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

BULLETIN

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Fall Automne 2020

PAIN DOESN’T WAIT, EVEN WHILE YOU DO. #FastTrackCare

Learn more about the COA’s latest advocacy campaign through Mobilize Canada on page 36.

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LA DOULEUR N’ATTEND PAS, MÊME SI VOUS ATTENDEZ. #SoinsLaVoieRapide

Détails sur la dernière campagne de défense des droits et intérêts de l’ACO par l’intermédiaire de Mobilize Canada, à la page 36.

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Publication Mail Envoi Poste-publication Convention #40026541

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

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Nous sommes passés en mode virtuel – Avons-nous été à la hauteur?. . . . . . . . . . . . . . . . . . . . . . . . . 11 The Use of Platelet-rich Plasma and Stem Cells in Orthopaedic Surgery.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 CIHI Report: Early Revisions of Hip and Knee Replacements in Canada.. . . . . . . . . . . . . . . . . . . . . . . 33 Reimagining Musculoskeketal Care in Edmonton: The Edmonton MSK Campus. . . . . . . . . . . . . . . . . . . . . . . . . 39

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Your COA / Votre association

Bulletin Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 128 - Fall / Automne 2020 COA / ACO 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.

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To Reconnect, We Must Begin with a Single Step Mohit Bhandari, M.D., FRCSC President, Canadian Orthopaedic Association

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ith a second wave of cases of the SARS-CoV2 infection sweeping across Canada [189,000 cases in Canada as of October 14th, 2020] and over 2000 cases daily, we still need to stay connected. But how? My original plan for the ReCOAnnect Tour was, indeed, to travel across the country and meet surgeons in all communities. We revised this approach mid-year to consider virtual town halls. However, the transition to virtual communications has left us all fatigued and quite frankly, somewhat less engaged. So, here’s the dilemma; nothing replaces the face-to-face interaction, yet meaningful interactions are highly challenged with large group virtual webinar and meeting formats. Our solution has found a middle ground. Following the belief that “Thinking Big means Going Small” we have confirmed a number of a small group discussions with surgeons. In honour and celebration of the COA’s 75th anniversary this year, I wanted to begin our national ReCOAnnect 2020 tour in the province of Québec. The rising second wave of cases in Québec and Ontario have necessitated virtual small group discussions in lieu of the originally planned face-to-face meetings. With strong collaboration from the current president of l’Association d’Orthopédie du Québec, my friend and colleague, Dr. Jean-François Joncas, we’ve road mapped a series of small group meetings across the province. Surgeons working in community sectors don’t often have the same opportunity to interact with association leadership on a one to one level. To be an association that represents all surgeons of diverse practice settings, we must change our practices to encourage greater inclusivity and appreciate the power of our diversity. To this end, we thought we would come to them for a change! What’s the purpose of this ‘virtual visit’? Is there an agenda? Simply put, no. I spend my visits listening, sharing perspectives, and going wherever the discussions lead. Here’s the point; there is no “cookie-cutter” approach to solving issues at a national level. If anything, I’ve learned that every surgeon, every institution, and every province has unique – and important - concerns that need to addressed with equally specific 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 - Fall / Automne 2020


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actions. Having had the privilege to discuss issues with a number of surgeons in Quebec, and the honour of addressing the Assemblée générale annuelle of l’Association d’orthopédie du Québec (September 24, 2020), I am committed to action. The truth is, surgeons across Quebec, (and similarly across Canada), are feeling the devastating impact of the last several months on their lives and practices. We need to reconnect, we need to share our stories, and we need find solutions together. I’m delighted to share that our Québec meetings launched with the surgeons of Lakeshore General Hospital in Pointe-Claire, Québec. Of note, Québec also has a long history of surgeon leaders who have served as president of the COA. We will continue meetings across Québec through November and will hold a past-president’s meeting as our finale.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 21 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 36 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 43

Friends and colleagues, this is just the beginning of meaningful cross-country tour. But everything must begin with its first step.

Il suffit d’un petit geste pour rétablir le contact Mohit Bhandari, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

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ne deuxième vague d’infections au SARS-CoV-2 déferle sur le Canada [189 000 cas au 14 octobre 2020] avec plus de 2 000 cas quotidiens, et nous devons malgré tout rester en contact. Mais comment faire? À l’origine, je souhaitais voyager partout au pays et rencontrer les orthopédistes de toutes les collectivités dans le cadre de la tournée RACOnnectons-nous. Après six mois, nous avons toutefois revu cette approche au profit de réunions virtuelles. Cette transition vers des communications virtuelles nous a par contre laissé épuisés et, bien franchement, un peu moins motivés. Le problème est le suivant  : rien ne vaut l’interaction en personne, mais nous devons plutôt avoir des interactions positives dans le cadre d’un webinaire ou d’autres formes de réunions virtuelles en grands groupes. Nous avons donc opté pour un compromis. Convaincus que «  Voir grand, c’est faire petit », nous avons convenu de tenir diverses discussions en petits groupes avec des orthopédistes. Pour souligner le 75e  anniversaire de l’ACO, j’ai commencé la tournée nationale  RACOnnectons-nous 2020 au Québec. L’arrivée d’une deuxième vague au Québec et en Ontario a imposé la tenue de discussions virtuelles en petits groupes plutôt que des réunions en personne qui étaient prévues. Grâce à la collaboration étroite du président de l’Association d’orthopédie du Québec, mon ami et collègue le Dr Jean-François Joncas, nous avons établi les grandes lignes d’une série des réunions en petits groupes partout dans la province. Les orthopédistes exerçant en milieu communautaire n’ont pas souvent l’occasion d’interagir directement avec la direction des associations.  Si nous voulons être une association qui représente tous les orthopédistes des divers milieux d’exercice, nous devons changer nos pratiques de sorte à favoriser une plus grande inclusion et reconnaître toute la force de notre diversité. À cette fin, nous avons décidé d’aller à leur rencontre, pour une fois!

COA Bulletin ACO - Fall / Automne 2020

Discussions avec des chirurgiens de l’Hôpital général du Lakeshore, à Pointe-Claire, Québec dans la cadre du project rACOnnections-nous.

Quel est le but de ces « visites virtuelles  »? Y avait-il y un ordre du jour? Essentiellement, non. Je consacre mes visites à l’écoute, à l’échange de points de vue, et me laisser guider par le cours des discussions. À vrai dire, il n’y a pas d’approche universelle à la résolution des problèmes à l’échelle nationale. Si j’ai appris quelque chose, c’est que chaque orthopédiste, chaque établissement et chaque province ont des préoccupations uniques – et importantes – pour lesquelles il faut prendre des mesures tout aussi précises. Après avoir eu le privilège


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de discuter de diverses questions avec des orthopédistes du Québec et de m’adresser à l’Assemblée générale annuelle de l’Association d’orthopédie du Québec (24 septembre  2020), je suis déterminé à agir. Le fait est que des orthopédistes de partout au Québec (mais aussi de partout ailleurs au pays) vivent les répercussions dévastatrices des derniers mois, tant sur le plan personnel que professionnel. Nous devons rétablir le contact, échanger nos histoires, et nous devons trouver des solutions ensemble.

Je suis ravi de vous informer que nos réunions au Québec ont commencé avec les orthopédistes de l’Hôpital général du Lakeshore, à Pointe-Claire. Il convient de signaler que le Québec a aussi une longue tradition de leadership, nombre de ses orthopédistes ayant assumé la présidence de l’ACO. Nous allons poursuivre nos réunions partout dans la province jusqu’en novembre et terminerons cette série par une réunion des anciens présidents. Chers amis et collègues, cela n’est que le début d’une importante tournée canadienne. Mais n’oubliez pas : tout commence par un petit geste.

Back to Where We Began in La Belle Province Cynthia Vezina CEO, Canadian Orthoapedic Association

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n my first two years at the COA in 2001, the Board of Directors hired an independent consultant to assess whether the COA should move its operations and head office from Québec to Ontario. The consultant recommended that the COA and COF merge operations, and move our head office to Toronto by the end of the year. When this news reached the membership, feedback from across the country was loud and clear - no way. Don’t do it. Keep the COA in its historical seat where it was inaugurated over a half century ago. Doug Thomson was the brand-new CEO at the time and carefully considered member and staff feedback. He went back to the Board with a counter proposal that kept the COA in Montréal, Québec where we are still headquartered today. Over 75 years ago, our national Association actually grew out of what was then the Montréal Orthopaedic Society, and most of the COA’s founding members were francophone surgeons. Despite political and cultural divides at the time, our Québec forefathers identified the need, importance, and value of forming a national society representing all Canadian orthopaedic specialists. Although Québec surgeons had such a pivotal role in establishing the COA, the Association has struggled in retaining, recruiting, and engaging orthopaedic surgeons from the province into the present day. Our lowest membership numbers are in la belle province. Although language is an obvious barrier to being able to effectively discuss and engage, we cannot let this divide the specialty and limit opportunities for collaboration. We are grateful for the recent discussions we’ve shared with the leadership of the Québec Orthopaedic Association (QOA). Dr. Mohit Bhandari was invited by QOA President, Dr. Jean-Francois Joncas (Université de Sherbrooke) to present at the provincial annual business meeting, where he invited the membership to reconnect through the 2020-2021 crosscountry ReCOAnnect Tour, launched last month in Québec.

Archive collection gifted to the COA from the family the late Dr. Jean-Marc Lessard (COA President 1972).

Over the next month alone, eight virtual town hall meetings are scheduled throughout Québec, and this is just the beginning. Through these conversations with orthopaedic surgeons, we will learn more about how the COA and QOA could better collaborate on initiatives and projects despite language differences. Past COA Presidents from Québec have contributed considerably to bridging the gap and engaging their provincial colleagues with the COA. The more we reconnect, the more learn and the more we grow. I hope that Québecois surgeons will continue to play pivotal roles in developing the COA and contributing to our education, advocacy, research, and leadership efforts. The COA head office was recently gifted with archives from the late Dr. Jean-Marc Lessard (COA President 1972 from Québec City). He kept a beautifully arranged scrapbook throughout his tenure called ‘My Life as President’. This memento included his addresses to the membership, introductions of guest speakers, meeting COA Bulletin ACO - Fall / Automne 2020


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programs, photographs, and correspondence with orthopaedic giants like Drs. Ted Dewar, Ian Macnab, Richard Cruess and Carroll Laurin. Collaboration and connections from across the country are evidenced in these lovely relics reminding us how important it is to keep working together and staying connected.

I’d like to thank Drs. Jean-Francois Joncas and Ms. Lise Guindon (QOA head office) for inviting us to this year’s virtual QOA meeting, and thank all of the Québec sites and surgeons who we have the opportunity to learn from through the ReCOAnnect program.

Retour aux sources dans « la Belle Province » Cynthia Vezina Directrice générale de l’Association Canadienne d’Orthopédie

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n 2001, le conseil d’administration a retenu les services d’un expert-conseil indépendant pour savoir si l’ACO, établie au Québec, devait relocaliser ses activités et ses bureaux en Ontario. C’était environ deux ans après mon arrivée. L’expert-conseil a recommandé la fusion de l’ACO et de la Fondation Canadienne d’Orthopédie, puis le déménagement des bureaux à Toronto avant la fin de l’année. Quand les membres ont eu vent de la nouvelle, leur réaction, d’un bout à l’autre du pays, a été sans équivoque : pas question. Ne faites pas ça. Gardez l’ACO là où elle a été fondée il y a plus d’un demi-siècle. Doug Thomson venait d’être nommé directeur général à l’époque, et il a mûrement réfléchi à la rétroaction fournie par les membres et le personnel. Il s’est présenté devant le conseil d’administration avec une contre-offre qui maintenait les bureaux de l’ACO à Montréal, au Québec, où ils sont encore aujourd’hui. Il y a plus de 75 ans, des membres de la Montreal Orthopaedic Society décidaient de fonder notre association nationale; la majorité des membres fondateurs de l’ACO étaient des orthopédistes francophones. Malgré les différends politiques et culturels de l’époque, nos pères fondateurs au Québec ont cerné le besoin, l’importance et la valeur d’une société nationale représentant tous les spécialistes de l’orthopédie au Canada. Bien que les orthopédistes du Québec aient joué un rôle crucial dans la création de l’ACO, l’organisation peine toujours à recruter des membres dans la province, à les garder au sein de l’organisation et à établir un dialogue avec eux. La plus faible adhésion à l’ACO est en effet au Québec. Bien qu’il soit manifestement difficile d’établir un dialogue et d’échanger quand on ne parle pas la même langue, nous ne pouvons pas laisser ce facteur diviser la spécialité et limiter les occasions de collaboration. Nous sommes donc heureux d’avoir pu échanger récemment avec la direction de l’Association d’orthopédie du Québec (AOQ). Le président de l’AOQ, le Dr  Jean-Francois Joncas (Université de Sherbrooke), a invité le Dr Mohit Bhandari à s’adresser aux membres à l’assemblée générale annuelle de son organisation, où ce dernier les a invités à renouer avec l’ACO dans le cadre de la tournée nationale RACOnnectons-nous 2020-2021, lancée le mois dernier au Québec. Au cours du prochain mois, pas moins de huit réunions virtuelles sont prévues un peu COA Bulletin ACO - Fall / Automne 2020

partout au Québec. Et ce n’est qu’un début! Ces conversations avec des orthopédistes nous permettrons d’en apprendre davantage sur ce que l’ACO et l’AOQ peuvent faire pour améliorer leur collaboration dans le cadre d’initiatives et de projets malgré l’obstacle de la langue. Des anciens présidents québécois de l’ACO ont beaucoup fait pour combler ce fossé et susciter la participation de leurs collègues provinciaux au sein de l’ACO. Plus la connexion sera forte, plus nous apprendrons et nous épanouirons. J’espère que les orthopédistes québécois continueront de jouer un rôle central dans le développement de l’ACO et qu’ils contribueront à nos efforts en matière de formation, de défense des droits et intérêts, de recherche et de leadership. Les bureaux de l’ACO ont récemment reçu en cadeau les archives de feu Jean-Marc Lessard, orthopédiste de Québec et président de l’ACO en 1972. Elles contiennent un magnifique album de coupures intitulé Ma vie de président. Cet ensemble de souvenirs comprend entre autres ses discours aux membres, la présentation de conférenciers invités, des programmes de réunions, des photos et de la correspondance avec des géants de la communauté orthopédique canadienne, dont les Drs Ted Dewar, Ian Macnab, Richard Cruess et Carroll Laurin. Ces petits moments d’éternité illustrent une collaboration et des relations pancanadiennes, et nous rappellent à quel point il est important de rester en contact et de continuer à œuvrer de pair. Je tiens à remercier le Dr  Jean-Francois Joncas et M me  Lise Guindon (bureaux de l’AOQ) pour leur invitation à l’assemblée virtuelle de cette année, de même que tous les sites et orthopédistes au Québec qui nous ont permis d’en apprendre davantage dans le cadre de la tournée RACOnnectons-nous.

Discours aux membres du Dr Jean-Marc Lessard à titre de président en 1972.


Your COA / Votre association

Congratulations to the 2020 COA Service Award Winners!

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he COA’s Annual Service Awards recognize members who have distinguished themselves through their exemplary contributions, influence and commitment to improving the Canadian orthopaedic community. Awarded each year at the COA Annual Meeting, the Service Awards are high honours bestowed on a member by the Canadian Orthopaedic Association. You can access each winner’s biography and additional information on the COA Annual Service awards on our website here. Congratulations to all our 2020 winners and nominees!

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Félicitations aux lauréats des prix pour service 2020 de l’ACO!

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es prix annuels pour service de l’Association Canadienne d’Orthopédie (ACO) visent à reconnaître les membres qui se sont distingués par leur contribution, leur influence et leur engagement exemplaires en vue d’améliorer la communauté orthopédique canadienne. Remis chaque année à la Réunion annuelle de l’ACO, les prix pour service constituent un grand honneur conféré à un membre par l’ACO. Vous trouverez la notice biographique de chaque lauréat et des renseignements supplémentaires sur les prix pour service annuels sur le site Web de l’ACO ici. Félicitations à tous les 2020 lauréats et candidats!

Emerging Leader Excellence in Service Excellence du service d’un jeune leader Drs. Brendan Sheehan and Ivan Wong

Service to Specialty Enrichment Service à l’enrichissement de la profession Dr. Timothy Daniels

Improving Clinical Care Service aux soins cliniques Dr. William Oxner

Service to the COA Service à l’ACO Dr. Jeffrey Gollish

Service to Orthopaedic Education Service à la formation en orthopédie Dr. Richard Buckley

Lifetime of Service Vie de service Dr. R. Baxter Willis

Service to Orthopaedic Research Service à la recherche en orthopédie Dr. Hubert Labelle

President’s Award for Excellence Prix d’excellence du président Dr. Alastair Younger

Look out for related communications and the upcoming opportunity to submit your nominations for the 2021 COA Service Awards.

La prochaine opportunité pour soumettre vos candidatures pour les Prix du service de l’ACO 2021 vous sera communiquée bientôt. COA Bulletin ACO - Fall / Automne 2020


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Global Outreach: Providing Sustainable Paediatric Orthopaedic Care in Vietnam with a Non-governmental Organization tice at Seattle Children’s Hospital in 2015, they invited me to join the board of directors and participate as a volunteer surgeon. MOi (previously Prosthetics Outreach Foundation) was founded in 1989 by orthopaedic hen I was a medical stusurgeon, Ernest Burgess (1911dent, awareness of the 2000). Vietnam War veteran inequities of the global groups encouraged him to help The COA Global Surgery (COAGS) Committee is pleased to share disease burden and distribution landmine victims in northern Canadian global health initiatives. If you are interested in COAGS of health-care resources was Vietnam and in 1991 he opened growing. With a small group of a prosthetics and orthotics (P&O) featuring your organization in the Bulletin, or if you are a resident classmates, we advocated for clinic in Hanoi providing free and you would like to share an essay about your global surgery access to essential medicines limbs using Cad Cam technolexperience, please contact schneida@canorth.org for details. and the establishment of a ogy. In the first year, the modCanadian bylaw to allow generic est clinic provided artificial limbs production of name-brand drugs to enable low-income counand braces to over 1000 patients. Dr. Burgess quickly expanded tries access to more affordable drugs for diseases like HIV, TB, P&O services to inaccessible rural communities using a mobile and malaria. outreach program. Maryse Bouchard, M.D., MSc, FRCSC The Hospital for Sick Children Division of Orthopaedic Surgery University of Toronto Toronto, ON

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When I started orthopaedic residency, I thought I would have to leave global health and political advocacy behind. The burden of musculoskeletal conditions hadn’t yet made it on the global health map. Slowly however, the impacts of road traffic accidents became evident through the work of the Global Burden of Diseases project. By 2010 with the tragic events of natural disasters like the earthquakes in Haiti or Nepal, orthopaedic surgeons increasingly contributed to global health efforts. I have always believed that volunteer global outreach should aim to ensure sustainable change and development. However, the typical orthopaedic mission was short-term without organized patient follow-up or education of local practitioners. In residency, I obtained a Masters degree to better understand the barriers of access to orthopaedic care in low-income countries. I spent three months in Uganda at a time when the country of 32 million people had 18 orthopaedic surgeons with 80% being in the capital city. Motorcycles are the primary mode of transportation and road traffic accidents in Uganda were among the highest in Africa. Corruption within the government and health-care systems, high costs of implants and equipment, poor salary and lack of incentives for skilled health-care workers to remain in remote areas or non-private institutions, and patient factors such as socioeconomic status, gravely impacted the country’s ability to ensure adequate orthopaedic care for its citizens. Although I gained a better understanding of the challenges of orthopaedic care delivery, I still didn’t know how I, as a full-time orthopaedic resident or surgeon in North America, could make a sustainable impact overseas. As a fellow in Seattle, I met Drs. Rob Veith and Mark Dales, two orthopaedic surgeons who worked with an organization called Mobility Outreach International (MOi). When I started my pracCOA Bulletin ACO - Fall / Automne 2020

Over the ensuing years, MOi’s programs have helped over 30,000 patients. Services include non-surgical clubfoot treatment for children and education for practitioners, P&O services including repair and manufacturing locally, physical rehabilitation, and orthopaedic surgery for adults and children that is predominantly foot and ankle focused. Today, MOi operates in Senegal, Haiti and Vietnam. MOi’s Vietnam Clubfoot Program was established in 2006 and has since supported Ponseti treatment for over 3200 patients. Local medical professionals are taught the Ponseti Method through courses sponsored by MOi and include local and volunteer instructors. Initially, the clubfoot programs are financially supported by MOi in partnership with local government. Once running successfully, they become independent, allowing MOi to initiate new projects in other areas. Currently, MOi supports ten clubfoot clinics Female patient with untreated clubfeet throughout Vietnam. presenting to MOi clinic in Son La.


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Drs. Nhi and Bouchard teaching at 2019 Ponseti Course in Hanoi.

Drs. Bouchard and Than performing clubfoot surgery in Son La in 2019.

In May 2020, 38 new clubfoot patients were treated. Sustainability of all centres is anticipated by the end of 2021.

success, there are challenges. Many patients speak rare dialects that even our local coordinators do not know which impacted our ability to deliver care. Furthermore, the remoteness of Son La province means few patients can access needed ancillary services, such as P&O, and/or further surgery or other specialized care, as they cannot afford to travel into the capital city. Travel time and road safety are also issues for the MOi team. Funding is a constant concern. It is impossible for MOi to produce research as the Vietnamese government opposes collection of patient information outside of clinical care, and there is no local academic institution to partner with.

In 2002, MOi partnered with the American Orthopedic Foot and Ankle Society (AOFAS) to sponsor orthopaedic surgeries for northern Vietnamese patients who otherwise would not be able to access essential surgery due to financial and geographic constraints. Volunteer orthopaedic surgeons have performed nearly 1500 surgical procedures mostly in children. This hugely successful program is soon to celebrate its 20th anniversary. MOi’s own long-standing surgical program was launched at Son La Provincial Hospital in the remote mountainous region of northwestern Vietnam. From 2006 to 2019, approximately 150 surgeries were performed. In 2019, only three surgeries were needed for residual/neglected clubfoot, attesting to the success of the Ponseti clubfoot program. A typical trip includes one to three volunteer surgeons, a rotation of nurses, physiotherapists, orthotists/prosthetists, students and cast/orthopaedic technicians. The team brings its own tools and supplies and partners with local nursing, anesthesia and rehabilitation medicine to help deliver perioperative care and follow up. A typical week in Son La includes two to three OR days, two to three clinic days of new and follow-up patients, and as needed, one to two days of home visits or visits to orphanages. Teaching of the local surgeons, surgical trainees and nurses occurs on rounds, in clinic, in the OR, and, when desired by the local team, through presentations or patient care conferences. I was attracted to MOi’s model as it ensured regular patient follow-up, a consistent surgeon team, and documentation of operations and clinic visits. There is a local Vietnamese team of program coordinators, led by Rose Hong, who help organize and advertise the trips, and build and maintain partnerships with local hospitals and governments. Despite the program’s

MOi has recently decided to end its surgery program in Son La but it continues to partner with the AOFAS surgery program. Due to COVID-19, 60 children’s operations that had been scheduled in 2020 were cancelled. The AOFAS surgery program is scheduled to resume in the fall of 2021 to carry out those operations. As my role with MOi concludes, I have joined the medical advisory board of Steps2Walk, an organization led by foot and ankle surgeon Dr. Mark Myerson, as their first paediatric foot and ankle specialist. Steps2Walk organizes approximately 15 missions per year globally, where the local hosts partner with volunteer surgeons from around the world to care for patients and develop an academic program including cadaver courses. I will help develop curricula for paediatric-focused missions, establish standards of care, and recruit paediatric surgeons to provide their expertise on missions. In my current practice setting, my involvement with non-governmental organizations enables me to maintain my full-time practice while achieving my goal of contributing to sustainable improvements in children’s orthopaedic care in remote resource-poor areas. COA Bulletin ACO - Fall / Automne 2020


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We Went Virtual – How Did We Measure Up?

Here’s What You Said About the First COA, CORS, & CORA Virtual Annual Meeting Lexie Bilhete Coordinator, COA Membership Services & Affiliate Programs

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s with all major in-person events scheduled for Spring 2020, the COA, CORS and CORA Annual Meeting unexpectedly moved from its original host city, beautiful Halifax, Nova Scotia, to a virtual platform due to the COVID-19 pandemic. Despite the quick change and short time frame to restructure the meeting, the COA leadership, committees, and staff stood strong for our members. We remained committed to providing an Annual Meeting filled with quality educational and presentation opportunities outside of an in-person platform, and worked around the clock with leadership and industry partners to deliver our first ever Virtual Annual Meeting! From June 19-22, 2020, hundreds of attendees from Canada, the USA, and overseas, tuned in to participate or present as a part of our cyber meeting. We creatively transitioned important ceremonies such as the transfer of presidential office and town hall, to fit our new online format. In the end, the COA was blown away by the support of the membership and positive feedback on the success of this unprecedented meeting. Below are just some of the comments and feedback we’ve received directly from our members and participants*. Thank you for your responses and suggestions for next year’s Annual Meeting – in whatever form it may take! 1. Top Reasons Why You Attended the Virtual Annual Meeting: a. “To see what research is being done and where.” b. “To support colleagues who were presenting and connect with fellow surgeons active in the Association.” c. “To obtain CME Credits.” 2. What did you Learn at this Year’s Virtual Meeting? a. “How COVID-19 is impacting the current and future practice of orthopaedics.” b. “How to use Zoom for presentations.” 3. Satisfaction Statistics: a. Scientific Programming: i. 91% found the Symposia topics important and were satisfied with the sessions. ii. 83% of attendees found the ICLs important and suitable. iiii. “Great opportunity to still have sessions, despite COVID-19 – Thank you!”

b. Adequate Diversity Represented in the Meeting’s Program: i. 96% of attendees felt that the COA, CORS, and CORA program faculty and speakers adequately represented the diversity of the orthopaedic profession in Canada. 1. The COA is ecstatic about this outcome and continues to strive for diversity throughout the Association and its projects! c. Overall Virtual Meeting Experience: The COA understands that the Annual Meeting is goes far beyond simply obtaining presentation experience and CME credits. Assembling together offers invaluable networking and social exchanges that are vital to various professional and personal advancements of our members. That is why the COA tried to offer as much networking opportunities as possible in a virtual realm – because we know that you miss your colleagues and peers from across Canada! i. 76% of attendees were satisfied with their experience at the Virtual Meeting 1. “I thought [that], given the short time frame for planning and difficulties in running a meeting [virtually] for the first time, it was successful.” 2. “When problems happened, solutions seemed to be found relatively quickly and moderators were calm and professional.” 3. “The Meeting reflected very well on the COA.”

COA Bulletin ACO - Fall / Automne 2020


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4. Suggestions: How Can We Make Our Next Meetings Even Better? a. “Make a bit more time in the sessions for moderators to be able to introduce themselves and explain the format, [and] make a bit more time for questions.” b. “The messaging system was a bit clunky [and one] cannot respond to someone with one click.” c. “If technology would allow, live questions would be great.”

What’s up Next for the COA, CORS, & CORA Annual Meeting?

On behalf of the COA leadership, Committees, and staff; We value your support and participation in making our first Virtual Meeting a success. Thank you!

*Responses received through the 2020 COA, CORS & CORA Annual Meeting session and overall evaluation forms.

Please make regular visits to the Annual Meeting web page at https://coa-aco.org/annual-meeting-2021/ for updated information about next year’s event. Despite many unknowns, the COA is committed to providing its members with quality educational experiences and presentation opportunities over an array of virtual or in-person platforms. Stay tuned for further developments!

Nous sommes passés en mode virtuel – Avons-nous été à la hauteur?

Voici ce que vous aviez à dire sur la première Réunion annuelle virtuelle de l’ACO, de la SROC et de l’ACRO Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés de l’ACO

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omme ce fut le cas pour tous les rassemblements majeurs prévus au printemps 2020, la Réunion annuelle de l’ACO, de la SROC et de l’ACRO a subitement dû troquer sa ville hôte, la magnifique ville de Halifax, en Nouvelle-Écosse, pour une plateforme virtuelle en raison de la pandémie de COVID-19. Malgré le changement rapide et le court délai pour restructurer la Réunion, la direction de l’ACO, ses comités et son personnel sont restés forts pour les membres. Nous nous sommes efforcés d’offrir une réunion annuelle au contenu scientifique de qualité et d’y proposer des possibilités de présentation de rechange intéressantes; nous avons travaillé sans relâche avec la direction et les partenaires de l’industrie afin de tenir notre toute première Réunion annuelle virtuelle! Du 19 au 22 juin 2020, des centaines de participants du Canada, des États-Unis et d’outre-mer se sont branchés afin d’assister à notre cyberréunion ou d’y faire une présentation. Nous avons fait preuve de créativité et transformé des cérémonies importantes, comme celle de transfert des charges, et la discussion ouverte en fonction de notre nouveau format en ligne. L’ACO a été soufflée par le soutien des membres et la rétroaction positive reçue à propos de cette réunion sans précédent. Voici une partie de la rétroaction que nous avons reçue des membres et des participants.* Merci pour vos réponses et vos suggestions en vue de la prochaine réunion annuelle, peu importe la forme qu’elle prendra!

COA Bulletin ACO - Fall / Automne 2020

1. Principales raisons pour lesquelles vous avez assisté à la Réunion annuelle virtuelle : a. « Voir quelles recherches sont en cours et où. » b. «  Soutenir des collègues qui effectuaient une présentation et discuter avec des collègues orthopédistes actifs au sein de l’Association. » c. « Obtenir des crédits d’ÉMC [éducation médicale continue]. » 2. Choses que vous avez apprises à la Réunion de cette année : a. « L’incidence de la COVID-19 sur l’exercice actuel et futur de l’orthopédie » b. «  L’utilisation de Zoom pour faire des présentations  » 3. Données sur la satisfaction : a. Programme scientifique : i. 91 % des participants ont trouvé les sujets abordés pendant les symposiums importants et sont satisfaits des séances. ii. 83 % des participants ont trouvé les conférences d’enseignement importantes et appropriées. iii. « Une super occasion d’avoir des séances, malgré la COVID-19. Merci! »


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b. Représentation de la diversité dans le programme de la Réunion : i. 96  % des participants croient que les présentateurs et conférenciers au programme de la Réunion annuelle de l’ACO, de la SROC et de l’ACRO représentaient bien la diversité du milieu de l’orthopédie au Canada. 1. L’ACO est extrêmement heureuse de ces résultats et continue de s’efforcer de refléter la diversité au sein de l’Association et de ses projets! c. Expérience globale  : L’ACO est consciente que la Réunion annuelle va bien au-delà des possibilités de présentation et des crédits d’ÉMC. Se réunir permet aussi un réseautage et des échanges sociaux inestimables et essentiels à l’avancement professionnel et personnel de nos membres. C’est pourquoi l’ACO a tenté de proposer autant de possibilités de réseautage que possible virtuellement, parce que nous savons que vos collègues et pairs partout au pays vous manquent! i. 76  % des participants sont satisfaits de leur expérience à la Réunion annuelle virtuelle. 1. «  Je pense [que], vu le court délai pour la planification et les difficultés liées à la tenue d’une première réunion [virtuelle], elle était réussie. » 2. « Quand il y avait des problèmes, on semblait trouver des solutions relativement vite, et les modérateurs étaient calmes et professionnels. » 3. « La Réunion a fait honneur à l’ACO. »

2021 Call for Abstracts – Extended! The COA appreciates that this year hasn’t been like any other. Ongoing COVID-19 related restrictions have impacted our specialty and the way that we do everything. To better support our members, investigators, trainees, and specialists, the abstract submission deadline is being extended to December 14. More information about the 2021 COA, CORS and CORA Annual Meeting format will be announced shortly as we continue to pursue the best options possible for our members and stakeholders. The COA remains committed to offering quality accredited programming, and to providing presentation opportunities to our members.

4. Suggestions : Comment pouvons-nous faire encore mieux aux prochaines réunions? a. « Prévoir un peu plus de temps pendant les séances pour que les modérateurs puissent se présenter et expliquer le format, [et] prévoir un peu plus de temps pour les questions. » b. «  Le système de messagerie était un peu chaotique, [et on] ne pouvait pas répondre à quelqu’un en un clic. » c. «  Si la technologie le permet, il serait bien de pouvoir poser des questions en direct. » La direction, les comités et le personnel de l’ACO vous sont reconnaissants pour votre soutien et votre contribution au succès de notre première réunion virtuelle. Merci! Qu’en est-il de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO? Consultez souvent le site Web de la Réunion annuelle, à https://coa-aco.org/fr/reunion-annuelle-2021, pour obtenir des renseignements à jour sur la manifestation. Malgré  les nombreuses inconnues, l’ACO s’engage à offrir à ses membres une expérience de formation et des possibilités de présentation de qualité à l’aide de plateformes virtuelles ou traditionnelles. Plus de détails à venir! * Réponses fournies dans les formulaires d’évaluation des séances et de la Réunion annuelle 2020 de l’ACO, de la SROC et de l’ACRO.

Prolongation de l’invitation à soumettre des précis pour la Réunion annuelle 2021! L’ACO est consciente que nous vivons une année hors de l’ordinaire. Les restrictions liées à la pandémie de COVID-19 ont une incidence sur notre profession et notre façon de faire les choses. Afin de mieux soutenir nos membres, chercheurs, résidents, fellows et spécialistes, la date limite pour la soumission de précis est reportée au 14 décembre. Nous fournirons sous peu de plus amples renseignements quant au format de la Réunion annuelle 2021 de l’ACO, de la SROC et de l’ACRO, et nous continuons d’étudier les meilleures options possibles pour nos membres et autres parties intéressées. L’ACO s’engage à offrir à ses membres un programme agréé de qualité et des possibilités de présentation.

Submit your abstracts by December 14!

Soumettez vos précis d’ici le 14 décembre.!

Click here to submit now

Cliquez ici pour soumettre votre précis dès maintenant!

Stay up to date by visiting the 2021 COA, CORS and CORA web site

Prenez connaissance des derniers développements en consultant le site Web de la Réunion annuelle 2021 de l’ACO, de la SROC et de l’ACRO. COA Bulletin ACO - Fall / Automne 2020


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

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fter completing her residency training at Northern Ontario School of Medicine in 2019, Dr. Dora Maria Pelletier is currently completing her fellowship specializing in spine surgery at the Toronto Western Hospital and Sunnybrook Hospital. 1. What drew you to orthopaedics (and your subspecialty)? Orthopaedic surgery was a mystery to me until the end of my third year of medical school. My two weeks on service was so transformative, that from that point forward I did everything in my power to make orthopaedics a part of my life. This included seeking electives in three countries and miraculously crossing over medical systems from Australia to Canada, my home country, for residency. I was drawn to the energy, passion, the big personalities, and the broad scope of practice. Coming from a molecular science background, where you can’t hold, manipulate, or directly visualize what you are testing, to experiencing the immediate gratification of treating a structural problem with your hands, tools, and definitive instrumentation, was exhilarating. Ultimately, giving a patient back more functionality, sometimes in the setting of the worst points in their life, was the largest factor that drew me in. 2. Can you recount a defining moment in your career thus far? In fact, this would be the cumulation of small, but meaningful moments: specific expressions of gratitude from patients that were unexpected and profoundly humbling for a variety of reasons; small but progressive mastery of techniques; cultivation of mentorships and friendships; witnessing dramatic recoveries. 3. What does diversity mean to you? It is a deviation from the norm; something that is worthy of note or remark, and thus the state of being uncommon or exceptional. Essentially, it is challenging the pre(mis)conceptions and inherent paradigms of what it should mean to be a surgeon, orthopaedic or otherwise: gender; age; physique; academic, social, or cultural background. 4. What advice would you give to orthopaedic residents? You’ve made it this far, keep going! To meet even the basic expectations, let alone to succeed, it’s a challenging field physically, academically and at times, psychologically. Residency can truly be the best of times and, most certainly, the worst of times. Find an outlet to help you refuel - hobbies, close friends and family etc. It doesn’t have to be in equal parts to work or take up hours of your valuable rest or study time. Something as litCOA Bulletin ACO - Fall / Automne 2020

tle as coffee, a quick pop-in visit, or Sunday dinner can make all the difference. Having acknowledged the grueling schedule and insurmountable expectations of daily residency, keep in mind that all of your training and experiences are ultimately for your benefit; to bolster your ability and confidence to care for your very own future patients, and enjoy doing it.

The COA recognizes the strength in diversity and promotes equity across its membership, services, and all community engagement. Each edition of the COA Bulletin will feature one of the many women members of the Association, their experiences and insights, contributions to the specialty and advice for junior colleagues and students. Get to know the membership! 5. What is one professional goal and one personal goal you hope to achieve in the next five years? Professional goal: To become a proficient and comprehensive spine specialist. As a second-year fellow in a large, wellestablished, program I have the opportunity and access to the resources to achieve this. This includes working with an array of excellent spine surgeons, in various subspecialties: deformity, trauma, oncology, and potentially even MIS. My objective is to learn their specific techniques and clinical reasoning to augment my armamentarium to attain my primary goal, and maximizing my ability to care for my patients. Personal goal: After over a decade of medical education with frequent moving, my goal is to finally settle down in one city. 6. Name one of your go-to tricks or hacks that has helped you in your day to day life? My helpful go-to’s are under-rated, but effective. These include talking to a patient like a friend and including them in understanding elements of their pathology; allaying their concerns, or bolstering their resolve for the journey ahead. Take for example spine MRI reports, which are a frequent cause for referral and topic of conversation with patients. These are especially unfriendly to most people, including a decent portion of non-spine specialists. They tend to foster patient anxiety and perseveration on terms like compression of the neural elements, moderate or severe stenosis, degeneration, multilevel herniation etc. - when in fact many of those changes may not be causing any issue for them. The manner in which the discussion occurs about how these changes relate to or don’t relate to their particular situation is key in gaining a partner in their surgical or non-surgical management.


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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

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près avoir terminé sa résidence à l’École de médecine du Nord de l’Ontario, en 2019, la Dre Dora Maria Pelletier a commencé sa spécialisation en chirurgie du rachis à l’hôpital Western de Toronto et au Sunnybrook Health Sciences Centre. 1. Qu’est-ce qui vous a amenée à choisir l’orthopédie (et votre sous-spécialité)? La chirurgie orthopédique a été un mystère pour moi jusqu’à la fin de ma troisième année de médecine. Mes deux semaines de service ont eu un effet tellement transformateur que, à partir de ce moment, j’ai tout fait pour que l’orthopédie fasse partie de ma vie. J’ai entre autres cherché des stages optionnels dans trois pays, et je suis miraculeusement passée du système médical australien au système canadien, mon pays d’origine, pour ma résidence. L’énergie, la passion, les grandes personnalités et le vaste champ d’exercice m’attiraient. Ayant fait des études en sciences moléculaires, où on ne peut pas tenir, manipuler ou regarder directement ce que l’on analyse, il était vivifiant de connaître la gratification immédiate associée au traitement d’un problème structural avec ses mains, des outils et une instrumentation qui fait autorité. Au bout du compte, donner à un patient une meilleure fonctionnalité, parfois à l’un des pires moments de sa vie, a été le facteur le plus important dans mon choix. 2. Racontez-nous un moment marquant de votre carrière. En fait, ce serait davantage une accumulation de petits moments significatifs  : des patients qui ont exprimé leur gratitude de manière inattendue et suscité chez moi une grande humilité, pour diverses raisons; la maîtrise lente, mais progressive de techniques; l’alimentation de relations de mentorat et d’amitiés; les patients dont le rétablissement est spectaculaire. 3. Pour vous, que signifie la diversité? C’est un écart par rapport à la norme, quelque chose qui se remarque et, donc, un état de singularité ou d’exception. Essentiellement, il s’agit de mettre en question les idées préconçues et erronées ainsi que les paradigmes inhérents à la profession de chirurgien, orthopédique ou autre : le sexe; l’âge; le physique; et le bagage universitaire, social ou culturel. 4. Quels conseils donneriez-vous aux résidents en orthopédie? Vous vous êtes rendus là, continuez! L’orthopédie est déjà un domaine difficile sur les plans physique, universitaire et, parfois, psychologique quand il s’agit de répondre aux attentes de base, et encore plus quand on veut y réussir. La résidence peut vraiment être le meilleur moment de sa vie et, sans aucun

doute, le pire aussi. Trouvez un exutoire pour vous aider à vous revigorer – des passe-temps, de bons amis et votre famille, par exemple. Il n’est pas besoin d’y consacrer autant de temps qu’au travail, ni de gruger ses précieuses heures de repos ou d’étude. Un petit café, une petite visite en passant ou un souper le dimanche peuvent suffire à faire une énorme différence. Oui, la résidence au quotidien est éreintante et les attentes sont insurmontables, mais n’oubliez pas que c’est vous qui bénéficiez de toute votre formation et expérience, au bout du compte; elles viennent soutenir les capacités et la confiance nécessaires pour traiter vos futurs patients, et pour avoir du plaisir à le faire.

L’ACO reconnaît la force inhérente à la diversité et fait la promotion d’une culture d’équité chez ses membres ainsi qu’en ce qui a trait à ses services et à son engagement communautaire. Chaque numéro du Bulletin comprendra le portrait de l’une des nombreuses femmes membres de l’ACO. On en apprendra davantage sur son expérience et ses idées, sa contribution à la profession et ses conseils pour ses jeunes collègues et les étudiants. Apprenez à connaître vos collègues! 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 : Devenir une spécialiste du rachis compétente et polyvalente. Comme j’en suis à la deuxième année de mon fellowship au sein d’un programme important et bien établi, j’ai l’occasion d’accéder aux ressources pour y parvenir. Cela implique de travailler avec un éventail d’excellents chirurgiens du rachis, dans diverses sous-spécialités : les déformations, les traumatismes, l’oncologie, voire la chirurgie endoscopique. J’ai pour objectif d’apprendre leurs techniques et la résolution de problèmes cliniques de sorte à accroître mon arsenal thérapeutique afin d’atteindre mon but principal, et de maximiser ma capacité à traiter mes patients. Objectif personnel  : Après plus d’une décennie d’études en médecine, et de nombreux déménagements, mon objectif est de m’établir enfin dans une ville. COA Bulletin ACO - Fall / Automne 2020


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6. Nommez le truc ou l’astuce que vous appliquez au quotidien pour vous faciliter la vie. Mes trucs utiles sont sous-estimés, mais efficaces. Parler à un patient comme à un ami, entre autres, et l’inclure en lui permettant de comprendre les éléments de sa pathologie; apaiser ses préoccupations ou nourrir sa volonté par rapport au cheminement qui l’attend. Prenez par exemple les rapports d’IRM du rachis, qui sont souvent la cause de l’aiguillage et un sujet de conversation avec les patients. Ils sont particulièrement arides

pour la plupart des gens, y compris un nombre non négligeable de spécialistes de domaines autres que le rachis. Ils ont tendance à nourrir l’anxiété des patients et l’usage obstiné de termes comme «  compression des éléments nerveux  », « sténose modérée ou grave », « dégénérescence » ou « hernie multiple  », même si, en fait, beaucoup de ces changements peuvent ne leur poser aucun problème. La façon de discuter de ces changements et de leur pertinence ou non par rapport à leur situation particulière est essentielle à la naissance d’un partenariat dans leur traitement, chirurgical ou non.

Scheherazade: One Thousand and One Arabian Nights The Internationalization of Surgical Training I subsequently spent the next ten years in the Kingdom of Saudi Arabia as the Kingdom’s first and inihere does one begin to write a brief time capsule of tially only spine surgeon, as fifty plus years in the practice of medicine and orthowell as one of the very few paedic surgery? I was born in April 1945, two months Western-trained orthopaebefore the inaugural meeting of the COA held that year in June dic surgeons. The King Faisal 1945. A very happy 75th birthday to us both. Specialist Hospital was the first and only modern hosMy career was relatively unique, although I suspect at the pital in the Kingdom. It had end of the day, we all say something similar. I spent the first opened just before I arrived ten years of my orthopaedic career in Saudi Arabia, trying to in 1978, and was built in come to grips with my own inadequacies, fears, and phobias the King’s date orchard, while simultaneously struggling to bring modern surgery to a essentially an adjunct to kingdom, which was more medieval than modern and, in many his palace. We lived in the respects, remains so. date orchard and the proximity made house calls a simpler affair than you might imagine. Perhaps Why Saudi Arabia, you may well ask? I should mention that although the Time-Capsule Testimonials: Celebrating Perhaps as the title suggests that I only spine surgeon and the Chairman was fascinated by what was unknown of orthopaedics, my main function, the COA’s 75 years with Memories from to me, by the mystique of a culture of politically speaking, was as the King’s our Membership which I knew nothing. Perhaps I was personal physician and surgeon. just entranced by the chance to pracIn recognition of the COA’s 75th anniversary, we tice what I had recently learned in a Although the King was our benefacsociety newly on the cusp of the modtor and top priority patient, I spent are collecting testimonials of pivotal moments ern age. More likely, it is a question I the vast majority of my time trying to in the careers of our membership. Help us shall never adequately answer. relearn the diseases I had only heard celebrate 75 years! Have a story from your about in our “History of Medicine” residency, training, or professional practice I think we all fear failure and the lectures. Tuberculosis, brucellosis, unknown. For many of us, myself neglected trauma, leprosy, polio etc. that you’d want to share with your colleagues? included, it is sometimes that fear of were endemic when we arrived in the E-mail info@canorth.org. failure that keeps us from fully realKingdom. The mayhem on the highway izing our potential. When I finished system was probably the highest in the medical school, at the University of Toronto, my lovely and world and first responders and emergency rooms were nonforgiving wife and I spent two years travelling overland around existent. Back then, as the only spinal surgeon and one of the the world, visiting and working in the Canadian North, Nepal, very few orthopaedic surgeons in a country with an estimated Iran, Afghanistan, and Australia. Many of these were definitely population of 11 to 13 million, I was somewhat overwhelmed. non-tourist destinations. After those two years, I realized how My first anterior thoracotomy for spinal tuberculosis took me limited my skill sets were, and I returned to Toronto to complete seven hours, assisted by a nurse and with an open medical my orthopaedic residency and fellowship. textbook beside me. I did eventually get much quicker, and hopefully better at my chosen craft. Robert M. Lifeso M.D., FRCSC, FACS, FAAOS Sarasota, FL

W

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We were inundated with complex surgical challenges on an hourly basis. Neglected polio with spinal and limb deformities was ever-present. Tuberculosis and brucellosis of the spine were endemic. Leprosy was another new challenge, as were the residuals of untreated auto accidents, congenital deformities (cousin-cousin marriage was the norm at the time) etc. Aside from the surgical challenges, the language and cultural differences, perhaps the most important thing I learned in Saudi was working in a traditional Moslem hierarchical society and all the nuances of language, religion, and culture that it entailed.

When I returned to Nepal, to share what I had learned in Saudi, I was thrust immediately back to where I had started in Riyadh, some years previously. On my first day in Kathmandu, I walked into the operating room to see two resident surgeons applying a forearm plate using a hand drill. I noted two new power drills sitting in the corner of the OR, gifts from Germany, both unopened and still in their shipping crates. As Chairman of orthopaedics and surgeon to the King, I was intimately involved in the running of the hospital, but also in attempting to assist in the formulation of health policy for a rapidly modernizing society. We were likewise working to establish a medical education system, where none had existed before our arrival. I became involved in trying to rationally allocate medical resources with (at best) mixed results. We were in an essentially private hospital built for the King and his family but open to Saudi patients. We were initially the only modern hospital in the Kingdom but that was to change. Over time the Saudi medical system rapidly expanded but simultaneously rapidly fragmented into competing medical fiefdoms. There was, of course, the Ministry of Health but also the Saudi National Guard, the Saudi Armed Forces, the Social Security Administration, and the newly-formed University system, all of whom wanted their own medical systems open only to their own constituents and they wanted it yesterday. For example, traffic and construction accidents were endemic, and there was initially no emergency nor long-term care for spinal cord injured patients. I began operating on these patients at the Riyadh Central Hospital and created a 44-bed acute spinal injury unit at that hospital. I was subsequently involved in the design and implementation of a 200- bed rehabilitation facility for spinal cord injuries. As I was to learn, each of the other hospital systems likewise wanted their own such surgical units, and I believe Riyadh now has multiple spinal rehabilitation units. There was a growing demand among the young Saudi population, both men and women, for medical education. On our arrival there were no medical schools in the Kingdom. Many of my fellow physicians and surgeons at the Royal Hospital were Canadian and we were able to place 375 young Saudis yearly into Canadian medical schools and hospital systems to further their medical education.

I assembled one and introduced the first such operating drill into my first operative case. I felt a sense of accomplishment when I sat down to show my new residents how to use power tools. I started to drill, and immediately the scrub nurse fainted, she had never seen, nor heard, such a thing. At the end of my sabbatical there, I stopped in at the OR to say goodbye, and there were the same two orthopaedic residents, using the same hand drill, to place yet another plate on yet another forearm. The two power drills safely stowed away, yet again in the corner of the OR. The moral, dear reader, is that maybe our greatest accomplishments are merely illusionary. Although I performed and taught anterior thoracic surgery in Kathmandu for spinal sepsis, that accomplishment will always be overshadowed in my mind by my experience in helping to introduce Nepal to the modern era of power surgical tools. When my children outgrew the schooling available in Saudi, I was forced to make yet another major life decision. Put my children in school in Switzerland and I would commute to Saudi from Geneva, or return to North America. I chose the latter. Lessons learned in my 50 plus years in the medical profession? Get involved, not just with medicine but continually with medical decision making at the highest levels. Unfortunately, once I returned to North America I did not get involved in medical politics, in governance issues, nor in any of the things I had done in Saudi. I now wish I had done so. If we do not control our profession, who should do so? Explore your world, medical and otherwise, today’s chosen career path will likely have many unforeseen twists, turns and detours. Be open to continued learning, life does not stand still and neither should your education nor your adventures. I know that there are multiple demands on a surgeon’s time, but I might suggest that one of the biggest demands should be to find oneself. I believe I did so in Arabia, and those ten years were among the best of my life.

COA Bulletin ACO - Fall / Automne 2020


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Schéhérazade : Les Mille et une nuits. L’internationalisation de la formation en chirurgie Robert M. Lifeso, MD, FRCSC, FACS, FAAOS Sarasota, FL

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ar où commencer quand on veut écrire une courte capsule temporelle reflétant plus de 50 années d’exercice de la médecine et de la chirurgie orthopédique? Je suis né en avril 1945, deux mois avant la réunion inaugurale de l’ACO, en juin 1945. Je nous souhaite un très joyeux 75e anniversaire.

ma principale fonction, sur le plan politique, était celle de médecin et chirurgien personnel du roi.

Bien que le roi fût notre bienfaiteur et patient prioritaire, j’ai passé la vaste majorité de mon temps à essayer de réapprendre sur Ma carrière a été relativement unique, même si je soupçonne des maladies dont j’avais que, au bout du compte, nous disions tous quelque chose du seulement entendu parler genre. J’ai passé les dix premières années de ma carrière en pendant nos conférences orthopédie en Arabie saoudite, à essayer de surmonter mes sur l’histoire de la médepropres insuffisances, peurs et phobies tout en luttant pour cine. La tuberculose, la amener la chirurgie moderne dans un royaume qui était plus brucellose, les traumatismes médiéval que moderne et, à bien des égards, l’est encore non traités, la lèpre et la polio, entre autres, étaient endémiques aujourd’hui. à notre arrivée au Royaume. Le bilan sur le réseau routier était probablement le pire dans le monde, Pourquoi l’Arabie saoudite, me direzet il n’y avait ni premiers intervenants Capsules temporelles : Célébrons le vous? Peut-être, comme le suggère mon ni salles d’urgence. À l’époque, comme e 75  anniversaire de l’ACO grâce aux titre, étais-je fasciné par l’inconnu, par seul chirurgien du rachis et l’un des très souvenirs de ses membres la mystique d’une culture dont je ne rares orthopédistes pour une populaconnaissais rien. Peut-être étais-je simtion estimée à  11 à 13  millions d’habiplement ravi de pouvoir mettre en pratants, j’étais quelque peu submergé. Ma Pour souligner le 75e anniversaire de tique ce que je venais d’apprendre au première thoracotomie antérieure pour l’ACO, nous recueillons des témoignages sein d’une société à la charnière de la traiter une tuberculose rachidienne m’a sur des moments marquants de la carrière pris sept heures, et j’avais à mes côtés modernité. Mais il s’agit plus probablement d’une question à laquelle je ne une infirmière et un manuel de médecine de ses membres. Aidez-nous à célébrer pourrai jamais répondre de façon approouvert. Je suis éventuellement devenu nos 75 ans! Vous avez une histoire vécue priée. beaucoup plus rapide et, je l’espère, meilpendant votre résidence, votre formation leur dans la profession que j’avais choisie. ou votre exercice professionnel et vous Je crois que nous avons tous peur de l’échec et de l’inconnu. Pour beaucoup Nous étions submergés de défis chiruraimeriez la partager avec vos collègues? d’entre nous, moi compris, c’est parfois gicaux complexes toutes les heures. Les Écrivez à, info@canorth.org. cette peur de l’échec qui nous empêche polios non  traitées avec déformations de réaliser notre plein potentiel. Quand du rachis et des membres étaient omnij’ai fini l’école de médecine, à l’Université de Toronto, ma charprésentes. La tuberculose et la brucellose rachidiennes étaient mante et indulgente femme et moi avons passé deux années endémiques. La lèpre présentait un autre nouveau défi, tout à voyager et travailler partout dans le monde, parcourant par comme les troubles résiduels découlant du non-traitement la terre le Nord canadien, le Népal, l’Iran, l’Afghanistan et l’Ausde traumatismes de la route et d’anomalies congénitales tralie. Bon nombre de ces destinations étaient tout sauf touristiques. Après ces deux années, je me suis rendu compte que mes compétences étaient limitées, et je suis retourné à Toronto afin d’effectuer ma résidence et mon fellowship en orthopédie. J’ai ensuite passé les dix années suivantes dans le Royaume d’Arabie saoudite en tant que premier, et initialement seul, chirurgien du rachis, ainsi que l’un des très rares orthopédistes formés en Occident. L’hôpital spécialisé Roi Faisal était le premier et seul hôpital moderne du Royaume. Il avait ouvert juste avant mon arrivée, en 1978, et avait été bâti dans le verger de dattiers du roi, essentiellement une annexe de son palais. Nous vivions dans le verger de dattes, et la proximité rendait les visites à domicile plus simples que vous ne pourriez l’imaginer. Je devrais peut-être mentionner que, même si j’étais le seul chirurgien du rachis et directeur du département d’orthopédie, COA Bulletin ACO - Fall / Automne 2020


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(suite de la page 18)

(le mariage consanguin était la norme à l’époque), entre autres. À part les défis chirurgicaux, la langue et les différences culturelles, ce que j’ai appris de plus important en Arabie résulte peut-être de mon travail dans une société hiérarchique musulmane traditionnelle et de toutes les nuances linguistiques, religieuses et culturelles que cela supposait. À titre de directeur du département d’orthopédie et chirurgien du roi, j’ai participé activement à la gestion de l’hôpital, mais aussi tenté de contribuer à l’élaboration de politiques en santé pour une société qui se modernisait rapidement. Nous essayions en outre d’établir un système de formation médicale, inexistant à notre arrivée. J’ai participé aux efforts d’allocation rationnelle des ressources médicales avec, au mieux, des résultats mitigés. Nous étions en gros un hôpital privé construit pour le roi et sa famille, mais ouvert aux patients saoudiens. Au départ, nous étions le seul hôpital moderne du Royaume, mais cela allait changer.

Avec le temps, le système médical saoudien s’est rapidement élargi, tout en se fragmentant en bastions médicaux concurrents. Le ministère de la Santé, bien sûr, mais aussi la garde nationale saoudienne, les forces armées saoudiennes, l’administration de la sécurité sociale et le récent réseau universitaire voulaient tous leur propre système médical réservé, et ils le voulaient pour hier. À titre d’exemple, les accidents de la route et de la construction étaient endémiques, et il n’y avait à l’époque aucuns soins d’urgence ou de longue durée pour les blessés médullaires. J’ai commencé à opérer ces patients à l’hôpital central de Riyad, où j’ai créé une unité de 44 lits pour les traumatisés médullaires aigus. Par la suite, j’ai participé à la conception et à la mise en œuvre d’un centre de 200 lits de réadaptation pour les blessés médullaires. Comme je devais l’apprendre, chacun des autres systèmes hospitaliers voulait sa propre unité de chirurgie spécialisée, et je crois que Riyad dispose maintenant de multiples unités de réadaptation pour les blessés médullaires. La demande pour la formation en médecine chez les jeunes saoudiens, hommes et femmes, était croissante. À notre arrivée, il n’y avait pas d’école de médecine dans le Royaume. Beaucoup de mes collègues médecins et chirurgiens de l’hôpital royal étaient canadiens, et nous avons pu placer 375 jeunes saoudiens par année dans les écoles de médecine et systèmes hospitaliers canadiens pour qu’ils puissent approfondir leur formation médicale.

Quand je suis retourné au Népal afin de partager ce que j’avais appris en Arabie saoudite, j’ai brusquement été ramené en arrière, là où j’avais commencé à Riyad quelques années auparavant. À ma première journée à Katmandou, je suis entré dans la salle d’opération pour voir deux résidents en orthopédie utiliser une perceuse à main pour poser une plaque sur un avantbras. J’ai remarqué deux perceuses électriques neuves dans un coin de la salle, un don de l’Allemagne, encore dans leur boîte d’expédition intacte.

J’en ai assemblé une, puis j’ai utilisé cette première perceuse chirurgicale pour mon premier cas. Un sentiment d’accomplissement m’a envahi quand je me suis assis pour montrer à mes nouveaux résidents comment utiliser des outils électriques. Quand j’ai commencé à forer, l’infirmière en service interne s’est évanouie : elle n’avait jamais vu, ni entendu, une telle chose. À la fin de mon année sabbatique là-bas, je suis passé en salle d’opération pour faire mes adieux, et les mêmes résidents en orthopédie étaient là, utilisant la même perceuse à main pour poser une autre plaque sur un autre avant-bras. Les deux perceuses électriques étaient bien rangées, encore une fois dans le coin de la salle d’opération. La morale de cette histoire, cher lecteur, est que nos plus grands accomplissements ne sont qu’illusoires. Même si j’ai effectué à Katmandou des chirurgies thoraciques antérieures dans le traitement de sepsis du rachis, et que j’y ai enseigné la procédure, cet accomplissement sera toujours assombri à mes yeux par mon expérience d’introduction d’outils chirurgicaux électriques modernes au Népal. Quand mes enfants sont arrivés au bout de la scolarité offerte en Arabie saoudite, j’ai dû prendre une autre décision majeure : inscrire mes enfants à l’école en Suisse, et faire l’aller-retour de l’Arabie saoudite à Genève, ou revenir en Amérique du Nord. J’ai choisi la dernière option. Quelles leçons ai-je tirées de ma carrière de plus de 50 ans en médecine? Impliquez-vous, non seulement en médecine, mais continuellement, aux échelons les plus élevés du processus décisionnel médical. Malheureusement, à mon retour en Amérique du Nord, je ne me suis pas impliqué dans les politiques médicales, les enjeux de gouvernance, ni les autres choses auxquelles j’avais participé en Arabie saoudite. Je le regrette aujourd’hui. Qui d’autre que nous devrait gérer notre profession? Explorez votre monde, médical ou autre; le parcours professionnel que vous avez choisi sera probablement parsemé de tournants, de virages et de détours imprévus. Soyez ouvert à l’apprentissage continu, car la vie n’est pas figée, et votre formation et vos aventures ne devraient pas l’être non plus. Je sais que le temps d’un chirurgien est sollicité de toutes parts, mais j’oserais dire que le plus important devrait être de se trouver. Je crois que je l’ai fait en Arabie saoudite, et les dix années j’y ai vécues figurent parmi les plus belles de ma vie. COA Bulletin ACO - Fall / Automne 2020


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

Current Issues: The Use of Platelet-rich Plasma and Stem Cells in Orthopaedic Surgery William M. Weiss, M.D., MSc, FRCSC, FAAOS Current Issues Editor, COA Bulletin

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here has been considerable discussion of the use of platelet-rich plasma (PRP) and stem cells by medical providers, among patients, and in the media. Interest in these biologic products is encouraged by promise in the proposed benefits in various conditions. There are also certainly proprietary and income-based reasons for consideration. Much of this discussion of biologic products has been related to osteoarthritis and sports medicine, making this an issue of interest for orthopaedic surgeons in both Canada and the United States. While both PRP and stem cells pose minimal risk and morbidity associated with their use, the evidence in support of their effectiveness for orthopaedic conditions remains limited. Regardless, it remains an area of promise with ongoing research in both basic science and clinical outcomes. Drs. Femi Ayeni and Moin Khan, who are both at the forefront of this area, review the current state of knowledge and indications for these biologic products.

Narrative Review: Stem Cell Treatment for Musculoskeletal Injuries: A 2020 Canadian Perspective Darren de SA, MBA(c), M.D., FRCSC Jeffrey Kay, M.D., MSc(c) Olufemi R. Ayeni, M.D., PhD, FRCSC McMaster University Hamilton, ON

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hough already in widespread use across multiple medical specialties, the increasing popularity and application of adult stem cells for musculoskeletal pathology has not gone unnoticed. In fact, a simple literature search combining “stem cell” and “orthopaedic surgery” returns nearly 20,000 peerreviewed publications addressing varying elements of this treatment modality – from its foundations in basic science, to optimal harvest/preparation techniques, to clinical applications and risk profiles. Made popular by their ability to differentiate into a wide variety of cell types including cartilage, bone, tendons and ligaments1,2, mesenchymal stem cells (MSCs), and their propensity to “self-renew” and assist with the healing of connective tissue. This has drawn interest across all fields of orthopaedics, including, but not limited to: fractures/non-unions, osteoarthritis, spinal injuries, and sports medicine3. However, “all that glitters is not gold”; and as a currently uninsured service within the Canadian healthcare system, tremendous potential exists to utilize this technology for various gains4. With the global market for orthobiologics and regenerative medicine predicted to surpass $81 Billion by 20235, a concise, evidence-based summary is paramount.

Harvest and Preparation MSCs may be obtained from a variety of different sources; however, bone marrow and adipose tissue comprise the most frequently accessed sources due to ethical acceptability and relative ease of preparation6. Bone marrow MSCs are acquired by means of an aspiration of bone marrow, with autologous harvest from the iliac crest yielding the highest percentage of bone-forming stem cells7. After harvest, the aspirate is centrifuged to yield bone marrow aspirate concentrate (BMAC)8. On the other hand, adipose-derived stem cells have become increasingly popular given their advantages in limiting harvest-related donor site morbidity, and abundant quantities accessible via subcutaneous adipose deposits9. Preparation of autologous adipose-derived MSCs involves aspirating adipose tissue from a subcutaneous fat pad, which is subsequently treated with collagenase, and finally centrifuged to yield a final product9. Adipose-derived stem cells have been shown to produce a more homogeneous product which may yield a more reliable and repeatable outcome6 – addressing an all-toofrequent criticism of the current literature on the topic. A recent systematic review of randomized controlled trials studying stem cell therapy for the knee found that there was substantial inconsistency in the nomenclature used to describe the details of the specific therapies, and different preparation strategies produced entirely different drugs10.

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

Articular Cartilage Application A treatment strategy that has gained popularity for use in articular cartilage defects in the knee involves the implantation of BMAC along with a scaffold made of hyaluronic acid (HA) within the articular cartilage defect in a single-step procedure, with the goal of promoting new hyaline-like tissue. This is thought to be an advantage over the previous commonly used method of microfracture, which lays down fibrocartilage, having structural and functional characteristics inferior to the native cartilage. In-vitro models for BMAC with HS scaffolds have yielded promising results in terms of the ability of MSCs within the BMAC along with the HA scaffold to differentiate into chondrogenic cells11,12. Furthermore, subsequent clinical trials have yielded promising short- and medium-term outcomes in patients with focal cartilage lesions in the knee, lending support to this treatment strategy as a safe and viable alternative in patients with focal cartilage lesions of the femoral condyles13,14. Early clinical data suggests that such treatment with BMAC along with a scaffold may have utility in cartilage defects of acetabular defects in the hip as well, however, data to date is limited to retrospective cohort studies15,16. Given the burden of degenerative osteoarthritis on society, for which the direct costs to Canadians in 2010 was $2.9 billion and projected to increase to $7.6 billion by 203117, the use of MSC may be a possible treatment option. Conceptually, it is thought that MSCs have strong anti-inflammatory properties,18 and may even promote differentiation into chondrogen cells19. Small randomized clinical studies to date have found that BMAC may provide improvement in clinical outcomes, however, there was no difference when compared to contralateral saline injections in some studies20,21. As a result, the position statement of the Arthroscopy Association of Canada remains that there is insufficient evidence to support the use of stem cells for treatment of knee OA, and its use should be limited to clinical trials22. Similarly, the Canadian Orthopaedic Association (COA) released a position statement stating that currently there have not been any clinical trials that have been sufficiently powered to prove the efficacy of stem cell therapy, and therefore direct marketing to patients should be prohibited23. Soft Tissue Applications Early studies have assessed the efficacy of stem cells for use in soft tissue injuries within sports medicine, with most studies assessing efficacy for meniscal tears, anterior cruciate ligament (ACL), and rotator cuff tears. In rabbit models, two studies have shown that meniscal defects managed with stem cells added to a scaffold results in improved meniscal-like tissue with fibrocartilage healing compared to control groups without stem cells24,25. A small randomized trial by Vangsness et al. assessed the use of MSCs after partial meniscectomy via injection into the knee immediately postoperatively and found that these patients had significantly increased meniscal volume on MRI postoperatively compared to controls26. The use of MSCs to augment graft-tunnel interface healing has been assessed in several animal studies that have demonstrated promising results27. Results from small clinical studies have been mixed to date with respect to graft integration and clinical outcomes28–30.

COA Bulletin ACO - Fall / Automne 2020

Given the complexity and difficulty managing large chronic rotator cuff tears, the potential efficacy of MSCs in such tears is of particular interest. Adipose-derived stem cells has demonstrated efficacy as an augment to surgical repair in chronic rotator cuff tears in a rat model31. In a clinical retrospective comparative study, Kim et al. assessed the use of adipose-derived MSCs injected following arthroscopic rotator cuff repair, and found that the group augmented with stem cells had significantly lower re-tear rates on MRI than a control group, however, clinical outcomes were not significantly different32. Regulation Within the United States, stem cell therapies are a topic of regulatory ambiguity due to uncertainty as to how MSCs could fall into the category of homologous, minimally manipulated cells33,34. Given that the verdict could be different depending on the site of harvest, use of enzymatic digestion, or preparation techniques, it is currently recommended that each product be evaluated within the FDA on an individual basis33. It had generally been accepted that BMAC is not cultured or expanded and does not have additives, and as such, is considered to comply with Health Canada and FDA standards of minimal manipulation22. However, Health Canada’s policy statement maintains that autologous stem cells meet the definition of a “drug” and therefore they must be authorized for use by Health Canada according to the Food and Drug Regulations35. The use of such manipulated stem cells currently, would therefore be limited to use in controlled phase clinical studies. The potential ability of MSCs to differentiate into musculoskeletal tissue provides an exciting possibility within the field of orthopaedic surgery. Canada has recognized the potential of this modality and has recently increased their investment of research dollars into their investigation36. Laboratory and animal studies have yielded promising results when MSCs have been used to augment cartilage and soft tissue repair. However, clinical trials proving efficacy are not yet available. Furthermore, although only mild complications such as donor site pain and joint swelling have been reported within the literature to date, the long-term risk of autogenic stem cell use requires further investigation37. Such clinical trials are warranted and pending the results of these trials, the use of stem cells to augment cartilage and soft tissue repair within the field of orthopaedics, though promising, needs more robust scientific investigation prior to clinical application. References 1. Johnstone B., Hering T.M., Caplan A.I., Goldberg V.M., Yoo J.U. In vitro chondrogenesis of bone marrow-derived mesenchymal progenitor cells. Exp Cell Res. 1998; 2. Anz A.W., Hackel J.G., Nilssen E.C., Andrews J.R. Application of biologics in the treatment of the rotator cuff, meniscus, cartilage, and osteoarthritis. J. Am. Acad. Orthop. Surg. 2014. 3. Fralinger D.J,. Kaplan D.J., Weinberg M.E,. Strauss E.J., Jazrawi L.M. Biological treatments for tendon and ligament abnormalities: A critical analysis review. JBJS Rev. 2016.


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4. Crowe K. “Stem cell” therapies offered at private clinics need to be approved as drugs, Health Canada says [Internet]. CBC News. 2019. Available from: https://www.cbc.ca/news/ health/autologous-stem-cell-bone-marrow-fat-privateclinic-health-canada-regulation-1.5141299 5. Global Regenerative Medicine Market Grow to Over $81 Billion by 2023; Stem Cells, Tissue Engineering, BioBanking & CAR-T Industries [Internet]. Reportsnreports. 2019. Available from: https://www.prnewswire.com/in/news-releases/global-regenerative-medicine-market-grow-to-over-81-billionby-2023-stem-cells-tissue-engineering-biobanking-ampcar-t-industries-891595393.html 6. Zhou W., Lin J., Zhao K., Jin K., He Q., Hu Y., et al. SingleCell Profiles and Clinically Useful Properties of Human Mesenchymal Stem Cells of Adipose and Bone Marrow Origin. Am J Sports Med. 2019; 7. Hyer C.F., Berlet G.C., Bussewitz B.W., Hankins T., Ziegler H.L., Philbin T.M. Quantitative assessment of the yield of osteoblastic connective tissue progenitors in bone marrow aspirate from the iliac crest, tibia, and calcaneus. J Bone Jt Surg - Ser A. 2013; 8. Veronesi F., Giavaresi G., Tschon M., Borsari V., Nicoli Aldini N., Fini M. Clinical use of bone marrow, bone marrow concentrate, and expanded bone marrow mesenchymal stem cells in cartilage disease. Stem Cells Dev. 2013. 9. Raposio E., Simonacci F., Perrotta R.E. Adipose-derived stem cells: Comparison between two methods of isolation for clinical applications. Ann Med Surg. 2017; 10. Jones I.A., Chen X., Evseenko D., Vangsness C.T. Nomenclature inconsistency and selective outcome reporting hinder understanding of stem cell therapy for the knee. J Bone Jt Surg - Am Vol. 2019; 11. Cavallo C., Desando G., Columbaro M., Ferrari A., Zini N., Facchini A., et al. Chondrogenic differentiation of bone marrow concentrate grown onto a hylauronan scaffold: Rationale for its use in the treatment of cartilage lesions. J Biomed Mater Res - Part A. 2013; 12. Facchini A., Lisignoli G., Cristino S., Roseti L., Franceschi L., De, Marconi E., et al. Human chondrocytes and mesenchymal stem cells grown onto engineered scaffold. Biorheology. 2006; 13. Gobbi A., Karnatzikos G., Scotti C., Mahajan V., Mazzucco L., Grigolo B. One-step cartilage repair with bone marrow aspirate concentrated cells and collagen matrix in full-thickness knee cartilage lesions: Results at 2-year follow-up. Cartilage. 2011; 14. Gobbi A., Scotti C., Karnatzikos G., Mudhigere A., Castro M., Peretti G.M. One-step surgery with multipotent stem cells and Hyaluronan-based scaffold for the treatment of full-thickness chondral defects of the knee in patients older than 45 years. Knee Surgery, Sport Traumatol Arthrosc. 2017;

15. Hotham W.E., Malviya A. A systematic review of surgical methods to restore articular cartilage in the hip. Bone Joint Res [Internet]. 2018;7:336–42. Available from: http://www. ncbi.nlm.nih.gov/pubmed/29922453 16. Tahoun M.F., Tey M., Mas J., Abd-Elsattar Eid T., Monllau J.C. Arthroscopic Repair of Acetabular Cartilage Lesions by Chitosan-Based Scaffold: Clinical Evaluation at Minimum 2 Years Follow-up. Arthrosc J Arthrosc Relat Surg [Internet]. 2018;34:2821–8. Available from: https://linkinghub.elsevier. com/retrieve/pii/S0749806318305255 17. Sharif B., Kopec J., Bansback N., Rahman M.M., Flanagan W.M., Wong H., et al. Projecting the direct cost burden of osteoarthritis in Canada using a microsimulation model. Osteoarthr Cartil. 2015; 18. Levy D.M., Petersen K.A., Scalley Vaught M., Christian D.R., Cole B.J. Injections for Knee Osteoarthritis: Corticosteroids, Viscosupplementation, Platelet-Rich Plasma, and Autologous Stem Cells. Arthrosc - J Arthrosc Relat Surg. 2018; 19. Tuan R.S., Chen A.F., Klatt B.A. Cartilage regeneration. J. Am. Acad. Orthop. Surg. 2013. 20. Shapiro S.A., Kazmerchak S.E., Heckman M.G., Zubair A.C., O’Connor M.I. A Prospective, Single-Blind, PlaceboControlled Trial of Bone Marrow Aspirate Concentrate for Knee Osteoarthritis. Am J Sports Med. 2017; 21. Shapiro S.A., Arthurs J.R., Heckman M.G., Bestic J.M., Kazmerchak S.E., Diehl N.N., et al. Quantitative T2 MRI Mapping and 12-Month Follow-up in a Randomized, Blinded, Placebo Controlled Trial of Bone Marrow Aspiration and Concentration for Osteoarthritis of the Knees. Cartilage. 2019; 22. Kopka M., Sheehan B., Degen R., Wong I., Hiemstra L., Ayeni O, et al. Arthroscopy Association of Canada Position Statement on Intra-articular Injections for Knee Osteoarthritis. Orthop J Sport Med. 2019; 23. COA. Stem Cell Therapy Position Statement by the Canadian Orthopaedic Association (COA). 2018; 24. Angele P., Johnstone B., Kujat R., Zellner .J, Nerlich M., Goldberg V., et al. Stem cell based tissue engineering for meniscus repair. J Biomed Mater Res - Part A. 2008; 25. Zellner J., Mueller M., Berner A., Dienstknecht T., Kujat R., Nerlich M., et al. Role of mesenchymal stem cells in tissue engineering of meniscus. J Biomed Mater Res - Part A. 2010; 26. Vangsness C.T., Farr J,. Boyd J,. Dellaero D.T., Mills C.R., LeRoux-Williams M. Adult human mesenchymal stem cells delivered via intra-articular injection to the knee following partial medial meniscectomy A Randomized, Double-Blind, Controlled Study. J Bone Jt Surg - Ser A. 2014;

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27. Hexter A.T., Thangarajah T., Blunn G., Haddad F.S. Biological augmentation of graft healing in anterior cruciate ligament reconstruction. Bone Joint J. 2018; 28. Silva A, Sampaio R, Fernandes R, Pinto E. Is there a role for adult non-cultivated bone marrow stem cells in ACL reconstruction? Knee Surgery, Sport Traumatol Arthrosc. 2014; 29. Alentorn-Geli E., Seijas R., Martínez-De la Torre A., Cuscó X., Steinbacher G., Álvarez-Díaz P., et al. Effects of autologous adipose-derived regenerative stem cells administered at the time of anterior cruciate ligament reconstruction on knee function and graft healing. J Orthop Surg. 2019; 30. Wang Y., Shimmin A., Ghosh P., Marks P., Linklater J., Connell D., et al. Safety, tolerability, clinical, and joint structural outcomes of a single intra-articular injection of allogeneic mesenchymal precursor cells in patients following anterior cruciate ligament reconstruction: A controlled double-blind randomised trial. Arthritis Res Ther. 2017; 31. Rothrauff B.B., Smith C.A., Ferrer G.A., Novaretti J.V., Pauyo T., Chao T., et al. The effect of adipose-derived stem cells on enthesis healing after repair of acute and chronic massive rotator cuff tears in rats. J Shoulder Elb Surg. 2019;

33. LaPrade R.F., Dragoo J.L., Koh J..L, Murray I.R., Geeslin A.G., Chu C.R. AAOS research symposium updates and consensus: Biologic treatment of orthopaedic injuries. J Am Acad Orthop Surg. 2016. 34. Chirba M.A. n., Sweetapple B., Hannon C.P., Anderson J.A. FDA regulation of adult stem cell therapies as used in sports medicine. J. Knee Surg. 2015. 35. Government of Canada. Health Canada Policy Position Paper – Autologous Cell Therapy Products [Internet]. 2020. Available from: https://www.canada.ca/en/health-canada/ services/drugs-health-products/biologics-radiopharmaceuticals-genetic-therapies/applications-submissions/ guidance-documents/cell-therapy-policy.html 36. Rowe D.J. Canada is investing $6.9 million in stem cell research [Internet]. CTV News. 2020. Available from: https:// montreal.ctvnews.ca/canada-is-investing-6-9-million-instem-cell-research-1.4834862 37. Pas H.I., Winters M., Haisma H.J., Koenis M.J., Tol J.L., Moen M.H. Stem cell injections in knee osteoarthritis: a systematic review of the literature. Br. J. Sports Med. 2017.

32. Kim Y.S., Sung C.H., Chung S.H., Kwak S.J., Koh Y.G. Does an Injection of Adipose-Derived Mesenchymal Stem Cells Loaded in Fibrin Glue Influence Rotator Cuff Repair Outcomes? A Clinical and Magnetic Resonance Imaging Study. Am J Sports Med. 2017;

Publication opportunities are available in the COA Bulletin

Des opportunités de publication sont disponibles dans le Bulletin

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

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

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# The 2019 ABC Travelling Fellowship Tour Diary: Building Leadership and Wellness Through Connection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12 Minimally Invasive Foot and Ankle Surgery . . . . . . . 32 Dissecting Disparity: Improvements Towards Gender Parity in Leadership and On the Podium Within the Canadian Orthopaedic Association . . . . . . . . . . . 37 Resetting a Broken Procurement System . . . . . . . . . 46

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Le nouveau Guide aLimentaire canadien favorise-t-iL La santé de L’appareiL Locomoteur?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 30

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

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DE LA CÔTE À VOTRE ORDINATEUR :

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

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Canadian Orthopaedic Association Association Canadienne d’Orthopédie Does the New CaNaDa FooD GuiDe support a healthy skeletoN? . . . . . . . . . . . . . . . . . . p. 30

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Bone & “Joint” Pain:

ThE EVOlVINg ROlE OF CANNABIS AND MUSCOlOSkElETAl PAIN � � � � � � � � � � � � � � � � � � � � � � � � � � � p� 33

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La LégaLisation variabLe du cannabis et Les patients en orthopédie

Spring Printemps 2019 Le président de l’ACO souligne l’importance de l’engagement des members � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 3 Code Orange - Lessons Learned from Ottawa’s Mass Casualty Response � � � � � � � � � � � � � 20 Introducing Competence by Design (CBD) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41 New Bulletin Feature Highlights ‘Canadian Perspectives’� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 44

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

Platelet-rich Plasma – Where is the Evidence? Aaron Gazendam M.D. Moin Khan M.D., MSc, FRCSC Division of Orthopaedic Surgery, McMaster University Hamilton, ON

Clinical and Research Landscape latelet-rich plasma has become a popular minimally invasive orthobiologic used in the treatment of various musculoskeletal conditions and injuries. Platelet-rich plasma (PRP) was first utilized as an orthobiologic in the 1990s to enhance mandible bone grafts1. Platelet-rich plasma is prepared by centrifuging whole blood and extracting the plasma that is rich in platelets to inject into the area of interest. Platelets are rich in growth factors and cytokines and the biologic rationale for the clinical use of PRP is to delivery growth factors to the region of injury to promote healing and recovery2.

P

Since its first clinical application, the popularity of PRP has exploded, in part due to the widespread coverage within the mainstream media3. The portrayal of PRP in the media has been largely focused in its use and anecdotal success stories in celebrities and professional athletes3. PRP is widely used among team physicians of high-level athletes, despite a lack of consensus regarding PRP preparation and utility4. Platelet-rich plasma falls into the category of minimally-manipulated tissue according to the U.S. Food and Drug Administration (FDA) making it easier to use clinically without extensive testing compared to other biologics5. This, among other factors, has led to an increase in annual utilization by 400% from 2010 to 2014 based on Medicare data6. This increase in popularity and utilization has led to an expansion of the global market that is projected to reach over $450 million in the next decade7. Within orthopaedics, the indications of PRP vary widely but the majority can be broadly categorized into soft tissue applications and joint-based applications. Various tendinopathies have been studied including rotator cuff, patellar and Achilles tendon tendinopathies and lateral epicondylitis8. Platelet-rich plasma has also been used as a postsurgical adjunct for rotator cuffs repairs and anterior cruciate ligament reconstructions9,10. With respect to joint-based applications, the majority of the literature has focused on PRP in the management of arthritis, primarily in the knee11. Alongside the exponential clinical growth of PRP, there has been a substantial increase in research interest in the potential orthopaedic applications7. There have been several systematic reviews and meta-analyses performed, with the latest broad spectrum meta-analysis including 78 randomized controlled trials (RCTs) with over 5000 patients7. However, the current literature is complicated by low quality data, lack of standardization in study protocols, variability in PRP formulations and patientreported outcomes12. The majority of reviews published have demonstrated substantial variability between studies which can cause misleading effect sizes7.

The lack of standardization in the application of PRP is potentially the most important factor leading to heterogeneity among studies and a lack of consensus regarding efficacy5. There are over forty commercially available separation systems, leading to significant variability regarding concentrations of platelets, leukocytes and growth factors8. A review of over 100 clinical studies evaluating the use of PRP for orthopaedic conditions found that only 10% of trials provided adequate reporting of the preparation protocol used5. Beyond the differences in formulations, variability exists in the number and timespan between injections, delivery method (blind vs. image-guided) and cointerventions10. These findings have led to a call for standardized reporting and preparation to allow for a deeper understanding and development of a gold standard preparation5. Given that the premise of PRP is to deliver a specific ratio of cells, platelets and growth factors, it is imperative that future studies provide detailed protocols regarding PRP formulations and treatment specifics. Current Evidence Rotator Cuff Tears Evidence supporting the use of PRP for rotator cuff tears varies with specific pathology. The evidence is limited regarding nonoperative management of partial thickness and full thickness tears. However, there appears to be some evidence supporting benefit in using PRP as an adjunct following surgical repair13. The addition of PRP to repairs may result in improved rates of healing, reduced retear rates, functional outcome scores and postoperative pain scores based on findings of a recent meta-analysis of RCTs13–15. Given the heterogeneity of rotator cuff injuries and repairs, the efficacy of PRP may depend on the location of application, tear pattern and repair technique16. Further research should focus on elucidating differences in these variables to obtain a deeper understanding of the injury pattern and surgical techniques that benefit from adjuvant PRP. Tendinopathies Among tendinopathies, the use of PRP has been most thoroughly investigated in patients presenting with lateral epicondylitis. Level I data has demonstrated that PRP provides improvements in pain and function in patients with lateral epicondylitis when compared to both placebo and corticosteroid injections17,18. A recent network meta-analysis of patients with rotator cuff tendinopathy demonstrated long-term improvement in functional scores when compared to placebo, however significant heterogeneity limited the interpretation of the results19. The evidence is mixed when it comes to patellar tendinopathy and PRP. Data from meta-analyses suggest a small improvement in functional outcomes when compared to placebo20,21. However, a recent appropriately powered RCT comparing both leukocyte-rich and leukocyte-poor PRP demonstrated no benefit compared to placebo saline injections22. A summary of level I evidence examining the utility of PRP in Achilles tendinopathy has demonstrated no improvement in clinical outcomes or tendon thickness and is not currently recommended for clinical use23.

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Osteoarthritis Perhaps the most robust data available for PRP is in patients with knee osteoarthritis. Platelet-rich plasma is thought to alter the intra-articular environment in osteoarthritis by reducing inflammatory stress and promote chondrogenesis24–26. There have been several RCTs comparing platelet-rich plasma to placebo along with commonly available injections including corticosteroids and hyaluronic acid27–29. A recent network meta-analysis of 43 RCTs compared common intra-articular injections and found that multiple PRP injections led to significant functional improvements over placebo with minimal severe adverse events28. However, there was no significant improvement in pain or functional scores when compared to hyaluronic acid or corticosteroids. These results different from another recent review that demonstrated PRP was superior to HA, with leukocyte-poor PRP being the preferred treatment compared to leukocyte-rich PRP29. Other reviews have highlighted the imprecise treatment effect sizes secondary to small sample sizes and variability in reporting30. Given the significant heterogeneity of the available evidence and lack of standardization in preparation and formulations used, the Arthroscopy Association of Canada was unable to recommend for or against the use PRP for symptomatic knee OA until higher quality evidence is available31,32. There is a paucity of high-level data to guide clinicians in the utility of PRP for other large joints including the shoulder and hip. Regarding hip OA, four RCTs comparing PRP to HA have been performed and demonstrate conflicting results33–36. Based on the current literature, no recommendations can be made on the regular use of PRP for hip OA. The literature surrounding the use of PRP for glenohumeral OA is limited to case series and the clinic effectiveness of PRP in this population is unproven37. Future Considerations Our understanding of the potential roles and limitations of PRP for orthopaedic applications is continuing to evolve rapidly. The best available evidence suggests that there may be a role for PRP as an adjunct in rotator cuff repairs and for symptom management in both lateral epicondylitis and knee OA. A focus on achieving a consensus among experts in defining a standardized classification for the reporting in future studies will provide deeper insights into the role of PRP in the future. References 1. Marx R.E., Carlson E.R., Eichstaedt R.M., Schimmele S.R., Strauss J.E., Georgeff K.R. Platelet-rich plasma: Growth factor enhancement for bone grafts. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 1998. doi:10.1016/S10792104(98)90029-4 2. Andia .I, Abate M. Platelet-rich plasma: combinational treatment modalities for musculoskeletal conditions. Front Med. 2018. doi:10.1007/s11684-017-0551-6 3. Rachul C., Rasko J.E.J., Caulfield T. Implicit hype? Representations of platelet rich plasma in the news media. PLoS One. 2017. doi:10.1371/journal.pone.0182496

COA Bulletin ACO - Fall / Automne 2020

4. Kantrowitz D.E., Padaki A.S., Ahmad C.S., Lynch T.S. Defining Platelet-Rich Plasma Usage by Team Physicians in Elite Athletes. Orthop J Sport Med. 2018. doi:10.1177/2325967118767077 5. Chahla J., Cinque M.E., Piuzzi N.S., et al. A Call for Standardization in Platelet-Rich Plasma Preparation Protocols and Composition Reporting. J Bone Jt Surg. 2017. doi:10.2106/jbjs.16.01374 6. Zhang J.Y., Fabricant P.D., Ishmael C.R., Wang J.C., Petrigliano F.A., Jones K..J. Utilization of Platelet-Rich Plasma for Musculoskeletal Injuries: An Analysis of Current Treatment Trends in the United States. Orthop J Sport Med. 2016. doi:10.1177/2325967116676241 7. Johal H, Khan M., Yung S. hang P., et al. Impact of PlateletRich Plasma Use on Pain in Orthopaedic Surgery: A Systematic Review and Meta-analysis. Sports Health. 2019. doi:10.1177/1941738119834972 8. Hsu W.K., Mishra A., Rodeo S.R., et al. Platelet-rich plasma in orthopaedic applications: Evidence-based recommendations for treatment. J Am Acad Orthop Surg. 2012. doi:10.5435/JAAOS-21-12-739 9. Davey M.S., Hurley E.T., Withers D., Moran R., Moran C.J. Anterior Cruciate Ligament Reconstruction with PlateletRich Plasma: A Systematic Review of Randomized Control Trials. Arthrosc - J Arthrosc Relat Surg. 2020. doi:10.1016/j. arthro.2019.11.004 10. Moraes V.Y., Lenza M., Tamaoki M.J., Faloppa F., Belloti J.C. Platelet-rich therapies for musculoskeletal soft tissue injuries. Cochrane Database Syst Rev. 2014. doi:10.1002/14651858. CD010071.pub3 11. Laudy A.B.M., Bakker E.W.P., Rekers M., Moen M.H. Efficacy of platelet-rich plasma injections in osteoarthritis of the knee: A systematic review and meta-analysis. Br J Sports Med. 2015. doi:10.1136/bjsports-2014-094036 12. Khan M., Bedi A. Cochrane in CORR ® : Platelet-rich Therapies for Musculoskeletal Soft Tissue Injuries (Review). Clin Orthop Relat Res. 2015. doi:10.1007/s11999-015-4207-z 13. Hurley E.T., Lim Fat D., Moran C.J., Mullett H. The Efficacy of Platelet-Rich Plasma and Platelet-Rich Fibrin in Arthroscopic Rotator Cuff Repair: A Meta-analysis of Randomized Controlled Trials. Am J Sports Med. 2019. doi:10.1177/0363546517751397 14. Zhang Q., Ge H., Zhou J., Cheng B. Are Platelet-Rich Products Necessary during the Arthroscopic Repair of Full-Thickness Rotator Cuff Tears: A Meta-Analysis. PLoS One. 2013. doi:10.1371/journal.pone.0069731 15. Cai Y. zhi, Zhang C., Lin X. jin. Efficacy of platelet-rich plasma in arthroscopic repair of full-thickness rotator cuff tears: A meta-analysis. J Shoulder Elb Surg. 2015. doi:10.1016/j. jse.2015.07.035


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16. Warth R.J., Dornan G.J., James E.W., Horan M.P., Millett P.J. Clinical and structural outcomes after arthroscopic repair of full-thickness rotator cuff tears with and without platelet-rich product supplementation: A meta-analysis and meta-regression. Arthrosc - J Arthrosc Relat Surg. 2015. doi:10.1016/j.arthro.2014.09.007 17. Dong W., Goost H., Lin X.B., et al. Injection therapies for lateral epicondylalgia: A systematic review and Bayesian network meta-analysis. Br J Sports Med. 2016. doi:10.1136/ bjsports-2014-094387 18. Xu Q., Chen J., Cheng L. Comparison of platelet rich plasma and corticosteroids in the management of lateral epicondylitis: A meta-analysis of randomized controlled trials. Int J Surg. 2019. doi:10.1016/j.ijsu.2019.05.003 19. Lin M.T., Chiang C.F., Wu C.H., Huang Y.T., Tu Y.K., Wang T.G. Comparative Effectiveness of Injection Therapies in Rotator Cuff Tendinopathy: A Systematic Review, Pairwise and Network Meta-analysis of Randomized Controlled Trials. Arch Phys Med Rehabil. 2019. doi:10.1016/j.apmr.2018.06.028 20. Andriolo L., Altamura S.A., Reale D., Candrian C., Zaffagnini S., Filardo G. Nonsurgical Treatments of Patellar Tendinopathy: Multiple Injections of Platelet-Rich Plasma Are a Suitable Option: A Systematic Review and Meta-analysis. Am J Sports Med. 2019. doi:10.1177/0363546518759674 21. Chen P.C., Wu K.T., Chou W.Y., et al. Comparative Effectiveness of Different Nonsurgical Treatments for Patellar Tendinopathy: A Systematic Review and Network Meta-analysis. Arthrosc - J Arthrosc Relat Surg. 2019. doi:10.1016/j.arthro.2019.06.017 22. Scott A., LaPrade R.F., Harmon K.G., et al. Platelet-Rich Plasma for Patellar Tendinopathy: A Randomized Controlled Trial of Leukocyte-Rich PRP or Leukocyte-Poor PRP Versus Saline. Am J Sports Med. 2019. doi:10.1177/0363546519837954 23. Zhang Y.J., Xu S.Z., Gu P.C., et al. Is platelet-rich plasma injection effective for chronic achilles tendinopathy? A meta-analysis. Clin Orthop Relat Res. 2018. doi:10.1007/ s11999.0000000000000258

27. C.C. B, J.P. S, P.A. S, et al. Acute management of ACL injuries using novel canine models. J Orthop Res. 2016;34(Supplement 1). doi: http://dx.doi.org/10.1002/ jor.23247 28. Han S.-B., Seo I.-W., Shin Y.-S. Intra-articular injections of hyaluronic acid or steroid associated with better outcomes than platelet-rich plasma, adipose mesenchymal stromal cell, or placebo in knee osteoarthritis: a network metaanalysis. Arthrosc J Arthrosc Relat Surg. 2020. doi:10.1016/j. arthro.2020.03.041 29. Belk J.W., Kraeutler M.J., Houck D.A., Goodrich J.A., Dragoo J.L., McCarty E.C. Platelet-Rich Plasma Versus Hyaluronic Acid for Knee Osteoarthritis: A Systematic Review and Metaanalysis of Randomized Controlled Trials. Am J Sports Med. 2020. doi:10.1177/0363546520909397 30. Phillips M., Vannabouathong C., Devji T., et al. Differentiating factors of intra-articular injectables have a meaningful impact on knee osteoarthritis outcomes: a network metaanalysis. Knee Surgery, Sport Traumatol Arthrosc. 2020. doi:10.1007/s00167-019-05763-1 31. Vannabouathong C., Bhandari M., Bedi A., et al. Nonoperative Treatments for Knee Osteoarthritis: An Evaluation of Treatment Characteristics and the Intra-Articular Placebo Effect: A Systematic Review. JBJS Rev. 2018. doi:10.2106/ JBJS.RVW.17.00167 32. Kopka M., Sheehan B., Degen R., et al. Arthroscopy Association of Canada Position Statement on Intra-articular Injections for Knee Osteoarthritis. Orthop J Sport Med. 2019. doi:10.1177/2325967119860110 33. Di Sante L., Villani C., Santilli V., et al. Intra-articular hyaluronic acid vs platelet-rich plasma in the treatment of hip osteoarthritis. Med Ultrason. 2016. doi:10.11152/mu-874 34. Doria C., Mosele G.R., Caggiari G., Puddu L., Ciurlia E. Treatment of early hip osteoarthritis: Ultrasound-guided platelet rich plasma versus hyaluronic acid injections in a randomized clinical trial. Joints. 2017. doi:10.1055/s-0037-1605584

24. Bennell K.L., Hunter D.J., Paterson K.L. Platelet-Rich Plasma for the Management of Hip and Knee Osteoarthritis. Curr Rheumatol Rep. 2017. doi:10.1007/s11926-017-0652-x

35. Dallari D., Stagni C., Rani N., et al. Ultrasound-Guided Injection of Platelet-Rich Plasma and Hyaluronic Acid, Separately and in Combination, for Hip Osteoarthritis. Am J Sports Med. 2016. doi:10.1177/0363546515620383

25. Osterman C., Mccarthy M.B.R., Cote M.P., et al. Platelet-Rich Plasma Increases Anti-inflammatory Markers in a Human Cocultu. Model for Osteoarthritis. Am J Sports Med. 2015. doi:10.1177/0363546515570463

36. Battaglia M., Guaraldi F., Vannini F., et al. Efficacy of ultrasound-guided intra-articular injections of platelet-rich plasma versus hyaluronic acid for hip osteoarthritis. Orthopedics. 2013. doi:10.3928/01477447-20131120-13

26. Kabiri A., Hashemibeni B., Pourazar A, Mardani M., Esfandiari E., Esmaeili A. Platelet-rich plasma application in chondrogenesis. Adv Biomed Res. 2014. doi:10.4103/22779175.135156

37. Rossi L.A., Piuzzi N.S., Shapiro S.A. Glenohumeral Osteoarthritis: The Role for Orthobiologic Therapies: Platelet-Rich Plasma and Cell Therapies. JBJS Rev. 2020. doi:10.2106/JBJS.RVW.19.00075

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ACL RECONSTRUCTION WOULD YOU

REPAIR THE ALL?

ACL on: cti ALL? u r t s n o Rec epair the u R atest o Y d l u Wo ke our l Ta rship poll reade t here! righ The decision to perform ALL reconstruction concomitantly with ACL reconstruction has been a question of debate, particularly in recent years. The aim of this survey is to present various patient- and surgeon-specific variables, and assess their influence on the decision to reconstruct the ALL in patients undergoing ACL reconstruction. Stay tuned for a summary of these survey results, along with an expert debate between Drs. Alan Getgood (Western University) and Mark Burman (McGill University) in the next edition of the COA Bulletin

Tell us what YOU would do!


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

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

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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 schneida@canorth.org for consideration: 1) Imaging – up to 5 images

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

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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 schneida@canorth.org : 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 - Fall / Automne 2020

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

This edition’s case was submitted by Dr. Thomas Turgeon from the University of Manitoba

Neurolysis and Denervation of Incisional Neuromas: A Consideration in the Chronically Painful Total Knee Arthroplasty Thomas Turgeon, BSc, M.D., MPH, FRCSC Director of Arthroplasty Research, Concordia Hip and Knee Institute Fellowship Director for Hip and Knee Arthroplasty, Concordia Joint Replacement Group Associate Professor, University of Manitoba Winnipeg, MB

Clinical History and Diagnosis 76-year-old woman presented with a six-year history of chronic knee pain, following an otherwise uncomplicated primary total knee arthroplasty, with a request to have her knee revised. She described her pain as “constant” and both “central” within the knee and inferiomedial to the knee. Stairs were limited to one step at a time. Hyperesthesia was reported to the anterior knee. Infection work up was negative. She had already undergone physiotherapy and two genicular nerve blocks in the pain clinic, each having partial benefit for only two weeks. Pregabalin gave modest relief. Her medical history was remarkable for well-controlled Type-II diabetes and hypothyroidism.

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Figure 1 Lateral, Anteroposterior and Sky-line view of the painful knee.

The patient had a mildly antalgic gait with no obvious effusion and minor tissue swelling. There were no clinical signs of infection. The knee was stable throughout the flexion arc of 0-120 degrees. She was significantly tender over the pes tendons. Thumb pressure sliding along the incision identified a 5mm diameter partially mobile mass in the incision distal to the patella that was exquisitely tender. One millilitre of 1% lidocaine was infiltrated into the mass. Ten minutes later, the patient was reassessed and found that 70-80% of her original pain was relieved. The pain in the pes region was unaffected by the injection. Treatment Measures Diclofenac gel and physiotherapy were prescribed for pes tendonitis. The patient was consented for neurolysis and denervation of her incisional neuroma. The technique described by Dellon, et al. was used1. Preoperatively, the location of the neuroma was marked. In the surgical suite, a 5cm incision was made medially over the infrapatellar nerve. Careful blunt dissection was performed to identify the nerve in the subcutaneous tissue. The nerve was gently tugged to confirm that dimpling of the skin occurred in the pre-marked location of the neuroma. The dissection of the nerve was carried medially down to the muscle where it was sharply transected and buried into the muscle. The patient was returned immediately to full activities.

COA Bulletin ACO - Fall / Automne 2020

Figure 2 Neuroma examination.

Neuroma localization for diagnostic injection

Outcome At nine weeks postop, the patient reported that virtually all of her “central” knee pain was relieved by the surgery. When seen at one year from surgery, she indicated that her discomfort in the knee was minor and she had discontinued her analgesics.


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

Take-Home Message All surgeons who perform total knee arthroplasty will encounter the “looks good – feels bad” knee. The frequency of knee incisional neuroma formation has been reported in up to 10% of primary cases and 21% of revision cases when carefully assessed2. The same study found partial denervation had good to excellent pain relief in 84% of 50 subjects at a mean of two years2. While it is imperative to assess for mechanical and infectious causes of pain, incisional neuromas should be considered as part of the assessment process given the simplicity of the assessment and the relative frequency of their presence. Neurolysis and partial denervation is an effective intervention that can have a lasting benefit in cases of chronically painful total knee arthroplasty.

References 1. Dellon A.L., Mont M.A., Krackow K.A., Hungerford D.S. Partial denervation for persistent neuroma pain after total knee arthroplasty. Clinical orthopaedics and related research 1995-316:145-50. 2. James N.F., Kumar A.R., Wilke B.K., Shi G.G. Incidence of Encountering the Infrapatellar Nerve Branch of the Saphenous Nerve During a Midline Approach for Total Knee Arthroplasty. Journal of the American Academy of Orthopaedic Surgeons. Global research & reviews 2019;3-12.

Geriatric Fracture Care: The Ability to Create a Construct that can Withstand Immediate Weight Bearing is the Key to Success! Amir Khoshbin, M.D, MSc, FRCSC Assistant Professor, University of Toronto, Division of Orthopaedic Surgery, St. Michael’s Hospital Toronto, ON Ross K. Leighton, M.D., FRCSC Professor of Surgery, Dalhousie University Halifax N.S.

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are of the elderly has always been front and centre within the trauma subspecialty of orthopaedic surgery. The changes that have occurred over the last five to eight years have been significant and almost unheralded when surgeons discuss fracture care.

Horizons

The practice of orthopaedic surgery continues to evolve. We are faced with an explosion of information stemming from published cutting-edge research (bench and clinical). Likewise, an increasingly informed public has rapid access to information about novel therapies and surgical techniques. Oftentimes the best way to integrate evidence-based practice and innovative treatments is unknown or challenging. To add some perspective on how to approach emerging and/or controversial topics, we have developed this Horizons feature in the COA Bulletin. In the Horizons articles, thought leaders from various subspecialties will provide insights based on their extensive clinical experience and ongoing research. The goal of this feature is to “shed some light” on the best way forward.

tion as fast as the patient feels capable. Delaying mobilization has been associated with increased hospital re-admissions and mortality rates. The next step was cephallomedullary nailing for subtrochanteric fractures in the same patient population. Periprosthetic fracture about the hip and knee have also been approached in the same fashion. Revision joint replacement or long locked plates that allow the distribution of forces around the component and extend the fixation to the knee or the hip depending on where the fracture is located. What we considered “long plates” a decade ago (i.e.: 14-hole plates) have now become 20- or 22-hole plates that extend from the greater trochanter to the knee. We have learned to “protect the entire bone” (femur) in this patient population.

Fracture fixation in this patient population can be very challenging because of concurrent osteoporosis, metaphyseal comminution, an Paul A. Martineau, M.D., FRCSC increased risk of loss of reduction, Scientific Editor, COA Bulletin and difficulty adhering to the weightExamples here are of an elderly bearing restrictions postoperatively. woman with a periprosthetic fracThe ability to allow immediate weight bearing on osteoporotic ture (Vancouver C) with a long periprosthetic curved plate fractures is new and a bit frightening to us as we have all seen extending from the knee to the greater trochanter. This conthese same patients with fracture nonunions and malunions struct allowed immediate weight bearing as tolerated with a due to poor bone quality and delayed healing. How then do walker assist for 12 weeks (Figure 1). This is a huge difference we create constructs that can allow at least some weight bearfor mobility with this elderly population. The second example ing in this frail population? The ideas have been originally would be an elderly woman with a fractured femur above a generated around fractured hip patients. We have all moved total knee replacement. All of this existed in the setting of to replacement (whether partial or total hip replacements) for concurrent osteoporotic bone. This case was treated with a the subcapital fractures and IMHS devices for intertrochanlong supracondylar plate extending to the lesser trochanter. teric fractures, as they allow us the ability to permit mobilizaOnce again following the philosophy of “protecting the entire COA Bulletin ACO - Fall / Automne 2020

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

bone� appropriately. This construct again allowed >50% weight bearing within the first few weeks, which in turn will generate significant positive repercussions in this patient’s independence and quality of life (Figure 2).

loss and the possibility of several incisions. The concept of a cage or cup-cage arthroplasty with a cemented cup has resulted in similar outcomes without the need for prolonged surgery, and had a significant reduction in operative times (30% reduction) and blood loss (50% reduction) (Figure 3). In Figure 3, this example illustrates a geriatric acetabular (in an osteoporotic female) fracture with anterior column and quadrilateral plate injury as is typical for osteoporotic acetabular injuries. A cemented stem is also used due to the poor bone quality. This injury is dramatically different that the posterior wall and column injury typically seen with high-energy motor vehicle traumas, usually resulting from a flexed knee striking the dashboard. This X-ray illustrates the acute cage plus total hip replacement achieved with this described construct. This gave this patient the ability to immediately weight bear with a walker assist. The final result show healing of the acetabulum and illustrate excellent bony support of the total hip replacement construct for long-term survival.

Figure 1 Periprosthetic fracture of the hip fixed with a long plate from the hip to the knee. An alternate fixation would be a long supracondylar plate extending to the greater trochanter.

Figure 3 Acute THR (Cup + Cage construct). Figure 2 Supracondylar fracture fixed with a long plate extending to the lesser trochanter.

Tibial plateau fractures and pilon fractures have also changed to include a posterior medial plate for tibial plateau fractures and a posterior malleolar plate for pilon fractures. This again improves stability and allows earlier mobilization although weight bearing is still restricted in the articular fractures. In the elderly patient, we tend to allow 50% weight bearing with a walking boot for pilon fractures, and with the use of a hinged brace, usually 50% weight bearing is allowed for tibia plateau fractures. This concept has also gained momentum in very complex fractures of the acetabulum. The initial attempts involved fixation of the acetabulum (with plates and screws) followed by an acute total hip replacement after the reduction was complete. This worked well with early weight bearing as the goal, but involved a prolonged operative procedure with more blood COA Bulletin ACO - Fall / Automne 2020

Postoperative protocols for each surgeon is obviously fracture- and patient-dependent but the trend is clear. Returning elderly patients to their pre-injury function and independence is critically dependent on achieving early weight bearing and range of motion to achieve the best short, intermediate and long-term outcomes.


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

CIHI Report: Early Revisions of Hip and Knee Replacements in Canada Lyubov Kushtova MPH1 Canadian Institute for Health Information Michael Dunbar, M.D., FRCSC, PhD2 QEII Health Sciences Center, Dalhousie University Halifax, NS Eric Bohm, M.D., MSc, FRCSC2 Concordia Joint Replacement Group, University of Manitoba Winnipeg, MB

The top reason for early revision surgery was PJI at over 30% (Figure 1). PJIs occurring so soon after surgery may arise from intra-operative contamination and are caused by fairly virulent microorganisms 5,6. Around 60% of revisions due to PJI were urgent admissions. Acute length of stay (LOS) was about two times longer for revisions due to PJI compared to without PJI. For both hips and knees, revisions had longer operating room (OR) times when due to PJI compared to without PJI.

1. On behalf of the Canadian Joint Replacement Registry (CJRR) 2. On behalf of the CJRR Scientific Working Group

In August 2020, the Canadian Institute for Health Information (CIHI) released Early Revisions of Hip and Knee Replacements in Canada, a new analysis looking at early revisions of hip and knee arthroplasties and their impacts on health system utilization in Canada. This article highlights key findings from the report1. Context lthough advancements in surgical techniques and perioperative care have greatly reduced the risk of complications following surgery, peri-prosthetic infection (PJI) persists as one of the leading causes for revision2,3. Focusing on revisions occurring within two years of the primary surgery is particularly important, as these may be related to modifiable risk factors or to the surgery itself4. Revisions are typically more complex and require longer patient recovery time, ultimately leading to higher health-system costs and negative outcomes on patients’ quality of life3.

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Methods In order to identify early revision surgeries, this analysis followed a cohort of 99,478 patients for two years who had a primary hip or knee replacement for osteoarthritis (OA) in Canada from April 1, 2016, to March 31, 2017. Patients were identified using CIHI’s Discharge Abstract Database (DAD) Hospital Morbidity Database (HMDB) and National Ambulatory Care Reporting System (NACRS). Average standard cost of a hospital stay was determined using data from CIHI’s Canadian Management Information System Database (CMDB) and Patient-Level Physician Billing Repository. Details about the methodology can be found in the report1. Key Findings Of the 99,478 primary hip and knee replacement surgeries performed in Canada to treat OA in 2016-2017, a total of 2,012 had an early revision surgery within two years. The early revision rate was 2.2% for patients with primary hip replacement and 1.9% for patients with primary knee replacement. Just over 64% of all early hip revisions took place within 90 days of the primary surgery. For knees, almost 60% of early revisions occurred within one year of the primary surgery.

Figure 1 Top reasons for first early revision within two years of primary hip and knee replacement, Canada*. Note *Based on 811 hip and 1,201 knee early revision surgeries that occurred within two years of the primary joint replacement surgery due to osteoarthritis in 2016–2017. Only the first revision is included. Reason for revision is based on the coded most responsible diagnosis for the hospital stay and the coded first problem for day surgery. Other complications due to prosthesis includes conditions such as embolism, fibrosis, hemorrhage and pain. Remaining reasons that are not shown include other specific mechanical reasons and other less common complications. Sources Hospital Morbidity Database and National Ambulatory Care Reporting System, 2016–2017 to 2018–2019, Canadian Institute for Health Information.

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 33)

The average cost per hospital stay for a hip revision was 1.6 times higher compared to primary surgery; knee revision was 1.4 times higher compared to primary surgery (Figure 2). When the early revision was due to PJI, the cost difference was even higher, with these ratios increasing to 2.3 and 2.0 times for hips and knees, respectively. The estimated annual total cost for early revisions is over $42.1 million in direct inpatient costs annually (including physician billing costs based on five provinces, excluding rehabilitation).

Monitoring revision risk can also help to better understand factors that influence early revisions. CIHI continues to regularly report on cumulative revision risk for hip and knee replacements performed in Canada. Read the latest CJRR Annual Report, also released in August 2020, for the updated statistics8. Additional findings and methodology details can be found in the full report1. All authors involved in the full report are listed in the Acknowledgements section. CIHI would like to thank the CJRR Advisory Committee for their support for their feedback on this analysis. CJRR was launched in 2001 in collaboration with the Canadian Orthopaedic Association. For additional information about the CJRR, contact cjrr@cihi.ca. Select References 1. Canadian Institute for Health Information. Early Revisions of Hip and Knee Replacements in Canada: A Quality, Productivity and Capacity Issue. Ottawa, ON: CIHI; 2020. 2. Risk factors for early revision after total hip and knee arthroplasty: National observational study from a surgeon and population perspective. 2019. https://journals.plos.org/plosone/article/file?id=10.1371/journal. pone.0214855&type=printable 3. Rehospitalizations, Early Revisions, Infections, and Hospital Resource Use in the First Year After Hip and Knee Arthroplasties. 2012. https://pubmed.ncbi.nlm.nih. gov/21752579/

Figure 2 Average estimated costs per hospital stay for primary hip and knee replacements and early revisions (due to and excluding PJI), Canada,* 2017–2018 Note *Early revisions are defined as within two years of the primary surgery. Sources Hospital Morbidity Database, Canadian Management Information System Database and Patient-Level Physician Billing Data Repository, 2017–2018, and Case Mix Group+ 2018, Canadian Institute for Health Information.

Implications for Clinical Practice Revision surgeries occurring within two years of the primary surgery, especially those due to PJI, may be considered avoidable and represent actionable opportunities to improve quality of care7. Strategies to prevent PJI, such as strict adherence to infection control practices and optimized peri-operative care, can help reduce early revisions and improve patient outcomes and health system sustainability.

COA Bulletin ACO - Fall / Automne 2020

4. Singh J, et al. Trends in revision hip and knee arthroplasty observations after implementation of a regional joint replacement registry. Canadian Journal of Surgery. 2016. 5. Tande AJ, Patel R. Prosthetic joint infection. Clinical Microbiology Reviews. 2014. https://cmr.asm.org/content/27/2/302.abstract 6. Patel H, et al. Burden of surgical site infections associated with arthroplasty and the contribution of Staphylococcus aureus. Surgical Infections. 2016. https://www.researchgate.net/publication/282243667_Burden_of_Surgical_ Site_Infections_Associated_with_Arthroplasty_and_the_ Contribution_of_Staphylococcus_aureus 7. Alamanda VK, Springer BD. The prevention of infection: 12 modifiable risk factors. The Bone & Joint Journal. 2019. https://pubmed.ncbi.nlm.nih.gov/30648488/ 8. Canadian Institute for Health Information. Hip and Knee Replacements in Canada: CJRR Annual Statistics Summary, 2018–2019. Ottawa, ON: CIHI; 2020.


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

36

It’s Time to Speak Up. It’s Time to #FastTrackCare

T

he COA is proud to announce the launch of a public awareness, government relations and advocacy campaign called ‘Fast Track Care‘, tackling surgical wait times in orthopaedics now, and as we navigate the new normal after the pandemic. You can get involved too! #FastTrackCare was developed by Mobilize Canada, a coalition made up of the COA, the Canadian Orthopaedic Foundation, and the orthopaedic industry members of Medtech Canada. The initiative uses simple one step resources to empower surgeons, patients and allies to engage with provincial governments to: • • •

bring awareness to orthopaedic wait lists further exacerbated by COVID-19 remove the misconception that ‘elective’ orthopaedic procedures are optional or lifestyle surgeries advocate for the prioritization of orthopaedic procedures amid the pandemic, and emphasize that Canada has the human resource capacity to ramp up procedures

On www.fasttrackcare.ca, the #FastTrackCare Campaign offers the opportunity to automatically send an e-mail to your respective Provincial MLA and Provincial Minister of Health. This e-mail can be customized with a personal impact story and emphasizes that patients are waiting in pain for restorative procedures that are now further delayed by the pandemic. These are tools that allow your voice to be heard.

How You Can Support #FastTrackCare 1. Direct your patients to https://fasttrackcare.ca to take action or copy/paste #FastTrackCare into the search engine of Facebook, Twitter or LinkedIn to engage on social media. 2. The web site also features a downloadable GR 101 document that outlines ways you could advocate for your patients through the #FastTrackCare campaign. 3. Share this campaign through your own social media, web site and member communications (newsletters, journals). It’s time make our collective voice and message louder and stronger together. It’s time to speak up. It’s time to #FastTrackCare. If you have any questions about the campaign, please do not hesitate to contact CEO, Cynthia Vezina: cynthia@canorth.org

Il est temps d’en parler. Le temps est venu pour des #SoinsLaVoieRapide.

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’ACO est fière d’annoncer le lancement d’une campagne de sensibilisation publique, de relations gouvernementales et de défense des droits et intérêts intitulée Soins, la voie rapide. Cette campagne s’attaque aux temps d’attente actuels en orthopédie tandis que nous tentons de trouver nos repères dans la nouvelle réalité imposée par la pandémie. Et vous pouvez nous aider! #SoinsLaVoieRapide est le fruit de Mobilize Canada, une coalition composée entre autres de l’ACO, de la Fondation Canadienne d’Orthopédie et des membres de Medtech Canada, une coalition de sociétés de technologie des dispositifs médicaux. Cette initiative mise sur des ressources simples d’accès direct qui habilitent les orthopédistes, les patients et leurs alliés à approcher les gouvernements provinciaux de sorte à : • • •

les sensibiliser à l’effet amplificateur de la COVID-19 sur les temps d’attente en orthopédie; dissiper la fausse idée que les interventions orthopédiques non urgentes sont facultatives ou des chirurgies d’  «  agrément »; demander la priorisation des interventions orthopédiques en temps de pandémie en insistant sur le fait que Canada a les ressources humaines nécessaires pour accélérer la cadence.

À https://soinslavoierapide.ca/, la campagne #SoinsLaVoieRapide permet d’envoyer automatiquement un courriel à votre député provincial ainsi qu’à votre ministre de la Santé. Vous pouvez personnaliser ce courriel en y ajoutant une histoire personnelle et en mettant l’accent sur les patients qui attendent dans la douleur une chirurgie restauratrice que la pandémie retarde maintenant davantage. Il s’agit d’un outil qui vous permet de vous faire entendre. COA Bulletin ACO - Fall / Automne 2020

Voici comment soutenir #SoinsLaVoieRapide : 1. Invitez vos patients à consulter https://soinslavoierapide.ca/ pour agir ou copiez-collez le mot-clic #SoinsLaVoieRapide dans le champ de recherche de Facebook, de Twitter ou de LinkedIn pour participer à la campagne dans les médias sociaux. 2. Le site Web comprend également un document téléchargeable d’introduction aux relations gouvernementales, qui précise des façons dont vous pouvez défendre les droits et intérêts de vos patients dans le cadre de la campagne #SoinsLaVoieRapide. 3. Parlez de la campagne sur vos pages dans les médias sociaux, sur votre site Web et dans vos communications aux membres (bulletins et revues). Il est temps de s’unir pour affirmer notre message haut et fort. Il est temps d’en parler. Le temps est venu pour des #SoinsLaVoieRapide. Si vous avez des questions sur la campagne, n’hésitez pas à communiquer avec Cynthia Vezina, notre directrice générale, à cynthia@canorth.org.


How YOU can get involved to #FastTrackCare! What is the Fast Track Care campaign?    The  Fast  Track  Care  campaign  was  developed  by  Mobilize  Canada,  a  coalition  of  surgeons,  nonprofits and corporations dedicated to supporting patients needing orthopaedic surgery. 

What is the situation? COVID-19  has  exacerbated  existing  competition  for  bed  space  and  caused  surgical wait times  to  reach  unsustainable  levels,  further  burdening  the  healthcare  system  at  this  crucial  time.  Nearly  200,000  Canadians  have  been  waiting  in  pain  for  important  orthopaedic  surgeries  across  the  country.  Investment  and  prioritization  of  the  orthopaedics  sector  is  desperately  needed. 

Our goal: Build  awareness  among  Canadians  about  the  need  for  provincial governments to invest in and  prioritize  orthopaedic  surgery  to  get  Canadians  out  of  pain  and  back  to  work.  Nearly  all  Canadians  are  touched  by  someone  waiting  for  orthopaedic  surgery,  whether  it’s  you  or  someone you know. If you just want to support the campaign we’d love for you to get involved.  

How can I help? 1. Visit ​www.FastTrackCare.ca​.  2. Use  our letter writing tool to find and write your provincial representative, add your own  custom  message  and  tell  them  why  it  is  essential  that  your  government  invests  in  orthopaedic surgeries.  3. Share  the  #FastTrackCare  campaign  on  Twitter,  Facebook  or  LinkedIn with your friends  and family using the share buttons on the website.  4. Write  your  own  social  media  content  and  use  the  hashtag  #FastTrackCare,  tag  your  local  provincial  representative  and  share  our  website.  The  more  voices  involved  the  better. Share, share, share!  5. Once  you’ve  found  your  local  provincial  representative  and  used  our  website  to  write  them,  set  up  time  to  call  or  virtually meet with your local representative by visiting their  website  and  share  your  story.  You  can  find  our  solutions  document  on  our  website  to  guide your conversation and tell them to #FastTrackCare!   

It’s because of people like YOU that important change happens.   Thank you for getting involved to help Mobilize Canada #FastTrackCare.  


#SoinsLaVoieRapide: comment vous pouvez contribuer Qu’est-ce que la campagne #SoinsLaVoieRapide?    La campagne​ Soins, la voie rapide ​est une initiative de ​Mobilize Canada, ​une coalition de chirurgiens,  d’organisations sans but lucratif et d’entreprises qui soutient les patients ayant besoin d’une chirurgie  orthopédique. 

Quelle est la situation actuelle ? La pandémie de COVID-19 a entraîné une pénurie de lits dans les hôpitaux et fait en sorte que les  temps d’attente pour des chirurgies sont maintenant inacceptables, ce qui contribue à accroître la  pression sur notre système de santé en cette période pourtant cruciale. Dans l’ensemble du pays, près  de 200 000 Canadiens aux prises avec des douleurs importantes sont en attente d’une chirurgie  orthopédique. Ces gens ont désespérément besoin que les gouvernements investissent et fassent des  chirurgies orthopédiques une priorité. 

Notre objectif Sensibiliser les Canadiens à la nécessité que les gouvernements provinciaux investissent dans les  chirurgies orthopédiques et que celles-ci soient pour eux une priorité afin de soulager les Canadiens  concernés et de favoriser leur retour au travail. Que ce soit eux-mêmes ou un de leurs proches, la  presque totalité des Canadiens sont touchés. Nous espérons que vous nous apporterez votre soutien.  

Comment puis-je contribuer ? 1. Visitez​ ​www.FastTrackCare.ca​.  2. Signez la lettre-type et faites-la parvenir au représentant concerné dans votre province et, si  vous le désirez, ajoutez-y un message personnalisé expliquant pourquoi il est important que  votre gouvernement investisse dans les chirurgies orthopédiques.  3. Partagez les contenus de la campagne #SoinsLaVoieRapide sur Twitter, Facebook ou LinkedIn  en utilisant le bouton Partager et en invitant votre famille et vos proches à le faire.  4. Publiez vos propres contenus sur vos réseaux sociaux en utilisant le mot-clic  #SoinsLaVoieRapide, en identifiant également votre représentant local concerné et en  partageant notre site Web. Plus nombreux nous serons, mieux nous réussirons. Partagez,  partagez, partagez!  5. Après avoir identifié le représentant concerné de votre province et lui avoir envoyé le message  que vous trouverez sur notre site Web, tentez d’organiser un appel ou une rencontre avec lui en  visitant son site Web et en partageant votre histoire. Vous pouvez​ ​télécharger​ notre document  pour vous aider à peaufiner votre message et parler de #SoinsLaVoieRapide. 

C’est grâce à des gens comme vous que l’on peut changer les choses.   Merci d’aider Mobilize Canada dans sa campagne #SoinsLaVoieRapide. 


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

Reimagining Musculoskeketal Care in Edmonton: The Edmonton MSK Campus David M. Sheps, M.D., MSc, MBA, FRCSC Assistant Clinical Professor Department of Surgery University of Alberta Edmonton, AB

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rthopaedic care in Canada has been at crossroads for a number of years. Long wait times combined with limited resources and ever-increasing costs have placed tremendous pressure on the publicly-funded health-care system to deliver care that Canadians deserve. This has been a tremendous challenge for both patients and providers. The recent British Columbia Supreme Court Decision has highlighted the complexity of the problem. Our health systems, of which there are essentially thirteen, are complex and increasingly difficult to navigate for both patients and our primary care colleagues. Throughout the country, there are innovators who have introduced more efficient models of care to address the aforementioned challenges. These models of care, which are team-based and leverage multiple types of providers with their respective skill sets, attempt, with generally high degrees of success, to promote high-quality, timely, and appropriate care, which is driven by value both to the patient and the system. There are examples in almost every jurisdiction which demonstrate how effective this model of care can be. Our colleagues in Victoria have been successful in improving almost all aspects of the musculoskeletal care continuum across Victoria’s catchment area, with envious wait times for patients and imbedded metrics that assess outcomes related to both wait times and quality. They have demonstrated that a successful publicly-funded system can be created through collaboration across disciplines that serves both patient and provider and essentially gets the right patient to the right provider at the right time. Edmonton has also been successful in implementing similar models of care delivered through the Edmonton Bone and Joint Centre, the Division’s central access clinic for musculoskeletal care. Based out of two clinics at Northgate Mall, the Surgery Assessment Clinic and the Joint Assessment Clinic, our multidisciplinary teams deliver care across multiple subspecialties. We have a greater than ten-year history of perioperative preparation of the hip and knee arthroplasty patients which has successfully reduced the cost of preparation by over $400 per patient compared to preparation historically performed at an acute care hospital. We have recently begun work on including shoulder arthroplasty patients into the perioperative preparation pathway so that their care can be similarly optimised with the tracking of both time-based and quality-based outcomes. Assessment and screening programs for shoulder, foot and ankle, and hip and knee arthritis have delivered care to over 8000 patients in the last year. The shoulder assessment program has evaluated almost 5000 patients since its start in the fall of 2018 and have brought first assessment wait times for shoulder down to approximately 120 days from well over 12 months. The program has successfully implemented evidencebased nonoperative treatment pathways and has increased the surgical yield for patients referred to our group of seven shoulder surgeons to upwards of 80%. We continue to work on establishing further programs and are developing similar pathways for soft tissue knee and elbow to start in 2021. We, like others across Canada, have clearly demonstrated that delivering care in a publicly-funded health-care system can achieve reasonable wait times in an efficient and value-driven environment. However, like most aspects of health-care, there is

ample room to improve how care is delivered. This is the opportunity the Edmonton Musculoskeletal Campus proposal represents. A collaborative effort that includes the Division of Orthopaedics at the University of Alberta, Alberta Health, and Alberta Health Services, the Campus would accept the challenge proposed by the Ernst and Young Alberta Health Services Review and the MacKinnon Report, both undertaken to review Alberta’s healthcare system, to redefine health-care delivery in Alberta. The proposed Campus would consolidate existing day and 23-hour surgical procedures performed in Edmonton and the surrounding area into a single facility and allow for the potential expansion of services, increasing access to care and reducing wait times for surgery in line with the Alberta Surgical Initiative. Supporting the proposed ambulatory surgical facility will be an outpatient ambulatory care facility that will consolidate ambulatory care musculoskeletal services into a single centre. This will include elective consultations and preoperative and postoperative assessments performed by the Division’s orthopaedic surgeons. Additionally, team-based assessment or triage clinics designed to ensure patients with musculoskeletal conditions are assessed within six to twelve weeks of their presenting complaint to their primary care physician, will further expand the already successful programs delivered through the Edmonton Bone and Joint Centre. Estimated unique patient visits per year are roughly 500,000, with approximately 75% of those visits covering existing visits at acute care sites. This will provide Alberta Health Services the opportunity to repurpose existing outpatient facilities presently delivering orthopaedic care to support the growth of other outpatient and inpatient services in Edmonton and surrounding area. An unfortunate CBC article in August of this year misrepresented the spirit of the Edmonton Musculoskeletal Campus proposal. The guiding document for the proposal, created as part of the Alberta Health Services Request for Expression of Interest for Alberta Chartered Surgical Facilities, did not, at any point in the document, reflect a desire for the establishment of private pay health-care. Instead, the document outlined how the proposed Greenfield site could employ operational systems and pathways of care that would capture outcomes related to all aspects of highvalue health-care delivered in a publicly-funded environment. This would include the use of information technology to collect clear metrics on access, cost, and quality, and allow for a granular assessment of outcomes not presently achievable in our existing system. The Campus would also partner with the Alberta Bone and Joint Health Institute, employing their extensive experience in health-care evaluation, including the newly announced Map to Motion Bone and Joint Information Hub, to assist with the design and implementation the aforementioned measurement structure. Finally, the Campus would support the Orthopaedic Residency Program at the University of Alberta, providing a skills lab that supports surgical training, and would bring together the elements of the Division’s research infrastructure into a purpose-built facility that supports the advancement of world class research. The Campus is a unique opportunity at a unique time in healthcare transformation in Alberta. It is a chance to partner publiclyfunded health care with a privately-delivered system designed to demonstrate greater efficiency and value in an intentional way through data-driven design and outcomes evaluation. It aligns with the vision of the Division of Orthopaedics at the University of Alberta to achieve better patient care in a wholly publicly-funded manner that ensures equitable access for all Edmontonians and the people of central and northern Alberta. Finally, it represents how a potentially generational facility could transform musculoskeletal care in central and northern Alberta for decades to come. COA Bulletin ACO - Fall / Automne 2020

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Not all medial-pivot knees are created equal. To learn more about our products and the EvolutionÂŽ advantage please visit microportortho.com

Every patient is different, and individual results will vary. There are risks and recovery times associated with surgery. Trademarks and registered marks of MicroPort Orthopedics Inc. Š 2020 MicroPort Orthopedics Inc. All Rights Reserved. 017183 OCT2020


Resident Scholarship Opportunity – Call for Applications The Canadian Orthopaedic Foundation is pleased to announce that applications are now being accepted for the 2021 Bones and Phones Legacy Scholarship Award. One thousand dollars is awarded on an annual basis to an orthopaedic resident in his or her year prior to their final year of clinical training who is a member of the Canadian Orthopaedic Association (COA) and who meets the criteria as outlined in the guidelines and application documentation. More information, including eligibility criteria, application forms and guidelines, is available at www.whenithurtstomove.org: click on ‘Bones and Phones Scholarship’ under ‘Research & Awards’.

Bourses offertes aux résidents — Soumission des candidatures La Fondation Canadienne d’Orthopédie est heureuse d’annoncer qu’il est maintenant possible de soumettre sa candidature pour la Bourse d’études Bones and Phones 2021 : Chaque année, 1 000 $ sont remis à un résident en orthopédie membre de l’Association Canadienne d’Orthopédie effectuant son avant-dernière année de formation clinique et respectant tous les critères établis dans les directives et le formulaire de demande. Pour accéder à de plus amples renseignements, y compris les critères d’admissibilité, le formulaire et les directives, rendez-vous à www.whenithurtstomove.org/fr et cliquez sur « Fonds de bourses d’études Bones and Phones », dans le menu « Prix, bourses et subventions ». 2020 Scholarship Recipient / Lauréat de la bourse d’études 2020 :

David Stockton

(University of British Columbia / Université de la Colombie-Britannique) for his role in / pour son rôle dans

A Low Cost Orthopaedic Traction Device for Low-and Middle-Income Countries (Project summary) (Résumé du projet)


PREVENA

INCISION MANAGEMENT SYSTEM

PREVENA™ Incision Management System is the only medical device intended to manage the environment of surgical incisions and surrounding intact skin in patients at risk for developing post-operative complication, such as infection, by maintaining a closed environment via the application of negative pressure wound therapy system to the incision. The PREVENA™ Dressing skin interface layer with silver reduces microbial colonization in the fabric, PREVENA™ Therapy can help protect your high risk patients.

PREVENA™ Therapy can help: • Hold incision edges together • Remove fluids and infectious materials • Act as a barrier to external contamination • Deliver continuous negative pressure at -125mmHg up to 7 days

For more information, please visit prevenatherapy.com or call 1-800-668-5403 to schedule a meeting with your local representative NOTE: Specific indications, contraindications, warnings, precautions and safety information exist for these products and therapies. Please consult a physician and product instructions for use prior to application. This material is intended for healthcare professionals. © 2020 3M. All rights reserved. 3M and the other marks shown are marks and/or registered marks. Unauthorized use prohibited. PRA-PM-CA-00107 (09/20)


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

Canadian Perspectives: The Use of Stem Cells in Orthopaedic Surgery 3. Autologous cellular products such as SVF and BMAC 4. Allogenic cellular and acellular products from cadavers and placental tissues as well as DBMs

Matthew Stiebel, M.D., FRCSC, FAAOS Palm Beach Sportsmedicine West Palm Beach, Florida

“In the beginning there is the stem cell; it is the origin of an organism’s life.” Stewart Sell

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s a Canadian-trained orthopaedic surgeon practicing in the United States, I am fortunate to appreciate the insight into two different health-care systems. While the basic theories, clinical and surgical management remains universal within our profession - often there are significant regional differences in practice. One such difference is the current American “hype” involving biologic products.

In recent years the U.S. Food and Drug Administration has increased its compliance focus on the regenerative medicine industry. Commissioner Scott Gottleib stated, “We are focusing more resources on enforcement when we see companies skirt safety measures and put patients at risk.” At the same time, we are nearing the end of the 36-month period of “enforcement discretion” which began in 2017 and applied to all biologic products that didn’t meet criteria for section 351 under the American Public Health Service Act (PHSA). Under 351, blood-derived cell or tissue-based products basically have to be minimally manipulated and only used for homologous (same) use. Most of the “next generation” of biologics fail to meet this criteria and are listed under section 361 – where they are barely regulated. Later this fall, these products will be removed from the U.S. market.

There have been a number of significant paradigm shifts in orthopaedic surgery over the last 50 years: from the advent of plating fractures, to the development of joint replacements, to the use of minimally-invasive arthroscopy. Will the use of biologic Canadian Perspectives products be the next milestone in In this feature, COA members currently working orthopaedic treatment? Can we figoutside of the country share their insight on various ure out the “holy grail” of orthopaedifferences they’ve realized working in the United dics and treat patients with medical States (U.S.) or abroad in comparison to their intervention by regrowing cartilage and tendon? orthopaedic training in Canada. These experiences As a sports medicine physician, I am focused on the preservation of joints. I am fortunate to be able to offer my patients procedures such as fresh osteochondral allografts, meniscal transplants, and MACI (autologous cultured chondrocytes on porcine collagen membrane). All of these options are very well-studied, peerreviewed surgical treatments for patients that meet strict criteria. Because of their cost, however, these options are often only available in the United States.

highlight the perspectives of the COA’s growing number of members now working outside of Canada. Dr. Matthew Stiebel discusses the differences in the use of orthobiologics in Canada and the U.S. The promise of these products has likely outpaced the evidence to support them, but as discussed, there is a push in the US for biologic solutions in orthopaedic surgery that is also present in Canada. While data is not yet conclusive, hope remains, and awaits higher level evidence of effectiveness.

Health Canada has been slower to react with a continued abundance of direct-to-consumer marketing for stem cell interventions. Despite the fact that there is almost no randomized controlled clinical trials on many peddled orthobiologics, Health Canada has not yet moved to shutdown these clinics - despite labeling some of these therapies as ‘drugs.’ One proposed solution is to work with the Canadian Competition Bureau via the Competition Act to end players who provide materially false or misleading advertising1. Additionally there is not yet a regulatory system in place for developers as structured as the U.S. FDA2.

The lack of randomized clinical controlled trials makes the use of biologics in both the U.S. and Canada very controversial. While there is The most cutting-edge (and controno doubt that there are significant versial) research, however, moves “bad players” in both countries sellWilliam M Weiss, M.D., MSc, FRCSC, FAAOS past these more traditional treating snake oil, this does not mean Current Issues Editor COA Bulletin ments (which have been around for that all biologics can be grouped as at least 15-20 years) and looks to the ineffective. RCT studies have shown use of biologics. Biologic products in the United States can be that even the use of simple PRP in osteoarthritic knees can subdivided into four categories: lead to improved IKDC and lower VAS scores – with a decrease 1. Synthetic osteobiologics such as protein/peptides and in inflammatory cytokines such as IL-1Beta and TNF alpha3. synthetic bone graft extenders However, most newer biologics have not yet been studied with 2. Autologous blood-derived products such as PRP and the same adherence to scientific methods. To gain a better variants as well as POC proteomics understanding of where we are going with adipose derived

In this same edition, check out the current evidencebased discussion of both stem cell and PRP therapy from Canadian leaders in these areas on page 21.

COA Bulletin ACO - Fall / Automne 2020

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Training & Practice Management / Formation et gestion d’une pratique (continued from page 43)

SVF or bone marrow aspirate requires looking at the literature outside of North America. Notably Korean, Japanese or Italian studies have demonstrated that the newest data is compelling - if not yet fully scientifically proven4,5,6. American teams are also looking at local offshore data from the Bahamas to St. Kitts where stem cell governance differs from American guidelines. Moving forward, the American Academy of Orthopaedic Surgeons has established a Biologics in Orthopaedics Committee to help health-care specialists navigate the evolving field, and to highlight evidence-based scientific papers. It is my hope that the COA will follow suit. I am an optimist on the future of biologics and recognize that global collaboration on solid evidence-based medicine will move the field into the next generation of orthopaedic care; currently we are truly at the “beginning” or “origin stems” of this exciting field.

References 1. Caulfield T., Murdoch B. “Regulatory and policy tools to address unproven stem cell interventions in Canada: the need for action” BMC Medical Ethics. 20:51 (2019) 2. Tigerstorm B., Nguyen T.M., Knoppers B.M. “Regulation of stem cell-based therapies in Canada: current issues and concerns” Stem Cell Rev Rep. 2012 Sept;8(3):623-8. 3. Cole B.J., et al. Hyaluronic Acid Versus Platelet-Rich Plasma: A Prospective, Double Blind Randomized Controlled Trial Comparing Clinical Outcomes and Effects on Intra-articular Biology for the Treatment of Knee Osteoarthritis. Am J Sports Med 2017 Feb;45(2):339-346. 4. Tsubosaka M., et al. The influence of adipose-derived stromal vascular fraction cells on the treatment of knee osteoarthritis. BMC Musculoskeletal Disorders. 21:207, 2020. 5. Pak, Jaewoo, et al. Regeneration of cartilage in human knee osteoarthritis with autologous adipose tissue derived stem cells and autologous extracellular marix. Biores Open Access.2016;5(1): 192-200. 6. Roato Ilaria, et al. Concentrated adipose tissue infusion for the treatment of knee osteoarthritis: clinical and histological observations. International Orthopaedics Oct 11, 2018.

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

June 16-19 juin

COA Bulletin ACO - Fall / Automne 2020

2022

June 8-11 juin

2023

June 21-24 juin

2024

June 12-15 juin


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

How and Why Men Should Mentor Women Laurie A. Hiemstra, M.D., PhD, FRCSC 2nd President Elect, Canadian Orthopaedic Association Banff Sport Medicine Banff, AB

‘More women in orthopaedics? And they all want a mentor?’ ‘I can’t do that, what would I say? We have nothing in common.’ ‘I have to be careful of the #metoo movement, I can’t risk mentoring a woman.’ ‘Women in medicine should have a female mentor.’ ‘Men cannot be just friends with women.’

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ound familiar? It is all too easy to be a mentor for someone who looks like you, talks like you, and likes the same things as you. If you really want to make a difference, both in your life and in someone else’s, mentor someone who is different from you. The research overwhelmingly shows that diverse workplaces function at a higher level than non-diverse settings. With the increasing numbers of Canadian women in orthopaedics, it is time to step up and mentor, and to mentor someone different than you. Seems like an insurmountable task? Here are some easy to access resources to help you on the way. Written by guys for guys. In their new book, Athena Rising: How and Why Men Should Mentor Women, W. Brad Johnson and David Smith tackle the question of why men should mentor women. The book is written as a practical, commonsense guide by men for men who should be mentoring women but find it a challenging place to be. Athena Rising is divided into two parts. Part 1 lays the groundwork by explaining the challenges that women face, especially in a male-dominated work environment. They make the case as to why it is so important for men to mentor women and discuss some of the barriers to successful cross-gender mentoring. They make the case clearly: men can and should mentor women. Part 2 provides a practical roadmap on how men can successfully mentor women. They walk the reader through the benefits to both the mentor and mentee, and clearly tackle the issue of the #metoo that is the elephant in the room for all cross-gender mentoring relationships.

Major General Chris Field of the US Army summarizes the main aspects of mentorship of women by men into two main frameworks: mentor self-awareness and mentor action1: Mentor Self-awareness: 1. Do no harm – always promote your mentee’s best interests. 2. Practice humility – value different perceptions and experiences. 3. Listen - don’t talk so much – listen with an intent to understand, not to reply. 4. Maintain a learning orientation – learn about your mentee and from your mentee. 5. Be direct, honest, and unconditionally accepting – freely admit your own imperfections and limits of your knowledge and expertise. Mentor Actions: 1. Encourage career efficacy – support your mentee’s belief they are capable of managing their own educational and career capabilities, including their range and type of career options, and success into the future. 2. Sharpen, but don’t change -  your mentee’s leadership style. 3. Challenge – encourage, persuade and, if necessary, push your mentee to assume new and unfamiliar tasks and responsibilities. 4. Create opportunities for your mentee– support and endorse your mentee and enable their access to wider developmental networks. 5. Encourage excellence, but challenge perfectionism – communicate high, not unrealistic, expectations of your mentee. For example, the Rosenthal and Jacobsen Pygmalion Effect, ‘when we expect certain behaviours of others, we are likely to act in ways that make the expected behaviour more likely to occur’. 6. Champion assertiveness  –  support and encourage your mentee’s determination to make her perspectives clear and voice heard while realising credit for her accomplishments. “Athena Rising reminds us that when men lean in for equality, we all benefit. Brad Johnson and David Smith have written a powerful and practical guide for men on the steps that will make a big difference for organizations and for women.” – Sheryl Sandberg, COO of Facebook and Founder of LeanIn.Org “Finally, someone has tackled the central issue to women’s advancement at work: why don’t men champion female talent like they do for other men? ‘Athena Rising’ answers that question and — through story-telling and research — inspires men to rethink reluctance and mentor for the good of heir female colleagues, their companies, and, ultimately, themselves.” – Kat Gordon Founder, The 3% Movement

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Click here to read the book summary from Amazon. Did you read and enjoy Athena Rising? Their next book has just been released, and a copy is on its way to my mailbox. Enjoy further explanation of how men can be an ally to women in the workplace. Enjoy Audio over Visual? Interested in listening to Drs. Johnson and Smith? Meet them both with leadership expert Laurie Baedke on the Growth Edge Podcast. Laurie was a guest speaker in the 2020 COA Annual Meeting symposium, “Practical Strategies to Enhance Diversity and Physician Wellness in Canadian Orthopaedics”. She hosts an amazing podcast called Growth Edge, which explores many aspects of leadership from a health-care perspective. It is available on Apple Podcasts. The Growth Edge podcast shares the habits and practices of peak performers and top leaders, from many walks of life; physicians, senior executives, entrepreneurs, and academics. And from every season, from the seasoned and sage to those emerging leaders and rising rock stars. All who are blazing trails and shining a light for others2. “My deepest passion is mentoring leaders; nurturing selfawareness, offering objective counsel, being a cheerleader and a champion of others. If you enjoy growth, personal and professional development, and consistently challenging yourself to elevate your own performance and engagement, you’re going to love this podcast! We chat all things leadership, performance, purpose, resilience, emotional intelligence, strengths-based leadership, and so much more” – Laurie Beadke. W Brad Johnson, PhD: Mentorship Mastery - Why and How Men Can Better Mentor Women. By now, most of us know that the research is conclusive - organizations and institutions are better all-around when they’re diverse, all the way up to the C-suite. Women and minorities are good for the bottom line, for creativity, and for healthier, happier work environments. But how can we encourage men to mentor women in a post #metoo world? Many men feel that mentoring a junior woman is just too risky...not to mention it can seem uncomfortable.

Click here to listen! COA Bulletin ACO - Fall / Automne 2020

David Smith PhD: On Mentorship, Allyship, and Being a Good Guy. David Smith, author, professor, and researcher, sits down with Laurie Baedke to discuss mentorship, sponsorship, allyship, and advancing equity and inclusion in the workplace. They dig into the psychosocial elements of mentorship that are crucial in times of crisis and the unique differences between mentorship, sponsorship, and allyship. The explore how to audit your networks and relationships for diversity and inclusivity and outline the benefits of reciprocal mentoring relationships.

Click here to listen! References 1. https://cove.army.gov.au/article/review-essay-athena-rising-raising-boys#_edn6 2. Growth Edge Leadership Podcast: https://growthedge.libsyn.com/

Reference to any specific product, entity or service does not constitute as an endorsement by the Canadian Orthopaedic Association (COA). All views expressed are those of the author. The COA and the author do not receive any financial or in-kind benefit from the sale or use of products and entities mentioned in this article.


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COA Bulletin #128 - Fall 2020  

The Fall edition of the COA Bulletin, the official publication of the Canadian Orthopaedic Association

COA Bulletin #128 - Fall 2020  

The Fall edition of the COA Bulletin, the official publication of the Canadian Orthopaedic Association

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