa were still in Africa. Of the 7% that had left, many COA Bulletin ACO - Summer / Été 2020

COSECSA Paediatric Orthopaedic Examiners Panel 2019. Drs. Andrew Howard (back row far right), Norgrove Penny (back row centre), Dr. Fabio Ferri-de-Baros (seated far right), Dr. Elaine Joughin (seated second from left).

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(continued from page 20)

both to enhance their surgical skills and to develop paediatric orthopaedic leadership in the country. Stimulus for the project came from Dr. Mark Barry, a Canadian-born and trained orthopaedic surgeon who has spent his working life in the United States, and who has set up a non-governmental charitable organization to establish paediatric orthopaedic training in the COSECSA countries. External professors have been recruited for one-month residential traineeships in succession, giving full-time professorial oversight for 12 months followed by intermittent visits for the second year. The volunteer trainers have been recruited from well-known members of the Paediatric Orthopaedic Society of North America and the European Paediatric Orthopaedic Society, and largely constitute senior or retired orthopaedic surgeons, all of whom are known international experts in their field. I cannot overstate what an extraordinary faculty we have, and the Ugandan fellows are being exposed to teachers I would have “given my eye teeth” to be exposed to in my own training. The teaching is hands-on mentorship, with regular academic rounds and case presentations. During the course of the 12 months, the entire paediatric orthopaedic curriculum is covered. Drs. Barry, Colleen Sabatini from California, and I act as facilitators and co-faculty. Dr. Sabatini brings extensive experience in Uganda, and has established a research office at CoRSU. Each of the fellows is required to complete a research project during the two years of training. The first trainer to spend the month of January 2020, was Dr. John Wedge, well-known Canadian orthopaedic surgeon and former head of orthopaedics at the Hospital for Sick Children in Toronto. We could not have asked for a better and more important first trainer than Dr. Wedge given his enormous experience in children’s orthopaedics and, most particularly, his involvement in leadership development and hospital accreditation. A significant part of the mentoring program is to develop leadership skills alongside orthopaedic skills. Dr. Moses Muhumuza is the head of the orthopaedic department at CoRSU. He is a mature orthopaedic surgeon with longstanding experience in paediatric orthopaedics, and who has proven leadership skills. Dr. Wedge has been instrumental in mentoring Dr. Muhumuza in the skills of being the head of an orthopaedic department, and the leader of a future training program.

2020 was planned to be the year for intense training with professors visiting monthly, but then the COVID-19 pandemic struck and, tragically, we have had to suspend the program after the second visit. However, taking advantage of modern telecommunication opportunities and reasonable internet access at the hospital, we have now established a weekly virtual seminar series with the professorial faculty. The fellows present a particular subject in PowerPoint, there is a case presentation, and then faculty feedback. Part of the mentoring is preparing for the examination process. The virtual seminars have been highly successful, with high-quality presentations from the fellows and international representation from the faculty. We hope to continue the on-site visits in 2021, depending on what travel restrictions allow.

Virtual clinical conference with Ugandan fellows and 8 international faculty.

What Have We Learned? The landscape for global surgical efforts has changed remarkably from short-term mission outreach to perform surgeries on a limited number of people, to the support of training in general orthopaedics, and now subspecialty orthopaedics. There is a major role for us to play in mentorship not just of orthopaedic skills, but orthopaedic leadership. We have seen the value of supporting and mentoring a College of Surgeons to develop its accreditation and examination process, now coming into its maturity. There is a completely new paradigm in even the most resource poor countries on the planet developing professional skills with indigenous training programs that we must do our best to support. The challenges of COVID-19 have proven that we can use distance education and telehealth effectively. Now, however, lagging behind training is infrastructure development. Our new trainees need places to work like CoRSU Hospital that are well-equipped so they can do what they have been trained to do and not become discouraged. This requires a major effort, including a current effort to support CoRSU hospital financially during the COVID-19 stress.

Drs. Moses Muhumuza and John Wedge.

Canadian orthopaedic surgeons have been instrumental in the whole process of the development of indigenous training in the COSECSA countries. I believe Canada has a specific role to play as a senior member of the Commonwealth, and as a country rich in multiculturalism and collaboration in our collective DNA. COA Bulletin ACO - Summer / Été 2020

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Welcome Aboard the COA Team

Bienvenue au sein de l’équipe de l’ACO

Lexie Bilhete COA Coordinator, Membership Services & Affiliate Programs Coordonnatrice, Services des members et programmes affiliés de l’ACO

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

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

As a result of several mandates coming to term at once, this year’s committee slate includes a fair amount of turn over at the committee chair level. Many terms were extended previously in anticipation of the COA’s strategic review held earlier this year. Despite the need to for continuity and stability, the Nominating Committee agreed that a balance of both new chairs, renewed terms and seasoned leadership would be considered for the 2020-2021 governance structure.

Comme plusieurs mandats prenaient fin en même temps, il y a passablement de nouveaux venus à la présidence des comités cette année. Bien des mandats avaient déjà été prolongés en prévision de l’examen stratégique de l’ACO, qui a eu lieu plus tôt cette année. Malgré le besoin de continuité et de stabilité, le Comité des candidatures a convenu de considérer un équilibre entre l’arrivée de nouveaux présidents, le renouvellement de mandats et la présence de leaders chevronnés pour la structure de gouvernance en 2020-2021.

The COA’s policy on diversity and inclusion was considered throughout the Nominating Committee’s deliberation and selection process. Efforts were especially made to foster leadership and growth opportunities among our junior members and those working outside the academic sector. With considerable changeover at once, the Nominating Committee agreed that some continuity and stability is required to balance out the governance while the COA continues to be impacted by COVID-19. The combination of new chairs and members, along with renewed terms and experienced leadership will provide the COA with both a strong foundation and fresh insights to carry it forward. We are proud to highlight the newest Chairs* of the COA’s various committees, announced at the Virtual Annual Meeting this past June 2020. The COA looks forward to working with all our committees toward the positive future and advancement of Canadian orthopaedics. *Biographies available in French upon request; e-mail info@canorth.org.

COA Bulletin ACO - Summer / Été 2020

Le Comité des candidatures a tenu compte de la politique de l’ACO en matière de diversité et d’inclusion pendant ses délibérations et son processus de sélection. On s’est particulièrement efforcé de favoriser les possibilités de leadership et de croissance pour nos jeunes membres et pour les membres œuvrant en dehors du milieu universitaire. Avec ces changements considérables, le Comité des candidatures a convenu qu’une certaine continuité et stabilité est nécessaire afin d’équilibrer la gouvernance alors que la COVID19 continue d’avoir une incidence sur les activités de l’ACO. La combinaison de nouveaux présidents et membres, de mandats renouvelés et de leaders chevronnés permettra à l’ACO de bénéficier à la fois d’une bonne base et de nouvelles idées. Nous sommes également fiers de souligner la nomination des tout derniers présidents* des comités, annoncée en juin dernier à la Réunion annuelle virtuelle, et nous avons hâte de travailler avec tous nos comités à l’avancement de l’orthopédie au Canada. * Les notices biographiques en français des membres suivants sont disponibles sur demande à info@canorth.org.

Your COA / Votre association

(continued from page 22)

Member at Large – Executive Committee: Dr. Pascale Thibaudeau Dr. Pascale Thibaudeau is a hip and knee reconstruction surgeon practicing in Montréal, Québec. After finishing residency at McGill University in 2012, she pursued a fellowship in adult reconstruction at the Queen Elizabeth II Health Sciences Centre in Halifax, NS. She then completed a second fellowship in knee reconstruction at the Ottawa Hospital, after which she returned to Montréal and joined her current practice at the Lakeshore General Hospital. Dr. Thibaudeau currently serves on the Continuing Professional Development Committee of the Québec Orthopaedic Association. She is an examiner for the Royal College of Physicians and Surgeons. She had also been serving on the Standards Committee of the COA for the past three years prior to accepting her new nomination as Member-at-Large for the Executive Committee.

Memberships Committee Chair, Dr. Chad Coles Dr. Chad Coles is an adult orthopaedic trauma surgeon practicing in Halifax, Nova Scotia. After completing residency in orthopaedic surgery at Dalhousie in 2002, he pursued an Advanced Clinical Experience in orthopaedic traumatology at Harborview Medical Centre in Seattle, Washington. He remained on staff at Harborview for an additional year, before returning to Halifax in 2004. Dr. Coles is an Associate Professor at Dalhousie University. He plays an active role in surgical education, including medical students, residents, fellows, and practicing surgeons. He has received clinical teaching awards at both the undergraduate and post-graduate level. He serves as an examiner for the Royal College of Physicians and Surgeons. Dr. Coles has a full-time academic practice in orthopaedic trauma at the Queen Elizabeth II Health Sciences Centre, which includes participation in several international, multi-centered research projects. He is on the Board of Directors of the Orthopaedic Trauma Association, serves on the Editorial Board of the Journal of Orthopaedic Trauma, and is a reviewer for Injury, and the Canadian Journal of Surgery. He has served on several COA committees, most recently on the Membership Committee, which he is now Chair.

Standards Committee Chair: Dr. Tim Daniels Dr. Tim Daniels is Professor at University of Toronto, Head of its foot and ankle program and Chief of Orthopaedic Surgery at St. Michael’s Hospital. He manages a quaternary referral practice with an emphasis on hindfoot deformity and ankle arthritis. He serves as Associate Editor and Reviewer at prestigious journals. Other notables include Co-founder/Coordinator of the Biennial COFAS Symposia (1993 to present), Co-Founder/Past President, COFAS (2002-04), Canada’s Representative at IFFAS (2004-07), Research Chair AOFAS (2010-13), Chair/PI COFAS Ankle Arthritis Study Group (2011 to present), Member-at-Large on the AOFAS Board of Directors (2013), and Term-Chair F&A Research (2012-17 and 2020-25). He’s the recipient of the U of T Orthopaedic Chair’s Teaching Award and Jameel Ali Continuing Education Award, COA Award of Merit, the Takakura Award (2005, 2014 – for best clinical paper at IFFAS’ Triennial meetings), the Roger Mann Award (2008, 2012, 2014, 2015, 2017 – for best clinical paper at AOFAS Annual Meetings), and the COA Service to Specialty Enrichment Award.

Practice Management Committee Chair: Dr. Mohit Bhandari Dr. Mohit Bhandari is the Practice Management Committee Chair during his terms as President and Past President. This committee’s membership includes leadership from all of the provincial orthopaedic societies, and is prime opportunity for the COA President to engage and strategize directly with our provincial partners.

Communications Committee Chair: Dr. John Antoniou Dr. John Antoniou is the Communications Committee Chair. Leadership of this committee by a recent Past President fosters continuity of the COA’s advocacy initiatives through our communications strategies. Dr. Antoniou served on this committee in the past both Scientific Editor and Editor in Chief of the COA Bulletin, and was President of the Association from 2018-2019.

COA Bulletin ACO - Summer / Été 2020

Your COA / Votre association

(continued from page 23)

CORS President: Dr. Simon Kelley Dr. Kelley practices at The Hospital for Sick Children, Toronto as a paediatric orthopaedic surgeon specializing in hip, limb lengthening and reconstruction surgery. Dr. Kelley has broad range of academic interests developed from his practice including a clinical research program focusing on clinical outcomes, process improvement, simulation and education in the treatment of hip dysplasia. Dr. Kelley currently serves in a number of leadership roles at SickKids including Associate Chief of Perioperative Services – Clinical and Ambulatory, and as the Orthopaedic Fellowship Director. Outside of SickKids he is a Deputy Editor of the Journal of Paediatric Orthopaedics, is a member of the Medical Advisory Board of the International Hip Dysplasia Institute and recently graduated from the inaugural Harvard Surgical Leadership Program.

CORA Co-chairs: Drs. Alex Hoffer & Stefan St. Georges Dr. Alex Hoffer is a fourth-year orthopaedic resident at the University of British Columbia. He grew up in Anmore, British Columbia, obtained a BSc in biomedical physiology and kinesiology from Simon Fraser University and completed his MD degree at UBC. While his interests in orthopaedics are broad, he has a special passion for sports and trauma surgery. Outside of orthopaedics, he enjoys playing sports, being outdoors and is looking forward to getting married next summer! Dr. Stefan St George is a fourth-year orthopaedic resident at the University of British Columbia. He grew up in Ottawa, Ontario, obtained a BSc in life sciences from Queen’s University and completed his MD degree at Western University. Dr. St. George’s primary interest is in arthroplasty. He recently got married and in his spare time enjoys exploring the outdoors and local craft breweries with his wife and labradoodle puppy.

Stryker Canada Hip Arthroscopy Webinar Series Stryker’s Sports Medicine business and our faculty will be highlighting and discussing a wide range of topics related to hip arthroscopy in Canada. Join us for our second webinar in the series on September 23rd via Zoom. Details below:

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COA Bulletin ACO - Summer / Été 2020

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

Management of Proximal Humerus Fractures Debate: An Introduction Paul A. Martineau, MDCM, FRCSC, ABOS Scientific Editor, COA Bulletin

his edition’s debate on proximal humerus fractures (PHF) gives us a glimpse into the minds of our experts and the ongoing struggle between evidence-based medicine (EBM) and surgical expertise. I asked the experts to take a firm stand on either operative or nonoperative management of PHF. Drs. Tohmé and Sandman strongly defended operative management, whereas Drs. Baisi and Lapner firmly represented the nonoperative treatment team. The experts do an excellent job summarizing the pertinent literature on PHF and help interpret the literature for our own practices. However, interesting points are made by both sides in support of their view. As Drs. Baisi and Lapner show, EBM seems to clearly favour nonoperative intervention in 3- and 4-part fractures in patients over the age of 65. In addition, complications tend to only happen in the operative groups. On the other hand, Drs. Tohmé and Sandman present key factors related to improved restoration of the anatomy, which may correlate with success. It is probable that these parameters are better restored in the hands of proximal humerus expert surgeons. Nevertheless, if we all chose to treat fractures nonoperatively, who remains an expert for the more complex fractures not covered in the literature (e.g. head splitting or fracture dislocations)?

Operative Versus Nonoperative Management of Proximal Humerus Fractures Survey Results Summary

Before selecting this debate topic, I thought the evidence strongly favoured nonoperative management for 3- and 4-part fractures in patients over the age of 65. The pre-debate survey consisted of short clinical vignettes presenting alternate patient-specific and surgeon-specific variables that we thought could influence decision making on operative or nonoperative management for PHF. However, our survey showed that practice patterns really did not reflect EBM. For Neer type 3 fractures, 68.3% of the respondents chose surgical management. For Neer type 4 factures, 46.9% elected to operate. If we look at other fracture types, 77.4% of our respondents operated on Neer type 2 fractures and 2.7% operated on undisplaced fractures. There is almost no difference between the responses of upper extremity specialist surgeons versus the rest of the respondents. Surgeons with more experience were however more likely to operate. We included the summary results of our second COA readership pre-debate survey. As shown in the results of our previous survey on Achilles tendon ruptures, despite strong EBM favouring nonoperative management, survey participants are still performing surgery quite frequently on PHF. I would like to thank the COA Bulletin readers and provincial association members for their participation in the survey. The results highlight one of the bigger issues in orthopaedics today: evidence-based medicine should be providing us with the best rationale for a given treatment, in this case nonoperative management of PHF. However, EBM seems to be having a limited impact in actually changing the practice of surgeons. We should all be asking ourselves why.

Overall Treatment Decision Overall Neer type 1 fracture Neer type 2 fracture Neer type 3 fracture Neer type 4 fracture

Operative Management 48.9% 2.73% 77.4% 68.3% 46.9%

Nonoperative Management 51.1% 97.27% 22.6% 31.7% 53.1%

Treatment Decision Based on Surgeon Specialty Overall Neer type 1 fracture Neer type 2 fracture Neer type 3 fracture Neer type 4 fracture

Hand and UE Operative management Nonoperative management 53.2% 46.8% 2.6% 97.4% 88% 12% 70.1% 29.9% 54.5% 45.5%

Operative management 47.9% 2.76% 75.7% 66.9% 45.3%

Rest Nonoperative management 52.1% 97.24% 24.3% 33.1% 54.7%

P value 0.11507 0.4721 0.03515 0.356 0.1313

Treatment Decision Based on Surgeon Experience Overall Neer type 1 fracture Neer type 2 fracture Neer type 3 fracture Neer type 4 fracture

<10 years experience Operative management Nonoperative management 45.3% 54.7% 2.23% 97.77% 72.6% 27.4% 65.9% 34.1% 40.2% 59.8%

>10 years experience Operative management Nonoperative management 51.3% 48.7% 3.1% 96.9% 80.8% 19.2% 70% 30% 51.5% 48.5%

P value 0.03754 0.35197 0.06811 0.24196 0.04551

COA Bulletin ACO - Summer / Été 2020

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

Why I Always Fix Proximal Humerus Fractures Emilie Sandman, M.D., M.Sc., FRCSC Hôpital du Sacré-Cœur de Montréal Université de Montréal Montréal, QC Patrick Tohmé, M.D. Université de Montréal Montréal, QC

roximal humerus fractures are the third most common type of fracture, after hip and distal radius fractures, are twice more frequent in female patients and account for approximately 4-6% of all fractures1. The incidence of proximal humerus fractures is increasing with the aging population and should triple by 20302,3. Although the mechanism of injury may vary, these fractures can occur in both young and elderly individuals, with the associated complications specific to each population. For the younger patient, these fractures often occur due to a high velocity injury. Whereas for the older patient, proximal humerus fractures are often the result of a low velocity trauma and of frail bones, secondary to associated osteoporosis, thus causing more complex fractures. In this population, the complications following this injury may have devasting effects, leading to reduced shoulder function, decreased independence and increased risk of mortality4. It is important to understand each patient-specific characteristic and demand, while keeping a global outlook when discussing the optimal treatment plan5. Although proximal humerus fractures are common in the adult population, some controversy remains in the literature regarding the best treatment option and orthopaedic surgeons still ask: To Operate or Not To Operate? Conservative management is a proven good option for certain cases, however it is important to have multiple close followup appointments with radiographic controls to make sure the fractures did not displace, or with humeral neck fractures, that osteonecrosis does not develop. Meanwhile, surgical management has improved apace with our understanding of the different fracture pattern types and the deforming forces surrounding the shoulder. Many surgical techniques are available to address proximal humerus fractures. When performing surgery, meticulous dissection of the soft tissues is one of the key principles to preserve vascularity to the fragments and optimize healing rates6. First, the intramedullary nailing technique, with the possibility of using locking screws in different directions. More commonly used in Europe, it has been slowly gaining popularity in North America within the past few years, due to improved nailing technology. It is indicated for 2-part fractures, 3-or 4part minimally displaced fractures, and diaphyseal fractures or pathological fractures of the humeral shaft. However, one must be careful with osteoporotic bone, since a biomechanical study has shown an increased risk of failure with torsional forces, versus an open reduction and internal fixation (ORIF) with plates and screws7. Moreover, it is important to carefully protect the rotator cuff during this type of surgery.

COA Bulletin ACO - Summer / Été 2020

Second, our preferred technique, the ORIF osteosynthesis with locking plates and screws. This technique revolutionized the surgical treatment for proximal humerus fractures and has now become, the gold standard for fracture fixation. According to the literature it is clearly indicated in younger and active patients, with good bone quality, with a 2-, 3-, or 4-part proximal humerus fracture, or a displaced greater tuberosity fracture >5mm. More and more studies report positive results when fixing complex fracture patterns with locking plates and screws, since the new locking mechanism offers good fixation for low density and osteoporotic bone, and decreases the risk of screw pullout8. However, to obtain good results, understanding the different fracture patterns and aiming for anatomic fracture reduction is crucial. Indeed, with a communitive medial calcar fracture, it is essential to avoid varus malreduction, which may lead to collapse and screw cutout. Moreover, it is important to understand the risk factors for humeral head ischemia, which may lead to osteonecrosis and other complications. It is known that a methaphyseal head extension greater than 8mm and a medial hinge inferior to 2mm are good predictors for humeral head ischemia9,10. Thus, there are two essential goals you need to know with this type of surgery: 1) to restore a stable medial calcar, the calcar screw must be positioned in the proximal infero-medial fragment, and 2) to avoid screw perforation, screws should be < 40 mm in the humeral head5,11-14 (Figure 1). Until recent studies, ORIF surgery was performed with caution in the elderly population. Literature has now shown that this treatment option is now indicated even for patients older than 75 years, offering them a good quality of life and independence. Indeed, in their retrospective study15, Goch et al. found no significant differ- Figure 1 ence for patients aged The calcar screw must be positioned in the proximal infero-medial fragment. between 55 and 69 years old versus patients older than 70 years old, for range of motion (ROM), function and risk of complications, following ORIF. Moreover, similar functional results have been reported for patients aged 65 years or older versus younger patients, when addressing osteoporotic fractures with a locking plate and fibula strut allograft16. Additionally, de Kruijf et al’s17 study revealed that, when indicated, it is reasonable to perform an ORIF in patients older than 75 years old, since it can potentially yield better functional results versus a conservative treatment. These patients also experienced less pain, fewer limitations in their daily activities and better overall function than after a hemiarthroplasty17. In fact, surgery could give patients a faster return to function with an earlier shoulder mobilization. Furthermore, we believe that a more global perspective is important, since the aging population often uses technical aids and needs good upper extremity function to securely mobilize themselves.

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

However, performing an ORIF can be problematic, in cases of comminution of the tuberosities or the calcar, of soft bone under the finger when operating, of fragile cortical bone resembling an “egg shell”, or of a torn rotator cuff (Figure 2). Solberg and al.18 compared fixed-angle locked plate with hemiarthroplasty in displaced 3- and 4-part fractures Figure 2 in patients older than Comminutive proximal humerus fracture. 55 years old. The locked plate cohort demonstrated better range of motion and a better ability to perform activities of daily living. In their systematic review, Gupta et al.1 showed that patients undergoing an ORIF had better clinical functional outcomes as well as ROM, when compared to reverse shoulder arthroplasty (RSA) or hemiarthroplasty (HA) surgeries. However, they emphasized that it is imperative to choose the right patients, since there is a greater risk of complications and higher reoperation rates versus HA and RSA surgeries. In their systematic review of the literature, Gallinet et al.3 found that RSA is a good option for patient older than 65 years who are not ORIF candidates, but future long-term studies should be undertaken to better evaluate the indications for RSA in younger patients. Yahuaca et al.19 looked at the outcomes, patient factors and fracture patterns between ORIF, HA and RSA for the treatment of proximal humerus fractures. At one year, all patients had similar shoulder ROM. However, there was a higher rate of revision surgery after ORIF and HA compared to RSA. RSA for communitive fractures has become more popular in the past few years but it remains important to choose the patients wisely and to know the indications and complications associated with RSA20. In conclusion, when possible, we believe that restoring a normal anatomy with an ORIF for a proximal humerus fracture is a better treatment option than conservative treatment. Recent studies have demonstrated that surgery yields good functional results for both the younger and the older patient. However, it is important to always consider patient characteristics and understand the different fracture patterns in order to guide the patients towards the optimal treatment. References 1. Gupta AK, Harris JD, Erickson BJ, Abrams GD, Bruce B, McCormick F, Nicholson GP, Romeo AA. Surgical management of complex proximal humerus fractures-a systematic review of 92 studies including 4500 patients. J Orthop Trauma. 2015 Jan;29(1):54-9. doi: 10.1097/ BOT.0000000000000229. 2. Palvanen M, Kannus P, Niemi S, Parkkari J. Update in the epidemiology of proximal humeral fractures. Clin Orthop Relat Res. 2006 Jan;442:87-92.

3. Gallinet D, Ohl X, Decroocq L, Dib C, Valenti P, Boileau P; French Society for Orthopaedic Surgery (SOFCOT). Is reverse total shoulder arthroplasty more effective than hemiarthroplasty for treating displaced proximal humerus fractures in older adults? A systematic review and metaanalysis. Orthop Traumatol Surg Res. 2018 Oct;104(6):759766. doi: 10.1016/j.otsr.2018.04.025. 4. Myeroff CM, Anderson JP, Sveom DS, Switzer JA. Predictors of Mortality in Elder Patients With Proximal Humeral Fracture. Geriatr Orthop Surg Rehabil. 2017 Aug 31;9:2151458517728155. doi: 10.1177/2151458517728155. 5. Spross C, Meester J, Mazzucchelli RA, Puskás GJ, Zdravkovic V, Jost B. Evidence-based algorithm to treat patients with proximal humerus fractures-a prospective study with early clinical and overall performance results. J Shoulder Elbow Surg. 2019 Jun;28(6):1022-1032. doi: 10.1016/j.jse.2019.02.015. 6. Spross C, Grueninger P, Gohil S, Dietrich M. Open Reduction and Internal Fixation of Fractures of the Proximal Part of the Humerus. JBJS Essent Surg Tech. 2015 Aug 12;5(3):e15. doi: 10.2106/JBJS.ST.N.00106. 7. Edwards SL, Wilson NA, Zhang LQ, Flores S, Merk BR. Twopart surgical neck fractures of the proximal part of the humerus. A biomechanical evaluation of two fixation techniques. J Bone Joint Surg Am. 2006 Oct;88(10):2258-64. 8. Sinha S, Kelly CP. Fixed angle locking plates for proximal humeral fracture fixation. Ann R Coll Surg Engl. 2010 Nov;92(8):631-4. doi:10.1308/003588410X12771863937322. 9. Hertel R, Hempfing A, Stiehler M, Leunig M. Predictors of humeral head ischemia after intracapsular fracture of the proximal humerus. J Shoulder Elbow Surg. 2004 JulAug;13(4):427-33. 10. Laux CJ, Grubhofer F, Werner CML, Simmen HP, Osterhoff G. Current concepts in locking plate fixation of proximal humerus fractures. J Orthop Surg Res. 2017 Sep 25;12(1):137. doi: 10.1186/s13018-017-0639-3. 11. Gardner MJ, Weil Y, Barker JU, Kelly BT, Helfet DL, Lorich DG. The importance of medial support in locked plating of proximal humerus fractures. J Orthop Trauma. 2007 Mar;21(3):185-91. 12. Newman JM, Kahn M, Gruson KI. Reducing Postoperative Fracture Displacement After Locked Plating of Proximal Humerus Fractures: Current Concepts. Am J Orthop (Belle Mead NJ). 2015 Jul;44(7):312-20. 13. Owsley KC, Gorczyca JT. Fracture displacement and screw cutout after open reduction and locked plate fixation of proximal humeral fractures [corrected]. J Bone Joint Surg Am. 2008 Feb;90(2):233-40. doi: 10.2106/JBJS.F.01351. Erratum in: J Bone Joint Surg Am. 2008 Apr;90(4):862. 14. Lowry V, Bureau NJ, Desmeules F, Roy JS, Rouleau DM. Acute proximal humeral fractures in adults. J Hand Ther. 2017 Apr - Jun;30(2):158-166. doi: 10.1016/j.jht.2017.05.005. COA Bulletin ACO - Summer / Été 2020

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 29)

15. Goch AM, Christiano A, Konda SR, Leucht P, Egol KA. Operative repair of proximal humerus fractures in septuagenarians and octogenarians: Does chronologic age matter? J Clin Orthop Trauma. 2017 Jan-Mar;8(1):50-53. doi: 10.1016/j. jcot.2017.01.006. 16. Hinds RM, Garner MR, Tran WH, Lazaro LE, Dines JS, Lorich DG. Geriatric proximal humeral fracture patients show similar clinical outcomes to non-geriatric patients after osteosynthesis with endosteal fibular strut allograft augmentation. J Shoulder Elbow Surg. 2015 Jun;24(6):889-96. doi: 10.1016/j.jse.2014.10.019. 17. de Kruijf M, Vroemen JP, de Leur K, van der Voort EA, Vos DI, Van der Laan L. Proximal fractures of the humerus in patients older than 75 years of age: should we consider operative treatment? J Orthop Traumatol. 2014 Jun;15(2):111-5.

18. Surgical Treatment of Three and Four-Part Proximal Humeral Fractures By Brian D. Solberg, MD, Charles N.Moon, MD, Dennis P. Franco, MD, and Guy D. Paiement, MD J Bone Joint Surg Am. 2009;91:1689-97 19. Yahuaca BI, Simon P, Christmas KN, Patel S, Gorman RA 2nd, Mighell MA,rankle MA. Acute surgical management of proximal humerus fractures: ORIF vs. hemiarthroplasty vs. reverse shoulder arthroplasty. J Shoulder Elbow Surg. 2020 Jan 13. pii: S1058-2746(19)30716-5. doi: 10.1016/j. jse.2019.10.012. 20. Jobin CM, Galdi B, Anakwenze OA, Ahmad CS, Levine WN. Reverse shoulder arthroplasty for the management of proximal humerus fractures. J Am Acad Orthop Surg. 2015 Mar;23(3):190-201. doi: 10.5435/JAAOS-D-13-00190.

Why I Never Fix Proximal Humeral Fractures Louis-Philippe Baisi, M.D. Peter Lapner, M.D., FRCSC University of Ottawa Ottawa, ON

roximal humerus fractures (PHF) in elderly patients are the third most common fracture after hip and distal radius fractures (DRF)1. The vast majority of PHF are undisplaced and are amenable to nonoperative treatment1,2. Despite this, the incidence of surgery for PHF has nearly quadrupled in the last 20 years3 due to improvements in implant technology1. Implant choices and surgical techniques for fixation of PHF include: closed reduction and percutaneous pining, open reduction and internal fixation (ORIF), and intramedullary nailing (IMN)1,2,4. As in any debate, it is necessary to frame the question and to define the problem: be it resolved that patients over 65 years of age with closed Neer 3- and 4-part proximal humeral fractures should never undergo open reduction/internal fixation. This argument does not pertain to isolated greater tuberosity fractures or to fracture-dislocations, head splitting fractures, or fractures of the proximal humerus in young patients. As of July 2020, there is no high level of evidence literature to support operative intervention in the treatment of most proximal humerus fractures. Yet, expert opinion and current practice in many centres does not appear to reflect this. As clinicians trained in the scientific method, why are we not practicing evidence-based medicine? Literature Review Zyto and colleagues5 undertook one of the earliest prospective randomized controlled trials (RCT), comparing tension band osteosynthesis to nonoperative treatment of displaced 3- and 4-part PHF. Their cohort comprised 40 patients randomized to either group. The mean ages were 73 and 75 for the surgical and nonoperative treatment arms respectively. The COA Bulletin ACO - Summer / Été 2020

vast majority of patients were female and most consisted of 3-part fractures. The study found no significant clinical difference between the two treatment approaches. They also found that radiographic outcomes (fracture alignment) were better in the group having undergone surgical intervention but that all those who developed a major complication were from the group who had surgery. Olerud et al.1 compared ORIF with locked plate to nonoperative treatment for displaced 3-part PHF in patients 55 years of age and over. This cohort comprised 60 patients with a mean age of 73.9 years; 81% were female. Osteoporosis, diagnosed by dual-emission X-ray absorptiometry, was present in 25% of patients. They found that ORIF with locked plates resulted in slightly higher Constant scores. This difference however was clinically and statistically insignificant. Further, with a surgical treatment effect size of 0.2, this difference would be considered trivial. The rate of reoperation due to complications for the ORIF group was 7% at one year and 30% at two years. Finally, they found that PHFs resulted in significant functional impairment and decreased quality of life overall regardless of treatment approach. A third RCT on this topic was undertaken by Fjalestad and colleagues2 comparing ORIF with locked plate to nonoperative treatment for displaced PHF in patients 60 years of age and older. Similar to Olerud et al.1, patients did not regain their preinjury level of function regardless of intervention. They also found that patient-reported outcome measures (PROMs) and health-related quality of life scores were very similar between treatment arms at two-year follow-up. Radiographic outcomes (fracture and implant alignment) favoured ORIF. Radiographic AVN at two years was found in 52% and 60% in the ORIF and nonoperative treatment groups respectively, although most of these cases were asymptomatic. Functional outcomes reached a peak at one year following injury and no further improvements were observed. Overall Fjalestad and colleagues2 found a 35% complication rate in the ORIF group.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 30)

The PROFHER trial6 randomized 250 patients to either surgical intervention (ORIF with locked plate, HA and IMN) to nonoperative treatment for displaced PHF involving the surgical neck in patients 16 years of age and older. Mean patient age was 66 with women representing 77% of the cohort. The most common fracture pattern was a 2-part fracture and the most common surgical intervention was ORIF with a locked plate. They found no statistical or clinically significant differences between groups in PROMs, health-related quality of life, rate of surgical or fracture complications, rate of complications requiring secondary surgery and mortality at two years. However, the only patients who had a medical complication were among those who underwent surgical intervention. At five years, there still was no clinical or statistical differences in PROMs between operative and nonoperative treatment, no patients had secondary surgery for a complication and there was no difference in quality of life overtime between groups7. The most recent RCT was performed by the NITEP group8. They compared ORIF with locked plate with nonoperative treatment for displaced 2-part surgical or anatomical neck PHF in patients 60 years of age and older. A total of 88 patients were randomized to operative treatment in the form of ORIF with a locking plate or nonoperative treatment. The mean age was 72 and 73 for the surgical and nonoperative treatment groups respectively. In both groups, over 85% of patients were female. All fractures involved the surgical neck. Again, no difference in clinical outcomes were seen at two years and peak function was attained by one year after injury regardless of treatment arm. In this study, all patients who developed a complication were from the group of patients who had surgery. A recent Cochrane review9 found high-quality evidence supporting no clinically important difference in PROMs at one or two years between nonoperative treatment and ORIF. This same review found moderate-quality evidence that there is no clinically important difference between these groups regarding quality of life at two years. Furthermore, there was little difference in mortality between groups, slightly favouring nonoperative treatment and there was a higher risk of additional surgery in patients having undergone surgical intervention. This systematic review pointed out that the current evidence does not address 2-part tuberosity fractures, fractures in young patients, high-energy trauma and less common entities such as fracture/dislocations and head splitting fractures. The current evidence is insufficient to guide practitioner’s choices between different nonoperative, surgical or rehabilitation interventions.

delayed healing. The latter two findings may be due to a loss of osteoinductive molecules present in the osteoporotic bone10. However, there is currently no clear answer in the literature whether osteoporosis causes delayed fracture healing10,11. The literature shows significantly higher rates of fixation failure in osteoporotic bone10,11. Surgical fixation is complicated by the poor quality of the available bone stock and inadequate purchase achieved by implants which leads to loss of reduction and fixation failure10. Gorter and colleagues11 conducted a retrospective study to determine whether osteoporosis was responsible for delayed or non-union in PHF and DRF comparing surgical treatment to nonoperative treatment. They found a complication rate, excluding delayed or non-union, of 8.1% for PHF treated nonoperatively, with 3.7% requiring secondary surgery, compared to a complication rate of 28.1% for PHF treated surgically. Radiological delayed or non-union was found in 7.3% of PHF. The incidence of delayed or non-union for PHF reported in the literature varies between 1.1% to 32.4%11. One reason that may explain such a large range in the incidence of delayed and nonunion is that no agreed upon definition of non-union exists for PHF11. Gorter and colleagues11 concluded that osteoporosis did not appear to affect the incidence of delayed or non-union or other complications but appeared to have a trend toward a negative effect. Their study was underpowered to evaluate the effect of osteoporosis on fracture healing. Complications of ORIF Complications of ORIF with locked plate for PHF are relatively high. A prospective multicentre analysis performed by Brunner and colleagues13 found that 9% of complications were related to implants (Figure 1), and 35% of complications were due to other causes. Increasing age was also found to increase the risk of developing a complication. Patients over the age of 60 had nearly a two-fold increase in risk of developing any complication. Patients over the age of 70 had a three-fold increase in risk in developing a plate-related complication. Other complications of ORIF for osteoporotic PHF include varus malunion, AVN, screw cut-out, subacromial impingement and infection14.

Finally, a recent network meta-analysis by Orman and colleagues3 looked at comparing surgical intervention (ORIF with locked plate, HA and rTSA) against nonoperative treatment for 3- and 4-part PHF. When comparing nonoperative treatment to ORIF, the former was not inferior and had lower rates of additional surgery and adverse events. Osteoporosis and Failure of Fixation Osteoporosis is a metabolic bone disorder which causes a loss of bone density and compromises the bone microarchitecture leading to bone fragility and an increased risk of fracture10. With advancing age, a decrease in the capacity for fracture healing has also been noted10. In animal models, weaker fracture calluses in the elderly have been shown, as well as impaired and

Figure 1 The most common complication of proximal humeral locking plates is screw cut-out. COA Bulletin ACO - Summer / Été 2020

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 31)

The available evidence has not demonstrated any benefit in functional outcomes following ORIF versus nonoperative treatment for osteoporotic PHF regardless of fracture severity. However, there is a higher risk of more serious complications in patients who undergo ORIF of PHF when compared to those who have nonoperative treatment. Despite this, rates of surgical intervention on osteoporotic PHF continue to rise. Recent literature appears to favour reverse shoulder arthroplasty (RSA) over ORIF for 3-and 4-part osteoporotic PHF in terms of functional outcomes3,15. However, complication rates of RSA remain higher than those associated with nonoperative treatment15. Future studies should focus on comparing different fixation techniques and implants as well as comparing ORIF with arthroplasty. The PROFHER-2 trial16 is currently underway and is expected to end in May 2023 with the aim of comparing PROMs between nonoperative treatment, hemiarthroplasty and RSA in cases of 3- and 4-part PHF in patients over 65 years of age.

7. Handoll H.H., Keding A., Corbacho B., Brealey S.D., Hewitt C., Rangan A. Five-year follow-up results of the PROFHER trial comparing operative and non-operative treatment of adults with a displaced fracture of the proximal humerus. Bone Joint J. 2017;99-B(3):383-392. doi:10.1302/0301-620X.99B3. BJJ-2016-1028

Until further data is available however, ORIF of closed Neer 3-and 4-part osteoporotic PHF, excluding isolated greater tuberosity fractures, fracture-dislocations and head splitting fractures, in patients over 65 years of age is not justified by current evidence.

10. Giannoudis P., Tzioupis C., Almalki T., Buckley R. Fracture healing in osteoporotic fractures: is it really different? A basic science perspective. Injury. 2007;38 Suppl 1:S90-S99. doi:10.1016/j.injury.2007.02.014

References 1. Olerud P., Ahrengart L., Ponzer S., Saving J., Tidermark J. Internal fixation versus nonoperative treatment of displaced 3-part proximal humeral fractures in elderly patients: a randomized controlled trial. J Shoulder Elbow Surg. 2011;20(5):747-755. doi:10.1016/j.jse.2010.12.018 2. Fjalestad T., Hole M.Ø. Displaced proximal humeral fractures: operative versus non-operative treatment--a 2-year extension of a randomized controlled trial. Eur J Orthop Surg Traumatol. 2014;24(7):1067-1073. doi:10.1007/s00590013-1403-y 3. Orman S., Mohamadi A., Serino J., et al. Comparison of surgical and non-surgical treatments for 3- and 4-part proximal humerus fractures: A network meta-analysis. Shoulder Elbow. 2020;12(2):99-108. doi:10.1177/1758573219831506 4. Sears, Benjamin W. MD; Hatzidakis, Armodios M. MD; Johnston, Peter S. MD Intramedullary Fixation for Proximal Humeral Fractures, Journal of the American Academy of Orthopaedic Surgeons: May 1, 2020 - Volume 28 - Issue 9 - p e374-e383. doi: 10.5435/JAAOS-D-18-00360 5. Zyto K., Ahrengart L., Sperber A., Törnkvist H. Treatment of displaced proximal humeral fractures in elderly patients. J Bone Joint Surg Br. 1997;79(3):412-417. doi:10.1302/0301620x.79b3.7419 6. Rangan A., Handoll H., Brealey S., et al. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA. 2015;313(10):1037-1047. doi:10.1001/jama.2015.1629

COA Bulletin ACO - Summer / Été 2020

8. Launonen A.P., Sumrein B.O., Reito A., et al. Operative versus non-operative treatment for 2-part proximal humerus fracture: A multicenter randomized controlled trial. PLoS Med. 2019;16(7):e1002855. Published 2019 Jul 18. doi:10.1371/ journal.pmed.1002855 9. Handoll H.H., Brorson S. Interventions for treating proximal humeral fractures in adults. Cochrane Database Syst Rev. 2015;(11):CD000434. Published 2015 Nov 11. doi:10.1002/14651858.CD000434.pub4

11. Gorter E.A., Gerretsen B.M., Krijnen P., Appelman-Dijkstra N.M., Schipper I.B. Does osteoporosis affect the healing of subcapital humerus and distal radius fractures?. J Orthop. 2020;22:237-241. Published 2020 May 6. doi:10.1016/j. jor.2020.05.004 12. WHO Scientific Group on the Assessment of Osteoporosis at Primary Health Care Level Summary Meeting Report; 2004. http://www.who.int/chp/topics/Osteoporosis.pdf. Accessed July 28, 2020 13. Brunner F., Sommer C., Bahrs C., et al. Open reduction and internal fixation of proximal humerus fractures using a proximal humeral locked plate: a prospective multicenter analysis. J Orthop Trauma. 2009;23(3):163-172. doi:10.1097/ BOT.0b013e3181920e5b 14. Stone M.A., Namdari S. Surgical Considerations in the Treatment of Osteoporotic Proximal Humerus Fractures. Orthop Clin North Am. 2019;50(2):223-231. doi:10.1016/j. ocl.2018.10.005 15. Chivot M., Lami D., Bizzozero P., Galland A., Argenson J.N. Three- and four-part displaced proximal humeral fractures in patients older than 70 years: reverse shoulder arthroplasty or nonsurgical treatment?. J Shoulder Elbow Surg. 2019;28(2):252-259. doi:10.1016/j.jse.2018.07.019 16. Tharmanathan P. and Arundel C. Effectiveness and costeffectiveness of reverse shoulder arthroplasty versus hemiarthroplasty versus non-surgical care for acute 3 and 4 part fractures of the proximal humerus in patients aged over 65 years – the PROFHER-2 randomised trial, www.isrctn.com/ ISRCTN76296703 (2020, accessed 29 July 2020).

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

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

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

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

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

1) Imaging – up to 5 images

1) Jusqu’à 5 images

2) 500-word case summary including: a) Brief clinical history and diagnosis b) Treatment measures c) Outcomes d) Take-home message

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

3) 5 references maximum

3) Maximum de 5 références

IMPORTANT TIPS FOR CASES!

CONSEILS IMPORTANTS POUR LES CAS!

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

- Une image vaut mille mots; assurez-vous que vos photos sont de grande qualité et nettes. - Soyez concis! Tenez-vous-en aux renseignements les plus importants afin d’illustrer la nature insolite du cas soumis. COA Bulletin ACO - Summer / Été 2020

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

This edition’s case was submitted by Dr. Félix Brassard from Université de Montréal

Stickler and Valgus SCFE Félix Brassard, M.D. Department of Surgery, CHU Sainte-Justine Paediatric Orthopaedic Surgery Université de Montréal Montréal, QC

Treatment Measures Since the area of slippage was not yet healed on CT scan, we decided to place the patient under skeletal femoral traction in attempt to at least partially reduce the SCFE to an acceptable level, where the epiphysis lies minimally within the acetabular cavity.

Clinical History ten-year-old boy presented in the outpatient paediatric orthopaedic clinic for severe debilitating ongoing right hip pain for the past six weeks after a breakdancing injury. Since then, he was unable to mobilize independently due to the high persistent pain, even with crutches, and was wheelchair-bound. The patient was known for Stickler disease, an autosomal dominant genetic disorder associated with hyperlaxity, ophtalmologic anomalies, scoliosis, pectus excavatum, mitral valve prolapse and flat irregular epiphyses.

After five weeks of skeletal traction with weekly plain films, we obtained very minimal improvement of the deformity, and the femoral epiphysis was still completely outside the acetabular cavity. Surgical correction of the deformity and fixation was planned.

Initial plain films (Figure 1) revealed a high-grade slipped capital femoral epiphysis (SCFE). Typically, SCFE will present with the femoral neck metaphysis displaced anteriorly and externally rotated. The epiphysis will then lie posteriorly and in varus. However, in this case, Figure 1 the epiphysis lies in a valgus position, which requires a completely different approach since a percutaneous in situ pinning places the femoral vessels and nerve at great risk. With Stickler disease, this patient naturally has significant coxa valga, thin femoral epiphysis, shallow acetabulum and deficient acetabular coverage of the femoral head. We obtained a computed tomography scan to better understand the displacement of the epiphysis of the right hip. Computed tomography showed a completely dislocated right femoral head laterally and posteriorly. The uncovered femoral neck metaphysis was against the acetabular cartilage (Figures 2 and 3).

Figures 2 & 3 COA Bulletin ACO - Summer / Été 2020

The modified Dunn procedure includes a lateral approach with a greater trochanter osteotomy and hip dislocation with the leg placed in a figure-of-four position. For this patient in particular, the significant coxa valga makes a greater trochanter osteotomy extremely difficult. Also, disuse osteopenia coupled with the stress applied on the proximal femur during the dislocation manoeuver, significantly increases the risk of iatrogenic fracture of the neck or the intertrochanteric area. We opted for an anterior approach since this patient had a very shallow acetabulum and an almost absent anterior acetabular wall. We used a Smith-Peterson approach to anteriorly dislocate the hip. We raised a large periosteal flap leaving the retinacular vessels intact. In order to reduce the epiphysis without tension on the retinacular vessels, we had to shorten the neck almost 1cm, knowing that it would potentially place Figure 4 the hip at risk of further instability (Figure 4.). We fixed the epiphysis with two 7.3mm cannulated screws. The patient’s anatomy made this very challenging since the trajectory of the cannulated screw wires was placing the sciatic nerve at risk of injury. Finally, we closed the capsule with a meticulous capsulorraphy to minimize the effect of femoral neck shortening. Outcomes The initial plan was to keep the patient in traction after the surgery. However, right at the beginning of the procedure, when removing the traction apparatus and prepping the leg, likely due to the disuse osteopenia and knee flexion contracture, the patient sustained a distal femoral fracture that required

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 34)

fixation at the end of the procedure (Figure 5.). He was placed in a custom made HKAFO orthotic instead. The patient was strictly nonweight-bearing initially and was allowed partial weight-bearing at four months with a CT scan showing complete healing of the proximal femur and a bone scan confirming a viable femoral epiphysis. He was allowed to transition to full weight-bearing at seven months postop. Plains films showed limited avascular Figure 5 necrosis and femoral head collapse. Unfortunately, he developed hip adduction contracture and subluxation (Figure 6.). This was then addressed with adductor tenotomy, hip arthrogram and hardware removal. Examination under fluoroscopy reveals a Figure 6 reducible femoral head with abduction (Figures 7 and 8). Therefore, the next step will require a varus derotation osteotomy (VDRO) with acetabular osteotomy to increase coverage of the femoral head.

Figures 7 & 8

Meanwhile, the patient is ambulating without aids, pain-free, with a mild Trendelenburg gait and a 18mm leg length discrepancy. Take Home Message • Valgus-type SCFE are a completely different entity than a regular SCFE. • For SCFE in patients with bone dysplasia, obtaining CT scan is mandatory to better understand the anatomy and the displacement of the femoral epiphysis. • The risk of instability after open reduction and femoral shortening for SCFE should always be considered.

Personalized Joint Replacement: The End of ‘One Size Fits All’ Pascal-André Vendittoli, M.D., MSc, FRCS Hôpital Maisonneuve-Rosemont, Université de Montréal, Department of Surgery Montréal, QC Charles Rivière, M.D., PhD2 The MSK Lab-Imperial College London, South West London Elective Orthopaedic Centre United Kingdom

ip and knee replacements are very successful procedures; however, non-negligible rates of residual symptoms, poor joint perception, and complications remain. Unsatisfactory clinical outcomes are primarily the consequence of poor, unnatural prosthetic joint biomechanics that arise from the more or less adequate execution of a suboptimal, nonphysiological surgical technique. Interestingly, recent advances in both material and design of prosthetic components, as well as precise technologically-assisted implantation, have not been game-changers. This may be due to the fact that gold-

standard techniques for implanting hip and knee components aim to implant all patients similarly (i.e. one size fits all), thus neglecting the unique joint anatomy and kinematics of each individual. Systematic techniques for joint replacement, such as the Lewinneck safe zone for THA acetabular orientation, or mechanical alignment for TKA, were originally devised COA Bulletin ACO - Summer / Été 2020

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

for simplifying implantation, making it more reliable in the surgeons’ hands. Since the initial worldwide spread of these systematic techniques in the 70s’, the world of arthroplasty has dramatically progressed. Surgeons have become much more specialized, often fellowship-trained, with the aim of being an expert of a single joint (hip or knee) or type of procedure (joint replacement). Implant designs have become much more sophisticated; hardwearing material, available in various shapes, sizes and with high modularity, resulting in a more anatomical fit overall. Finally, accuracy and precision of implantation have significantly improved through the use of pre- or intra-operative three-dimensional dynamic planning and intra-operative assistive technological tools (e.g. computed or robotic-assisted surgery, patient-specific cutting guides), respectively. These changes in practice over the last few decades, combined with recent evidence highlighting the detrimental clinical effect of neglecting individual joint anatomy and kinematics, have led to the development of a more personalized philosophy for arthroplasty1-3. With talent, expertise, and technological support, there is no doubt that a ‘Personalized & À la Carte’ philosophy for replacing joints will play a significant role in our future. The quest for the forgotten joint is our ultimate goal. Drs. Rivière and Vendittoli gathered a group of experts in the field to write The Personalized Hip and Knee Joint Replacement book (open access link: https://link.springer.com/book/10.1007/978-3-030-24243-5). The first of its kind, this book has been written to highlight the paradigm shift from systematic to personalized surgery. It is a practical manual for the practicing or training orthopaedic surgeon, treating patients with hip and knee disorders, who intends to personalize the implantation of prosthetic components in order to achieve an optimal outcome for every patient. A description of personalized surgical techniques and

Personalized Hip and Knee Joint Replacement Charles Rivière Pascal-André Vendittoli Editors

component designs that aim to preserve the unique individual joint anatomy and kinematics, as well as the rationale behind these, are provided in detail. The technological tools that enable precise and accurate personalized implantations are also described. We hope this book will pave the way for a significant philosophy change in orthopaedic practice and highlight the potentially deleterious clinical effects of homogeneous, simplistic surgical practices that are currently pushed by some public and private organisations. Continuing on this train of thought, we came to the decision to create an International Society named the ‘Personalized Arthroplasty Society (PAS)’, which will lead the paradigm shift from systematic to personalized surgery (www.personalizedarthroplasty.com). The objectives of the Society are: • To improve the profile of the ‘Personalized Arthroplasty’ philosophy, through publications (research articles and textbooks) and educational events such as congresses and workshops • To foster networking, information sharing, mentoring, career opportunities, leadership training, and professional development in the field of ‘Personalized Arthroplasty’ • To standardize the teaching of ‘Personalized Arthroplasty’ through textbooks, educational events (annual congress, workshops), and fellowship travel tour • To support the assessment & refinement of ‘Personalized Arthroplasty’: Support audit/research projects on personalized arthroplasty We welcome membership applications and are looking forward to building new strong scientific and personal relations.

References 1. Rivière C., Vigdorchik J.M., Vendittoli P.A. Mechanical alignment: The end of an era!. Orthopaedics & traumatology, surgery & research: OTSR. 2019 Nov;105:1223. 2. Dorr L.D., Callaghan J.J. Death of the Lewinnek “Safe Zone”. The Journal of arthroplasty. 2019 Jan 1;34:1-2. 3. Rivière C., Lazic S., Villet L., Wiart Y., Allwood S.M., Cobb J. Kinematic alignment technique for total hip and knee arthroplasty: the personalized implant positioning surgery. EFORT open reviews. 2018 Mar;3:98-105.

123 COA Bulletin ACO - Summer / Été 2020

INJECT UP TO 244% MORE IMPLANT STABILITY 1,2

(In a biomechanical study comparing augmented and non-augmented constructs)

Introducing the new TRAUMACEM™ V+ Augmentation System: The first and only intramedullary nail system that has specific indications for augmentation with PMMA cement, allowing surgeons to inject a controlled amount of cement into the femoral head in patients with poor bone quality, reducing the risk of cut-out. +Demonstrated resistance to cut-out: Augmented head elements have up to a 244% increase in resistance to cut-out in biomechanical testing.1,2 +Enhanced surgical flexibility: Sterile packed design allows for intra-operative decision to inject augmentation, after head element placement, in at-risk patients. +Published clinical results: 0 cut-outs and no unexpected head element migration observed in three prospective multicenter trials when using augmentation.3,4,5 Disclaimer: Bench test results may not be indicative of clinical performance.

For use exclusively with the ®

References: 1. DePuy Synthes test data on file, Windchill 0000268245. 2. Hofmann L, Zderic I, Hagen J, Agarwal Y, Scherrer S, Weber A, Altmann M, Windolf M, Gueorguiev B. Biomechanical effect of bone cement augmentation on the fixation strength of TFNA blades and screws. Presented at 22nd Congress of the European Society of Biomechanics. 10-13 July 2016. Lyon, France. 3. Kammerlander C, Gebhard F, Meier C, et al. Standardised cement augmentation of the PFNA using a perforated blade: A new technique and preliminary clinical results. A prospective multicentre trial. Injury. 2011;42(12):1484-1490. 4. Kammerlander C, Doshi H, Gebhard F, Scola A, Meier C, Linhart W, Garcia-Alonso M, Nistal J, Blauth M (2014). Long-term results of the augmented PFNA: a prospective multicenter trial. Arch Orthop Trauma Surg 134(3):343-9. 5. Kammerlander C, et al.Cement Augmentation of the Proximal Femoral Nail Anti-Rotation (PFNA) - A multi-centre randomized controlled trial, Injury (2018), http://doi.org/10.2016/j.injury.2018.04.022.

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

In Development of a New COA Gender Diversity Task Force into the task will enhance the work of this advocacy initiative and bring new ideas, one of the benefits of diversity.

Laurie Hiemstra, M.D., Phd, FRCSC 2nd President Elect, COA Executive Committee Banff, AB

n recent years, gender diversity has been identified as a priority within the Canadian Orthopaedic Association. The goal of this initiative is to develop, cultivate, implement, and support an inclusive culture that maximizes the talent, skill, and diversity of Canadian orthopaedics. Over the last two years, measures have been taken to advance this purpose at the COA Annual Meeting, including instructional course lectures on implicit bias, mentorship, leadership, resilience, and physician wellness. Improved representation of women on the podium at the Annual Meeting was another priority and a study assessing these efforts was published in an International Journal. An official diversity and inclusion position statement is available on the COA web site and a gender diversity strategic plan has been developed to advance this work over the next five years. Diversity, equity, and inclusion initiatives are vital – but ultimately, culture change is necessary to ensure that diversity is woven into all aspects of our work as physicians and as members of the COA. Until this culture change is achieved, dedicated and concerted efforts toward improving equity and inclusion for women and all minorities must continue in order close the gap for those who remain disadvantaged. Currently, the most conspicuous of these inequities in orthopaedics is regarding gender. Improving female representation in our Association requires creating a culture of equity and inclusivity. By engaging female members and providing equal opportunities, the COA can remove the systematic disadvantages that have existed for women in a male-dominated profession. The COA Gender Diversity Task Force was established in early 2020 with a two-year mandate to accomplish a set of finite tasks that would advance the gender diversity strategic plan. Thirtyone members answered a call for interest. They included residents, fellows, and early and late career surgeons, from across the country, including eight men. With such robust interest, we divided into groups to accomplish these assignments. Bringing new minds and hands COA Bulletin ACO - Summer / Été 2020

One goal of the Task Force was to accomplish some finite tasks that were outlined within the Strategic Plan. • Cultivate a rich environment to promote female leaders within the COA and Canada • Oversee and grow a robust mentorship program within the COA and in Canada • Advocate for and promote physician wellness and quality of life • Create a database of gender-specific position statements as a resource for members and an opportunity to identify data gaps A second goal was to establish and expand relationships with other organizations that influence our orthopaedic specialty in Canada with the goal of working together to enhance equity and inclusion.

Recommended Twitter Hashtags #womeninortho #diversityandinclusion #womeninmedicine #needherscience #womenleadership #gendergap #lookslikeasurgeon #genderequality #diversitymatters #Heforshe Task Force Members (in no particular order) 1. Laurie Hiemstra 17. Michelle Ghert 2. Kristen Barton 18. Joyce Fu 3. Chloe Cadieux 19. John Theodoropoulous 4. Joy MacDermid 20. Jesse Shantz 5. Olivia Cheng 21. Kevin Hildebrand 6. Veronica Wadey 22. Linda Mrkonjic 7. Tiffany Lung 23. Victoria Avram 8. Meaghan Rollins 24. Alexandra Bunting 9. Erin Boyton 25. Henry Broekhuyse 10. Ruth Chaytor 26. Marie Gdalevitch 11. Kelly LaFaivre 27. Amelia Suddaby 12. Mike Dunbar 28. Kelly Hynes 13. Stephanie Atkinson 29. Gwyneth DeVries 14. Colm McCarthy 30. Jeff Poon 15. Jeremy Reed 31. Theresa Li 16. Patricia LaRouche 32. Katherine Cabrejo-Jones

• Collaborate with CARMS and the Universities to explore opportunities to encourage residency selection to be more equitable and to push for national standards for residency positions • Communicate with Canadian orthopaedic programs to explore opportunities to influence Fellowship selection to be more equitable and to push for national standards for post graduate positions • Explore where partnerships with provincial organizations can be strengthened with regards to equity and inclusion The final goal was to look to the future and what data might be necessary to both understand and act on gender inequities. • Identify data gaps in Canadian orthopaedics to determine the feasibility of filling these gaps with quality research that is realistic and logical to support the advancement of equity and inclusion When improvements are made for one minority group, all minority groups can potentially benefit. Although the goals of this Task Force are largely focussed on gender inequities, many of these items cross-over into other minorities, both visible and invisible.

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

Création d’un nouveau groupe de travail sur la diversité des sexes de l’ACO Laurie Hiemstra, MD, Ph.D., FRCSC Deuxième présidente élue, Comité de direction de l’ACO Banff (Alberta)

es dernières années, l’Association Canadienne d’Orthopédie (ACO) a fait de la diversité des sexes un enjeu prioritaire. Cette initiative a pour objet de créer, nourrir, mettre en œuvre et soutenir une culture inclusive qui maximise le talent, la compétence et la diversité au sein de la communauté orthopédique canadienne. Depuis deux ans, des mesures ont été prises afin de concrétiser cet objectif à la Réunion annuelle de l’ACO, y compris par la présentation de conférences d’enseignement sur le biais implicite, le mentorat, le leadership, la résilience et le bien-être des médecins. Une autre priorité était l’amélioration de la représentation des femmes au podium à la Réunion annuelle, et une étude évaluant ces efforts a été publiée dans une revue internationale. Un énoncé de position officiel sur la diversité et l’inclusion est accessible sur le site Web de l’ACO, et un plan stratégique en matière de diversité des sexes a été conçu en vue de poursuivre ce travail au cours des cinq prochaines années. Les initiatives en matière de diversité, d’équité et d’inclusion sont essentielles, mais au bout du compte, un changement de culture est nécessaire pour s’assurer que la diversité fait partie intégrante de tous les aspects de notre travail en tant que médecins et membres de l’ACO. Jusqu’à ce que ce changement de culture ait lieu, il faut continuer de déployer des efforts sérieux et concertés afin d’accroître l’équité et l’inclusion des femmes et de toutes les minorités de sorte à réduire les disparités pour les personnes qui restent désavantagées. Actuellement, la disparité la plus flagrante dans le milieu de l’orthopédie est celle fondée sur le sexe. L’amélioration de la représentation des femmes au sein de notre association nécessite la création d’une culture d’équité et d’inclusivité. En favorisant la participation des femmes membres et l’égalité des chances, l’ACO peut supprimer les désavantages systémiques pour les femmes dans une profession à prédominance masculine. Le Groupe de travail sur la diversité des sexes de l’ACO a été créé au début de 2020, fort d’un mandat de deux ans axé sur une série de tâches établies afin de concrétiser le plan stratégique en matière de diversité des sexes. Trente et un membres ont répondu à l’appel d’intérêt; parmi eux, des résidents, des fellows et des orthopédistes en début et en fin de carrière de tout le pays, y compris huit

hommes. Vu cette réponse enthousiaste, nous nous sommes divisés en équipes afin d’accomplir ces tâches. Cet apport de sang neuf permettra d’améliorer le travail réalisé dans le cadre de cette initiative de défense des droits et intérêts et d’apporter de nouvelles idées, l’un des avantages de la diversité. L’un des objectifs du Groupe de travail était d’accomplir certaines tâches établies dans le Plan stratégique : • Cultiver un milieu riche afin de promouvoir les femmes leaders au sein de l’ACO et au Canada. • Superviser et développer un programme de mentorat solide au sein de l’ACO et au Canada. • Promouvoir le bien-être des médecins et leur qualité de vie. • Créer une banque de données des énoncés de position selon le sexe comme ressource pour les membres et occasion de cerner les lacunes dans les données. Un deuxième objectif consistait à établir et accroître les relations avec d’autres organisations influençant notre profession au Canada, dans le but de travailler avec elles à améliorer l’équité et l’inclusion :

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Membres du Groupe de travail (dans le désordre) : 1. Laurie Hiemstra 17. Michelle Ghert 2. Kristen Barton 18. Joyce Fu 3. Chloe Cadieux 19. John Theodoropoulous 4. Joy MacDermid 20. Jesse Shantz 5. Olivia Cheng 21. Kevin Hildebrand 6. Veronica Wadey 22. Linda Mrkonjic 7. Tiffany Lung 23. Victoria Avram 8. Meaghan Rollins 24. Alexandra Bunting 9. Erin Boyton 25. Henry Broekhuyse 10. Ruth Chaytor 26. Marie Gdalevitch 11. Kelly LaFaivre 27. Amelia Suddaby 12. Mike Dunbar 28. Kelly Hynes 13. Stephanie Atkinson 29. Gwyneth DeVries 14. Colm McCarthy 30. Jeff Poon 15. Jeremy Reed 31. Theresa Li 16. Patricia LaRouche 32. Katherine Cabrejo-Jones

• Collaborer avec les responsables du CaRMS et des universités dans l’exploration des possibilités de rendre la sélection des résidences plus équitable et de faire pression pour la création de normes nationales pour les places en résidence. • Communiquer avec les responsables des programmes d’orthopédie canadiens afin d’étudier les possibilités d’influencer la sélection des fellowships de sorte qu’elle soit plus équitable et de faire pression pour la création de normes nationales pour les postes postdoctoraux. • Explorer les possibilités de renforcement des partenariats avec les organisations provinciales en ce qui a trait à l’équité et à l’inclusion. Le dernier objectif était d’envisager l’avenir et les données qui pourraient être nécessaires pour comprendre les disparités fondées sur le sexe et agir en conséquence : • Cerner les lacunes dans les données touchant la communauté orthopédique canadienne afin d’établir la faisabilité de les combler grâce à des recherches de qualité, réalistes et logiques de sorte à soutenir l’amélioration de l’équité et de l’inclusion. Quand des améliorations sont apportées pour un groupe minoritaire, tous les groupes minoritaires peuvent en bénéficier. Même si les objectifs du Groupe de travail sont en grande partie axés sur les disparités fondées sur le sexe, beaucoup s’appliquent également à d’autres minorités, visibles ou non. COA Bulletin ACO - Summer / Été 2020

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Foundation / Fondation

The COA Basic Science Course: Introducing a New Resident’s Scholarship

r. Thomas Smallman is an orthopaedic surgeon with a passion for understanding the basic science of the human body in general, and of the musculoskeletal system in particular. This understanding, he believes, helps to build a solid base for a surgical career. On the 18th of January 1987 on a snowy, bitter-cold day, Tom presented the idea of offering a basic science course for residents to the Program Directors of the COA, then assembled in Montréal as the Training and Education Committee, chaired by Garth Johnson. The Committee agreed, and the Basic Science Course (BSC) was born. Emerson Brooks from McGill University was named Co-Chairman, sharing responsibility for ten years with Tom, who was the Head of Orthopaedics for the Canadian Armed Forces and a member of the Canadian Orthopaedic Association. The founding of the BSC was multi-faceted: a core intellectual idea; a career-changing educational experience; the idea that the COA could partner with the health-care industry to support a national course available to all Canadian residents; and enthusiastic support from interested Canadian educators. The eureka moment for Tom was becoming aware of the core concept: that understanding is fostered by correlating clinical, radiologic and pathologic data. In 1982, during a six-week elective at the Armed Forces Institute of Pathology (AFIP) in Washington, DC, Tom interacted with Lent Johnson, Don Sweet, and Bruce Ragsdale, who had long-been advocates of this approach. This was such an intellectual awakening for Tom that it motivated him to seek a mechanism to emulate the one-week course the AFIP provided for the American military. Such an endeavour would require funding, and the support of the COA. Zimmer Canada, an industry leader, had supported resident education by underwriting the annual Canadian Orthopaedic Resident Association Annual Meeting for years. Tom approached first the CEO from Zimmer, and then Howmedica (now Stryker) and both promised start-up funding. This was the essential starting point for a partnership between the BSC and the health-care industry that has expanded and continues to this day. It seemed that with funding in place, the decision by the COA to proceed was a given. From the beginning, the two most important elements sustaining the course were a high quality, committed faculty, and the requirement to have consistent participant evaluation of each course followed by the will to act on appropriate suggestions for ongoing improvement. There are simply too many Canadian names to list, but Cy Frank’s participation and ongoing support for the BSC must be mentioned. The link to the faculty of the now-closed AFIP continues to this day. Dr. John Murnaghan, a trained educator, with oversight for the evaluation process, is responsible in large measure for the high quality of the course as an educational product. Tom appreciates now his perseverance in following the principle “less is more”.

The BSC is not an exam preparation course. The goal is to provide the trainee with a solid set of information on which to base thought processes for the task of solving clinical problems throughout his or her subsequent career. The COA Executive has established the BSC as a COA Training Course, responsible to the Committee of Professional Development for the provision of this educational resource. While uncertainty prevails in the COVID pandemic, the Course will continue to evolve with the leadership of a committed Board, Educational Team and skilled Faculty. This fall the traditional in-person Basic Science Course, scheduled to support the careers of Canadian orthopaedic surgeons for the 33rd year, has been cancelled, and the First Virtual Basic Science Course will take place, hopefully as a temporary measure. To mark the occasion and in tribute to Tom’s commitment, the Board of the Basic Science Course has funded an annual basic science scholarship of $1000, launching in 2020 through the Canadian Orthopaedic Foundation. Dr. Pierre Guy, President and Chair of the Board of the Canadian Orthopaedic Foundation and himself a graduate of the course, says “I personally benefited from attending the Basic Science Course as a trainee. Through it, I better understood the physiological processes and mechanisms that underpin both disease, repair and recovery in our field. It made me look at MSK conditions with a different lens and, truthfully, made me a better orthopedic surgeon. I keep going back to foundational principles taught at the course in my practice, to this day. This course must be seen as an essential supplement to the curriculum. By anchoring clinical knowledge into science, the course prepares residents to think through clinical scenarios for their exams, and importantly for real life practice. We are fortunate to have this course available in Canada. I encourage all residents to attend and all Program Directors to support their trainees’ attendance.” The COF is inviting applications for the Basic Science Course Scholarship. Find details here.

COA Bulletin ACO - Summer / Été 2020

Foundation / Fondation

Cours annuel de science fondamentale de l’ACO : Nouvelle bourse pour les résidents

e Dr Thomas Smallman est un orthopédiste passionné par la compréhension de la science fondamentale du corps humain en général, et de l’appareil locomoteur en particulier. Selon lui, cette compréhension contribue à jeter une bonne base pour une carrière en chirurgie. Le 18 janvier 1987, par une journée neigeuse et glaciale, Tom présentait l’idée d’offrir un cours de science fondamentale à l’intention des résidents aux directeurs de programme de l’ACO, réunis à Montréal dans le cadre d’une réunion du comité de formation, présidé par Garth Johnson. Le comité a approuvé l’idée, et le cours annuel de science fondamentale est né. Emerson Brooks, de l’Université McGill, a été nommé coprésident du cours, responsabilité qu’il a partagée pendant 10 ans avec Tom, alors chef de l’orthopédie au sein des Forces armées canadiennes et membre de l’ACO. La création du cours comprenait plusieurs volets : une idée fondamentalement intellectuelle; une expérience de formation ayant une incidence sur une carrière; l’idée que l’ACO pouvait conclure un partenariat avec l’industrie des soins de santé de sorte à soutenir un cours national à l’intention de tous les résidents canadiens; et un soutien enthousiaste de la part de formateurs canadiens intéressés. L’éclair de génie est venu à Tom en prenant conscience du concept fondamental, c’est-à-dire que la corrélation entre les données cliniques, radiologiques et pathologiques favorise la compréhension. En 1982, au cours d’un stage optionnel de six semaines à l’Institut de pathologie des forces armées (AFIP) à Washington, DC, Tom interagissait avec Lent Johnson, Don Sweet et Bruce Ragsdale, qui défendaient cette approche depuis longtemps déjà. Cet éveil intellectuel l’a motivé à chercher un mécanisme d’émulation du cours d’une semaine que l’AFIP offrait aux militaires américains. Une telle initiative nécessiterait des fonds, et le soutien de l’ACO. Zimmer Canada, chef de file de l’industrie, soutenait déjà la formation des résidents, par l’intermédiaire de la Réunion annuelle de l’Association canadienne des résidents en orthopédie, depuis des années. Tom a d’abord approché le président-directeur général de Zimmer, puis de Howmedica (aujourd’hui Stryker), qui ont tous deux promis des fonds de démarrage. Ce fut le point de départ essentiel d’un partenariat, qui ne cesse de prendre de l’expansion depuis, entre les responsables du cours et l’industrie des soins de santé. Ces fonds sécurisés, la décision de l’ACO d’aller de l’avant coulait de source. Depuis le début, les deux éléments les plus importants en faveur du cours étaient la présence de formateurs hautement qualifiés et engagés, ainsi que la nécessité de procéder à une évaluation constante de chaque cours par les participants, combinée à une volonté de répondre aux suggestions appropriées pour en assurer l’amélioration continue. Il y a beaucoup trop de noms canadiens pour les citer tous, mais le soutien continu et la participation de Cy Frank doivent être soulignés. COA Bulletin ACO - Summer / Été 2020

L’association avec les formateurs du défunt AFIP se poursuit de nos jours. Le Dr John Murnaghan, formateur qualifié supervisant le processus d’évaluation, est responsable en grande partie de la grande qualité de ce produit de formation. Tom apprécie maintenant son insistance sur le principe selon lequel « le moins vaut le plus ». Le cours annuel de science fondamentale n’est pas un cours de préparation aux examens; il a pour but de fournir aux participants un ensemble d’information solide sur lequel fonder leur réflexion lorsqu’ils devront résoudre des problèmes cliniques tout le long de leur carrière. La direction de l’ACO en a fait un de ses cours de formation, dont la prestation relève du Comité de perfectionnement professionnel. Bien que l’incertitude règne en raison de la pandémie de COVID-19, le cours continuera d’évoluer grâce au leadership et à l’engagement de son conseil, de son équipe de formation et de ses formateurs qualifiés. Cet automne, le cours traditionnel, qui devait nourrir la carrière d’orthopédistes canadiens pour la trente-troisième année, a été annulé et remplacé par le premier cours virtuel de science fondamentale, une mesure que nous espérons temporaire. Afin de souligner l’occasion, et en hommage à l’engagement de Tom, le conseil du cours finance une bourse du cours annuel de science fondamentale de 1 000 $, lancée en 2020 par l’intermédiaire de la Fondation Canadienne d’Orthopédie (FCO). Le Dr Pierre Guy, président du conseil d’administration de la FCO et lui-même ancien participant au cours, témoigne : « J’ai personnellement profité de ma participation au cours annuel de science fondamentale lorsque j’étais résident. Grâce au cours, j’ai amélioré ma compréhension des processus et mécanismes physiologiques à la base des maladies, des réparations et du rétablissement dans notre domaine. Il m’a fait voir les troubles de l’appareil locomoteur sous un autre jour, et j’en suis honnêtement un meilleur orthopédiste. Encore aujourd’hui, je continue de retourner aux principes fondamentaux qui m’ont été enseignés lors du cours dans ma pratique. Ce cours doit être considéré comme un supplément essentiel au programme de formation. En ancrant les connaissances cliniques dans la science, le cours prépare les résidents à évaluer les situations cliniques dans leurs examens et, plus important encore, dans leur pratique. Nous avons de la chance d’avoir accès à ce cours au Canada. J’invite tous les résidents à y assister, et tous les directeurs de programme à favoriser leur participation. » La FCO accepte les candidatures pour la Bourse du cours annuel de science fondamentale. Pour les détails, cliquez ici.

Foundation / Fondation

COF Awards First CSES Research Grant

he Canadian Orthopaedic Foundation proudly introduced a new research award this year, in collaboration with the Canadian Shoulder and Elbow Society (CSES). The CSES Research Grant was established to support and encourage orthopaedic surgeons to conduct collaborative shoulder or elbow research. The first award recipient was announced during the virtual COA Meeting in June: Dr. Danny Goel, University of British Columbia, Vancouver, BC. Dr. Goel’s project is titled “Immersive Virtual Reality Effectiveness in Orthopaedic Education: A Randomized Controlled Trial.” Here, he explains the project: Immersive virtual reality (iVR) is at the forefront of surgical simulation in orthopaedic surgery. This technology allows the user to combine high-fidelity audiovisuals with sense of touch, or haptics, in a simulated operating room environment. Portability, cost-effectiveness, and design principles rooted in behavioral science concepts of deliberate practice provide theoretic benefits in learning using iVR systems. Evidence previously provided by our research group and CSES shows that iVR provides rapid, efficient learning with demonstrable transfer of skills to realistic operating room scenarios. Traditional training structures such as the use of cadavers lack evidence despite widespread use. Our goal is to characterize patterns of learning to produce more competent and proficient surgeons. To achieve this end, the value of iVR in teaching complex surgical skills must continue to be studied. The funding provided by the COF and CSES will allow for continued protocols to rigorously validate iVR compared to other traditional learning methods. We will be completing a randomized controlled study of orthopaedic trainees to directly compare the learning effects of iVR compared to training on cadavers. This has never been performed and could signal a paradigm shift in thinking in surgical education towards enhancing or perhaps reducing the need for costly cadaver-based laboratories. Effective use of iVR technology in transferable motor skills will also be studied. The current generation of iVR allows for haptic feedback and will be used to assess how well it can teach basic orthopaedic skills to novices compared to other currently available products. We may see this as seminal research changing the structure of orthopaedic training around the world. The COF and CSES look forward to seeing the outcomes of the research project.

La FCO remet sa première bourse de recherche de la CSES

ette année, la Fondation Canadienne d’Orthopédie (FCO) a eu l’immense plaisir de lancer une nouvelle bourse de recherche, en partenariat avec la Société canadienne de l’épaule et du coude (CSES). La Bourse de recherche de la CSES a été créée afin de soutenir les orthopédistes et de les inciter à mener des recherches concertées sur l’épaule ou le coude. Le premier lauréat de la bourse a été annoncé en juin, pendant la Réunion annuelle virtuelle de l’ACO : il s’agit du Dr Danny Goel, de l’Université de la Colombie-Britannique, à Vancouver. Le projet de recherche du Dr Goel a pour titre Immersive Virtual Reality Effectiveness in Orthopaedic Education: A Randomized Controlled Trial. Il explique son projet : La réalité virtuelle immersive (RVI) est à la fine pointe de la simulation chirurgicale en orthopédie. Cette technologie permet à son utilisateur de combiner un audiovisuel de haute fidélité et les perceptions tactiles, ou l’haptique, dans une salle d’opération simulée. Les principes de portabilité, de rentabilité et de conception enracinés dans les concepts de science comportementale liés à la pratique délibérée constituent des avantages théorétiques dans l’apprentissage par systèmes de RVI. Les données probantes précédemment fournies par notre équipe de recherche et la CSES montrent que la RVI permet un apprentissage rapide et efficace, avec un transfert de compétences démontrable aux situations chirurgicales réalistes. Les structures de formation traditionnelles, comme le recours aux laboratoires d’anatomie, ne sont pas appuyées par des données probantes suffisantes, malgré leur usage répandu. Nous avons pour objectif de caractériser les tendances d’apprentissage de sorte à produire des chirurgiens plus compétents. À cette fin, il faut continuer d’étudier la valeur de la RVI dans l’enseignement de compétences chirurgicales complexes. Le financement octroyé par la FCO et la CSES permettra l’application continue de protocoles afin de valider avec rigueur l’usage de la RVI comparativement à des méthodes d’enseignement traditionnelles. Nous effectuerons un essai aléatoire auprès de résidents et fellows en orthopédie de sorte à comparer directement les effets de la RVI et des laboratoires d’anatomie sur l’apprentissage. Une telle étude est inédite, et pourrait marquer un changement de paradigme en enseignement de la chirurgie, vers l’amélioration voire la réduction des coûteux laboratoires d’anatomie. On étudiera en outre l’usage efficace de la RVI pour les compétences motrices transférables. La génération actuelle de systèmes de RVI permet une rétroaction haptique et servira à évaluer son efficacité dans l’enseignement aux novices des compétences de base en orthopédie, comparativement à d’autres produits actuellement disponibles. Nous pourrions voir cela comme la recherche fondamentale qui change la structure de la formation en orthopédie dans le monde. La FCO et la CSES ont hâte de voir les résultats de ce projet de recherche. COA Bulletin ACO - Summer / Été 2020

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

COVID-19 Pandemic: Impact on Orthopaedic Surgery Iain McPhee, MDCM (cand), MSc1 Carl Laverdiére, MDCM (cand), BEng1 Susan Ge, MDCM, MSc (cand)2 Jason Corban, MDCM, HBSc2 Emilie Sandman, M.D., MSc, FRCSC3 Paul Andre Martineau, MDCM, HBSc, FRCSC, ABOS, SCOSM2 1. Faculty of Medicine, McGill University, Montréal, QC 2. Division of Orthopaedic Surgery, McGill University Health Centre, Montréal, QC 3. Division of Orthopaedic Surgery, Université de Montréal, Montréal, QC

n March 11th, 2020 the Severe Acute Respiratory Syndrome coronavirus 2 (SARS-COV-2), causing an illness commonly known as COVID-19, was declared a pandemic by the World Health Organization1. Within a week of this announcement, the majority of Canada’s provinces made the decision to put all non-essential care and elective surgeries on hold in an effort to free up hospital beds for those with COVID-19. As a result of this decision, orthopaedic surgical practice in Canada was significantly impacted. It is estimated that 1, 196, 372 (525, 886– 2, 813, 418) orthopaedic operations were cancelled in North America over the 12-week period of peak COVID-19 disruptions2. Additionally, many clinic appointments for new consults and follow-ups were cancelled, postponed, or held remotely. With cancellations and changes in practice of this scale, we are left wondering what impact COVID-19 will have on the practice of orthopaedic surgery. Presented below are the results of our nation-wide survey that was disseminated in June and July 2020 to Canadian Orthopaedic Association (COA) members via the COA Dispatch, website and directly by e-mail, along with members of the Quebec Orthopaedic Association (QOA), who were contacted directly via e-mail. We assessed the impact of COVID-19, as perceived by orthopaedic surgeons, fellows, and residents across Canada. Overall, we had a total of 236 respondents (204 staff and 32 fellows/ residents) (Table 1). The survey questions aimed to characterize perceived impact on orthopaedic practice, education and career opportunities of orthopaedic residents, the health and wellbeing of orthopaedic surgeons, and most importantly, the long-term outcomes of their patients. Practice COVID-19 has had a considerable impact on orthopaedic practice in Canada, with 72.5% of staff reporting a decrease in trauma patients overall (Figure 1). This finding, which has also been reported in other countries3,4, could be due to both federal and provincial government encouragement of the “stay home, and stay safe” measure in an effort to flatten the curve of COVID-19 spread. Furthermore, resource re-allocation leading to delays in urgent procedures and the postponement of elective surgery likely had an even greater effect on surgical practice. This is reflected by the 96.6%, 91.7% and 61.3% of orthopaedic staff reporting a decrease in operating room time, clinic access and nursing resources, respectively (Figure 2). Decreased operating and clinic time have led many staff to use alternative means to communicate with patients, such as

Table 1: Respondent Demographics

Staff

DEMOGRAPHICS

Sex N M 155 F 46 Other/Non-Binary 3 Years in practice 0-2 years 18 3-5 years 39 6-10 years 35 11-20 years 51 >20 years 61 Scope of Practice Full time academic staff 95 Part time academic staff 10 Full time community staff 95 Part time community staff 8 Private 5 Not currently employed 2 Other 2 Location of practice Quebec 111 Ontario 41 Alberta 17 BC 14 Saskatchewan 5 Nova Scotia 5 New Brunswick 4 Newfoundland 2 Manitoba 1 Prince Edward Island 1 Outside of Canada 3

% 76.0% 22.5% 1.5% 8.8% 19.1% 17.2% 25.0% 29.9% 46.6% 4.9% 46.6% 3.9% 2.5% 1.0% 1.0% 54.4% 20.1% 8.3% 6.9% 2.5% 2.5% 2.0% 1.0% 0.5% 0.5% 1.5%

Resident Sex N % M 20 62.5% F 12 37.5% Other/Non-Binary 0 0.0% Level of Training R1 4 12.5% R2 4 12.5% R3 6 18.8% R4 4 12.5% R5 3 9.4% Fellow 11 34.4% Location of practice Quebec 19 59.4% Ontario 5 15.6% Alberta 1 3.1% British Columbia 1 3.1% Saskatchewan 2 6.3% Nova Scotia 1 3.1% New Brunswick 0 0.0% Newfoundland 0 0.0% Manitoba 1 3.1% Prince Edward Island 0 0.0% Outside Canada 2 6.3%

Figure 1 Patient Demographics.

COA Bulletin ACO - Summer / Été 2020

Training & Practice Management / Formation et gestion dâ&#x20AC;&#x2122;une pratique (continued from page 45)

phone and telemedicine follow-ups. 69.6% of staff respondents reported using telemedicine, however out of these users, only 49.5% of staff reported their experience as being [moderately effective] or better (Figure 3).

Table 3: Fellow/Resident- Future Impact

Do you anticipate the COVID-19 pandemic having an impact on your graduation/licencing/fellowship/job prospects? Yes No Unsure

11 11 10

34.4% 34.4% 31.3%

Figure 2 Pandemic Effect on Access to Resources. Figure 4 Resident Training.

Figure 3 Use of Telemedicine.

Fellow and Resident Education Due to the pandemic, physicians across various specialties have been re-deployed to COVID-19-related tasks. At the time of the survey, the majority (78.1%) of fellows and resident respondents had not been re-deployed as a result of the pandemic (Table 2). Although most orthopaedic fellows and residents have previous experience using electronic textbooks, journal articles, and surgical videos, the COVID-19 pandemic appears to have led to an expansion in the use of virtual teaching methods: 87.5% of fellow and resident respondents stated that their education format has changed to be virtual-based (Figure 4). When asked whether they felt the pandemic will affect their graduation, licencing, and job prospects, fellows and residents were almost exactly split with 34.4% saying yes and no respectively, and 31.3% saying they are unsure (Table 3).

Health and Wellbeing The majority of staff respondents (63.7%) are [somewhat stressed] or more, about the pandemic (Figure 5), with a majority (50.5%) of respondents saying that the pandemic has affected their health and wellness (Figure 6). Similarly, most residents and fellows (56.3%) felt [somewhat stressed] or more about the pandemic (Figure 7), with 53.1% reporting that the pandemic has affected their health and wellness (Figure 8). Survey respondents who felt the pandemic affected their health and wellness were qualified to elaborate via written response. Written responses varied with some reporting increased stress and anxiety, reduced fitness and sleep, while others reported the opposite. 78.1% of fellows and resident respondents felt that their medical education office had provided them with support during the pandemic (Figure 9), while staff did not perceive the same level of support (Figure 10). Whether due to decreased work, restricted resources, or stress from the pandemic, 65.7% of staff reported that the pandemic has affected their standard of living (Figure 11).

Table 2: Fellow/Resident Redeployment

In the context of the pandemic, are you being redeployed to another department/specialty? Yes No Not yet, but I have been told this is coming COA Bulletin ACO - Summer / Ă&#x2030;tĂŠ 2020

4 25 3

12.5% 78.1% 9.4%

Figure 5 Staff Stress.

Training & Practice Management / Formation et gestion d’une pratique (continued from page 46)

Figure 6 Staff Health and Wellness.

Figure 9 Resident Support.

Figure 7 Resident Stress.

Figure 10 Staff Support.

Figure 8 Resident Health and Wellness.

Figure 11 Staff Standard of Living. COA Bulletin ACO - Summer / Été 2020

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

(continued from page 47)

Long-Term Outcomes When asked how concerned they were about the COVID-19 pandemic impact on their patients’ long-term outcomes, the majority of staff (75.5%) felt [somewhat concerned] or more (Figure 12). Of those who chose to elaborate on this impact via written response, almost all surgeons were concerned that patients will experience surgical delays with increased wait times, on already long wait times compared to international standards5, as well as reduced access to physiotherapy.

capacity, further discussion is needed to determine the most efficient and effective way to move forward in addressing the backlog of surgeries that were postponed while also preparing for a purported second wave of COVID-19, should that occur. Only then can we ensure that the tens of thousands of patients who require restorative surgery are treated as soon as possible. We would like to thank the COA and QOA readers and association members for their participation in this survey. In doing so, we were able to capture perspective on the impacts of this pandemic on orthopaedic surgery in Canada. References 1. Astuti I., Ysrafil. Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2): An overview of viral structure and host response. Diabetes Metab Syndr. 2020;14(4):407412. doi:10.1016/j.dsx.2020.04.020 2. COVIDSurg Collaborative. Elective surgery cancellations due to the COVID-19 pandemic: global predictive modelling to inform surgical recovery plans. Br J Surg. 2020. doi:10.1002/ bjs.11746.

Figure 12 Concern of Patient Long-Term Outcomes.

Based on the responses of this survey, it is clear that the COVID19 pandemic has had an apparent and significant impact on the practice of orthopaedic surgery in Canada. Large scale postponement of surgeries brought the practice to a grinding halt, leaving surgeons, fellows, residents, and patients hanging in the balance. Telemedicine and virtual learning were encouraged and now, may very well become a staple of orthopaedic training and clinical practice for the long term. The impacts on standard of living, health and wellbeing are substantial, with many stating they experienced increased stress and anxiety. As provinces continue to reopen through various deconfinement strategies and our health-care system returns to its full

Have You Applied? The 2021 ABC Fellowship Deadline is Fast Approaching!

3. Park C., Sugand K., Nathwani D., Bhattacharya R., Sarraf K.M. Impact of the COVID-19 pandemic on orthopedic trauma workload in a London level 1 trauma center: the “golden month”. Acta Orthop. 2020;1-6. doi:10.1080/17453674.2020 .1783621. 4. Wong, J., Cheung, K. Impact of COVID-19 on Orthopaedic and Trauma Service. J Bone Joint Surg Am. 2020; 102(14):e80. doi:10.2106/JBJS.20.00775 5. Viberg N., Forsberg B., Borowitz M., Molin R. International comparisons of waiting times in health care – Limitations and prospects. Health Policy. 2013;112(1-2):53-61. doi. org/10.1016/j.healthpol.2013.06.013

Avez-vous postulé? La date limite des bourses ABC 2021 approche!

reminder to all COA members that the 2021 ABC Tour application deadline has been extended to October 1, 2020. Need inspiration? Read Drs. Sukhdeep Dulai and Ruby Grewal’s experience on the 2019 tour here. The 2021 application form is accessible here and you can contact Lexie Bilhete via e-mail with any questions. In light of COVID-19, any changes or adjustments made to the 2021 tour will be updated to the COA web site. Thank you for your understanding during this time.

COA Bulletin ACO - Summer / Été 2020

N 2019 ABC Fellows at Worcester College in Oxford. COA Fellows : Drs. Sukhdeep Dulai and Ruby Grewal. Boursiers ABC 2019 au Worcester College d’Oxford. Boursiers de l’ACO: Dres Sukhdeep Dulai and Ruby Grewal.

’oubliez pas que la date limite de soumission des candidatures pour la Bourse de voyage américano-britanno-canadienne (ABC) 2021 est reportée au 1er octobre 2020. Vous avez besoin d’inspiration? Lisez le journal de la tournée des Dres Sukhdeep Dulai et Ruby Grewal, en 2019. Remplissez le Formulaire de demande 2021, et n’hésitez pas à écrire à Lexie Bilhete si vous avez des questions. Si des changements ou ajustements sont apportés à la tournée 2021 en raison de la COVID-19, ils seront publiés sur le site Web de l’ACO. Nous vous remercions pour votre compréhension.

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

Canadian Perspectives

n this feature, COA members currently working outside of the country share their insight on various differences they’ve realized working in the United States (US) or abroad in comparison to their orthopaedic training in Canada. These experiences highlight the perspectives of the COA’s growing number of members now working outside of Canada.

Canadian Perspectives: Patient Experience or Customer Satisfaction? Krista A. Goulding, M.D., FRCSC, M.P.H. Assistant Professor of Orthopaedics, Mayo Clinic College of Medicine Mayo Clinic-Arizona Phoenix, AZ Affiliate Member, McGill University Health Centre McGill University Department of Surgery, Division of Orthopaedic Surgery Montreal General Hospital Montréal, QC

he following quote on the wall greets me as I enter the hospital each morning: “The best interest of the patient is the only interest to be considered” (William Mayo, 1910). A change in career path brought me back to Mayo Clinic-Arizona, where I completed an orthopaedic oncology fellowship in 2014, after nearly four years in academic practice in Montréal. Since my return to the United States (U.S.), I have noticed several cross-border discrepancies in practice, the most striking being the focus on the patient experience. This attention to patient-centeredness has many faces: an interactive and patient-facing electronic medical record (EMR), an office of patient experience (OPE) which encourages patient feedback, physician communication skills training and patient experience surveys, to name a few. Having completed much of my career and training in Canada, apart from fellowships in the U.S. and in the United Kingdom, I have not been accustomed to this type of routine patient feedback. However, in my experience working in an academic orthopaedic oncology practice in the U.S., I find that our institutional efforts to intentionally incorporate the patient experience in practice improvement efforts leads to innovation and quality improvement in care provision. Patient satisfaction does not always correlate with better care; indeed, it is associated with higher expenditures and increased mortality1. Patient feedback can be a source of stress for individual practitioners who may have differing practice styles, practice complexity and organizational structures2,3. As such, organizations have grappled with best practices in incorporating patient reported outcomes measures in delivery of care. Nevertheless, measurement of patient experience through practice surveys (Press Ganey Associates Inc.) has become routine across the care continuum in the U.S. Hospitals are incentivized to publicly report survey scores due, in part, to Centres

for Medicare and Medicaid Service requirements and reimbursement under value-based purchasing4. There is mounting evidence that patient experience is linked to health outcomes. The Institute of Medicine recognizes patient experience as a key objective to improve health-care delivery5. Patient-centered care is predicated upon improving patient experience, ameliorating health outcomes and health-care cost reduction6. Communication, partnership and health promotion are at the heart of patient-centeredness2. Multiple studies support the association between relationship-centered communication skills training of physicians and increased patient safety, medication adherence and improved outcomes, not to mention physician satisfaction, improved empathy, self-efficacy and burnout4,6-15. Since my transition to Arizona in 2018, I have been involved in several didactic and small group-based training sessions focused on communication skills and leadership, as part of the standard hiring process and continuing medical education. Routine professional practice evaluations, based on patient experience surveys, provide me with information on my performance from the patients’ viewpoint, prioritizing issues that matter most to patients. This allows me to identify areas with highest potential for practice improvement. While one can easily focus on a small number of negative comments or dismiss feedback, what is more helpful is viewing this feedback as an opportunity for personal and organizational improvement. Concern for the patient experience is not, of course, U.S.centric17,18. Care equity is undoubtedly an on-going issue in this system in general. However, I have been impressed with the pace of innovation and institutional change rooted in patientcenteredness that can occur in a competitive marketplace in my experience at Mayo Clinic over the last two years. The near immediate roll-out of remote EMR video visits during the start of the COVID-19 pandemic while the out-patient practice was paused is a good example of this capacity to pivot. Leveraging EMR tools to respond to patient questions, disseminate results rapidly and provide educational material in the ambulatory setting has improved communication and patient experience COA Bulletin ACO - Summer / Été 2020

Training & Practice Management / Formation et gestion d’une pratique (continued from page 49)

in my sarcoma practice, made possible with dedicated expertise in nursing, physician assistant, sarcoma patient navigator and others. Patient experience and satisfaction have indeed been associated with organizational factors such as increased staff-to-physician ratio and job satisfaction among health-care providers2,17,19. Compared to my experience working north of the border, attention to each component of the in-patient or ambulatory journey feels very deliberate in the business model; for instance, connecting to patients prior to their appointment to better understand goals; alerts, medical information and questionnaires embedded in mobile applications; continual improvement in workflows, standardizing (warm) handoffs between patient and scheduling staff, and customized education follow-up care instructions. Hospitals in the US definitely seem to leverage resources to accomplish these goals.

8. Brock D.M., Mauksch L.B., Witteborn S,. Hummel J., Nagasawa P., Robins L.S. Effectiveness of intensive physician training in upfront agenda setting. J Gen Intern Med. 2011;26(11):1317–23.

I have been very fortunate to train in Canada, and even more fortunate to have worked as an orthopaedic oncologist for both the Canadian and American health-care systems alongside excellent mentors, partners and collaborators. My experience is based solely on working in one system in the U.S and of course is not generalizable to every hospital or private practice. Lessons I have learned are that neither system is perfect but that we can certainly learn from one another. Embracing patient experiences and feedback at an individual and institutional level are necessary growing pains that can enhance physician satisfaction and improve quality in a value-based healthcare system in alignment with patient values and preferences.

11. Mazor K.M., Beard R.L., Alexander G.L., Arora N.K., Firneno C., Gaglio B., et al. Patients’ and family members’ views on patient-centered communication during cancer care. Psycho-Oncology. 2013;22(11):2487–95. doi:10.1002/ pon.3317.

References

13. Stewart M., Brown J.B., Donner A., McWhinney I.R., Oates J., Weston W.W., et al. The impact of patient-centered care on outcomes. J Fam Pract. 2000;49(9):796–804.

1. Fenton J.J., Jerant A.F., Bertakis K.D., Franks P. The cost of satisfaction: a national study of patient satisfaction, health care utilization, expenditures, and mortality. Arch Intern Med. 2012;172(5): 405-411. 2. Philpot L.M., Khokhar B.A., DeZutter M.A., Loftus C.G., Stehr H.I., Ramar P., Madson L.P., Ebbert J.O. Creation of a PatientCentered Journey Map to Improve the Patient Experience: A Mixed Methods Approach. Mayo Clin Proc Innov Qual Outcomes. 2019 Sep 24;3(4):466-475. doi: 10.1016/j.mayocpiqo.2019.07.004. PMID: 31993565; PMCID: PMC6978601. 3. Berkowitz B. The patient experience and patient satisfaction: measurement of a complex dynamic. Online J Issues Nurs. 2016;21(1):1. 4. Boissy A, Windover A.K., Bokar D. et al. Communication skills training for physicians improves patient satisfaction. J Gen Intern Med 2016 Jul; 31(7): 755-761. 5. Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: The National Academies Press; 2001. 6. Constand M.K., MacDermid J.C., Dal Bello-Haas V., Law M. Scoping review of patient-centered care approaches in healthcare. BMC Health Serv Res. 2014;14:271. 7. Marvel M.K., Epstein R.M., Flowers K., Beckman H.B. Soliciting the patient’s agenda: have we improved? JAMA. 1999;281(3):283–7. COA Bulletin ACO - Summer / Été 2020

9. Mauksch L.B., Dugdale D.C., Dodson S., Epstein R. Relationship, communication, and efficiency in the medical encounter: creating a clinical model from a literature review. Arch Intern Med. 2008;168(13):1387–95. doi:10.1001/ archinte.168.13.1387. 10. Abraham N.S., Naik A.D., Street R.L. Jr. Shared decision making in GI clinic to improve patient adherence. Clin Gastroenterol Hepatol: Off Clin Pract J Am Gastroenterol Assoc. 2012;10(8):825–7. doi:10.1016/j.cgh.2012.06.001.

12. Robinson J.D., Hoover D.R., Venetis M.K., Kearney T.J., Street R.L. Jr. Consultations between patients with breast cancer and surgeons: a pathway from patient-centered communication to reduced hopelessness. J Clin Oncol: Off J Am Soc Clin Oncol. 2013;31(3):351–8. doi:10.1200/ JCO.2012.44.2699.

14. Stewart M., Brown J.B., Hammerton J., Donner A., Gavin A., Holliday R.L., et al. Improving communication between doctors and breast cancer patients. Ann Fam Med. 2007;5(5):387–94. 15. Roter D.L., Hall J.A., Kern E, Barker L.R., Cole K.A., Roca R.P. Improving physicians’ interviewing skills and reducing patients’ emotional distress. A randomized clinical trial. Arch Intern Med. 1995;155(17):1877–84. 16. Kelley J.M., Kraft-Todd G., Schapira L., Kossowsky J., Riess H. The Influence of the patient-clinician relationship on healthcare outcomes: a systematic review and meta-analysis of randomized controlled trials. PLoS One. 2014;9(4):e94207. doi:10.1371/journal.pone.0094207. 17. Flott K., Darzi A., Mayer E. Care pathway and organisational features driving patient experience: statistical analysis of large NHS datasets. BMJ Open. 2018;8(7):e020411. 18. Lobo Prabhu K., Cleghorn M.C., Elnahas A,. et al. Is quality important to our patients? the relationship between surgical outcomes and patient satisfaction. BMJ Qual Saf. 2018; 27(1):48-52. 19. Perzynski A.T., Caron A., Margolius D., Sudano J.J. Primary care practice workplace social capital: a potential secret sauce for improved staff well-being and patient experience. J Patient Exp. 2019;6(1):72-80.

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

The Effect of COVID-19 Closures on Orthopaedic Sport Medicine Patients: Insights from Banff Sport Medicine Michaela Kopka, M.D., FRCSC Laurie Hiemstra, M.D., PhD, FRCSC Julie-Anne Fritz PhD Sarah Kerslake, MSc, PT Banff Sport Medicine Foundation Banff, AB

he coronavirus (COVID-19) outbreak was first described in Wuhan, Hubei, China in December 2019, and was declared a global pandemic by the World Health Organization on March 11, 2020. In response, the Government of Canada initiated a nationwide lockdown that resulted in the cancellation of restorative orthopaedic surgeries as well as supportive healthcare services such as physiotherapy. The Banff Sport Medicine Foundation sought to assess the impacts of COVID-19 closures on patients via questionnaires targeting two patient populations at the Banff Sport Medicine clinic: 1) Patients who had their surgeries postponed (n=269), and 2) Patients who were up to three-months postoperative (n=476).

• 85.5% of feelings expressed by patients about the postponement of their surgery were negative (Figure 1) Negative feelings described: anxious, stressed, angry, concerned, frustrated, lost, annoyed, irritable, resigned, disappointed, useless, depressed, down. Positive feelings described: empowered, positive, motivated, grateful, happy. Effects on the ability of patients to return to work and other activities • 62.6% of patients indicated that postponement of their surgery has, or will, negatively affect their ability to return to work (Figure 2) • 90.4% of patients indicated there are, or will be, negative effects on their ability to return to sport and leisure activities (Figure 3)

The surveys were designed as Quality Assurance assessments, predominately using a 7-point Likert Scale for the responses. The EQ-5D was also included as a measure of generic health status. Completed surveys were submitted by 42.8% of the postponed surgery group and 41.6% of the acute postoperative group. Descriptive statistics were used to analyze the data. How have COVID-19 closures affected patients waiting for orthopaedic surgery? More than 90% of patients were between the ages of 18 to 64 years (94.8%). The most common three postponed surgical procedures were anterior cruciate ligament (ACL) reconstruction, shoulder stabilization and knee arthroscopy for meniscal injury. Effects on physical & emotional health Figure 1 • 87.8% of patients were Feelings expressed by patients that able to stay physically had their surgery postponed. active • 68.7% indicated the delay in surgery negatively impacted their physical health • 75.7% of patients experienced pain because of their injury during the COVID-19 closures • 51.1% indicated their pain increased, while 41.5% of patients indicated that their pain stayed the same • 41.7% stated that their symptoms increased in severity

Quotes from patients that indicated their delayed surgery will negatively affect their return to work: “If I am scheduled in the coming months, then it will affect my ability to do field work in the summer months.” “Will be able to return to work but I will be in pain and have trouble rescheduling surgery due to the financial strain of being off for COVID and then off for surgery.” “I am unable to work in my field until I recover from surgery.” Figure 2 Survey Q. To what extent has the postponement of your surgery affected (or will affect) your ability to return to work? Please specify why in “Other”. COA Bulletin ACO - Summer / Été 2020

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

(continued from page 51)

Figure 4 EQ-5D VAS Health State indicated by patients that had their surgery postponed.

Quotes from patients that indicated their delayed surgery will negatively affect their return to sport / leisure activities: “I cannot do the same activities at the same intensity levels as before... especially as my symptoms continue to worsen.” “My mobility is compromised in movements of my knee.” “I cannot participate in any of the outdoor activities I love and it’s making me depressed.” Figure 3 Survey Q. To what extent has the postponement of your surgery affected (or will affect) your ability to return to your sport/leisure activities? Please specify why in “Other”.

During COVID-related shutdowns, most patients relied on resources provided by Banff Sport Medicine for support • 85.2% of patients said they used the prehabilitation exercises provided by Banff Sport Medicine • 39.1% of patients accessed additional support that included physiotherapy, their surgeon, other health-care professionals, and online exercise and educational materials

How have patients who underwent orthopaedic surgery within three-months of the COVID-19 closures been affected? More than half of the respondents (55.1%) were between the ages of 25 and 44. The most common surgical procedures included ACL reconstruction, patellar stabilization, and knee arthroscopy. Effects on physical & emotional health • 43.4% of patients perceived their recovery was behind due to COVID-19 closures, with 69.7% of patients responding that they were worried that closures have negatively affected their recovery in some way • 70% of feelings expressed by patients about the lack of postoperative care and follow-up were negative (Figure 5) Negative feelings described: anxious, stressed, angry, concerned, frustrated, lost, worried, disappointed, uncertain, alone, nervous, not accountable, less motivated, unable to return to work. Positive feelings described: empowered, positive, motivated, grateful, happy.

Figure 5 Feelings expressed by patients following orthopaedic surgery.

Based on the EQ-5D, patients in the postponed surgery group predominately reported having problems with performing their usual activities, and experiencing symptoms of pain/discomfort (Table 1), while indicating their overall health state was good (Figure 4)

Table 1. EQ-5D-3L frequencies reported by dimension and level of problem for patients that had their surgery delayed

No problems

MOBILITY N (%) 58 (50.4)

SELF-CARE N (%) 106 (92.2)

USUAL ACTIVITIES N (%) 39 (33.9)

PAIN / DISCOMFORT N (%) 20 (17.4)

ANXIETY / DEPRESSION N (%) 62 (53.9)

Any problems

57 (49.6)

9 (7.8)

76 (66.1)

95 (82.6)

50 (46.1)

Total

115 (100)

COA Bulletin ACO - Summer / Été 2020

Training & Practice Management / Formation et gestion d’une pratique (continued from page 52)

Most patients were satisfied with virtual follow-up with their surgeon • 39.9% of patients had a virtual consult with their surgeon. Of these, 46.8% were within one-month postoperative when COVID-19 closures were initiated • Of the patients that had a virtual consult with their surgeon, 67.8% perceived it to be helpful in some way (Figure 6) • 37.9% of patients perceived the lack of surgical follow-up negatively impacted their recovery

Quotes from patients regarding perceived barriers to their recovery: “Not being able to meet with the surgeon in person to ask questions/be examined.” “Lack of access to gyms to complete physio program.” “Just having someone to visually make sure doing exercises proper and along right schedule and time line. As well, lack of equipment available at home vs physio office.” Figure 7 Survey Q. What, if any, barriers to your recovery have you encountered during this time? Check all that apply.

Quotes from patients that indicated they found virtual contact with their surgeon helpful in some way*: “Hearing only, what is needed to be done (exercise/stretching/activity/ limits) is less effective than seeing and hearing and doing.” “Definitely answered questions but can’t replace in person.” “It was nice to hear to reaffirm that I was on the right track, but I don’t really feel like it helped me in any way.”

Most patients accessed a variety of resources to support them during COVID-related shutdowns • 84.5% of patients accessed a variety of resources that included physiotherapy, their surgeon, other healthcare professionals (e.g. GP), and freely available on-line resources (Figure 8) • 86.9% of patients followed the Banff Sport Medicine rehabilitation protocol, with 92.9% being able to complete these recommended exercises at home • 60.4% of ACL reconstruction patients indicated that the emailed videos of their rehabilitation exercises were helpful

Figure 6 Survey Q. How helpful have you found virtual contact with your surgeon? Please specify why in “other”. *None of the patients that responded with “unhelpful” chose to comment.

Lack of access to physiotherapy was identified as a significant barrier to recovery • 64.1% of patients indicated that limited access to physiotherapy due to COVID-related shutdowns was a barrier to their recovery (Figure 7) • 73.2% stated that lack of in-person physiotherapy has negatively impacted their recovery • 41.4% had a virtual consult with a physiotherapist, with 42.9% indicating that the visit was helpful

Figure 8 Survey Q. What sources of support or resources have you accessed to help you during your recovery? Check all that apply. COA Bulletin ACO - Summer / Été 2020

Training & Practice Management / Formation et gestion dâ&#x20AC;&#x2122;une pratique

(continued from page 53)

Based on the EQ-5D, postoperative patients reported problems with performing their usual activities and experiencing symptoms of pain / discomfort (Table 2), while indicating their overall health state was good (Figure 9) Table 2. EQ-5D-3L frequencies reported by dimension and level of problem reported by post-operative patients

No problems

MOBILITY N (%) 142 (71.7)

SELF-CARE N (%) 182 (91.9)

USUAL ACTIVITIES N (%) 87 (43.9)

PAIN / DISCOMFORT N (%) 45 (22.7)

ANXIETY / DEPRESSION N (%) 129 (65.2)

Any problems

56 (28.3)

16 (8.1)

111 (56.1)

153 (77.3)

69 (34.8)

Total

198 (100)

Figure 9 EQ-5D VAS Health State reported by postoperative patients.

Discussion This is the first study in Canada to investigate the impact of COVID19-related health-care closures on orthopaedic sport medicine and arthroscopy patients. Patients whose restorative surgeries were postponed, as well as those in their early postoperative period (<3 months) were asked a series of questions pertaining to their physical and emotional health, barriers to recovery, and access to resources. The findings of this study revealed that, in both groups, the COVID19-related closures had an overall negative impact on physical and emotional health and resulted in significant barriers for accessing necessary care. Patients whose surgical procedures were postponed due to COVID19 indicated that they experienced physical pain due to their injury, and nearly half (41.7%) stated that their symptoms increased as a result of the health-care closures. This finding is particularly concerning as sport medicine and arthroscopy patients are generally healthy and high-functioning individuals who form an integral part of the work force. The fact that these types of injuries result in significant physical dysfunction highlights the importance of timely and appropriate management of these patients. Another important finding was that 62.6% of postponed patients felt that delaying their surgery would have a negative effect on their ability to return to work. This underscores the impact of restorative surgeries on quality of life and the overall societal burden of disease.

COA Bulletin ACO - Summer / Ă&#x2030;tĂŠ 2020

The majority (69.7%) of patients who were in their early postoperative period described a negative impact on their recovery as a result of the COVID19-related health-care closures. Inability to access hands-on physiotherapy was the most significant barrier reported. Despite efforts by physiotherapy clinics to offer virtual visits, only 41.4% of patients were able to access this service, and of these patients only 42.9% found them to be helpful. Postoperative rehabilitation is an essential component of a successful and timely recovery following restorative surgery. Without access to hands-on care, patients are at risk of complications including swelling, stiffness, and weakness. These complications can contribute to a prolonged recovery and, in some cases, to additional surgical interventions. Accordingly, limited access to physiotherapy (particularly during the critical, early stages of recovery) can contribute to poor outcomes and increased health-care costs1. With respect to virtual orthopaedic care, this study demonstrated that although 67.8% of postoperative patients found it to be beneficial, the majority stated that it did not replace an in-person visit. This underscores the value of a hands-on assessment and in-person contact to answer patient questions and provide guidance on the course of recovery. In the setting of restorative orthopaedic surgery, virtual care may be viewed as an adjunct or alternative in select scenarios, but based on the information obtained in this survey, likely cannot replace in-person visits. In summary, this study highlighted the significant impact of COVID19-related health-care closures on pre and postoperative sport medicine and arthroscopy orthopaedic surgery patients. The findings clearly demonstrated that restorative procedures play an important role in restoring physical and emotional health, as well as returning individuals to work and leisure activities. The study also revealed that virtual care does not adequately replace the hands-on assessments of allied care and orthopaedic specialists. As the health care system begins to reopen, it will be important to ensure that patients awaiting restorative procedures are triaged appropriately in order to reduce both the individual and societal burden of disease. References 1. Jack K., McLean S.M., Moffett J.K., Gardiner E. Barriers to treatment adherence in physiotherapy outpatient clinics: a systematic review. Manual therapy 2010;15:220-8.

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

Upcoming COA/CORS/CORA Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO 2021

2022

2023

2024

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June 8-11 juin

June 21-24 juin

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

CORA Meeting Réunion de l’ACRO June 8 juin Québec City, QC

CORA Meeting Réunion de l’ACRO June 21 juin Calgary, AB

CORA Meeting Réunion de l’ACRO June 12 juin Halifax, NS

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COA Bulletin ACO - Summer / Été 2020

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COA Bulletin #127 - Summer 2020

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BULLETIN Summer Été 2020