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Canadian Orthopaedic Association Association Canadienne d’Orthopédie

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

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

BULLETIN

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Planning in the New Tax Regime and Avoiding Investment Fraud – Tips and Advice on Protecting Your Assets and Effective Financial Planning...................................... Page 53 La planification et le nouveau régime d’imposition et la fraude liée aux placements – Trucs et conseils sur la protection des actifs et une planification financière efficace

Rising to the Challenge – Read Dr. John Antoniou’s President Elect Address���������������������� 5 COA Spotlight: Women in Orthopaedics������������������������������������������������������������ 16 Early Revision Risk Curves from the Canadian Joint Replacement Registry���������������������� 35 Navigating the System: the Banff Sport Medicine Model������������������������������������������ 45 Nouveau leadership et croissance soutenue à la Fondation Canadienne d’Orthopédie�������� 50


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Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 121 - Fall / Automne 2018 COA / ACO John Antoniou President / Président Kishore Mulpuri Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Femi Ayeni Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

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Rising to the Challenge Through Advocacy and Research John Antoniou M.D., PhD, FRCSC President, Canadian Orthopaedic Association

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he 2018 Annual Meeting in Victoria was once again a resounding success. The beautiful setting and outstanding weather provided a perfect backdrop for this year’s excellent scientific and social programs, which were enjoyed by over 750 registrants. Our local arrangements and program committees, led by Drs. Colin Landells and Peter Dryden respectively, as well as Doug Thomson and the COA office staff including Cynthia Vezina, Meghan Corbeil, Trinity Wittman, and Lexie Bilhete ensured that all went off without a hitch. As in previous years, we had the honour of hosting three impressive guest lecturers. The R.I Harris Lecture was delivered by Dr. Stuart Weinstein. Dr. Weinstein gave very interesting insight into the promise and the reality of health-care reform in the United States. Professor David Hunter delivered this year’s Ian Macnab Lecture. The lecture focused on the principles and development of biomarkers for the musculoskeletal system. Finally, Dr. Frank Sim, Presidential Guest Speaker, delivered a very thought-provoking presentation on teamwork in orthopaedic oncology, featuring some awe-inspiring cases from his illustrious career. A full article on this year’s presidential award winners is featured on page 18 of this COA Bulletin. Other highlights of this year’s meeting include a symposium on acute pain management in orthopaedics, the combined Indian and Canadian Orthopaedic Association’s symposium on trauma, the presidential carousel symposium, and spine as the featured subspecialty. Finally, over 300 of our delegates enjoyed the excellent Gala at the Crystal Garden, which featured a crowd favourite band, Squidjigger. The band regaled the enthusiastic crowd to a series of great medleys. I would like to acknowledge the excellent work of our outgoing president Dr. Kevin Orrell and his wife Anne performed over the past year. They tirelessly and enthusiastically represented our Association on a national and international stage with grace and dignity. It is with great humility and honour that Johanna and I accept the privilege that our Association has bestowed upon us. Over the coming year, I hope to address some critical issues facing our specialty through advocacy at the regional, national, and international levels. 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 2018


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Johanna and I have just returned from the South African Orthopaedic Association, meeting where each Carousel president addressed the group on the subject of physician wellness in their respective countries. Shockingly, orthopaedic surgeon burnout rates have reached over 50% in some parts of the world. We must do a better job of documenting and promoting improved physician wellness here in Canada. To this end, the Continuing Professional Development (CPD) Committee with direction from Drs. Veronica Wadey, Ted Tufescu and Carrie Kollias has sent out a wellness survey to the entire membership entitled “Canadian Orthopaedic Surgery Physician Wellness Study”. Thank you for your participation in this important initiative.

Following this article, I am pleased to share the address I delivered at the recent Annual Meeting in Victoria as President Elect, entitled “Rising to the Challenge”. If you have any questions, I invite you to contact me at president@canorth.org or to follow me on twitter @JohnAntoniou3. Thank you.

Please mark your calendars for next year’s Annual Meeting in Montreal from June 19-22, 2019. It will be a combined meeting with the International Combined Orthopaedic Research Societies. As such, many international leaders in orthopaedic research will be present and participating. This promises to be one of the largest combined clinical and research meetings ever to be held in Canada. Don’t miss it!

Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 45

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 33

Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 52

Se montrer à la hauteur grâce à la défense des droits et intérêts et à la recherche John Antoniou, MD, Ph.D., FRCSC Président de l’Association Canadienne d’Orthopédie

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a Réunion annuelle, à Victoria, a une fois de plus été une grande réussite. Le cadre enchanteur et le temps exceptionnel convenaient parfaitement aux excellents programmes scientifique et d’activités sociales de cette année, dont plus de 750 participants ont profité. Les comités organisateur et responsable du programme, dirigés par les Drs  Colin  Landells et Peter  Dryden, respectivement, de même que Doug  Thomson et le personnel de l’ACO, soit Cynthia  Vezina, Meghan  Corbeil, Trinity  Wittman et Lexie  Bilhete, ont veillé au déroulement impeccable de la Réunion. Comme à l’accoutumée, nous avons eu l’honneur d’accueillir trois conférenciers impressionnants. Le Dr Stuart Weinstein a donné la conférence R.I.  Harris, qui brossait un portrait très intéressant des promesses de la réforme des soins de santé aux États-Unis par rapport à la réalité. Le  Pr  David  Hunter a donné la conférence Macnab. Il a principalement traité des principes et du développement de biomarqueurs pour l’appareil locomoteur. Enfin, le  Dr  Frank  Sim, conférencier invité par le président, a offert un exposé très stimulant sur le travail d’équipe en oncologie orthopédique, où il abordait quelques cas impressionnants de son illustre carrière. Un article sur les lauréats des prix de distinction du président figure à la page 18 de ce numéro du Bulletin de l’ACO.

COA Bulletin ACO - Fall / Automne 2018

Parmi les autres moments forts de la Réunion de cette année, mentionnons le symposium sur la gestion de la douleur aiguë en orthopédie, le symposium conjoint des associations indienne et canadienne d’orthopédie sur les traumatismes et le symposium du groupe Carousel, sans oublier la sous-spécialité à l’honneur, le rachis. Enfin, plus de 300 des participants à la Réunion ont assisté à la Soirée d’amusement au Crystal Garden. Le groupe chouchou Squidjigger y a fait le bonheur d’une foule déjà conquise avec d’excellents pots-pourris. Je tiens à souligner le travail remarquable du président sortant, le Dr Kevin Orrell, et de son épouse, Anne, au cours de la dernière année. Ils ont représenté l’ACO avec enthousiasme, ardeur, grâce et dignité sur la scène nationale et internationale. C’est donc avec beaucoup d’humilité et de gratitude que Johanna et moi acceptons le privilège que nous accorde notre association. Au cours de l’année qui vient, j’espère travailler à des dossiers cruciaux pour notre spécialité en militant tant à l’échelon régional que national et international. Johanna et moi revenons tout juste du congrès de la South  African Orthopaedic Association, où chaque président membre du groupe Carousel a traité du mieux-être des médecins dans son pays. J’ai été stupéfait d’apprendre que le taux d’épuisement professionnel chez les orthopédistes atteint plus de 50  % dans certains pays. Nous devons mieux documenter et promouvoir le mieux-être des médecins ici, au Canada. Pour ce faire, le Comité de perfectionnement professionnel (CPP), sous la houlette des Drs Veronica Wadey, Ted Tufescu et Carrie Kollias, a envoyé à tous les membres un


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sondage sur le sujet intitulé Sondage de l’ACO sur la santé des orthopédistes. Merci de participer à cette initiative importante.

plus imposants du genre jamais organisé au pays. Un incontournable!

À noter que la prochaine réunion annuelle aura lieu à Montréal, du 19 au 22 juin  2019. Elle sera tenue conjointement avec le congrès des International  Combined Orthopaedic Research Societies  (ICORS). Ainsi, nombre de sommités internationales de la recherche en orthopédie seront présentes. Ce rendezvous réunissant praticiens et chercheurs s’annonce l’un des

C’est en outre avec grand plaisir que je vous transmets ciaprès l’allocution que j’ai prononcée à titre de président élu à la Réunion annuelle de Victoria, intitulée « Se montrer à la hauteur  ». Si vous avez des questions, n’hésitez pas à m’écrire, à president@canorth.org, ou à me suivre sur Twitter, à @JohnAntoniou3. Merci.

Rising to the Challenge

Se montrer à la hauteur

We are pleased to share the President Elect Address delivered by Dr. John Antoniou on Friday, June 22 during the COA Annual Meeting held in Victoria.

C’est avec grand plaisir que nous vous transmettons ci-après l’allocution prononcée par le Dr John Antoniou à titre de président élu à la Réunion annuelle de Victoria, le vendredi 22 juin.

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r. Chairman, honoured guests, members of the Board and Executive, fellow colleagues, ladies and gentlemen, chers collègues, Mesdames et Messieurs. Thank you very much Kevin, for your kind introduction and thank you and Anne for your excellent leadership and outstanding representation of the COA nationally and internationally over the last year. It is with great humility, pride, honour, and most importantly, gratitude that I stand before you as the Dr. Kevin Orrell transfers the COA COA’s 73rd President. presidency to Dr. John Antoniou Il y a peu d’occasions dans la vie où l’on se voit donner la possibilité de s’adresser à un large groupe d’amis et de confrères pour leur parler sur un thème librement choisi. Pour cette raison, les mots des présidents antérieurs se ressemblent peu et reflètent en fait les intérêts personnels de chacun. Il y a cependant un thème que l’on retrouve dans tous les discours présidentiels, et c’est celui de la gratitude du président envers les membres de l’Association. Johanna et moi sommes extrêmement reconnaissants du grand honneur que vous nous avez fait en m’élisant président de l’Association Canadienne d’Orthopédie. Recevoir de manière aussi tangible l’approbation de ses confrères est une des expériences les plus satisfaisantes.

Dr. Bill Johnston, in his presidential address of 1999, made reference to the Canadian Orthopaedic family, one of whom was his late orthopaedic surgeon father, Dr. Cooper Johnston. Interestingly, the COA has many such family ties. These include three father-son presidents. My father did his residency at the Rizzoli institute in Bologna in the late 50’s. He was convinced to move to Montreal in the early 60’s by the COA’s 7th president, Dr. J. Calixte Favreau, who welcomed my father into the J Edouard Samson program in Montreal. The Favreaus treated my parents like family from day one. My parents never forgot their generous hospitality. My father then spent the better part of 35 years as the founding member and chief orthopaedic surgeon of a community hospital in Montreal. Here’s a picture of my father performing one of the first total knees in his hospital, with my mother performing the anaesthesia looking on. The national media covered this event and I’ve had this image imprinted in my mind ever since. The orthopaedic ward of that hospital now bears his name. My father and mentor passed in November 2010, a proud member of the Canadian orthopaedic family. My son, Anthony Antoniou, who is here today, bears his name.

Like many in our association, my orthopaedic journey dates back to my childhood, when I was fascinated by what my orthopaedic surgeon father did for a living.

COA Bulletin ACO - Fall / Automne 2018


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During my medical training at McGill, I had the privilege of observing one of our ex-COA presidents, Dr. Dick Cruess, expertly guide McGill Medicine as its medical Dean. My orthopaedic training was also at McGill. Dr. Max Aebi was the Chair and was also a key mentor of mine. It was he who instilled in me a passion for science and the love of research. I took time off during my residency to complete my PhD under Dr. Aebi and Dr. Robin Poole’s guidance at the Shriners hospital. It is during that time, more specifically in the summer of 1993, that I started going to the COA meetings and I haven’t missed one since. That was 25 years ago, it was also the last time that the Habs, or any Canadian hockey team for that matter, have won the Stanley cup - that’s a long time! As Dr. Ross Leighton and Dr. Emil Schemitsch have stated in previous addresses, the COA can improve your life and stimulate your career. It has certainly done so for me. Having the opportunity to serve in various capacities as CORS President, Editor of the Bulletin, on the Board and the Executive committees, as well as being an ABC travelling fellow, has helped me foster relationships and friendships in the orthopaedic community nationally and internationally. It has also given me a perspective that I would have never had otherwise. Many of the presidential addresses over the years have dealt with very scholarly, political and personal topics. Choosing a topic that resonated with me was difficult as I’m sure it was for all past presidents. Despite each past president speech’s unique nature, all of them finally centered around the constantly evolving role of the COA, whose core mission statement is to promote excellence in orthopaedic and musculoskeletal health for Canadians. I decided to highlight how the COA must rise to the challenges that are facing us in the coming years. Rising to the challenge through education, research, communication, collaboration, and advocacy, with the ultimate goal being excellent orthopaedic care for our patients.

Dr. John Antoniou delivers his President Elect Address at the Annual Meeting in Victoria

provincial innovations which have improved access to timely and appropriate MSK care. In 2017, the Steering Committee met with several federal agencies, including Health Canada, to promote Canadian MSK innovations. We are continuing our advocacy efforts this year by further partnering with champions from the provincial orthopaedic associations, starting with Ontario, to encourage provincial Ministry collaboration on piloting improvements in access to care.

An example of this is the position paper that was developed by some of the senior leadership in 1997, on access to hip and knee replacement with the end result being increased federal and provincial funding to address this issue.

A recent example of the COA’s role in shaping our surroundings includes the work performed in tracking and generating a position statement on the issue of under-employed orthopaedic graduates across the country. At its worst, there were 178 underemployed recently graduated surgeons in 2015. Although we strongly advocate for increasing resources to help existing surgeons deliver care across the country, we must also be aware of the existing financial reality facing us, and refrain from training an unsustainable number of orthopaedic surgeons who will end up not finding suitable employment. Currently, there are approximately 165 recent graduates who are in the market for a full-time position, coupled with a decrease to 54 new residency positions offered across the country in 2017 from a high of 81 in 2011. The COA needs to continue to closely monitor this situation as it improves to make sure that the governments and programs don’t overshoot the mark and potentially lead to an orthopaedic shortage. This is a moving target indeed. We encourage all members to make use of the COA Job Board to post job openings in a transparent fashion and to familiarize themselves with the COA Guidelines for Late Career Transition and job sharing.

As a result, we have continued to advocate for shorter wait times and improved access to quality orthopaedic care. In 2016, the COA Access to Care Steering Committee enlisted member support in developing an inventory of dozens of local and

Other recent position statements of note include the Intimate Partner Violence Position Statement, the Position Statement on Global Travel Restrictions, the COA Response to the Constitutional Challenge to B.C.’s Ban on Private Health

I would like to concentrate on the two important pillars that are closest to my heart - those of advocacy and research. Let’s start with advocacy. As you know, our volunteer association has tirelessly canvassed the orthopaedic landscape since its inception in Montreal in June 1945, at the Mount Royal Hotel with its 24 founding members in attendance. It has since grown to represent over 80% of the 1300 active orthopaedic surgeons from across the country. It has many “wins” to its credit over the decades. Position statements have been developed over the years and have helped shape and develop national policy. Whereas we used to generate one to two position statements per decade, we have now issued nine in the last three years.

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Insurance led by the Cambie Surgery Centre, and a Consensus Statement on Patients with Total Joint Replacement having Dental Procedures. We are also delighted to report that after ten years of joint advocacy between the COA and COFAS on the issue of podiatrists trying to alter the current restrictions on their podiatric scope of practice, the Ontario health ministry has decided that podiatric practice restrictions will continue despite the podiatrist’s persistent attempts to widen their scope of care to include surgeries. It is important to note that these position statements and advocacy efforts do not occur in a vacuum. The COA initiates efforts at the subcommittee level with the help of subspecialty representation. The position statements are published and disseminated to serve the needs of orthopaedic surgeons, patients and policy makers across Canada. They are also reviewed every year and modified to reflect current standard of care. For this reason, I am happy that the COA has worked hard to defragment our specialty to have us all represented under one unified and collaborative umbrella. It is for this reason that I am delighted and proud to see a strong representation from the various subspecialty societies that are so closely affiliated with the COA. We are the only association that speaks with one united voice to both levels of government, media, colleagues, and the population at large. The COA has the moral duty to be the arbiter of evidence-based truth. More than 1.5 billion people currently carry around a smartphone, that’s more power than organized religion. Fake news is now crowding out facts and people don’t have the ability to triangulate in order to fact check what is out in the ether. The COA has to be the guardian and disseminator of truth. Our current advocacy efforts must keep up with the ever changing information landscape. We are in an enviable position to be a trusted source. We must continue to advocate for better orthopaedic care through our continued publishing of up to date position statements. We are just now publishing on the current standard of care in the treatment of early arthritis with our sports medicine colleagues and we are completing a consensus statement on the use of opioids in orthopaedic surgical practice. The COA is also a trusted partner in identifying musculoskeletal interventions with Low or Limited Levels of Efficacy in partnership with the Choosing Wisely movement. Over the last year the number of recommendations has doubled from five to ten and have been disseminated to health-care professionals and the public at large through an extensive social media blitz. We must also advocate with our respective federal and provincial partners to continue to improve the delivery of orthopaedic care, the importance of setting up registries, and continued access to the latest in orthopaedic implant technology. While we understand the importance of cost containment in a time where health-care costs represent more than half of any provincial budget, we must fight against the growing trend among some provinces to request for regional tenders, and to push for ever lower implant costs provided by fewer and fewer companies.

As advocates for our patients, we must balance fiscal responsibility with this risky “race to the cheapest”. If these trends continue, at an extreme, the lion’s share of the orthopaedic landscape will be controlled by a few companies, and Canada will be relegated to a third rate jurisdiction when it comes to introducing newer technology and new implants, potentially hurting the level of care we provide for our patients. In order to rise to this challenge, the COA must partner with govern- Dr. John Antoniou with his spouse, ments and our indus- Dr. Johanna Choremis and their eldest try partners through son, Anthony MEDEC to help maintain a balance. To this end, we plan to hold meetings with our industry partners and government representatives at the federal and provincial levels over the coming year. How about research and innovation? The COA, along with CORS and the Canadian Orthopaedic Foundation, have been strong supporters of orthopaedic research ever since their inception. Despite this, the COA needs to do more to help promote strong collaboration between surgeon-scientists, researchers, and surgeons in the “real world” who can help in the advancement of orthopaedics. In general, the surgeon-scientist is an endangered species. Given the time pressures of clinical practice, the number of surgeons participating in research, especially of the basic variety, has diminished dramatically. NIH and CIHR funding to surgeon scientists has steadily declined over the last three decades. A recent publication from the University of Toronto’s Surgeon Scientist’s program has demonstrated a significant decline in the number of surgeons participating in the basic sciences over the past three decades. The traditional model of the surgeon–scientist working alone and essentially performing two full-time jobs, while also competing for funding, is becoming increasingly unviable. A surgeon–scientist with substantial clinical, teaching, and administrative responsibilities cannot effectively compete for the same grants as a full-time basic scientist. To level the playing field, several paradigms of surgeon–scientists have emerged, including team science, with many players working on the same clinical problem as a team, leveraging each other’s expertise, skill, and knowledge. The surgeon–scientist can have a critical role in formulating a clinically relevant hypothesis, in setting up a systematic approach for its study, COA Bulletin ACO - Fall / Automne 2018


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and in performing the critical experiments in partnership with pathologists, other clinicians, basic scientists, and bioinformaticians. Surgeon–scientists often have the right personality, work ethic, and training to lead a research team, in the same way that they lead a team in the operating room. Such teamwork can facilitate the generation of new knowledge that can result in clinically translatable ideas and contribute to developing successful training and project grants. As an association, we need to continue our efforts to promote orthopaedic surgeon scientists as the de facto leaders in MSK care. We need to promote leaders that will take seats in important decision-making bodies that directly impact orthopaedic care and research. One of our former presidents was such a leader. The late Dr. Cy Frank was the scientific Director of IMHA at the CIHR from 2001-2007. Cy and his Institute Advisory Board created innovative research and training programs that demonstrated the importance of musculoskeletal research in improving the health of Canadians. Ever since his untimely passing, orthopaedics has not seen such leadership and representation at CIHR. We are also getting less research dollars from CIHR and from industry alike. This lack of research support and the diminishing importance of surgeonscientists threaten our specialty, and may relegate our role to technician status. We, as surgeons, understand the clinical problems facing our patients and we participate in delivering new therapies. But we must be willing to do more than just inject PRP or stem cells into our patients without true in-depth knowledge of what such interventions are accomplishing. If we don’t, then others will, and we will lose our leadership role in MSK care. The advent of new gene editing techniques through CRISPR, new tissue engineering technology, nanotechnology, 3D bioprinting, the use of big data and many more new technologies must be tapped in order to translate them into new therapeutic techniques in our specialty. I propose that orthopaedic leadership in collaborative research work is the only true way to rise to these coming challenges. CIHR has taken note and steps are being taken to re-institute the MD/PhD program along with having more orthopaedic surgeons involved in the grant review process. The COA needs to continue advocating for an increased orthopaedic presence at the CIHR. Under the expert guidance of Dr. Geoff Johnston, the Canadian Orthopaedic Foundation has increased the number of CORL awards being granted every year including the J. Edouard Samson, Community Innovation, Carroll A. Laurin, Robert B. Salter, and Cy Frank awards, the Bones and Phones scholarship and the recently announced Robin Richards endowment Fresh off the heels of being the guest nation at this year’s ORS meeting in New Orleans, our CORS is now being re-vamped to help garner more interest in orthopaedic research in Canada. We are busy organizing what will likely be the largest combined orthopaedic meeting in Canadian history.

COA Bulletin ACO - Fall / Automne 2018

Along with our usual excellent COA meeting in Montreal, we will be hosting the International Combined Orthopaedic Research Societies’ meeting in a parallel venue. Our members will have the opportunity to interact and participate in a meeting that will showcase cutting-edge orthopaedic research from around the world. In addition to the CORS and American ORS, we will host delegations from Europe, Britain, Australia, New Zealand, Turkey, China, Korea, Japan, among others. Furthermore, we are developing a new travelling fellowship in conjunction with the ORS to allow American and Canadian orthopaedic researchers to visit labs from across North America in order to foster collaboration, and innovation in orthopaedic research. As Cy Frank stated in his presidential address, the COA will promote collaborative research in order to link researchers with collaborative surgeons in the real world. These initiatives in research will be an important part of our continued mission to promote excellence in orthopaedic and musculoskeletal health for Canadians. In closing, I would like to reiterate how honoured I am to have been selected to serve as President in the coming year. I will work diligently with the Executive, the Board, and the COA staff to promote the COA’s collective vision nationally and internationally. The COA staff has been led by the expert hand of Doug Thomson whom I’ve worked with in various capacities over the last couple of decades. He has been instrumental in helping me attract, organize, and promote the coming ICORS/ COA combined meeting. Thanks Doug, and thank you to the entire COA staff. I am also grateful to my mentors, collaborators, friends, family and supporters. In particular, Dr. Fackson Mwale who is my friend and co-director of the orthopaedic research lab at the Lady Davis Institute, and to all of my colleagues at the Jewish General Hospital, who have supported me and helped protect my time to attend to the duties that await me as COA President. When I look at my colleagues, I am honoured to be part of such a diverse group of professionals. I’m proud to say that women represent 42% of my orthopaedic partners at the JGH. The COA membership landscape is now comprised of 18% women and the COA is working hard to ensure that this is reflected in its committee membership, (currently made up of 15% women), and Annual Meeting faculty and presenters (this year made up of 22% women). In fact, diversity among members and Annual Meeting participants is promoted and supported by the COA. A number of initiatives to support gender and diversity inclusion in our profession are underway, including a mentorship program at future Annual Meeting sessions. I encourage all of you to consider getting involved in the COA in order to give back to our beloved specialty. Churchill famously said “we make a living by what we get … we make a life by what we give”. I hope you will consider giving your time by getting involved in the COA and help us all rise to the coming challenges! Finally, I would like to thank my beautiful wife Dr. Johanna Choremis, and our sons Anthony and Constantine, whose unwavering love and support have been pillars of strength and inspiration for me. Je vous souhaite une bonne réunion. Merci beaucoup, thank you very much.


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Kevin Orrell Reflects on his Presidential Year

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r. Kevin Orrell completed his term as the COA’s 72nd President at the Annual Meeting in Victoria this past June. We asked him to share some of the highlights of his presidential year, what he learned from the membership during his mandate, and what issues he thinks should be the focus of the COA going forward as the voice of the profession.

DR. K. ORRELL: While travelling to orthopaedic centres worldwide, we were fortunate to befriend many amazing orthopaedic leaders from around the world. They have become great friends and these friendships continue. The visit to a game reserve in South Africa was truly amazing and was one of our most enjoyable cultural events.

COA BULLETIN: The COA Annual Meeting is a significant event for the President. Share with us some of your favourite moments from the Annual Meeting in Victoria?

Domestically, I was very pleased to get to know even more of my colleagues across the country and learn about the concerns of our membership. It is rewarding to be involved in strategies to improve our ability to care for Canadians and to enrich our specialty.

DR. K. ORRELL: The Annual Meeting was a magnificent event. By far, the most exciting moment for Anne and I was the Fun Night. It was a true celebration with friends and colleagues and a wonderful finale to our presidential year. The band, Squidjigger, was truly amazing and had everyone on their feet for the entire evening. We were very proud of the spirit of Canadian orthopaedics witnessed by our international and special guests. As well, this event was a true celebration of the very rich academic quality to the Annual Meeting. Many thanks to the Program Committee Chair, Dr. Peter Dryden the Local Arrangements Chair, Dr. Colin Landells, and all members of the various committees for their hard work in Victoria on our behalf. COA BULLETIN: What are some of the highlights of your presidential year?

COA BULLETIN: Being President gave you the opportunity to meet and network with your membership on a much larger scale. What did you learn from the membership through these interactions? DR. K. ORRELL: Canadian orthopaedic surgeons are concerned about many things. Individually, we experience a great deal of job satisfaction in our daily work. However, access to care, wait times, remuneration, and recent changes in tax law has independent surgeons, provincial, and regional associations very concerned for the future. The unemployment and underemployment of young, well educated orthopaedic surgeons is a national disgrace. I have heard from many individual surgeons and have attended meetings of provincial associations. This is a wonderful opportunity for the COA President to interact with the membership and become intimately aware of the regional concerns of our membership. This will help unite our advocacy efforts at all levels of government.

Dr. Kevin and Anne Orrell with the presidents and guests of the Carousel orthopaedic societies COA Bulletin ACO - Fall / Automne 2018


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(continued from page 9)

COA BULLETIN: How can member engagement and active participation within the COA benefit the orthopaedic profession? DR. K. ORRELL: We are fortunate to have many very talented and energetic members who are also leaders in their community, province, and country. Their participation has always enriched our Association and helped to direct our focus. Yet, we must all come forward and become involved in some capacity, especially the younger generation of orthopaedic surgeons and researchers. There is a very important role for the academic as well as community surgeons, so that all members of our profession are well represented. These combined efforts will increase our chances for positive change in the future. COA BULLETIN: What are the primary issues that the Association should focus on and address over the next year? DR. K. ORRELL: Over the last few years there has been persistent focus on access to care, employment of our trainees, as well as transition into and out of practice. These remain

important considerations for our members. This year we have focused on access to care and advocacy initiatives. There is a need to work together with our provincial and regional associations. The COA now has a position paper addressing the opioid crisis in Canada. Diversity has become a very important issue worldwide, and is a major consideration of our Association at the present and coming years. COA BULLETIN: Any words of advice for your successor, Dr. John Antoniou? DR. K. ORRELL: John has distinguished himself as a research scientist, orthopaedic surgeon and leader. He has been very active in the COA for many years. He brings a great deal to the table, and I am certain he will be an outstanding president. We are fortunate to have him in this leadership role. My only advice would be that he and Johanna enjoy every minute of the new things they will learn and friendships they will experience this year. It is an opportunity of a lifetime.

Réflexions de Kevin Orrell sur son année à la présidence

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e Dr Kevin Orrell a terminé son mandat à titre de 72e président de l’ACO à la Réunion annuelle de Victoria, en juin dernier. Nous lui avons demandé de nous parler des moments marquants de son année à la présidence, de ce qu’il a appris des membres pendant son mandat, ainsi que des enjeux sur lesquels l’ACO devrait axer ses efforts en tant que représentante des orthopédistes. BULLETIN DE L’ACO  : La Réunion annuelle de l’ACO est une manifestation importante pour le président. Racontez-nous quelques-uns de vos moments préférés de la Réunion annuelle de Victoria. Dr K. ORRELL : La Réunion annuelle était magnifique. La Soirée d’amusement a été de loin le moment le plus emballant pour Anne et moi. C’était une véritable fête entre amis et collègues, et une très belle façon de conclure notre année à la présidence. Le groupe Squidjigger était vraiment incroyable, et tout le monde a passé la soirée à danser. Nous sommes très fiers de l’impression que les orthopédistes canadiens ont faite sur nos invités spéciaux et internationaux. Aussi, c’était une véritable célébration de la très grande qualité de la recherche présentée à la Réunion annuelle. Je souhaite remercier sincèrement le Dr Peter Dryden, président du Comité responsable du programme, et le Dr Colin Landells, président du Comité organisateur, de même que tous les membres des différents comités pour leur dur labeur en notre nom à Victoria. BULLETIN DE L’ACO : Quels ont été les moments marquants de votre année à la présidence?

COA Bulletin ACO - Fall / Automne 2018

Dr K. ORRELL : Dans nos voyages, nous avons eu l’occasion de tisser des liens avec nombre de leaders exceptionnels dans des centres orthopédiques partout sur le globe. Ce sont aujourd’hui de bons amis, et ces amitiés perdurent. Notre visite dans une réserve de gibier en Afrique du Sud a été extraordinaire, et l’une de nos activités culturelles les plus agréables. Ici, j’ai été très heureux d’apprendre à connaître un plus grand nombre de mes collègues de partout au pays et de découvrir ce qui préoccupe nos membres. Participer aux stratégies déployées pour améliorer notre capacité à traiter la population canadienne et à enrichir notre spécialité s’est avéré très gratifiant. BULLETIN DE L’ACO : La présidence vous a donné l’occasion de rencontrer les membres à bien plus grande échelle. Que vous ont-ils appris? Dr K. ORRELL : Beaucoup de choses préoccupent les orthopédistes canadiens. Chacun d’entre nous tire une grande satisfaction de son travail au quotidien, mais l’accès aux soins, les temps d’attente, la rémunération et la récente réforme fiscale préoccupent énormément les orthopédistes, tout comme les associations provinciales et régionales, qui envisagent l’avenir avec appréhension. Le chômage et le sous-emploi de jeunes orthopédistes dûment formés est une honte nationale. J’ai écouté beaucoup d’orthopédistes et assisté aux réunions d’associations provinciales. C’est une excellente occasion pour le président de l’ACO d’interagir avec les membres et d’être directement sensibilisé aux préoccupations régionales, ce qui favorise la concertation des efforts de défense des droits et intérêts à tous les échelons du gouvernement.


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(suite de la page 10)

BULLETIN DE L’ACO : De quelle façon l’engagement des membres et la participation active au sein de l’ACO profitent-ils à la profession? Dr K. ORRELL : Heureusement, nous avons beaucoup de membres très talentueux et dynamiques qui sont aussi des leaders dans leur collectivité, leur province et à l’échelle nationale. Leur participation est toujours enrichissante pour notre association et nous aide à mieux cibler nos efforts. Cela dit, nous devons tous participer d’une façon ou d’une autre, et c’est encore plus vrai pour la nouvelle génération d’orthopédistes et de chercheurs. Les universitaires tout comme les orthopédistes communautaires ont un rôle très important à jouer afin que tous les volets de notre profession soient bien représentés. Ces efforts conjoints amélioreront nos perspectives d’avenir.

Dr K. ORRELL : John a fait sa marque en tant que chercheur, orthopédiste et leader. Il est très actif au sein de l’ACO depuis de nombreuses années. Il apporte beaucoup à la présidence, et je suis persuadé qu’il sera un président exceptionnel. Nous avons de la chance de l’avoir à ce poste. Le seul conseil que je donnerais à Johanna et lui, c’est de profiter à chaque instant de ce qu’ils vont apprendre et des amitiés qu’ils vont nouer au cours de l’année. Une occasion comme celle-là ne se présente qu’une fois.

BULLETIN DE L’ACO : Quels sont les principaux enjeux sur lesquels l’ACO devrait se concentrer au cours de l’année à venir? Dr K. ORRELL  : Ces dernières années, on a beaucoup insisté sur l’accès aux soins, l’emploi chez nos résidents et la transition vers l’exercice et vers la retraite. Ces considérations demeurent importantes pour nos membres. Cette année, nous avons mis l’accent sur l’accès aux soins et les initiatives de défense des droits et intérêts. Nous devons œuvrer de pair avec les associations provinciales et régionales. L’ACO a maintenant son énoncé de position sur la crise des opioïdes au Canada. La diversité est devenue un sujet important à l’échelle mondiale, et un dossier de premier plan pour notre association, tant aujourd’hui que pour les prochaines années. BULLETIN DE L’ACO : Avez-vous des conseils pour votre successeur, le Dr John Antoniou? Le Dr Kevin Orrell, et sa femme, Anne, au souper des anciens présidents de l’ACO

Dr. Cy Frank COA Literary Award Recognizes Top CONA Manuscript Awarded annually, the Cy Frank Literary Award recognizes a CONA member who is author or co-author of manuscript published in the last year in CONA’s Orthoscope newsletter or health-related journal. The COA is honoured to support this award and congratulates the 2018 winner, Heather Ead, MHS, BScN, RN Trilliam Health Partners, Mississauga. Thanks are extended to Dr. Blair Ogle for presenting this award at the 2018 National CONA Conference in June on behalf of the COA.

From l to r: Angela Dunklee, RN, BN, ONC(C) (CONA Continuing Ed, Industry Liaison and Web Site Advertising), Heather Ead (recipient). and Dr. Blair Ogle (representing COA)

COA Bulletin ACO - Fall / Automne 2018


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Welcome Aboard the COA Team

Bienvenue au sein de l’équipe de l’ACO

Lexie Bilhete Coordinator, Membership Services & Affiliate Programs Canadian Orthopaedic Association

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

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

We are proud to highlight the newest members* of the Board of Directors, announced at the Annual Meeting in Victoria this past June 2018, and look forward to working with all our committees toward a positive future and the advancement of Canadian orthopaedics.

Nous sommes également fiers de souligner la nomination des tout derniers membres* du conseil d’administration, annoncée en juin dernier à la Réunion annuelle de Victoria, et nous avons hâte de travailler avec tous nos comités à l’avancement de l’orthopédie au Canada.

*French biographies for the officers listed below available upon request to: info@canorth.org

* Les notices biographiques en français des membres suivants du conseil sont disponibles sur demande à info@canorth.org.

2nd COA President Elect, Mohit Bhandari, M.D., FRCSC Dr. Bhandari is presently Professor and Academic Head of the Division of Orthopaedic Surgery at McMaster University. He is also the Associate Chair of Research in the Department of Surgery, and holds position as a Canada Research Chair in Evidence-based Orthopaedics. He obtained his Master’s degree in Clinical Epidemiology and Biostatistics from McMaster University, and later his PhD degree from Goteborg University in Sweden. Dr. Bhandari is nothing short of a global leader in evidence-based surgery and orthopaedic research. He has received top awards including the Royal College of Physicians and Surgeons Medal, the J. Edouard Samson Award, and the Kappa Delta Award. He has been acknowledged among the top ten most cited orthopaedic fracture surgeons in the world.

Dr. Bhandari’s commitment to evidencebased practice, high-quality research, and translating this into patient care has garnered him induction into the Order of Ontario. He also has been awarded the Canadian Orthopaedic Association’s Award of Merit, and McMaster University’s Distinguished Alumni Award, and most recently the College of Physicians and Surgeons of Ontario’s Council Award for Outstanding Achievement. Most recently, on June 29, 2018, Dr. Bhandari received the greatest Canadian civilian honour. He was named to the Order of Canada for his work in orthopaedic trauma and spearheading research in domestic and intimate partner violence.

Prairies Regional Representative, Ted Tufescu, M.D., FRCSC Dr. Ted Tufescu has an undergraduate Pharmacology degree from the University of Toronto, and a medical degree from Queen’s University. He completed his orthopaedic training at the University of Saskatchewan and continued his subspecialty fellowship training in orthopaedic trauma at Sunnybrook Health Sciences Centre in Toronto, where he also began his practice. He currently works at the Health Sciences Centre in Winnipeg, where he focuses on complex orthopaedic trauma and post-traumatic problems. He is an Assistant Professor at the University of Manitoba, while also serving as Fellowship and Research Director for Orthopaedic Trauma. Presently, he is also the Residency Program Director for the University of Manitoba Orthopaedic Program. COA Bulletin ACO - Fall / Automne 2018

Dr. Tufescu actively supports orthopaedic  education through his service to the Canadian Orthopaedic Association, as past Program Co-chair for the 2013 Annual Meeting, and the current Vicechair on the Continuing Professional Development (CPD) Committee. He has served as AO faculty at numerous fracture care courses for nursing staff, residents and surgeons, and he chairs a fracture care course in Winnipeg.


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(continued from page 12)

Atlantic Regional Representative, Tracey Wentzell, MDCM/MBA, FRCSC Dr. Tracey Wentzell is an orthopaedic surgeon originally from Portland Creek, NL and attended Holy Cross School in Daniel’s Harbour. Residency training brought her to the east coast and in Halifax, NS, she completed residency in orthopaedic surgery. She went on to do a fellowship with subspecialty training in sports medicine under the mentorship of Dr. Doug LeGay in Dartmouth, NS. She then returned home to Western Newfoundland and commenced practice in Corner Brook, NL. Dr. Wentzell has previously served on the Board of Directors of the Newfoundland and Labrador Medical Association, and is currently on the Board of Directors of the College of Physicians

and Surgeons of Newfoundland and Labrador. Her professional interests also include the provision of sustainable, equitable, appropriate health-care resources, and the nuances of rural and very rural health-care systems. She and her husband, Dwayne Parsons, live in Pasadena, NL with their two cats. When not delivering exceptional orthopaedic care, they both enjoy running, travelling, NFL football, and outdoor activities such as skiing, snowmobiling and seadooing.

Chair and President, Canadian Orthopaedic Foundation, Pierre Guy, MDCM, MBA, FRCSC Dr. Pierre Guy is Associate Professor and clinician-scientist at the Department of Orthopaedics at the University of British Columbia (UBC). He completed his medical training and residency at McGill University, followed by orthopaedic trauma fellowships in Hannover and Berlin, Germany and at UBC. Dr. Guy also holds a Master’s degree (MBA) from the John Molson School of Business at Concordia University. He is a practicing orthopaedic trauma surgeon at BC’s level 1 Trauma Centre, Vancouver General Hospital. He also acts as Director of the Centre for Hip Health and Mobility at UBC, where he collaborates with engineers and biostatisticians and their trainees in research in surgery and hip fracture care. He co-leads BC Hip Fracture Redesign, a province-wide quality improvement project.

Dr. Guy joined the Canadian Orthopaedic Foundation (COF) Board as a Director in 2013, holding positions on the Investment Committee and Governance & Nominating Committee. He became Vice-chair in 2016 and was elected as Chair this past July 2018. Alongside his presidential role at the COF, he is an active member of the Canadian Orthopaedic Association and the Orthopaedic Trauma Association.

CORA Representatives, Magdalena Tarchala, M.D., M.Sc., and Véronique Drapeau-Zgoralski, M.D. Each year, the orthopaedic program directors in Canada name two candidates to represent the interests and concerns of the Canadian Orthopaedic Residents Association (CORA). Drs. Magdalena Tarchala and Véronique Drapeau-Zgoralski will act as Co-chairs for 2019. Dr. Magdalena Tarchala is currently a fourth year orthopaedic resident at McGill University in Montreal. Her primary interests are in paediatrics and sports medicine, and she will be embarking on two fellowships respective to these subspecialties later on in 2019. Dr. Tarchala advocates for promoting resident wellness, and organized weekly resident workouts before AHDT’s. She is also interested in women’s MSK health and gender-specific sports injuries.

Dr. Véronique Drapeau-Zgoralski has had a life-long passion for sports, having competed at road cycling on an international level and becoming a professional in the discipline. Her love for physical activity translated into her orthopaedic interests in paediatrics, sports medicine, and upper extremity. She is currently a third year resident at the Université de Montréal, and though her future plans are undetermined at the moment, she aims at pursuing an academic career and looks forward to upcoming fellowship training.

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COA Bulletin – Online Reading Tip #4

Bulletin de l’ACO – Conseil de lecture en ligne no4

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oulez-vous agrandir le texte du Bulletin ou zoomer sur une photo ou une section en particulier? Voici donc la façon d’agrandir le texte et d’utiliser le zoom en lisant le Bulletin de l’ACO.

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

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

How to ENLARGE print size and ZOOM o you want to read the Bulletin in a larger print, or zoom in on specific photo or section? Here’s how to enlarge the print and zoom in when reading the COA Bulletin.

AGRANDISSEMENT du texte et ZOOM

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1) Reading in FULLSCREEN MODE will automatically enlarge the size of the print and font. Click on the Fullscreen icon in the bottom right corner of the viewer.

1) En optant pour le MODE PLEIN ÉCRAN, le texte est automatiquement plus gros. Cliquez sur l’icône du mode plein écran, dans le coin inférieur droit du lecteur.

2) Whether or not in fullscreen mode, you could always ZOOM in to the Bulletin to increase the size of the print and images by clicking on the PLUS SIGN found at the bottom of the journal.

2) Que le mode plein écran soit activé ou non, on peut toujours utiliser le ZOOM pour augmenter la taille du texte et des images en cliquant sur le SIGNE PLUS au bas du lecteur.

3) Keep clicking on the plus sign until you reach the size/zoom you need.

3) Il suffit de cliquer sur le signe plus jusqu’à la taille désirée.

Reading the Bulletin on a mobile device (smartphone or tablet)? Simply use the touchscreen on your device to enlarge the image and print.

Lecture du Bulletin sur téléphone ou tablette – Il suffit d’utiliser l’écran tactile de l’appareil pour agrandir l’image et le texte.

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

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

COA Bulletin ACO - Fall / Automne 2018


More possibilities

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

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


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COA Spotlight: Women in Orthopaedics

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

Dr. Carol Ann Reed, Pioneering Canadian Women in Orthopaedics

Looking back, my eventual career in orthopaedics was shaped by a number of pioneers and mentors who encouraged me to pursue my interests beyond the normal boundaries of the times. One of these individuals was my high school English teacher, Ms. Jessie McFarlane. Upon hearing of my interest in sciences, she challenged me to apply for medicine instead of my plan for a Bachelor of Science in nursing (BScN) - “better to give orders than to take them!” She also encouraged four other women in my high school English class to apply for medicine at Western University. We were the only four women accepted in a class of sixty, and often felt that we had 56 big brothers looking out for us.

Biography

Dr. Carol Ann Reed is a retired surgeon who specialized in foot and ankle orthopaedics. Born in 1940, she became a member of the COA in 1979. As the first woman to graduate from an orthopaedic residency training program in Canada, Dr. Reed is a true pioneer in the field. She studied medicine at the University of Western Ontario (MD 1963) and at the University of Toronto’s orthopaedic program (FRCSC, 1969).  Dr. Reed worked for the Department of Surgery at Women’s College Hospital, and as Assistant Professor at the University of Toronto, from 1970-2005. She also worked as Medical Director at St. John’s Rehabilitation Hospital for the five-year period (July,1980-85) while also maintaining office work and surgery practice. She was awarded a prestigious Travelling McLaughlin Fellowship, (1970-71) studying rheumatoid hand surgery in Europe.

My father also encouraged my choice, and later my husband continued to support my career pathway. My Hungarian husband was very open-minded about female orthopaedists, which was then more acceptable in Europe than North America. My initiation into the world of orthopaedic surgery was driven forward when I decided to become first a medical student, and then a surgical resident. In the early 1960s, medicine was an unusual career choice for a woman to pursue. Women were traditionally expected to be teachers, nurses, or secretaries but certainly not doctors, lawyers, or engineers. While in medical school I was drawn to cardiology, and carried out basic cardiology research for two summers. This interest was directly influenced by my father’s heart attack in my first year of pre-medical training. Later obstetrics and gynecology attracted my interest but I was discouraged by the professor of OB/GYN, who surprisingly felt that it was too onerous for women! He was certainly very surprised to later discover that

COA Bulletin ACO - Fall / Automne 2018

I had become an orthopaedic surgeon when I looked after his aunt. During my junior internship year at Toronto General Hospital, I encountered Dr. Ted Dewar,  the Professor of orthopaedic surgery, at University of Toronto. He had long wanted to train a female orthopaedic surgeon and felt strongly that the specialty should be open to both women and men. I enthusiastically accepted the offer and challenge to train in orthopaedic surgery at the University of Toronto at the age of 23. I really enjoyed the active role that surgeons had, repairing fractures and musculoskeletal deformities, relieving pain and improving function. Certainly, Dr. Dewar opened a door for me to enter a very unusual field for women in the 1960s.  He supported my decision to both marry and have children, which I appreciate caused some controversy at the time. Dr. Dewar was a man of persuasion and vision!  In 1970, when I finished training, there were only four women in Canada who held their FRCSC in general surgery. I had the opportunity to be on staff at Women’s College Hospital with three of them, Drs. Jessie Grey, Margery Davis and Olive Ibberson. However, none of them were married with children, so I had to chart my own course. I was married at the age of 27, and had two children, a daughter in 1970 and then a son in 1972. I had to learn how to balance an orthopaedic career and a young family. Thankfully, my supportive husband took a six month leave of absence from his work to provide child care. This was well before paternity care was even recognized or accepted, so truly an exceptional husband.   Along with the support from mentors and family, I myself had to learn a few tips and tricks to help me along the way. One of which was to snatch a short 20-minute nap whenever possible, which I called my “Winston Churchill” technique (a handy trick used by the wartime leader to quickly recharge). I used this little trick throughout residency and during my working years to gain an extra needed burst of energy.  I learned to fall asleep on any available surface, including examining tables (hard as it was, it was always very handy), upright in chairs, and in airport lounges.


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(continued from page 16)

I have been fortunate to have been surrounded by supportive men and women, who have generously shared their expertise. For example, Dr. Ian Macnab showed me an easy way to reduce a dislocated shoulder and his suggestions made my professional life easier. Recognizing that I would never have a man’s physical strength, we adapted techniques and materials in a way that would work for me. Also, the nursing staff, physiotherapists, and occupational therapists who were always there, providing assistance and advice. Now retired, I can explore my special interests, enjoying live theatre, ballet, classical concerts, documentaries, continuing

education and travelling with both  family, and friends. It has been my privilege to have hopefully improved the lives of many patients over the years, and a pleasure teaching students and residents.  Hopefully, by example, I may have encouraged women to enter orthopaedics and other surgical specialties, and men to realize how much women can contribute. Looking back now at age 78, I can see just how different my life would have been, without the influences and choices that I embraced along the way. My advice to everyone is simply, “Carpe Diem”. Your dreams might just be possible, but you won’t know unless you try and explore all the different opportunities that open up for you.

Des membres que démarquent : Les femmes en orthopédie

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

La Dre Carol Ann Reed, l’une des premières femmes orthopédistes au Canada Avec le recul, je constate que ma carrière en orthopédie a été façonnée par nombre de pionniers et de mentors qui m’ont incitée à explorer mes intérêts au-delà des limites usuelles à l’époque. Ma professeure d’anglais au secondaire, Mme Jessie  McFarlane, était du nombre. Quand elle a appris que je m’intéressais aux sciences, elle m’a mise au défi de m’inscrire en médecine plutôt qu’à un baccalauréat en sciences infirmières, comme j’en avais l’intention. «  Vaut  mieux donner des ordres qu’en recevoir!  » Elle a aussi incité quatre autres jeunes filles de mon cours à s’inscrire en médecine à l’Université Western. Nous étions les seules femmes dans une classe de 60  étudiants, et nous avions souvent l’impression d’avoir 56 grands frères qui veillaient sur nous. Mon père a aussi soutenu mon choix et, plus tard, mon mari a continué de m’appuyer dans ma carrière. Mon mari, d’origine hongroise, était très ouvert d’esprit par rapport aux femmes orthopédistes, qui étaient alors plus acceptées en Europe qu’en Amérique du Nord. Mon entrée dans le monde de la chirurgie orthopédique s’est faite dans la foulée de ma décision de faire ma médecine, puis une résidence en chirurgie. Au début des années  1960, la médecine était un choix de carrière inhabituel pour une femme. Nous devenions habituellement des enseignantes, des infirmières ou des secrétaires, mais certainement pas des médecins, des avocates ou des ingénieures.

Pendant mes études de médecine, je me suis intéressée à la cardiologie et j’ai fait de la recherche fondamentale dans ce domaine pendant deux étés. La crise cardiaque de mon père à ma première année de formation prémédicale y était pour beaucoup. Ensuite, je me suis intéressée à l’obstétrique et à la gynécologie, mais j’ai été dissuadée par mon professeur d’obstétrique et de gynécologie qui, étonnamment, jugeait que c’était une profession trop pénible pour les femmes! Il a donc été très surpris de constater que j’étais devenue orthopédiste quand je me suis occupée de sa tante. Pendant mon année d’internat général à l’hôpital général de Toronto, j’ai rencontré le Dr Ted  Dewar, professeur de chirurgie orthopédique à l’Université de Toronto. Il désirait depuis longtemps former une femme et était convaincu que la spécialité devait être ouverte tant aux femmes qu’aux hommes. Du haut de mes 23  ans, j’ai accepté avec enthousiasme son offre, et par le fait même son défi, de suivre une formation en orthopédie à l’Université de Toronto. J’aimais vraiment le rôle actif du chirurgien, la réparation des fractures et des déformations musculosquelettiques, le soulagement de la douleur et l’amélioration de la mobilité. Il est clair que le Dr  Dewar m’a ouvert la voie dans un domaine très inhabituel pour les femmes dans les années 1960. Il a appuyé ma décision de me marier et d’avoir des enfants, ce qui, j’en suis consciente, a causé une certaine controverse à l’époque. Le Dr Dewar était un homme de conviction et de vision! À la fin de ma formation, en 1970, il n’y avait que quatre femmes qui détenaient le titre de FRCSC en chirurgie générale au pays et, au Women’s College Hospital, j’ai eu l’occasion de travailler avec trois d’entre elles, soit les Dres  Jessie  Grey, Margery  Davis et Olive  Ibberson. Cela dit, j’étais la seule qui était mariée et avait des enfants, alors j’ai dû tracer ma propre voie. Je me suis mariée à 27 ans et j’ai eu 2 enfants : une fille née en 1970 et un garçon, en 1972. J’ai dû apprendre à jongler avec une carrière en orthopédie et une jeune famille. Heureusement, mon mari a pris six mois de congé pour s’occuper des enfants. C’était bien avant qu’on reconnaisse, voire qu’on accepte, la participation du père aux soins aux enfants. Donc, j’ai vraiment eu un mari exceptionnel. COA Bulletin ACO - Fall / Automne 2018


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En plus du soutien de mes mentors et de ma famille, j’ai dû acquérir quelques trucs pour me faciliter un peu la vie. Par exemple, je faisais une petite sieste de 20 minutes dès que j’en avais la possibilité, ce que j’appelais ma technique Winston  Churchill (un  truc employé par le dirigeant britannique en période de guerre pour reprendre rapidement des forces). J’ai employé ce petit truc pendant ma résidence et mes années de pratique pour aller chercher la petite dose supplémentaire d’énergie dont j’avais bien besoin. J’ai appris à dormir sur n’importe quelle surface, y compris les tables d’examen (certes très inconfortables, mais toujours très pratiques), les chaises droites et les salons d’attente des aéroports.

Notice biographique La Dre Carol Ann Reed, aujourd’hui à la retraite, était spécialisée dans l’orthopédie du pied et de la cheville. Née en 1940, elle devient membre de l’ACO en 1979. Première femme à effectuer sa résidence en orthopédie au Canada, la Dre Reed est une véritable pionnière dans le domaine. Elle étudie la médecine à l’Université Western, où elle obtient son grade en 1963, avant de se spécialiser en orthopédie à l’Université de Toronto (FRCSC, 1969). La Dre Reed travaille au département de chirurgie du Women’s College Hospital, en plus d’être professeure adjointe à l’Université de Toronto de 1970 à 2005. Elle assure également la direction médicale de l’hôpital de réadaptation de St. John’s pendant cinq ans, de juillet 1980 à juillet 1985, tout en assumant des fonctions administratives et en exerçant au bloc opératoire. La Dre Reed reçoit la prestigieuse bourse de voyage McLaughlin (1970-1971), ce qui lui permet d’étudier la chirurgie de la main rhumatoïde en Europe.

J’ai eu la chance d’être entourée d’hommes et de femmes qui m’ont appuyée et qui m’ont généreusement transmis leur savoir. Par exemple, le Dr Ian Macnab m’a montré une façon simple de procéder à une réduction d’une luxation de l’épaule, et ses suggestions ont facilité ma vie professionnelle. Conscients que je n’aurais jamais la force physique d’un homme, nous avons adapté des techniques et de l’équipement à mes capacités. Aussi, j’ai toujours

pu compter sur l’aide et les conseils du personnel infirmier, des physiothérapeutes et des ergothérapeutes.

Maintenant que je suis à la retraite, je peux m’adonner à mes loisirs de prédilection, comme le théâtre, le ballet, les concerts de musique classique, les documentaires, la formation continue et les voyages, tant avec ma famille que mes amis. Je suis sincèrement reconnaissante d’avoir pu, je l’espère, améliorer la vie de nombre de patients au fil des ans, et d’avoir eu le plaisir d’enseigner à des étudiants et résidents. J’espère que, par mon exemple, j’ai pu inciter des femmes à faire carrière en orthopédie ou dans d’autres spécialités chirurgicales, et montrer aux hommes tout ce qu’une femme peut apporter à la profession. À 78 ans, je peux voir à quel point ma vie aurait pu être différente sans l’influence que les gens ont eue sur moi et sans les choix que j’ai faits au fil des ans. Si j’ai un conseil à donner à qui que ce soit, il est très simple : carpe diem. Vos rêves pourraient bien être possibles, mais vous ne le saurez que si vous essayez de les concrétiser et explorez les occasions qui se présentent à vous.

Congratulations to the 2018 Recipients of the COA Awards of Merit and Presidential Awards for Excellence Kevin Orrell, M.D., FRCSC Immediate Past President Canadian Orthopaedic Association

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would like to congratulate this year’s winners of the COA awards of distinction, which were presented at the Opening Ceremonies of the 2018 Annual Meeting in Victoria, BC. This year, the COA honoured both Drs. Gregory Clarke and Edward Abraham with the Award of Merit, and Drs. William Dust and Ross Leighton with the Presidential Award for Excellence.

COA Bulletin ACO - Fall / Automne 2018

Dr. Gregory Vernon Clarke – Award of Merit It was a privilege to present Dr. Greg Clarke with the Award of Merit. Dr. Clarke is a longstanding community orthopaedic surgeon, based out of Nova Scotia. He is currently active within the COA, serving as the current Chair of the Practice Management Committee, and sits on the Board of Directors as representative of the Committee. One of his most important


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contributions to the Practice Management Committee is his work on fee code comparison, a project he has continuously developed for many years. Dr. Clarke has devoted a great deal of energy and passion into improving the conditions of orthopaedic surgery and care in Canada. As a native to the Canadian East Coast, Dr. Clarke completed his undergraduate degree in science and later medical degree at Dalhousie University. He also completed a clinical fellowship at Dalhousie from 1986-1987. He continued on to become orthopaedic surgeon in Sydney, Nova Scotia, and even made the trip westward to work in North Vancouver, British Columbia, from 1989-2000. Presently, he is practicing surgery in Kentville, Nova Scotia, a position he has held since returning east in 2000. Today, he is also active on the orthopaedic consulting staff and physical leader of fracture liaison services at Valley Regional Hospital in Kentville, and a courtesy consultant staff at South Shore Regional Hospital in Bridgewater, Nova Scotia. He also practices at Yarmouth Regional Hospital and consults for Scotia Surgery Inc. Dr. Clarke has contributed immensely to the field of orthopaedic surgery both locally and across Canada. Dr. Clarke also acts on professional associations advocating for correct orthopaedic practice management. He has been a member of the Committee on Orthopaedic Practice, Economics, and Fulfillment (COPEF – now known as the Practice Management Committee) since 2007, and works to resolve fee interpretation issues as a part of the Doctors Nova Scotia Medical Advisory Group since 2013. Alongside being a powerful voice in correct orthopaedic fee management, Dr. Clarke is a champion water polo player and enjoys hiking, camping, and cycling. For his hard work in representing and expressing concerns regarding orthopaedic practice in Canada, amongst his other great achievements, Dr. Clarke greatly merits this award. Dr. Edward Abraham – Award of Merit It was a true pleasure to award Dr. Edward Abraham with the Award of Merit. Dr. Abraham stands out as an exceptional spine surgeon, contributing to the advancement of orthopaedic care and cutting-edge spinal surgery. Graduating from Dalhousie University Medical School in 1982, he went on to a one-year spine fellowship at the University of Western Ontario in 1987. He presently is a practicing orthopaedic surgeon at the Horizon Health Network in Saint John, New Brunswick, a position he has held since 1988. Dr. Abraham is an extraordinary mentor and teacher for orthopaedic residents and students, working as Associate Professor at the Saint John campus of Dalhousie University and Memorial University.

Dr. Abraham actively participates in scientific and researchbased development of spine surgery, delivering presentations and engagement on local, national, and international stages. He pioneers new research initiatives for spinal conditions, establishing the Canada East Spine Centre with colleagues and contributing significantly to the Canadian Spine Outcomes Research Network. He is a member of the Canadian Spine Society and was past president of the CSS in 2005. Dr. Abraham participates in many organizations, including the North American Spine Society, Canadian Orthopaedic Association, and American Association of Orthopaedic Surgeons to list a few. He is also past Chair of the Canadian Spine Research and Education Fund, dedicated to fundraising for spine research. Overall, Dr. Abraham’s extensive work in spinal orthopaedic care, focusing on deformity and disease, make him more than worthy of this award. Dr. Ross Leighton – Presidential Award for Excellence For his years of hard work and dedication to the field of orthopaedic surgery in Canada, the Presidential Award for Excellence is awarded to Dr. Ross Leighton. Dr. Leighton’s outstanding career began when he graduated from Acadia University and was a Rhodes scholar finalist. He attended Dalhousie University for medical school and pursued his residency training at his alma mater. He completed fellowship training at the University of Toronto under the mentorship of Dr. James Waddell, and at Sacramento University in California under Dr. Mike Chapman. Dr. Leighton has a profound connection to the Canadian Orthopaedic Association, as he was Past President in 2011 and continues to engage actively with the Association. His past presidency history also includes that of Doctors Nova Scotia and the Orthopaedic Trauma Association (OTA). Dr. Leighton has received the Lifetime Achievement Research Award as well as many Bovill Awards for research by the OTA. Presently, Dr. Leighton is the president of the clinical trials group at the Canadian Orthopaedic Trauma Society (COTS). He has maintained his longstanding ties with the COA, currently representing the COA on the Board of Councilors with the American Association of Orthopaedic Surgeons. He also actively participates in fundraising and acts as a Board member for the Canadian Orthopaedic Foundation. His tremendous and continuous involvement with the COA, and dedication to perfecting orthopaedic care, make Dr. Leighton unquestionably deserving of the 2018 Presidential Award for Excellence.

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Dr. William Dust, Presidential Award for Excellence I was honoured to stand on stage alongside Dr. William Dust and present him with the Presidential Award for Excellence, in recognition of his success as a surgeon, teacher, and researcher in Saskatoon. Dr. Dust is a strong voice on ethical behavior in the profession of orthopaedics across Canada. He has represented and upheld the realm of proper orthopaedic ethics throughout the COA, serving as Chair of the Ethics Committee for several years. Born in Prince Albert, Saskatchewan, Dr. Dust has had an unconventional road to achieving a very successful career in Canadian orthopaedics. As a result of the introduction of Medicare and the Doctor’s strike in 1962, his family moved to Edmonton. The political and medical environment of his youth inspired him to eventually study medicine at the University of Alberta, graduating in 1980. He completed his family medicine residency training at the University of Saskatchewan, Regina. From there, Dr. Dust went to McGill to study general surgery. It was at this point that he became acutely passionate about orthopaedics and chose to pursue the field at Memorial University in St. John’s. Ultimately, Dr. Dust transferred to the orthopaedics residency program at McGill University, graduating in in 1987. He also completed 18-month fellowship training at the Sunnybrook Medical Centre, at the University of Toronto, under the mentorship of Drs. Joseph Schatzker and James Kellam. While in Toronto, Dr. Dust worked alongside Dr. Allan Gross, who became a powerful positive influence on the young surgeon. Dr. Dust started his practice in Saskatoon in

1989, where he continues to work today. His orthopaedic focus is on trauma and joint reconstruction. Dr. Dust has held a number of positions locally, including Program Director (2000-2010) and Academic Division Head, as well as the Departmental Head of Surgery, at the University of Saskatchewan. He is an active staff member at the Royal University Hospital in orthopaedic surgery since 1989. He has held membership on many committees, including the CARMS Interviewer and Selection Committee (2017), and reviewed a plethora of manuscripts for journals, holding the position of Associate Editor for the CJS from 2015-2017. He is also a member of the Canadian Orthopaedic Foundation Board of Directors. Alongside being highly honoured and prolifically published surgeon, Dr. Dust is passionate about music. He plays the principal French horn for the Saskatoon Philharmonic community orchestra, among other groups. He also enjoys fitness running, cycling or cross-country skiing.

Cannot Breathe, But Can Still Ream: Learning and Leadership Opportunities for Ottawa-nian Residents in Ecuador Youjin Chang, M.D., PGY4, University of Ottawa Olivier Gauthier-Kwan, M.D., PGY5, University of Ottawa Ottawa, ON

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r. James Jarvis, a paediatric orthopaedic surgeon in Ottawa, who has extensive global surgery experience, introduced us to Canadian Association of Medical Teams Abroad. He has been a mentor to us throughout residency, and encouraged us to get involved with the team to explore an aspect of orthopaedics that few get the opportunity to experience. CAMTA is an initiative founded in Edmonton, Alberta by Dr. Marc and Mrs. Barbara Moreau, which provides orthopaedic surgery services at Un Canto a la Vida Hospital in Quito, Ecuador, to patients who would otherwise be unable to obtain the care they need, as well as continuing education to medical personnel.

COA Bulletin ACO - Fall / Automne 2018

The COA Global Surgery (COAGS) Committee is pleased to share Canadian global health initiatives. If you are interested in COAGS featuring your organization in the Bulletin, or if you are a resident and you would like to share an essay about your global surgery experience, please contact trinity@canorth.org for details. Along with a team of five surgeons and over 50 members of a multidisciplinary team from across the country, we signed up to participate in a CAMTA mission from February 23rd to March 5th. After many months of fundraising efforts and counting down the days, we were off to Ecuador!


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Drs. Olivier Gauthier-Kwan and Youjin Chang in the park near Un Canto a la Vida Hospital in Quito, Ecuador

On our first day in Quito, we were overwhelmingly welcomed with applause by the locals waiting in line to be assessed by the team. Patients ranged from toddlers to adults and presented with a variety of orthopaedic concerns. Two separate teams of arthroplasty and paediatric orthopaedic specialists had a very full day of clinic to determine surgical candidacy and non-operative recommendations. Previous years’ patients were also seen in follow-up along with their grateful families. The collaborative care path involved skilled nurses, preoperative assessment by anesthesiologists, clerks and administrators who managed logistics, volunteer students, a local social worker, and translators who helped us communicate with the patients. The variety and severity of cases were more pronounced than what we normally see at home. This was a humbling experience for us, emphasizing how fortunate we are to live in Canada and to have accessible and free health care, despite some of the challenges we face in our own system.

recommend that our resident colleagues get involved with a global health initiative during training years. On the paediatric side, we were involved with procedures that are now seldom performed in Canada due to routine screening. For instance, development dysplasia of hip and clubfoot patients rarely need surgeries in Canada. In Ecuador, due to limited access and resources, we treated many children with dislocated hip, and severe clubfoot cases. The operative learning experience for residents was extraordinary – we performed numerous procedures which we scarcely get the opportunity to see in Canada, such as pelvic osteotomies, posteromedial releases for clubfoot, and severe Enjoying Ecuadorian nature deformity corrections. The team frequently had to problem-solve issues with limited resources. For example, the one and only overhead OR light short-circuited on the first day, requiring us to use headlamps for the rest of the week. The entire experience made us more appreciative of the availability of fluoroscopy in Canada (which gives us instant X-ray views during surgery). In Quito, an intraoperative X-ray required a tech to run down to get the film printed, which could take up to a half-hour.

As the first OR day got underway, we helped set up two operating rooms – one for adult arthroplasty cases for severe hip osteoarthritis, and the other for paediatric cases. On the adult side, we saw high-riding hips and very severe arthritis in young patients rarely seen in Canadians. Quito being at nearly 3000m of altitude, every little effort felt strenuous. Reaming an acetabulum or climbing a flight of stairs left us short of breath. Some cases were very challenging. One patient had a very dysplastic acetabulum, requiring a femoral head auto-graft shelf reconstruction for additional coverage of the femoral head component. We had a great experience working with the local surgeons, whose passion for their line of work and enthusiasm to teach were phenomenal. Despite the short time we spent with them, we learned so much, in and out of the operating room. Global surgery travel can offer residents exposure to clinical experiences and leadership roles that might not be feasible in Canadian training centres, just one of the reasons we highly

Paediatric operating room team on our last day in Quito COA Bulletin ACO - Fall / Automne 2018


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As a team, we also visited the inpatient ward, where translators, physiotherapists, hospitalists, and nurses worked closely with postoperative patients. The extent of gratitude we felt from these patients was moving, and their level of motivation to get actively involved in their postoperative care was admirable. Some patients wrote us heart-warming letters in Spanish and English and sang us songs to commemorate this event in their lives. It brought tears, joy and laughter to all, and we truly felt blessed and fortunate to be part of their care. We worked hard and learned a lot, but we also had an opportunity to explore the city. After work, we went for a quick run around the city, and stopped to enjoy street food. We visited

NATF Fellowship Application Deadline: December 30

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pplications for the North American Travelling Fellowship (NATF) are being accepted until December 30, 2018. This dynamic fellowship is open to surgeons who have completed their residency training in Canada up to three years ago. The tour of Canadian and American centres will begin in the Fall of 2019. We encourage all eligible members to apply. Complete criteria and a downloadable application form can be found here.

local markets where we bought souvenirs for loved ones, mentors, and friends. We also enjoyed going to local stores just to immerse ourselves in the daily lives of Ecuadorian people. “We may have poverty of wealth, but we do not lack happiness. Before we take our last breath, lack of money does not matter, but lack of happiness does matter”. Those strong words by an Ecuadorian politician continued to ring in our ears as we slowly closed our eyes on our flight back home, hoping that we may have the privilege to come back again in the near future. To learn more about CAMTA, please visit their web site at https://camta.com/.

Bourse de voyage VNA Date limite de soumission des demandes : le 30 décembre

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’ACO accepte les demandes pour la Bourse VNA jusqu’au 30 décembre 2018. Cette bourse stimulante est offerte aux orthopédistes qui ont terminé leur résidence au Canada au cours des trois dernières années. La tournée des centres canadiens et américains participants commencera à l’automne 2019. Nous invitons tous les membres admissibles à faire une demande. Vous trouverez tous les détails et un formulaire ici.

The COA’s 2019 ABC Fellows

Drs. Sukhdeep Dulai and Ruby Grewal

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rs. Sukhdeep Dulai (University of Alberta) and Ruby Grewal (Western University) have been selected as the COA’s 2019 American-British-Canadian (ABC) travelling fellows. Dr. Sukhdeep Dulai is a paediatric orthopaedic surgeon at the Stollery Children’s Hospital (Edmonton, AB) and Glenrose Rehabilitation Hospital (Edmonton, AB), and an Associate Professor in the Department of Surgery at the University of Alberta, where she has been based since 2006. After undergraduate, medical and residency training at the U of A, she completed fellowships at the Children’s Hospital at Westmead (Sydney, Australia) and BC Children’s Hospital (Vancouver, BC) and a master’s degree in clinical epidemiology at UBC. Her subspecialty interests are limb deformity (including complex hip and foot reconstruction) and neuromuscular disorders. COA Bulletin ACO - Fall / Automne 2018

Her clinical research program focuses on developing multicentre and multidisciplinary collaborations, and she has a special interest in the use of novel clinical technologies in orthopaedics. She is the co-chair of the Paediatric Orthopaedic and Rehabilitation medicine Research Team of Alberta (PORRTAL) which investigates gait disorders and the technology used in their assessment and management. She is also the orthopaedic lead of the Paediatric Developmental Dr. Sukhdeep Dulai, Hip Dysplasia study group at the 2019 ABC Fellow


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University of Alberta. Dr. Dulai is the current President of the Canadian Paediatric Orthopaedic Group (CPOG) and an active member of the Canadian Orthopaedic Association. Dr. Ruby Grewal received her medical degree at the University of British Columbia in 1999 and completed her residency in orthopaedic surgery at the University of British Columbia in 2004. Following her residency, she completed an upper extremity fellowship at the University of Western Ontario at the Roth|McFarlane Hand and Upper Limb Centre in 2005, and a fellowship in Hand and Peripheral Nerve at the Royal North Shore Hospital in Sydney in 2006. Concurrent with her fellowship at UWO, Dr. Grewal fulfilled the requirements of a Master of Science in Epidemiology in 2006. She currently practices orthopaedic surgery in London, Ontario. She is an attending orthopaedic surgeon at the Roth|McFarlane Hand and Upper Limb Centre at St. Joseph’s Health Centre. Her clinical practice includes the treatment of elbow, hand and wrist disorders. In addition to her clinical practice, Dr. Grewal serves as an Associate Professor of Orthopaedics at The University of Western Ontario. Her research interests include the treatment and outcomes of elbow and wrist disorders, as well

as the epidemiology of wrist and elbow injuries. She has published papers in numerous journals including the Journal of Hand Surgery (Am and Eur), Journal of Wrist Surgery, Shoulder and Elbow, Journal of Hand Therapy, HAND, Journal of Bone and Joint Surgery and Clinical Orthopedics and Related Research. Drs. Dulai and Grewal were selected from a pool of applicants by the COA’s Exchange Fellowships Committee this past spring. They will tour centres in the United Kingdom, Australia Dr. Ruby Grewal, and New Zealand with five additional 2019 ABC Fellow ABC fellows from the United States for five weeks in the spring of 2019. We wish them both safe travels and a most enjoyable tour! Stay tuned for a summary of their experience in a future edition of the COA Bulletin. Congratulations!

COA Global Surgery Committee Congratulates Dr. John Murnaghan

Le comité Planète ortho de l’ACO félicite le Dr John Murnaghan

he COA Global Surgery (COAGS) Committee is pleased to announce the winner of the second COAGS Norman Bethune Orthopaedic Travel Scholarship, Dr. John Murnaghan.

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e comité Planète ortho de l’ACO (POACO) est heureux d’annoncer l’attribution de la deuxième Bourse de voyage d’études en orthopédie Norman  Bethune au Dr John Murnaghan.

Dr. Murnaghan is a lower limb arthroplasty surgeon and Associate Professor at the University of Toronto. His recent work has concentrated on thromboprophylaxis following lower limb arthroplasty and perioperative blood use.

Le Dr  Murnaghan est un orthopédiste spécialisé dans les arthroplasties des membres inférieurs et professeur agrégé à l’Université de Toronto. Ses travaux récents ont surtout porté sur la thromboprophylaxie à la suite d’une arthroplastie des membres inférieurs et la transfusion sanguine périopératoire.

The aim of this scholarship is to forge bonds and exchange knowledge between China and Canada. Dr. Murnaghan will travel to Wenzhou, China, as both a teacher and a learner, during a two-week period during the 2018-2019 academic year. COAGS is very grateful to the Second Affiliated Hospital of the Wenzhou Medical University (WMU), for this opportunity and is confident that Dr. Murnaghan will be a tremendous ambassador for Canadian orthopaedics. Click here to read Dr. Vaughan Bowen’s blog recap of the 2018 COAGS Bethune tour.

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La Bourse de voyage d’études en orthopédie Norman Bethune vise la création de liens et l’échange de connaissances entre la Chine et le Canada; le  Dr  Murnaghan sera à Wenzhou, en Chine, pendant deux semaines au cours de l’année universitaire 2018-2019 à titre d’enseignant et d’apprenant. Le comité POACO est très reconnaissant au deuxième hôpital affilié de l’Université médicale de Wenzhou  (WMU) pour cette occasion et est persuadé que le Dr  Murnaghan sera un fabuleux ambassadeur pour le milieu orthopédique canadien. Cliquez ici pour lire le blogue du Dr  Vaughan  Bowen, premier lauréat de la Bourse, sur le voyage qu’il a effectué en 2018. COA Bulletin ACO - Fall / Automne 2018


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Run by Residents: Leadership at the CORA Annual Meeting 2018 David Stockton, BSc, M.D., PGY5, University of British Columbia Amar Cheema, BSc, M.D., PGY4, University of British Columbia Vancouver, BC Trinity Wittman, MSc, Director of Advocacy and Development Canadian Orthopaedic Association

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anadian Orthopaedic Residents’ Association (CORA) Co-chairs, Drs. Amar Cheema and David Stockton from UBC, were pleased to host colleagues from across the country on June 20th for a lively afternoon of clinical talks and career lessons. The Meeting kicked off with an informative presentation by the COA’s (then) President, Dr. Kevin Orrell, on the current state of the orthopaedic job market. Residents learned that surgeon unemployment rates in Canada have improved slightly from 2016 to 2017, and that this upward trend is projected to continue. In addition to administering the COA Job Board, collecting accurate metrics on current employment status, and hiring projections across the country, attendees heard about some of the advocacy initiatives that the COA undertakes on behalf of orthopaedic trainees. This includes the development and adoption of several CORA Co-Chairs Drs. Amar Cheema and position statements, as David Stockton well advocating at various government levels for improved access to care and more efficient models of care, ultimately the best way in which the Association can make a positive difference in the job market. Dr. Orrell’s presentation was followed by a series of high-quality resident podium and poster presentations. Attendees were fortunate to have Drs. Danny Goel and Kelly Lefaivre from UBC moderating this session. Congratulations are extended to the CORA Award recipients, listed at the end of this article. Following the research presentations, residents were treated to an engaging symposium entitled “Staying on the Leading Edge of the Changing Field of Orthopaedic Surgery”. Dr. Danny Goel presented his talk, “The Surgeon Expert: A COA Bulletin ACO - Fall / Automne 2018

CORA Annual Meeting in session

Paradigm Shift in Surgical Education may be Virtual.” Residents saw first-hand how surgical education is undergoing a technological revolution via virtual reality simulators like those produced by his company Precision OS. Dr. Kelly Lefaivre spoke about “Clinicians’ Role in Major Infrastructure Projects in Canadian Health Care.” Dr. Lefaivre is one of the Clinician Leads for the Vancouver General Hospital Operating Room Redesign Project. She discussed critical considerations her team has taken in the process, and of the importance of surgeon involvement in projects like these across the country. Drs. Sheila Sprague and Anthony Bozzo from McMaster introduced McMaster University’s EDUCATE program, which trains orthopaedic surgeons and fracture clinic staff on screening and appropriate intervention for intimate partner violence. The Meeting concluded with an inspiring lecture by honourary guest, Dr. Stuart Weinstein from the University of Iowa. He outlined a number of useful “Guideposts for Life in Orthopaedics.” All residents in attendance were grateful for the opportunity to learn career and life pearls from a world-renowned surgeon.


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Finally, later that night, residents gathered at the Bard & Banker Pub in Victoria for a well-attended social event. Residents were also invited to attend a Resident ICL during the COA Annual Meeting program titled “The Future of Orthopaedics in Canadian Health Care”, chaired by fellow resident Dr. Andrew Adamczyk as well as Dr. Veronica Wadey. Panelists, Drs. Alex BrooksHill, Kevin Hildebrand, and Alastair Younger, gave compelling talks Dr. Stuart Weinstein from the about impacting change, practice University of Iowa speaking on “Guideposts for Life in landscapes, performance metrics, Orthopaedics” and the challenges faced by new surgeons. Future COA meetings will build upon the session’s success with additional resident-focused ICLs. A critical part of the CORA presence at the COA Annual Meeting is the CORA Board meeting, where resident representatives from each of the 17 training programs have a chance to discuss current issues and collaborate on future projects. Top of mind for trainees is the ongoing unemployment crisis, which continues to be a priority at all levels of COA leadership. The Chairs updated Board members about various strategies for further addressing underemployment by the COA leadership, including media utilization, patient advocacy resources, and direct contact with elected officials by various stakeholders. Dr. Cheema will hold the resident position on the COA Practice Management Committee, which is tasked in part with addressing this issue. Most COA committees include a resident representative, each of whom reported back to the CORA Board about the committee’s recent relevant projects. Elections were held in order to appoint COA committee positions for the 2018-2019 academic year. Please join us in welcoming Drs. Alexandra Bishop, Alexandra Munn, Amar Cheema and James Yan to the COA Committee Slate. Mark your calendars and join us for next year’s CORA Annual Meeting in Montreal on June 19, 2019, hosted by Drs. Magdalena Tarchala from McGill University and Véronique Drapeau-Zgoralski from Université de Montréal. The CORA Call for Abstracts will be open until January 31, 2019. For more info, visit http://coa-aco.org/residents-cora/cora-annual-meeting/. CORA Podium and Poster Prize Winners Congratulations are extended to Drs. David Burns, Ryan Lohre, Samuel Larrivée, and Anthony Bozzo for their commitment to orthopaedic research. The winners were announced on-site and offered a cash prize. Their complete abstracts follow.

First Prize CORA Paper: J.A. Nutter Award sponsored by Sanofi Canada

Shoulder Physiotherapy Exercise Classification and Monitoring: Machine Learning the Inertial Signals from a Smartwatch David Burns, University of Toronto Nathan Leung, Michael Hardisty, Cari Whyne, Patrick Henry, Stewart McLachlin Purpose: Participation in a physical therapy program is considered one of the greatest predictors for successful conservative management of common shoulder disorders, however, adherence to standard exercise protocols is often poor (around 50%) and typically worse for unsupervised home exercise programs. Currently, there are limited tools available for objective measurement of adherence and performance of shoulder rehabilitation in the home setting. The goal of this study was to develop and evaluate the potential for performing home shoulder physiotherapy monitoring using a commercial smartwatch. We hypothesize that shoulder physiotherapy exercises can be classified by analyzing the temporal sequence of inertial sensor outputs from a smartwatch worn on the extremity performing Dr. David Burns, First Prize CORA Paper Award Winner the exercise. Method: Twenty healthy adult subjects with no prior shoulder disorders performed seven exercises from a standard evidencebased rotator cuff physiotherapy protocol: pendulum, abduction, forward elevation, internal/external rotation and trapezius extension with a resistance band, and a weighted bent-over row. Each participant performed 20 repetitions of each exercise bilaterally under the supervision of an orthopaedic surgeon, while 6-axis inertial sensor data was collected at 50 Hz from an Apple Watch. Using the scikit-learn and keras platforms, four supervised learning algorithms were trained to classify the exercises: k-nearest neighbour (k-NN), random forest (RF), support vector machine classifier (SVC), and a deep convolutional recurrent neural network (CRNN). Algorithm performance was evaluated using 5-fold cross-validation stratified first temporally and then by subject. Results: Categorical classification accuracy was above 94% for all algorithms on the temporally stratified cross validation, with the best performance achieved by the CRNN algorithm (99.4± 0.2%). The subject stratified cross validation, which evaluated classifier performance on unseen subjects, yielded lower accuracies scores again with CRNN performing best (88.9 ± 1.6%).

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Conclusion: This proof-of concept study demonstrates the feasibility of a smartwatch device and machine learning approach to more easily monitor and assess the at-home adherence of shoulder physiotherapy exercise protocols. Future work will focus on translation of this technology to the clinical setting and evaluating exercise classification in shoulder disorder populations.

Second Prize CORA Paper: Alexandra Kirkley Award sponsored by Depuy Synthes A Pilot Study to Assess Dynamic Deformation of the Femoral Head During Weight Bearing in Perthes Disease Ryan Lohre, University of British Columbia Anthony Cooper, Alexander Aarvold, Angela Eugenio, Harpreet Chhina, Christopher Reilly, David Wilson, Kishore Mulpuri

Purpose: This study utilizes an upright MRI scanner to image hips in children affected by Legg-Calve-Perthes Disease (LCPD). The aim of this study is to assess the feasibility and reproducibility of assessing for any dynamic deformation of the femoral head shape when the child is weight bearing compared to supine. Methods: Protocols have been previously developed in this unique upright MRI scanner in healthy adult and child volunteers. Satisfactory image acquisition is possible with Coronal T1 GFE sequences, both hips in Field of View. 2.5min scans were performed, first with the child standing and then supine. Digital measurements were made to assess the bony and cartilaginous femoral head height, width, and lateral extrusion. Comparisons between standing and supine unaffected and affected hips were made by two-raters and reliability assessed using the intra-class correlation coefficient (ICC) for intra-and inter-rater reliability. Results: Hips in eleven patients, five in early fragmentation stage and five in the revascularization stage of LCPD were imaged both supine and standing. One child could not tolerate the scan, resulting in images too blurred for measurement. Preliminary analysis demonstrated dynamic deformity of the femoral head on weight bearing. Femoral epiphysis height in early or fragmentation stage decreased on standing (0.85 SD ±0.48 mm) width increased on standing (1.89 ± SD 1.92 mm) and lateral extrusion increased on standing (1.60 ± 1.48 mm). In the revascularization stage epiphyseal height decreased on standing (1.71 ± 1.84 mm), width increased on standing (1.42 ± 1.20mm), and lateral extrusion increased on standing (1.39 ± 0.944mm). Differences were demonstrated in all parameters of femoral epiphyseal height, width and lateral extrusion when the child stood and loaded the LCPD hip. Contra-lateral unaffected hips did not deform. The study size was too small to determine statistical significance. Reliability was determined using the intra-class correlation coefficient (ICC) for intra-and inter-rater reliability. Standing measurements of affected hips demonstrated excellent intra-rater reliability for width (ICC=0.99, 95%CI = 0.98-0.99) and height (ICC = 0.98, 95%CI = 0.95-0.99), and extrusion (ICC = 0.78, 95%CI = 0.40-0.92) demonstrated good intra-rater reliability. Inter-rater reliability demonstrated moderate reliability for standing width (ICC = 0.73, 95%CI = 0.51-5.02), with poor to moderate reliability for standing height (ICC = 0.46, 95%CI = -0.792 – 0.843) and lateral extrusion (ICC = 0.043, 95%CI = -2.32 – 0.73). COA Bulletin ACO - Fall / Automne 2018

Conclusion This is the first reported use of standing weight bearing MRI in LCPD. A dynamic deformity has been demonstrated in the early fragmentation stage, with flattening, widening and worsened lateral extrusion on weight bearing. The developed protocol demonstrates reproducibility and reliability. The use of standing MRI is feasible in the assessment of LCPD and supports further investigation with larger numbers of patients. Level of Evidence: 2, Prospective comparative study

Third Prize CORA Paper: COA Award

Musculoskeletal Ultrasound Curriculum for Orthopaedic Surgery Residents Samuel Larrivée, University of Manitoba Robyn Rodger, Patricia Larouche, Tomislav Jelic, Jeff Leiter Purpose: Musculoskeletal ultrasound (MSK-US) can have many uses for orthopaedic surgeons, such as assisting in clinical diagnosis for muscle, tendon and ligament injuries, providing direct guidance for joint injections, or assessing the adequacy of a reduction in the emergency department. However, proficiency in sonography is not a requirement for Royal College certification, and orthopaedic trainees are rarely exposed to this modality. The purpose of this project was to assess the usefulness in clinical education of a newly implemented MSK-US course in an orthopaedic surgery program.

Dr. Samuel Larrivée, Third Prize CORA Paper Award Winner

Methods: An MSK-US course for orthopaedic surgery residents was developed by an interdisciplinary team involving a paediatric orthopaedic surgeon, an emergency physician with a fellowship in point-of-care ultrasonography, and an orthopaedic surgery resident. Online videos were created to be viewed by residents prior to a half-day long practical course. The online portion covered the basics of ultrasonography, as well as the normal and abnormal appearance of musculoskeletal structures, while the practical portion applied those principles to the examination, injection, and aspiration of joints, and ultrasoundguided fracture reduction. An online survey covering the level of training of the resident and their previous use of ultrasound (total hours) was filled by the participants prior to the course. Residents’ knowledge acquisition was measured with a written pre-course, same-day post-course and six-month followup tests. Residents were also scored on a practical shoulder


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examination immediately after the course and at six-month follow-up. An online survey was also sent to evaluate residents’ satisfaction with different aspects of the course (NAS). Change in test scores were calculated using an ANOVA and a Wilcoxon signed-rank test. Results: Ten orthopaedic surgery residents underwent the MSK-US curriculum. Pre-course interest to MSK-US was moderate (65%) and prior exposure was low (1.5 hours mean total experience). MSK-US has been previously mostly observed in the emergency department and sports orthopaedic clinic. Satisfaction with the online curriculum, hands-on practice session and general quality of the course were high (8.78, 8.70 and 8.60/10 respectively). Written test scores improved significantly from 50.7 ± 17.0% to 84.0 ± 10.7% immediately after the course (p=0.005), but dropped significantly to 75.0 ± 8.7% at six months (p=0.013). Average post-course practical exam score was 78.8 ± 3.1% and decreased to 66.2 ± 11.3% at six months (p=0.012). Residents significantly improved their subjective comfort level with all aspects of ultrasound use at six months (p=0.007-0.018), but did not significantly increase clinical usage frequency. Conclusion: An MSK-US curriculum was successfully developed and implemented using an interdisciplinary approach. The course was rated high quality and succeeded in improving the residents’ knowledge, skills, and comfort with MSK-US. However, this improvement was not constantly sustained at six months and did not result in higher frequency of use by the residents.

First Prize CORA Poster Award

Sarcoma Treatment in Ontario: A Population-based Study Anthony Bozzo, McMaster University Hsien Seow, Michelle Ghert Purpose: Due to the low prevalence of sarcoma, most of the evidence in sarcoma care is based on uncontrolled and relatively small case series. Evidence-based information on outcomes following sarcoma care requires larger studies. Our objective is to leverage the large number of sarcoma patients available through a comprehensive provincial administrative database to better inform the evidence regarding outcomes after sarcoma treatment.

Methods: We used administrative data from the Institute for Clinical Evaluative Sciences (ICES) database. All patients in Ontario with biopsy-confirmed sarcoma between 1993-2015 were identified with ICD-10 codes. We report patient demographics, tumour characteristics, comorbidity and mortality data on this cohort. We determined treatment patterns for soft tissue sarcomas (STS) and bone sarcomas (surgery, chemotherapy, radiation therapy, and any combination of the above). We generated survival curves for each stage of sarcoma and report 5, 10, and 15-year survival rates. A Cox regression analysis was performed to evaluate the association between sex, income quintile, or treatment at academic or rural center and survival. Results: Demographics: A total of 10,627 Ontario Sarcoma patients were eligible for analysis, 8706 STS and 1921 Bone sarcomas. Males comprised 56% of our cohort. Incidence of STS was highest in patients in their 5th, 6th and 7th decades of life who comprise 17%, 18%, and 19% of the cohort respectively. Patients aged less than 35 years comprised 49% of the Bone sarcoma cohort. The three most common STSs based on coding were: Sarcoma, NOS (1385, 16%), Leiomyosarcoma (1121, 13%) and Liposarcoma (1062, 12%). The most common bone sarcomas are Osteosarcoma (677, 35%), Chondrosarcoma (618, 32%) and Ewing’s Sarcoma (410, 21%). The most common location for sarcoma was lower Limb with 3019 cases (22.4%). The number of sarcoma cases reported each year increased steadily from 364 in 1993 to 514 in 2004 and 910 in 2015, an average increase of 11% annually, most likely related to more efficient capture by the linked databases. The majority of sarcomas were treated in academic centers (86.5%) and the average sarcoma patient received 2.5 lung surveillance CT scans in the two years following sarcoma surgery. Treatment Patterns and Survival: Patients with STS were treated with surgery in 75% of cases, received radiation therapy in 60% of cases, and chemotherapy in 27% of cases. Patients with bone sarcomas were treated with surgery in 65% of cases, received radiation therapy in 26% of cases, and chemotherapy in 61% of cases. Please see Table 1 for complete treatment information. The 5, 10 and 15-year survival rates for Stages 1-4 are displayed in Figure 1. No differences in overall survival were seen between patients from different income quintiles, rural vs. urban patients, males or females. Table 1 – Sarcoma Treatment Total Patients with treatment information

Soft Tissue Sarcoma Bone Sarcoma N N 5646 1546

Surgery Alone Surgery + Rads Radiation Alone Surgery + Chemo Chemotherapy alone Chemo + Rads Surgery + Chemo + Rads

1864 (33%) 1169 (20.7%) 1001 (17.7%) 668 (15%) 453 (9.5%) 385 (6.8%) 361 (6.4%)

428 (27.7%) 67 (4.3%) 114 (7.3%) 397 (25.7%) 303 (20%) 129 (8.3%) 108 (7.0%)

Not Reported

3060

375

Dr. Anthony Bozzo, First Prize CORA Poster Award Winner COA Bulletin ACO - Fall / Automne 2018


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Conclusion: Our analysis of a very large cohort of sarcoma patients reveals treatment patterns and outcomes for sarcoma patients in Ontario, Canada. In this Canadian health-care setting, the vast majority of sarcoma patients are treated at academic high-volume specialty centres. Specific knowledge on outcomes based on stage or other disease, patient and treatment factors can be helpful for sarcoma care providers in Ontario as well as in other health-care environments.

Figure 1 Overall survival after sarcoma diagnosis by stage

Your COA in Review: What We’ve Done, Where We’re Going Cynthia Vezina Executive Director, Strategic Initiatives Canadian Orthopaedic Association

“What is the COA’s focus this year?” “What are the new initiatives being pursued by the leadership and committees?” “What is the COA doing for its membership?”

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ondering what’s been happening at the COA? Your questions (and more!) are answered at the new “Your COA in Review” session, added into the Annual Meeting program. This is your opportunity to learn more about which directions the COA is heading into and the Board, Executive and Committees’ new projects and programs. Most importantly, this is your chance to provide feedback, input, and suggestions to the COA’s leadership and senior staff. Look out for this session at every Annual Meeting and be sure to attend, participate, and help shape the direction of your Association on behalf of its members. The “Your COA in Review” session held in Victoria at this year’s Annual Meeting included presentations by the President, Committee Chairs, COF, staff leads, and ended with a town hall COA Bulletin ACO - Fall / Automne 2018

discussion led by the President Elect. A summary of the key issues and items discussed are featured here, along with a few updates on recent projects that have been pursued since the Meeting. If you have any questions or would like further information, please contact the head office through policy@canorth.org. Advocacy New Board-approved Position Statements: The COA Position Statement on Access to Orthopaedic Care in Canada has been updated by the COA Executive to include a recommended wait time benchmark for T2, as well as a list of evidence-based strategies that the Association believes should be included in provision of timely and quality orthopaedic care.


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The COA Position Statement on Opioids and Orthopaedic Surgical Practice was written and presented to the Board by the COA Standards Committee, under the leadership of Dr. Jeff Gollish. With the annual number of deaths attributed to opioid overdose in Canada on the rise, there is increased attention to the availability of opioids, whether through prescription or illicit acquisition. The statement was developed based on a review of relevant literature as well as the results from a COA member survey. It encourages all orthopaedic surgeons to reflect on their own responsibility in safe and effective pain management, including the role of prescription opioids. The COA Position Statement on Diversity and Inclusion actively endorses diversity throughout the COA’s membership, research, education, service, and community engagement. In support of the Association’s longstanding value for excellence, collaboration, engagement, and respect, the COA Executive Committee recently released a position statement in September.

Featured Subspecialty Program Reconnects Specialists with the COA Thanks are extended to our spine members, experts, and to the Canadian Spine Society (CSS) for their contributions to the new Featured Subspecialty initiative. As a result of their collaboration, this year’s COA Annual Meeting offered the most comprehensive spine program in over a decade. It also brought together specialists who had not participated in a COA meeting in several years, and strengthened our collaborations with the CSS. The 2019 Annual Meeting program will highlight hand and wrist as the Featured Subspecialty. Speakers in the program will include Dr. Todd Kuiken, a true pioneer in the innovative treatment and research of amputation. More information about the Annual Meeting program and featured speakers will be included in the next edition of the COA Bulletin.

Diversity in the COA The Canadian orthopaedic community is made up of a diverse and talented pool of professionals, and the COA strives to ensure that our program’s presenters and faculty effectively represent diversity in geography, gender, ethnicity, seniority, practice settings, and more

Big Things to Come! We take into strong consideration all the suggestions and input received from members during the discussions at the “Your COA in Review” session and in meeting evaluation forms. Your feedback directly influences the development of new projects and programs that we are building and launching in the New Year. We are working on numerous initiatives that support gender and diversity in orthopaedics. These new projects include focused sessions at next year’s Annual Meeting in Montreal, access to online leadership resources, and programs to expose medical students to the field of orthopaedics, among others. An exciting ‘Mentor for a Day’ program, where residents and fellows can sign up to shadow a staff surgeon for one day during the Annual Meeting, will be available as of next year. Watch out for announcements through the COA’s communications and social media.

Education Accredited Summer Learning COA members were offered exclusive access to the recordings of this year’s three webinars through the COA & OrthoEvidence Best Evidence Series. These convenient, free webinar recordings on shoulder and elbow, sport medicine, and foot and ankle topics gave COA members the opportunity to earn CME credits during the summer, and participate in a webinar they might have missed. Look for more learning opportunities through our Best Evidence Series next year.

Tell Us More! Some of the COA Committees are issuing surveys to assist the development of important projects. Please take a moment to participate in these surveys when you receive them via email. Keep an eye on your inbox for surveys on: - Physician Wellness - OR Access - Membership Value for Female Surgeons - Membership Value for Community Surgeons

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Coup d’œil sur l’ACO : Réalisations et initiatives Cynthia Vezina Directrice générale, Initiatives stratégiques Association Canadienne d’Orthopédie

« Quelle est la priorité de l’ACO cette année? » « Quelles sont les nouvelles initiatives de la direction et des comités? » « Que fait l’ACO pour ses membres? »

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ous vous demandez ce qui se passe à l’ACO? Trouvez réponse à vos questions (et bien plus encore!) à la séance Coup d’œil sur l’ACO, une nouveauté au programme de la Réunion annuelle. Il s’agit d’une occasion d’en apprendre davantage sur les orientations de l’ACO et les nouveaux projets et programmes du conseil, du Comité de direction et des comités. Plus important encore, c’est une occasion de formuler de la rétroaction, de partager des idées et de faire des suggestions à la direction et aux gestionnaires de l’ACO. Prenez part à cette séance à chaque réunion annuelle afin de contribuer à établir l’orientation de votre association au nom de ses membres.

surdose d’opioïdes au Canada ne cesse de croître, on s’intéresse de plus en plus à la disponibilité des opioïdes, qu’ils soient obtenus sous ordonnance ou de façon illicite. L’énoncé a été rédigé à la suite d’un examen de la littérature pertinente et d’un sondage auprès des membres de l’ACO. On y incite tous les orthopédistes à réfléchir à leur propre responsabilité dans la gestion sûre et efficace de la douleur, ce qui comprend leur recours aux opioïdes. L’Énoncé de position de l’ACO sur la diversité et l’inclusion favorise la diversité chez ses membres ainsi qu’en ce qui a trait à la recherche, à la formation, à la sensibilisation, aux services et à l’engagement communautaire. Le Comité de direction de l’ACO a publié en septembre cet énoncé de position illustrant les valeurs d’excellence, de collaboration, d’engagement et de respect qui font depuis longtemps la marque de l’Association.

La séance Coup d’œil sur l’ACO de la Réunion annuelle de Victoria, en juin dernier, comprenait des présentations par le président, les présidents des comités, la Fondation Canadienne d’Orthopédie et des membres du personnel, et s’est terminée par une discussion ouverte animée par le président élu. Le sommaire des principaux points abordés est présenté ici, en plus de quelques mises à jour sur des projets Diversité au sein de l’ACO mis en œuvre depuis la Réunion annuelle. Si vous avez des questions ou souhaitez obtenir des précisions, n’hésitez pas à écrire aux bureaux de l’ACO, à policy@canorth.org. Défense des droits et intérêts Nouveaux énoncés de position approuvés par le conseil L’Énoncé de position de l’ACO sur l’accès aux soins orthopédiques au Canada a été mis à jour par la direction de l’ACO de sorte à inclure un point de repère applicable aux temps d’attente pour la période T2, de même qu’une liste de stratégies fondées sur des données probantes qui, de l’avis de l’ACO, devraient être employées pour offrir des soins orthopédiques de qualité en temps opportun. Le Comité sur les normes nationales de l’ACO, présidé par le Dr  Jeff  Gollish, a terminé la rédaction de l’Énoncé de position sur les opioïdes et la chirurgie orthopédique, puis l’a soumis au conseil. Alors que le nombre annuel de décès dus à une COA Bulletin ACO - Fall / Automne 2018

La communauté orthopédique canadienne est composée d’un éventail de professionnels de talent, et l’ACO s’efforce d’en refléter toute la diversité (tant sur le plan de la géographie que du sexe, de l’ethnie, de l’expérience et du milieu d’exercice, entre autres) dans le choix des intervenants au programme de la Réunion annuelle.


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Sensibilisation Formation estivale reconnue Les membres de l’ACO avaient exclusivement accès à l’enregistrement des trois webinaires sur les données probantes les plus pertinentes de l’ACO et d’OrthoEvidence offerts cette année. En accédant à l’enregistrement de ces webinaires sur l’épaule et le coude, le pied et la cheville et en médecine sportive, les membres de l’ACO pouvaient accumuler des crédits d’éducation médicale continue (ÉMC) et assister gratuitement à un webinaire qu’ils avaient peut-être manqué, et ce, au moment leur convenant le mieux pendant l’été. Soyez à l’affût, d’autres possibilités d’apprentissage seront offertes l’an prochain dans le cadre de notre série de webinaires sur les données probantes les plus pertinentes. Le programme de la sous-spécialité en vedette resserre les liens entre les spécialistes et l’ACO Merci à nos membres spécialistes du rachis, aux autres spécialistes invités et à la Société canadienne du rachis (CSS) pour leur contribution à l’initiative de mise en vedette des sous-spécialités à la Réunion annuelle. Grâce à leur collaboration, la Réunion annuelle de l’ACO proposait cette année le programme sur le rachis le plus exhaustif en plus d’une décennie. Le programme a en outre permis d’attirer des spécialistes qui n’avaient pas participé à une réunion de l’ACO depuis plusieurs années, en plus de renforcer notre collaboration avec la CSS. Le programme de la Réunion annuelle 2019 mettra en vedette la main et le poignet. Parmi les conférenciers au programme, mentionnons le Dr  Todd  Kuiken, véritable pionnier dans la recherche sur les amputations et leur traitement. De plus amples renseignements sur le programme de la Réunion annuelle et les conférenciers invités seront fournis dans le prochain numéro du Bulletin de l’ACO.

De grands projets sont à venir! Nous étudions sérieusement toutes les suggestions et idées formulées par les membres pendant la séance Coup d’œil sur l’ACO et dans les formulaires d’évaluation de la Réunion annuelle. Votre rétroaction influence directement la création de nouveaux projets et programmes que nous lancerons au début de 2019. Nous travaillons sur diverses initiatives sur le sexe et la diversité en orthopédie. Ces nouveaux projets comprennent des séances ciblées à la Réunion annuelle de Montréal, l’an prochain, l’accès à des ressources en ligne sur le leadership et des programmes d’introduction des étudiants en médecine au milieu de l’orthopédie, entre autres. Le programme Mentor d’un jour, une nouveauté fort intéressante qui permettra à des résidents et boursiers de suivre un orthopédiste pendant une journée à la Réunion annuelle, sera offert à compter de l’an prochain. Les annonces sur ces projets seront publiées dans les communications de l’ACO et dans les médias sociaux. Donnez-nous votre opinion! Dans le cadre de projets importants, certains des comités de l’ACO mènent des sondages par courriel. Veuillez prendre quelques minutes pour y répondre. Vous devriez recevoir des courriels annonçant des sondages sur les sujets suivants : - Santé des orthopédistes - Accès au bloc opératoire - Valeur de l’adhésion pour les femmes - Valeur de l’adhésion pour les orthopédistes en milieu communautaire

ARMSTRONG, Gordon Walter Duncan, C.M., M.D., FRCSC 1923-2018

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eacefully at Grace Manor, Ottawa, June 24, 2018. Loving husband of Molly (nee Mary F. Burnett) for 62 wonderful years. Beloved father of Douglas (Janet), John (Arlene), James (Pamela), Mary Jane, and Beth (Gregory Park). Cherished Poppa of Christy (Matt Carlson), Gillian, Gordon, Ian, William, Ross, Molly, and three greatgrandchildren. Predeceased by his parents, Rev. Dr. B. Douglas and Katharine (McBeath) Armstrong, and sister Margaret. Born in Hong Kong to Presbyterian missionaries, raised in rural Ontario, he graduated from Queen’s University (Meds 1948), and trained in orthopaedic surgery in Canada and England. In 1954, began his surgical practice in Ottawa and became internationally recognized for his skills as a surgeon, teacher, mentor and innovator in the development of modern spine surgery. Believed deeply in sharing his knowledge and techniques to benefit others, training medical professionals from around the world and never accepting royalties for medical devices he invented. Long, productive relationship with National Research Council. Former Chief of Orthopaedics, Ottawa Civic Hospital; practised at Children’s Hospital of Eastern Ontario; first Medical Director of Ottawa Children’s Treatment Centre; Professor of Surgery, University of Ottawa;

Past President of the Canadian Orthopaedic Association; founding member and Past President of the Scoliosis Research Society; Honorary Professor of Surgery, Chinese Academy of Medical Sciences. Highly regarded for his compassion and humility, Gordon is also remembered for his keen sense of humour. In retirement, he enjoyed repairing antique clocks His greatest joy was spending time with his family at his cottage at Aylen Lake, farm near Merrickville, or home in Ottawa. The family gratefully acknowledges the care of Grace Manor and Dr. Lloyd Rossman. Gifts to Presbyterian World Service and Development or Carefor Community Services would be appreciated in lieu of flowers. Condolences/Tributes/Donations Hulse, Playfair & McGarry www.hpmcgarry.ca 613-728-1761 http://presbyterian.ca/pwsd/donate/to-honour-and-remember/ https://www.carefor.ca/?action=show&lid=PCITZ-GSDM7-2A3RQ COA Bulletin ACO - Fall / Automne 2018


INTRODUCING

TRIATHLON TRITANIUM ®

Orthopaedics

®

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

FONT: Helvetica with bell curve

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


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

2019 Annual Meeting Featured Subspecialty Program Highlights Hand and Wrist

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e will be shining the spotlight on a different subspecialty at each year’s Annual Meeting and look forward to featuring hand and wrist at next year’s event.

Highlighted poster and paper sessions, cutting-edge symposia, ICLs, international faculty, guest speakers, research discussions, combined sessions with paediatrics, elbow and upper extremity, and a full hand and wrist specialty day will be featured in the 2019 COA Annual Meeting program.

La main et le poignet seront la sous-spécialité en vedette à la Réunion annuelle 2019

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a main et le poignet seront la sous-spécialité à l’honneur à la Réunion annuelle 2019.

Des séances de présentation de précis sous forme d’exposés et d’affiches, des symposiums de pointe, des conférences d’enseignement, des spécialistes de partout dans le monde, des conférenciers invités, des discussions sur la recherche, des séances conjointes main-poignet et coudemembres supérieurs, ainsi qu’une journée complète sur la main et le poignet seront mis à l’honneur dans le programme de la Réunion annuelle 2019 de l’ACO.

Improving Patient Outcomes in Orthopaedic Oncology: Addressing System Challenges Sophie Mottard, M.D., FRCSC Consultant in Orthopaedic Oncology, Maisonneuve-Rosemont Hospital, Associate Professor, Sainte-Justine Hospital Montréal, QC Georges Basile, M.D., FRCSC Consultant Orthopaedic Surgeon, Maisonneuve-Rosemont Hospital, Fellow in Orthopaedic Oncology, Mount Sinai Hospital Toronto, ON

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uick recognition and early referral of patients with malignant soft tissue and bone tumours has led to a dramatic decrease in “whoops” procedures performed by orthopaedic surgeons. Across orthopaedic residency programs in Canada, increased importance has been applied to the integration of orthopaedic oncology fundamentals, which has unequivocally improved the standard of care of sarcoma patients. Per Royal College training requirements, residents in

orthopaedic surgery are now required to complete a musculoskeletal oncology rotation. Under the supervision of orthopaedic oncologists, they are taught to refine every aspect of the sarcoma patient’s assessment and management. Starting with a complete history and thorough physical examination, residents learn how to read imaging and histology reports in order to generate an appropriate differential diagnosis and treatment. Recognizing atypical and aggressive features on imaging and respecting oncologic surgical principles is emphasised. Prompt referral of any worrisome bone or soft tissue lesion to a tertiary centre is strongly encouraged. Throughout the world, standard of care of sarcoma patients has dramatically improved by establishing national referral networks. However, standardizing and expediting the referral process throughout the province of Quebec, and across the different involved health-care specialists still presents a challenge today. To better understand the factors causing referral COA Bulletin ACO - Fall / Automne 2018

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delays in our province, we undertook a prospective study elaborated in 2010 that followed more than 500 patients referred to our orthopaedic oncology service within a four-year period. We concluded that the two main factors contributing to referral delays were: 1) difficulties accessing a primary care physician, 2) limited access to magnetic resonance imaging. Two very challenging issues to tackle head-on.

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

Compared to other Canadian provinces, in 2011-2012 only 56% of Quebec’s population were registered with a primary care physician. This percentage has been steadily rising with over 74% of patients enlisted in 2017. This increased access will undoubtedly favour early detection. However, much work is still needed in sensitizing the general population as the median time interval between the patient’s first reported symptoms and their first medical visit with a primary care physician was 32 weeks.

Although a majority of patients are eventually seen by a general physician, the time to referral to a tertiary centre is still dramatically long. Primary reasons for these delays are difficulties accessing imaging, and patients being sent to the wrong specialists. Our prospective study revealed that the median wait time for an MRI in our province was 33 weeks, far from the accepted standard of two weeks for probable sarcoma cases. The current situation is unacceptable knowing that early detection in soft tissue tumours will affect prognosis and survival. Beyond the long wait times, patients unfortunately often show up with incomplete investigations with MRI being frequently done in private radiology clinics, and seldom reimbursed by private medical insurance. Of these, 70% need to be repeated in hospital because of poor quality, incomplete images or imaging not done with gadolinium contrast. These repeat exams cost money and time for both the patient and the public health system. Although today’s newly-trained orthopaedic surgeons are more likely to recognize and properly assess sarcoma patients, the same cannot be said for community general surgeons

and plastic surgeons. While orthopaedic oncology rotations are not consistently part of their surgical residency curriculum, adding seminars or focused conferences on the subject might help sensitize them to the problem and furthermore diminish the rate of “whoops” procedures still being routinely observed. Additionally, radiologists who routinely read musculoskeletal imaging also play a prominent role in the early recognition of sarcoma patients since they will commonly recommend an orthopaedic oncology referral if there is any concern for malignancy. Targeting these specialities can also lead to decreasing referral delays.

Following the dramatic conclusions of our study, an urgent need to create a collaborative provincial referral network between Quebec’s three sarcoma reference centres (Montreal, McGill and Laval Universities) was identified. This led to the creation of the “Réseau Sarcome Québec”. Following a consensus between the three centres, a proposal was sent to Quebec’s Health Ministry, strongly advising the creation of a defined sarcoma network in order to improve the current standard of care. Two years following the deposition, the provincial government finally gave its approval in creating the sarcoma network. Clearly, there is still a lot of work ahead of us, but this recognition marks the first stepping stone in initiating a referral pathway similar to other provinces, like Ontario and British Columbia, that is likely to improve the standard of care. Orthopaedic oncology is in full bloom in Canada and ideas are not lacking. Cutting-edge research is currently being developed in immunotherapy, genomics, 3D printed implants, tumour microenvironment, and navigated surgeries. The orthopaedic oncology community in Canada is quite small and as always been closely knit. Now, more than ever, Canadian sarcoma centres have a global objective of increasing the number and quality of prospective national and international studies to answer important questions in sarcoma care. Collaborative efforts are being made across the country and across different subspecialties in sarcoma care. It is truly an exciting period to be an orthopaedic-oncologist in Canada.

Honouring Legacy and Commitment

Un legs et un engagement à célébrer

We were privileged to acknowledge both Drs. Robert McGraw & Theodore Siller as the longest serving members in attendance at the Victoria Annual Meeting. Both Drs. McGraw and Siller joined the COA in 1970 and we thank them for their continued support and commitment.

Nous avons rendu hommage aux Drs Robert McGraw et Theodore Siller, doyens de tous les membres de l’ACO présents à la Réunion annuelle de Victoria. Tous les deux sont membres depuis 1970; nous les remercions de leur soutien et de leur engagement soutenus.

COA Bulletin ACO - Fall / Automne 2018


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

Early Revision Risk Curves from the Canadian Joint Replacement Registry Carolyn Sandoval, MSc; Julia M Di Bella, MSc, MPH; Alina Dragan, MSc; Catherine Yu, CHIM; Nicole de Guia, MHSc; Greg Webster, MSc Canadian Institute for Health Information Michael Dunbar, M.D., FRCSC, PhD QEII Health Sciences Centre, Dalhousie University Halifax, NS

age of product barcodes to the International Product Library maintained by the International Consortium of Orthopaedic Registries and International Society of Arthroplasty Registries. Figure 1 Cumulative percentage revision for primary total hip replacement by bearing surface

Eric Bohm, M.D., MSc, FRCSC Concordia Joint Replacement Group, University of Manitoba Winnipeg, MB

In June 2018, the Canadian Institute for Health Information (CIHI) released Hip and Knee Replacements in Canada, 2016-2017: Canadian Joint Replacement Registry Annual Report1and Quick Stats Data Tables, which provide updated national statistics on these surgeries and also revision risk curves using the latest data available in CJRR. This article highlights two key new revision curves in this report, which were selected for addition by CJRR’s Scientific Working Group. Context he demand for hip and knee replacement surgeries continues to grow in Canada, with over 123,000 occurring in 2016-2017, an increase of 5% from the previous year. The need for a repeat surgery — particularly shortly after the first one — is an especially negative outcome for the patient’s quality of life. It is also costly for the health-care system, with revision surgeries costing on average more than $13,700 per surgery in inpatient costs alone2.

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Two new revision curves are highlighted in this article: 1) total hip arthroplasty (THA) by bearing surface; and 2) hemiarthroplasty for hip fractures by femoral fixation and surgeon arthroplasty volume. In Canada, while the majority of THAs use metal on cross-linked polyethylene as the bearing surface, other materials are also used. The impact of bearing surface on outcomes remains an area of interest in orthopaedic research. For hip fracture treatment, most hemiarthroplasties in Canada involve cementless fixation; however, it has been reported that cemented fixation has better outcomes. Methods The study cohort included all primary hip arthroplasties (N=123,673) reported in CJRR from provinces with mandated CJRR reporting (British Columbia, Manitoba and Ontario) between April 2012 and March 2017. Revisions and in-hospital deaths were identified by linkage by health card number to the Discharge Abstract Database and National Ambulatory Care Reporting System, which together capture nearly all hip replacements in Canada (excluding Quebec). Time to first revision or in-hospital death was used to estimate cumulative revision risk using the stratified Kaplan-Meier method, excluding same day revisions. Bearing surface was obtained by link-

Bearing surface of primary replacement Ceramic on XLPE

Ceramic on ceramic

Metal on XLPE

Metal on non-XLPE

Years after Cumulative 95% Number primary percentage confidence at risk replacement revision (%) interval 1 1.36 1.12–1.61 6,018 2 1.65 1.37–1.94 3,989 3 2.06 1.70–2.41 2,490 4 n/r n/r n/r 1 1.31 0.91–1.72 2,772 2 1.93 1.43–2.43 2,357 3 4 1 2 3 4 1 2 3 4

2.16 n/r 1.71 2.06 2.36 2.59 2.04 2.46 n/r n/r

1.62–2.70 n/r 1.61–1.81 1.95–2.17 2.23–2.48 2.44–2.73 1.48–2.61 1.83–3.10 n/r n/r

1,784 n/r 53,919 38,605 24,009 10,832 2,154 1,673 n/r n/r

XLPE: cross-linked polyethylene n/r: not reportable; data suppressed due to small numbers Sources: Canadian Joint Replacement Registry (British Columbia, Manitoba and Ontario only), Discharge Abstract Database and National Ambulatory Care Reporting System, 2012–2013 to 2016–2017, Canadian Institute for Health Information. International Consortium of Orthopaedic Registries–International Society of Arthroplasty Registries (ICOR-ISAR). Global Arthroplasty Product Library. November 9, 2017 version.

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Total Hip Arthroplasty by Bearing Surface Of the 97,462 primary total hip arthroplasties in the cohort, 1,995 (2.1%) required revision. The most common bearing surface was metal on cross-linked polyethylene (XLPE) (72.5%), followed by ceramic on XLPE (9.8%), ceramic on ceramic (3.2%), and metal on non-cross-linked polyethylene (2.5%). There were no significant differences in the two-year revision risk across bearing surfaces (Figure 1). This is consistent with findings from other registries, which show that most modern bearing surfaces have comparable early revision risks. The most common reason for revision was infection (31.5-43.8%) for all bearings except ceramic on XLPE, where instability was the most common reason (37.2%). Hemiarthroplasty for Hip Fractures: Impact of Femoral Fixation and Surgeon Volume Of the 18,632 primary hip arthroplasties for acute hip fracture in the cohort, 87.8% were hemiarthroplasties. Although published reports support the use of cement fixation for better outcomes3, 73.7% of the procedures in this cohort used cementless femoral fixation, with cement use increasing with patient age. In this cohort, 58.0% of cementless and 48.8% of cemented hemiarthroplasties for acute hip fracture were done by surgeons who performed 50 or more hip arthroplasties in that fiscal year. Surgeon volume had a positive effect on survivorship with cementless fixation. Surgeon volume did not have an effect on survivorship with cemented fixation (Figure 2). Overall, revision risk was higher with cementless fixation. These findings align with research showing that the risk of early revisions is inversely proportional to the volume of procedures carried out by the operating surgeon, and that cemented hemiarthroplasty results in better outcomes than cementless procedures3-6. Future Directions for CJRR Revision Curves CJRR coverage nationally is at 72% based on 2017-2018 data. As CJRR coverage increases, more data will be available to enable reporting of more detailed and longer-term revision risk investigations involving prosthesis information. Future analyses will update existing curves with longer term follow-up, adjusted results by age and sex, and provide more detailed investigations of revision risk, such as by additional component properties (e.g. prosthetic mobility or stability) or manufacturer.

Additional findings and methodology details can be found in the full report available on www.cihi.ca/cjrr under Reports and Analyses. CIHI would like to thank the CJRR Advisory Committee; the co-chairs, Drs. Eric Bohm and Michael Dunbar; and the Scientific Working Group for their support. CJRR was launched in 2001 in collaboration with the Canadian Orthopaedic Association. For additional information about the CJRR, contact cjrr@cihi.ca.

COA Bulletin ACO - Fall / Automne 2018

Figure 2 Cumulative percentage revision for primary hip hemiarthroplasty by femoral fixation and arthroplasty surgeon volume in patients with primary diagnosis of acute hip fracture.

Femoral fixation of primary replacement

Cemented

Cementless

Hip arthro- Years Cumulative 95% Number plasties after percentage confiat risk per year primary revision (%) dence performed replaceinterval by surgeon ment 1 1.97 1.33–2.61 1,337 2 n/r n/r n/r 50+ 3 n/r n/r n/r 4 n/r n/r n/r 1 1.99 1.36–2.63 1,474 2 2.62 1.86–3.39 1,049 <50 3 n/r n/r n/r 4 n/r n/r n/r 1 2.74 2.33–3.14 4,776 2 3.31 2.85–3.77 3,357 50+ 3 3.89 3.35–4.43 2,035 4 4.29 3.66–4.92 918 1 3.22 2.70–3.73 3,384 2 3.85 3.26–4.44 2,424 <50 3 4.52 3.84–5.20 1,489 4 n/r n/r n/r

n/r: not reportable; data suppressed due to small numbers Sources: Canadian Joint Replacement Registry (British Columbia, Manitoba and Ontario only), Discharge Abstract Database and National Ambulatory Care Reporting System, 2012–2013 to 2016–2017, Canadian Institute for Health Information. References 1. Canadian Institute for Health Information. Hip and Knee Replacements in Canada, 2016-2017: Canadian Joint Replacement Registry Annual Report. 2018. Ottawa: Canadian Institute for Health Information; 2018. URL: www.cihi.ca/cjrr 2. Canadian Institute for Health Information. Patient Cost Estimator. Ottawa: Canadian Institute for Health Information; 2018. URL: www.cihi.ca/en/patient-cost-estimator


Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 36)

3. Parker, M.J., Gurusamy, K.S., Azegami, S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database of Systematic Reviews. 2010; DOI: 10.1002/14651858.CD001706.pub4. 4. Paterson, J.M., Williams, J.I., Kreder, H.J., Mahomed, N.N., Gunraj, N., Wang, X., Laupacis, A. Provider volumes and early outcomes of primary total joint replacement in Ontario. Can J Surg. 2010;53(3):175-183.

5. Ravi, B., Jenkinson, R., Austin, P.C., Croxford, R., Wasserstein, D., Escott, B., Paterson, J.M., Kreder, H., Hawker, G.A., Relation between surgeon volume and risk of complications after total hip arthroplasty: propensity score matched cohort study. BMJ. 2014;348:g3284. 6. Le Cossec, C., Colas, S., Zureik, M. Relative impact of hospital and surgeon procedure volumes on primary total hip arthroplasty revision: a nationwide cohort study in France. Arthroplasty Today. September 2017;3(3):176-182.

Prophylaxis of Heterotopic Ossification An Introduction to this Edition’s Debate

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s hip arthroscopy moves into the mainstream of orthopaedic practice, we are learning about the opportunities, complexities and, of course, complications that may occur following its use. With regards to heterotopic ossification (HO), its incidence is unique to hip arthroscopy but it’s not always symptomatic when present radiographically.  In this

debate, two experienced hip arthroscopists from the University of Ottawa and the University of British Columbia debate the merits of prophylaxis for HO following hip arthroscopy. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

If You Perform Hip Arthroscopy, You Should Prophylax Against Heterotopic Ossification Parth Lodhia, M.D., FRCSC Fortius Sport & Health, Burnaby, BC Footbridge Centre for Integrated Orthopaedic Care Vancouver, BC Mark McConkey, M.D., FRCSC Orthopaedic Surgeon, Division of Arthroscopic Reconstructive Surgery and Joint Preservation, Department of Orthopaedics, UBC Pacific Orthopedics and Sports Medicine North Vancouver, BC

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irst described in 1883, heterotopic ossification (HO) is the abnormal mature lamellar bone formation in soft tissues where it normally does not exist8,11. It has been commonly implicated in complications after open hip surgery, especially total hip replacement (THR) with its incidence being reported as high as 90%14. As the 21st century has seen a global rise in hip arthroscopy5,6,10,15, orthopaedic surgeons have developed a better appreciation of some of the complications following the procedure. The incidence of HO after hip arthroscopy has been reported between 4.7%4 and 44%12. As such, it is important to understand the impact it may have on outcomes (including need for revision or HO excision), as well as preventative prophylactic measures that exist. The exact mechanism of HO formation is not fully understood, however, current literature suggests it develops after severe tissue trauma that incites a local inflammatory reaction, which

A

B

Figure 1 AP pelvis (A) and 45 degree Dunn (B) views of a symptomatic patient with left hip pain and stiffness after hip arthroscopy and femoroplasty for femoroacetabular impingement, referred for consideration of revision hip arthroscopy and heterotopic ossification excision.

results in a change in the tissue micro-environment promoting angiogenesis, fibroproliferation, enchondral ossification and HO17. Prevention of HO has been successful with the use of nonsteroidal anti-inflammatory drugs (NSAIDs) or radiation therapy in the perioperative period with no significant differences in the efficacy of either option1. However, for practical considerations NSAIDs are more commonly used postoperatively for HO prophylaxis in hip surgery18. Interestingly, HO after arthroscopic procedures other than the hip is rare, with only case reports of HO after arthroscopic surgery of the knee, shoulder, and elbow. It has been hypothesized that an arthroscopic hip capsulotomy enables interface between COA Bulletin ACO - Fall / Automne 2018

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injured muscle (from portal introduction) and injured periosteum (from acetabuloplasty and femoroplasty). However, the relationship between HO formation and capsular management during hip arthroscopy has not been studied12.

References

Beckmann et al.2 looked at patients undergoing hip arthroscopy and identified the absence of NSAID prophylaxis and mixedtype femoroacetabular impingement (FAI) resections were predictors of HO formation. The authors reported a reduction in the incidence of HO in these patients from 25% to 5.6% after three weeks of NSAID use postoperatively. Bedi et al.4 echoed these findings with HO rates reducing from 8.3% to 1.8% upon NSAID prophylaxis in the postoperative period. Beckmann et al.3 went on to perform a double-blind randomized control trial to assess the effect of Naproxen prophylaxis for HO in patients undergoing hip arthroscopy. Their results showed a 4% versus 46% final prevalence of HO in the naproxen and placebo groups, respectively. The frequency of adverse events between the two groups was comparable.

2. Beckmann J.T., Wylie J.D., Kapron A.L., Hanson J.A., Maak T.G., Aoki S.K. The Effect of NSAID Prophylaxis and Operative Variables on Heterotopic Ossification After Hip Arthroscopy. Am J Sports Med. 2014;42(6):1359-1364.

Yeung et al.18 performed a systematic review of the recent literature to determine the efficacy of NSAIDs for HO in patients undergoing hip arthroscopy. The authors identified five studies with a total of 1662 patients pooled from all the studies. Of these, 1265 patients received NSAIDs for HO prophylaxis while 395 patients did not receive any HO prophylaxis. The incidence of HO in patients with HO prophylaxis was 3.3% while that of patients without HO prophylaxis was 13.4%. Among patients who did not receive prophylaxis with NSAIDs, 7.6% had symptomatic HO and 3.7% required revision surgery.

5. Colvin A.C., Harrast J., Harner C. Trends in hip arthroscopy. J Bone Joint Surg Am. 2012;94(4):e23.

Successful resection of HO after hip arthroscopy has been reported in multiple studies with good patient reported outcome scores and no further development of HO, perhaps due to the vigilance of the authors to place these patients on HO prophylaxis after their revision surgeries2,4,9,13. Revision rates for HO resection in two of these studies were 24%4 and 26.5%2.

8. Naraghi F.F., DeCoster T.A., Moneim M.S., Miller R.A., Rivero D. Heterotopic ossification. Orthopedics. 1996;19(2):145-151.

The use of NSAIDs for prophylaxis is not without side effects, most notably of gastrointestinal (GI) and renal systems7. However, the population undergoing hip arthroscopy tends to be younger and healthier with a lower risk profile than an arthroplasty cohort2,11. Furthermore, the development of new prophylactic modalities with increased efficacy and fewer side effects is underway. The frontrunners include Noggin (Bone Morphogenic Protein [BMP] antagonist), pulsed electromagnetic fields (PEMF), and free radical scavengers like allopurinol and N-acetylcysteine1.

10. Palmer A.J., Malak T.T., Broomfield J., et al. Past and projected temporal trends in arthroscopic hip surgery in England between 2002 and 2013. BMJ Open Sport Exerc Med. 2016;2(1):e000082.

In conclusion, unless there is a medical contraindication, the evidence guides hip arthroscopy surgeons to provide their patients with HO prophylaxis, particularly when addressing mixed FAI where bony resection can create bony debris. This position statement is in agreement with a 79% majority of hip arthroscopy surgeons in an international survey of hip arthroscopy practice patterns who recommended HO prophylaxis always (62%) or most of the time (17%)16. Furthermore, it is worth noting that radiographic HO may not necessarily correlate to symptomatic HO. Our preference is NSAIDs over radiation for pragmatic reasons. Currently, there is no consensus on type and duration of NSAID use. If a treatment is discovered with a safer side effect profile than NSAIDs, routine chemical prophylaxis will be an even more attractive option.

12. Rath E., Sherman H., Sampson T.G., Ben Tov T., Maman E., Amar E. The incidence of heterotopic ossification in hip arthroscopy. Arthroscopy. 2013;29(3):427-433.

COA Bulletin ACO - Fall / Automne 2018

1. Baird E.O., Kang Q.K. Prophylaxis of heterotopic ossification an updated review. J Orthop Surg Res. 2009;4:12.

3. Beckmann J.T., Wylie J.D., Potter M.Q., Maak T.G., Greene T.H., Aoki S.K. Effect of Naproxen Prophylaxis on Heterotopic Ossification Following Hip Arthroscopy: A Double-Blind Randomized Placebo-Controlled Trial. J Bone Joint Surg Am. 2015;97(24):2032-2037. 4. Bedi A., Zbeda R.M., Bueno V.F., Downie B., Dolan M., Kelly B.T. The incidence of heterotopic ossification after hip arthroscopy. Am J Sports Med. 2012;40(4):854-863.

6. Degen R.M., Bernard J.A., Pan T.J., et al. Hip arthroscopy utilization and associated complications: a population-based analysis. J Hip Preserv Surg. 2017;4(3):240-249. 7. Fransen M., Neal B. Non-steroidal anti-inflammatory drugs for preventing heterotopic bone formation after hip arthroplasty. Cochrane Database Syst Rev. 2004(3):CD001160.

9. Ong C., Hall M., Youm T. Surgical technique: arthroscopic treatment of heterotopic ossification of the hip after prior hip arthroscopy. Clin Orthop Relat Res. 2013;471(4):1277-1282.

11. Randelli F., Pierannunzii L., Banci L., Ragone V., Aliprandi A., Buly R. Heterotopic ossifications after arthroscopic management of femoroacetabular impingement: the role of NSAID prophylaxis. J Orthop Traumatol. 2010;11(4):245-250.

13. Redmond J.M., Keegan M.A., Gupta A., Worsham J.R., Hammarstedt J.E., Domb B.G. Outcomes of heterotopic ossification excision following revision hip arthroscopy. J Hip Preserv Surg. 2017;4(2):164-169. 14. Rosendahl S., Christoffersen J.K., Norgaard M. Para-articular ossification after total hip replacement. Acta Orthop Scand. 1973;43:400.


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15. Sing D.C., Feeley B.T., Tay B., Vail T.P., Zhang A.L.. Age-Related Trends in Hip Arthroscopy: A Large Cross-Sectional Analysis. Arthroscopy. 2015;31(12):2307-2313 e2302. 16. Smith K.M., Gerrie B.J., McCulloch P.C., et al. Arthroscopic hip preservation surgery practice patterns: an international survey. J Hip Preserv Surg. 2017;4(1):18-29.

17. Winkler S., Craiovan B., Wagner F., Weber M., Grifka J., Renkawitz T. Pathogenesis and prevention strategies of heterotopic ossification in total hip arthroplasty: a narrative literature review and results of a survey in Germany. Arch Orthop Trauma Surg. 2015;135(4):481-489. 18. Yeung M., Jamshidi S., Horner N., Simunovic N., Karlsson J., Ayeni O.R. Efficacy of Nonsteroidal Anti-inflammatory Drug Prophylaxis for Heterotrophic Ossification in Hip Arthroscopy: A Systematic Review. Arthroscopy. 2016;32(3):519-525.

Heterotopic Ossification Prophylaxis: Use Cautiously As a Standard in Hip Arthroscopy Meaghan Marien, M.D. PGY 5, University of Ottawa Sasha Carsen, M.D., MBA, FRCSC Assistant Professor, University of Ottawa Ottawa, ON

“Bone deposition in all the wrong places: Reconsidering routine HO prophylaxis in hip arthroscopy”

H

eterotopic ossification (HO) is an abnormal deposition of bone in soft tissues that results from an altered signaling pathway. It is thought to be secondary to certain local prerequisites, including the presence of inducible signaling pathways and osteoprogenitor cells, and an environment conducive to osteogenesis1. Excluding rare genetic diseases, HO has been associated with spinal cord injuries, traumatic brain injuries, vascular diseases, arthropathies, and soft tissue injuries such as hematomas and surgical manipulation1,2. In the orthopaedic population, a significant amount of research has been published on the incidence and management of HO in patients who have undergone total hip arthroplasty (THA) or pelvic fixation, while the literature in hip arthroscopy patients is still evolving. Although HO is not generally considered to be a high-risk complication in hip arthroscopy, it can at times have significant clinical implications when it does occur, and is a notable potential postoperative complication in what is generally thought to be a relatively low-risk and minimally invasive operation (see Figure 1 for an example of postoperative HO post hip arthroscopy). As case volumes rise, debate regarding HO prophylaxis and management in this patient population has become increasingly important. Incidence and Risk Factors The incidence of HO in hip arthroscopy varies from 0-46%3–8, which is largely the result of retrospective reporting and inconsistent use of HO prophylaxis. As the technique is more widely adopted, a more accurate understanding of the incidence and associated risk factors is being obtained. To date, suggested factors in the literature include male gender, osteochondroplasty, the absence of capsular repair, surgeon experience, and having combined femoral and acetabular resections2,4–6.

Although not identified in arthroscopy patients, other risks from the THA literature include bilateral surgeries, trochanteric osteotomies, lateral or anterolateral approach, and ankylosing spondylitis2,9. Further research to identify the specific risks associated with hip arthroscopy is required, with the intention of develop- Figure 1 ing a risk stratification AP view of pelvis, showing heterotopic ossification of right hip algorithm for HO prevention. Heterotopic Ossification Prophylaxis: The Evidence To prevent the development of ectopic bone formation, many arthroscopists prescribe non-steroidal anti-inflammatories (NSAIDs) routinely in the postoperative setting. A recent survey of 65 hip arthroscopists from 32 countries revealed that 45% use HO prophylaxis in all patients, while only 9% never use prophylaxis10. The evidence supporting this practice comes from a series of mostly non-randomized trials that employed varying prophylactic regimens. Despite the heterogeneity of these studies, all have shown favourable results in decreasing the incidence of HO3,5–8. Recently, Beckmann and colleagues performed a doubleblinded randomized controlled trial (RCT) that provided level I evidence supporting the use of HO prophylaxis in hip arthroscopy. One hundred and eight patients were randomized to either placebo or Naproxen 500mg twice daily for three weeks post hip arthroscopy for femoroacetabular impingement. At one-year follow-up, 46% of patients in the placebo group developed HO, compared to 4% in the prophylaxis group (p<0.001)6. Compliance was similar between groups (68% vs. 69% respectively) and there was no significant difference in reported adverse events (35% vs. 42% p=0.45). The authors COA Bulletin ACO - Fall / Automne 2018

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concluded that NSAID prophylaxis for three weeks postoperatively has a significant effect on decreasing the risk of HO, however cautioned that NSAIDs have associated side effects and need to be prescribed with caution. Side Effects and Dosing Considerations NSAIDs are not entirely benign and do have important side effect profiles. They therefore require careful consideration prior to being recommended for routine HO prophylaxis. These include risks of gastrointestinal, renal, cardiovascular, and bleeding complications, and have previously been documented in the arthroplasty literature where HO prophylaxis was prescribed11,12. There has thus been an attempt to limit the duration of NSAIDs, while choosing medications with lower side effect profiles8. To the best of our knowledge, only three studies have reported on using different NSAID medications and treatment durations, however all presented with limitations that prevented definitive conclusions on the optimal HO prophylaxis regimen3,7,8. Without further investigations designed to compare the superiority of NSAIDs in the prevention of ectopic bone formation post hip arthroscopy, it is difficult to confidently recommend the most efficacious regimen that also minimizes potential complications. Prophylaxis Considerations Although the current literature supports a reduction in the incidence of ectopic bone formation with HO prophylaxis, many of the studies did not differentiate between symptomatic and asymptomatic patients. The majority reported severity of HO using the Brooker classification13 , but documentation on symptomatology was varied. In some studies, patients did not require further management, while others reported up to a 24% resection rate3â&#x20AC;&#x201C;6,8. Meanwhile in the arthroplasty literature, a recent RCT showed that despite ectopic bone formation post THA, there was no significant difference in self-reported hip pain or physical function using the Western Ontario and McMaster University Arthritis Index (WOMAC)11. The authors therefore concluded that there is no additional benefit to routine HO prophylaxis in THA patients. Similar studies are required in the hip arthroscopy population to better quantify the effects of HO prophylaxis on symptomatic ectopic bone formation. In recent years, hip arthroscopy has seen significant advancements in surgical techniques and instrumentation which has likely resulted in the mitigation of HO risk factors. As a result, periodical reassessment of the incidence of HO and the evidence supporting routine prophylaxis is required. Examples of recent advancements include decreased surgical time with increased surgeon experience, more common, if not yet routine capsular closure, and improved debris clearance with the introduction of more effective and efficient shaver-integrated fluid inflow and outflow systems. Adjustments to prophylactic protocols have been documented in other areas of orthopaedics, including the recent changes to venothromboembolism (VTE) prophylaxis for the arthroplasty patient14. Similar adjustments may be required for HO prophylaxis in the future as technology and techniques evolve. In the meantime, there are strategies to limit the adverse events associated with NSAID prescription. A recent meta-analysis in the Lancet concluded that gastroprotectant medications are COA Bulletin ACO - Fall / Automne 2018

useful in preventing peptic ulcer disease and associated complications, even when NSAIDs are prescribed15. It is thus at the discretion of the treating surgeon whether a gastroprotectant medication should be added to prevent unwanted complications of NSAID medications. In conclusion, though HO is a possible complication post hip arthroscopy that can be mitigated with NSAID prophylaxis, we would argue for careful and judicious routine use. Despite the positive HO prophylactic results with NSAIDs, surgeons must weigh their significant potential risks and benefits and strongly consider adjuvant gastroprotectant prophylaxis, as bleeding and gastrointestinal complications are not uncommon. Risk stratification algorithms designed to identify patients at high risk of developing HO are required and would further assist in identifying target populations to reduce the overall NSAID burden. Although NSAIDs are effective prophylactic medications for HO, future studies are still required to determine appropriate evidence-based regimens prior to recommending routine prophylaxis to all patients post hip arthroscopy. References 1. Kaplan F., Glaser, D., Hebela, N., Shore, E. Heterotopic Ossification. J AM Acad Orthop Surg. 2004;12:116-125 2. Amar E., Sharfman Z.T., Rath E. Heterotopic ossification after hip arthroscopy. J Hip Preserv Surg. 2015:hnv052. doi:10.1093/jhps/hnv052 3. Randelli F., Pierannunzii L., Banci L., Ragone V., Aliprandi A., Buly R. Heterotopic ossifications after arthroscopic management of femoroacetabular impingement: the role of NSAID prophylaxis. J Orthop Traumatol. 2010;11(4):245-250. doi:10.1007/s10195-010-0121-z 4. Rath E., Sherman H., Sampson T.G., Ben Tov T., Maman E., Amar E. The incidence of heterotopic ossification in hip arthroscopy. Arthrosc - J Arthrosc Relat Surg. 2013;29(3):427433. doi:10.1016/j.arthro.2012.10.015 5. Beckmann J.T., Wylie J.D., Kapron A.L., Hanson J.A., Maak T.G., Aoki S.K. The effect of NSAID prophylaxis and operative variables on heterotopic ossification after hip arthroscopy. Am J Sports Med. 2014;42(6):1359-1364. doi:10.1177/0363546514526361 6. Beckmann J.T., Wylie J.D., Potter M.Q., Maak T.G., Greene T.H., Aoki S.K. Effect of Naproxen Prophylaxis on Heterotopic Ossification Following Hip Arthroscopy. J Bone Jt SurgeryAmerican Vol. 2015;97(24):2032-2037. doi:10.2106/ JBJS.N.01156 7. Bedi, A., Zbeda, R., Bueno V. The incidence of heterotopic ossification after hip arthroscopy. Am J Sports Med. 2012;42(6). 8. Rath E., Warschawski Y., Maman E., et al. Selective COX-2 Inhibitors Significantly Reduce the Occurrence of Heterotopic Ossification after Hip Arthroscopic Surgery. Am J Sports Med. 2016;44(3):677-681. doi:10.1177/0363546515618623


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

9. Zhu Y., Zhang F., Chen W., Zhang Q., Liu S., Zhang Y. Incidence and risk factors for heterotopic ossification after total hip arthroplasty: a meta-analysis. Arch Orthop Trauma Surg. 2015;135(9):1307-1314. doi:10.1007/s00402-015-2277-8

13. Brooker A.F., Bowerman, J.W., Robinson R.A., Lee H., Riley J. Ectopic Ossification Following Total Hip Replacement :Incedence and a Method of Classification. J bone Jt surgery. 1973;55-A(8):1629-1632.

10. Loken, S., Ayeni, O.R., Randelli F, Bonin, N. Results from the ESSKA survery on prophylaxis for heterotopic ossification (HO) after hip arthroscopy. ESSKA Newsletter 2018

14. Anderson D.R., Dunbar M., Murnaghan J., et al. Aspirin or Rivaroxaban for VTE Prophylaxis after Hip or Knee Arthroplasty. N Engl J Med. 2018;378(8):699-707. doi:10.1056/ NEJMoa1712746

11. Fransen M., Anderson C., Douglas J., et al. Safety and efficacy of routine postoperative ibuprofen for pain and disability related to ectopic bone formation after hip replacement surgery (HIPAID): Randomised controlled trial. Br Med J. 2006;333(7567):519-521. doi:10.1136/bmj.38925.471146.4F 12. Baird E.O., Kang Q.K. Prophylaxis of heterotopic ossification – an updated review. J Orthop Surg Res. 2009;4(1):12. doi:10.1186/1749-799X-4-12

15. Scally B., Emberson J.R., Spata E., et al. Effects of gastroprotectant drugs for the prevention and treatment of peptic ulcer disease and its complications: a meta-analysis of randomised trials. Lancet Gastroenterol Hepatol. 2018;3(4):231-241. doi:10.1016/S2468-1253(18)30037-2

General Principles in the Management of Open Fractures Ammar Qutub, M.D., FRCSC1,2 Abdelrahman Lawendy, M.D., PhD, FRCSC1, Associate Professor Department of Surgery University of Western Ontario University of Western Ontario, Department of Orthopaedic Surgery, London, ON 2 King Abdulaziz University, Department of Orthopaedic Surgery, Jeddah, KSA 1

O

pen fractures are not uncommon injuries with a reported rate of 11.5 per 100,0000, per person, per year1,2. Because of the high complication rates associated with open fractures, such as infection, compartment syndrome, neurovascular injury and nonunion, they have gained special consideration. Due to the lack of strong evidence, there are widely accepted treatment protocols among orthopaedic surgeons with regards to timing of initial surgical intervention, initial versus delayed closure, type and duration of antibiotics and type of fixation. This review gives some guidance for the clinical scenarios involved when managing fractures, using contemporary reported guidelines and evidence. Antibiotics and Open Fracture Infection after surgical fixation of closed fracture with open reduction and internal fixation has been reported to be approximately 5%; however it may exceed 30% in open fractures3. Treatment of open fracture is partially guided by the Gustilo and Anderson classification of open fracture (Table 14). In one randomized controlled trial (RCT), Patzakis et al. reported the effectiveness of systemic antibiotic administration in reducing infection in open fractures. They concluded that early administration of antibiotics is the single most important factor in reducing the rate of infection5,6. In 2011, the Eastern Association for the Surgery of Trauma (EAST)7 published an update for practice guidelines for the use of antibiotics in open fracture as follows:

Level I • Systemic antibiotic coverage directed at gram-positive organisms should be initiated as soon as possible after injury. • Additional gram-negative coverage should be added for type III fractures. • High-dose penicillin should be added in the presence of fecal or potential clostridial contamination (e.g., farmrelated injuries). • Fluoroquinolones offer no advantage compared with cephalosporin/aminoglycoside regimen. Moreover, these agents may have a detrimental effect on fracture healing and may result in higher infection rates in type III open fractures. Level II • In type III fractures, antibiotics should be continued for 72 hours after injury, or not >24 hours after soft tissue coverage has been achieved. • Once-daily aminoglycoside dosing is safe and effective for types II and III fractures. TABLE 1. Gustilo Classification of Open Fractures4 Type I Type II Type III IIIA IIIB IIIC

Open fracture with a skin wound _1 cm in length and clean. Open fracture with a laceration _1 cm in length without extensive soft tissue damage, flaps, or avulsions. Open segmental fracture with _10 cm wound with extensive soft tissue injury or a traumatic amputation (special categories in Type III include gunshot fractures and open fractures caused by farm injuries). Adequate soft tissue coverage. Significant soft tissue loss with exposed bone that requires soft tissue transfer to achieve coverage. Associated vascular injury that requires repair for limb preservation.

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Surgical Considerations “The 6-hour rule” to initiate surgical intervention before six hours from time of injury has been a controversial and well-debated topic. Multiple recent studies have shown no association between time to initial surgical intervention and the rate of development of deep infection or nonunion8-10. However, a higher grade of open fracture is associated with increased rate of infection9. Furthermore, the pressure and type of fluid used for irrigation and debridement has been studied by the FLOW group in 41 clinical centres. They concluded that normal saline with very low pressure irrigation is as effective as high pressure irrigation, and the use of soap is associated with increased reoperation rate11. There is no definitive evidence for the exact amount of fluid for irrigation; however, the recommended volumes are 3L, 6L and 9L for Grade I, II and III fractures, respectively12.

References

Evidence-based Vignettes These vignettes are a series of articles led by experts and thought leaders who advise on how to manage clinical controversies or address emerging treatment trends while applying evidence-based principles. With these vignettes, we aim to help provide the best evidence-based strategies to enable clinicians to incorporate new treatment and diagnostic strategies into current practice. Although no patient or condition fits into the proverbial “box,” we often need to solve problems in “real time” and these comprehensive opinions will, hopefully, provide some useful and applicable insights. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

Although the use of antibiotics is very effective in reducing infection rate in open fractures, aggressive debridement and removal of all nonviable tissue remain paramount in the treatment of open fractures. Primary wound closure is advocated, except in wounds with gross contamination with feces, dirt or stagnant water, farm injuries, freshwater contamination, more than 12 hours delay in antibiotic administration, or uncertainty of tissue viability at initial surgery13. A recent prospective cohort study demonstrated a decrease in the rate of deep infection and nonunion with primary wound closure, compared to delayed closure14. Interestingly in a study evaluating primary closure for all open fractures there was no increase in infection rate or delayed union15. Special attention is given for open tibia fracture, as it constitutes the majority of open fracture cases. The superiority of fixation method of open tibia fracture is an area of debate. In a recent meta-analysis of RCTs, Fu et al.16 suggested the superiority of unreamed intramedullary nailing over external fixation. Another level I meta-analysis demonstrated a method of ranking, with unreamed nailing ranked at the lowest risk of reoperation, followed by reamed nailing, external fixation, while the highest risk of reoperation was found with internal plate fixation17. Summary Open fractures are associated with higher risk of complications. A large body of evidence suggests that risk of complication can be mitigated with expedient initiation of appropriate antibiotics, adequate irrigation and debridement, and early definitive fixation and wound closure whenever feasible.

COA Bulletin ACO - Fall / Automne 2018

1. Howard M., Court-Brown C. M. Epidemiology and management of open fractures of the lower limb. Br J Hosp Med 1997;57(11):582-587. 2. Court-Brown C. M, Rimmer S., Prakash U., McQueen M. M. The epidemiology of open long bone fractures. Injury 1998;29(7):529-534. 3. Trampuz A., Widmer A. F. Infections associated with orthopedic implants. Curr Opin Infect Dis 2006;19(4):349356. 4. Gustilo R. B., Mendoza R. M., Williams D. N. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma 1984;24(8):742-746. 5. Patzakis M. J., Harvey J. P. Jr., Ivler D. The role of antibiotics in the management of open fractures. J Bone Joint Surg Am 1974;56(3):532-541.

6. Patzakis M. J.,Wilkins J. Factors influencing infection rate in open fracture wounds. Clin Orthop Relat Res 1989;(243):3640. 7. Hoff W. S., Bonadies J. A., Cachecho R., Dorlac W. C. East Practice Management Guidelines Work Group: update to practice management guidelines for prophylactic antibiotic use in open fractures. J Trauma 2011;70(3):751-754. 8. Prodromidis A. D., Charalambous C. P. The 6Hour  Rule  for  Surgical  Debridement  of  Open  Ti bial  Fractures: A  Systematic  Review  and  MetaAnalysis  of  Infection  and  Nonunion  Rates. J Ortho Trauma 2016;30(7):397-402 9. Weber D., Dulai S. K., Bergman J., Buckley R., Beaupre L.A. Time  to  initial  operative  treatment  following  open fracture  does not impact development of deep infection: a prospective cohort study of 736 subjects. J Orthop Trauma 2014;28(11):613-619 10. Schenker M. L., Yannascoli S., Baldwin K. D., Ahn J., Mehta S. Does  timing  to  operative  debridement  affect  infectious  complications  in open  long-bone fractures? A systematic review. J Bone Joint Surg Am 2012;94(12):1057-1064. 11. Bhandari M., Jeray K. J., Petrisor B. A., Devereaux P. J., HeelsAnsdell D., Schemitsch E. H.,  Anglen J.,  Della Rocca G. J., Jones C.,  Kreder H., Liew S., McKay P., Papp S.,  Sancheti P., Sprague S., Ston T. B., Sun X., Tanne S. L., Tornetta P., Tufescu T.,  Walter S., Huyatt G. H. A  Trial  of  Wound  Irrigation  in the  Initial  Management  of  Open Fracture  Wounds. N Engl J Med 2015;373(27):2629-2641


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12. Anglen, J. O. Wound irrigation in musculoskeletal injury. J Am Acad Orthop Surg 2001;9(4):219-226. 13. Weitz-Marshall A.D., Bosse M. J. Timing of closure of open fractures. J Am Acad Orthop Surg 2002;10(6):379-384. 14. Scharfenberger A.V., Alabassi k., Smith S., Weber D., Dula S. K., Bergma J. W., Beaupre L. A. Primary Wound Closure After  Open Fracture:A Prospective Cohort Study Examining Nonuni onand Deep Infection. J Orthop Trauma 2017;31(3):121-126

16. Fu Q., Zhu L., Lu J., Ma J., Chen A. External Fixation versus Unreamed Tibial Intramedullary Nailing for Open Tibial Fractures: A Meta-analysis of Randomized Controlled Trials. Sci Rep 2018;8(1):12753. 17. Foote C. J., Guyat G. H., Vignes K. N., Mundi R., Chaudhry H., Heels-Ansdell D., Thabane L., Tornetta P.,  Bhandari M. Whi ch Surgical Treatment for Open Tibial Shaft Fractures Results  in the  Fewest  Reoperations? A  Network  Meta-analysis. Clin Orthop Relat Res. 2015;473(7):2179-2192.

15. Moola F. O., Carli A., Berry G. K., Reindl R., Jacks D., Harvey E. J. Attempting primary closure for all open fractures: the effectiveness of an institutional protocol. Can J Surg 2014;57(3):E8288.

COA Endorsement of CPSI Enhanced Recovery After Surgery (ERAS) Program

L’ACO souscrit au programme de Récupération améliorée après la chirurgie de l’Institut canadien pour la sécurité des patients

The COA is one of numerous organizations supporting the Canadian Patient Safety Institute (CPSI)’s Enhanced Recovery After Surgery (ERAS) Program, calling for implementation of the most relevant and timely surgical best practices across Canada. ERAS consists of a number of evidence-based principles that support better outcomes for surgical patients including an improved patient experience, reduced length of stay, decreased complication rates, and fewer hospital readmissions. Details about the ERAS program, including a PPT slide deck, can be downloaded here.

L’ACO fait partie des nombreuses organisations qui appuient le programme de Récupération améliorée après la chirurgie (RAAC) de l’Institut canadien pour la sécurité des patients (ICSP), qui demande la mise en œuvre des pratiques chirurgicales exemplaires les plus pertinentes et appropriées partout au Canada. Il est composé d’un certain nombre de principes fondés sur des preuves qui favorisent des résultats améliorés chez les patients ayant subi une chirurgie, notamment une meilleure expérience du patient, un séjour plus court, un taux de complications diminué et un nombre réduit de réadmissions. Pour plus de renseignements sur le programme de RAAC, y compris une présentation PowerPoint à télécharger, cliquez ici.

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

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

2020

June 3-6 juin CORA Meeting / Réunion de l’ACRO June 3 juin Halifax, NS

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PROstepâ&#x201E;¢ Minimally Invasive Surgery


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

Navigating the System: the Banff Sport Medicine Model Laurie Hiemstra, M.D., PhD, FRCSC Mark Heard, M.D., FRCSC Greg Buchko, M.D., FRCSC Michaela Kopka, M.D., FRCSC Sarah Kerslake, Msc, BPhty Banff Sport Medicine Banff, AB

B

anff Sport Medicine (BSM) is uniquely located within a Canadian National Park. It is also within the referral area of greater Calgary, all of southern Alberta, as well as southeastern British Columbia, encompassing a potential patient population of over 1.5 million. The practice currently has four orthopaedic surgeons, three sport-medicine physicians, and a part-time orthotist. BSM also has close ties with the physiotherapists and allied health professionals within the Bow Valley and surrounding Mountain Parks. Banff Sport Medicine has developed three pillars of focus within the practice: clinical care, research and education. The base of our clinical care is the ligament injured knee and specifically, the torn anterior cruciate ligament (ACL). We perform between 500-600 ACL reconstructions annually, and have been working on improving patient access and care pathways over the last 25 years. The ACL injury is an excellent example to demonstrate the need for a more integrated and seamless care model than the current referral-based system.

Banff Sport Medicine faculty. From l to r: Drs. Mark Heard, Laurie Hiemstra, Mireille Marquis, Michaela Kopka, Greg Buchko

referrers and their patients. Introduction of a process to reduce the risk of specialist referrals being lost is one step, but there remain a number of challenges and potential delays in referral to other specialists.

Banff has the unique situation of being both a rural centre providing general orthopaedic care for local patients within the Mountain Parks region, as well as functioning as a tertiary subspecialty referral centre for southern Alberta and Western Canada for knee ligament and arthroscopic surgery. This situation has The COA will regularly be inviting presented distinct challenges for optimembers to feature innovative mizing patient-care strategies, and subsequently, the care pathways at Banff orthopaedic care pathways from across Sport Medicine have developed along the country. If you would like to submit two streams:

The current pathway for patient referral to orthopaedic surgery in Canada is generally very fragmented and poorly integrated with other health-care providers1,2. Emergency physicians, family your model of care for publication in the doctors, therapists, and other healthcare providers often work in isolated Bulletin, please contact Trinity Wittman at Orthopaedic Intake Clinic practices. Furthermore, even orthopaeFor the range of orthopaedic and muspolicy@canorth.org. dic surgery has become subspecialized culoskeletal disorders in our rural catchwith frequent gaps in communication ment area, BSM has developed a multibetween specialties. This often results in the injured patient disciplinary Intake Clinic. This weekly clinic includes a physiwaiting to see the incorrect health-care provider, leading to otherapist, an orthotist, a sport-medicine physician as well as long delays in treatment, and increased health-care costs. The an orthopaedic surgeon. This clinic accepts referrals from local two main “stressors“ for patients are excessive wait times, and family physicians and physiotherapists into a centralized referinadequate understanding or expectation of the care pathway. ral system. Referrals are triaged based on the most suitable end This problem is only amplified if the patient is down an incorprovider, and on this basis, sport medicine and orthopaedic rect pathway. clinics are run simultaneously in the same space. The physiotherapist can function as initial assessor4, but also provides In an effort to reduce wait times and to improve care coordirehabilitation advice as needed. We work as a team and, based nation with specialist providers, The Health Quality Council upon assessments, a patient may see all team members durof Alberta released a number of recommendations related to ing a single visit. This has virtually eliminated the wait time electronic referrals in 20163. These included acknowledgement between the sport medicine physician and orthopaedic surof referrals to both providers and patients, as well as develgeon for those patients requiring a surgical consult. The Intake opment of patient portals to enable viewing of key referral Clinic provides multidisciplinary services with access to physiinformation. The College of Physicians and Surgeons of Alberta otherapy advice and bracing services in one visit for patients adopted a number of these referral processes, and implethat may have to travel for up to eight hours to complete this mentation has improved communication between BSM, our assessment. COA Bulletin ACO - Fall / Automne 2018

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Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 45)

This clinic model has worked very well within our rural area with a limited population. BSM has reduced wait-times for acute musculoskeletal injury assessment to less than a couple of weeks from receipt of referral, and has effectively eliminated the wait time from sport medicine physician to orthopaedic surgeon. An integrated EMR for the sport medicine physicians and orthopaedic surgeons has enabled improved communication, has reduced duplication of records and investigations, and facilitates more streamlined patient care. This model, however, is not without its challenges. These include the ability to access subspecialty referral for patients requiring orthopaedic services not provided by our centre such as joint replacement, spine, hip arthroscopy or other complex orthopaedic specialties. Access to operating room time is limited so surgical wait times are not being reduced. In addition, despite the benefits to patients provided by this Intake Clinic model, it is challenging to demonstrate any cost saving within the health-care system as the reduced costs to patients are not adequately captured in the current funding model. Future directions include improving the triage process with more detailed initial allied health consultations, introducing patient self-referral for acute musculoskeletal injuries, and engaging in work on knee injury treatment and outcome cost models. Tertiary Sport Medicine Orthopaedic Care The second stream of the BSM clinical practice relates to subspecialty sport medicine arthroscopic surgery of the knee and shoulder, where the clinic functions as a tertiary referral centre for patients from across Western Canada. BSM provides world-class service for complex knee injuries with an emphasis on knee ligament reconstruction, osteotomies, patellofemoral instability, and meniscal allograft and osteochondral transplantation. BSM provides current evidence-based care for the more common knee injuries, and strives to generate evidence for treatment of complex injuries through our research program5. Referrals are accepted from sport medicine physicians following injury diagnosis to facilitate non-operative management strategies such as medications, bracing, physiotherapy, and injections. In this model, patients diagnosed with a condition that may benefit from surgery, who have not had success with non-operative treatment strategies, or are unable to return to their previous level of function, are referred for a surgical consultation. Another efficiency introduced by BSM is facilitating referral by sport medicine to the first available surgeon in the practice, rather than a specific provider, which has reduced wait times for initial consultations6. BSM developed this system to provide superior care to surgical patients by streamlining wait lists and reducing consultations for conditions unlikely to benefit from surgical intervention. Another goal of this referral process is the provision of specialist and expert sport medicine diagnosis and treatment to reduce the incidence of secondary injury, and to provide a clear referral pathway for patients. Referral system information is provided publicly on our web site and we communicate and collaborate regularly with our sport medicine physician colleagues. This system cannot work without integrated cooperation between sport medicine physicians and orthopaedic surgeons. The anterior cruciate ligament injury is a good example of the utility of this treatment and referral stream. ACL injuries can be difficult to diagnose clinically by the inexperienced knee COA Bulletin ACO - Fall / Automne 2018

examiner. These injuries are often diagnosed as a “knee sprain” and patients are sent away, with or without appropriate therapy. The knee typically settles down in six to eight weeks with minimal or no intervention, and the patient returns to activity where a re-injury frequently occurs. It is this second injury that can cause an irreparable meniscal tear or a chondral injury that will have lifelong consequences and almost guarantees early osteoarthritis of the knee. Within the Bow Valley and Calgary region, emergency and family physicians frequently refer acute knee injuries to sport medicine physicians for diagnosis and treatment. Ongoing education and collaboration by BSM with physiotherapists, often the first treatment providers for these patients, also encourages early referral to sport medicine. Regular dialogue with referring physicians encourages a team atmosphere and excellence in patient care. Prompt diagnosis and complete non-operative management by the sport medicine physicians including education, and referral to physiotherapy and bracing, eliminates much of the ‘injury to diagnosis’ time in which many of the secondary knee injuries occur. Referral for patients that require surgical consultation is prompt. Once the referral is received at BSM, an evidence-based triage protocol works to ensure that high-risk patients are seen on an expedited basis. For example, young patients (under 25 years) are seen in consultation as a priority, as this group has the highest risk of reinjuring their knee leading to poorer outcomes. Delays in the time from injury to diagnosis is the most alterable of the times on the treatment pathway. Delays in the diagnosis of a knee ligament injury, can lead to lost wages, mental health concerns, further knee injury, and potential long-term implications on the health-care system. Education Education is another key component at BSM. Our team hosts education sessions on the acutely injured knee targeting community health-care providers, including physicians, therapists, EMS, mountain guides and ski patrol. We teach hands-on physical exam skills as well as awareness of secondary injury. These initiatives improve the assessment skills of the community health-care providers and build relationships to improve communication. For our patients, we provide education and preoperative rehabilitation protocols on the benefits of linear exercise and motion while awaiting surgery, and discuss nonsurgical treatment including therapy, bracing and lifestyle modification. All of these resources are provided to patients in writing while also being available on our clinic web site. Research BSM has a highly developed research program that includes a database with over 2500 ACL and 600 patellar instability surgery cases, including pre- and postoperative data. The clinic has partnered with local and regional physiotherapists to develop postoperative follow-up clinics that include diagnostic imaging, patient-reported outcome measures, and objective functional testing. Physiotherapists are also involved in the development and updating of pre- and postoperative rehabilitation protocols which are published on our web site7. BSM is also involved in the development and validation of patient-reported outcome measures. By following these large cohorts of patients clinically, BSM will continue to answer questions pertaining to risk assessment, injury prevention, surgical


Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 46)

technique, rehabilitation, and return to sport planning. We participate in a wide variety of multi-centre and randomized clinical trials assessing surgical techniques, pain management, rehabilitation, and clinical outcomes. The research pillar of the practice is integral to our ability to provide excellent patient care that is evidence-based. Future Vision The future vision for BSM includes patient self-referral for acute musculoskeletal injuries to bypass the referral process, and to effectively accept patients “direct from the ski patrol hut.” Further expansion includes adapting the work of Dr. Nicholas Mohtadi and the University of Calgary8 to our clinic location by training “acute orthopaedic injury examiners” to facilitate the initial assessment of patients; appointing a “patient navigator” as the key contact for patients to provide consistent advice and care pathway options; introducing a mobile knee assessment unit (i.e. “Knee Van”) which would visit local ski areas, sport organizations and schools; and coordinating an exercise and healthy living program targeting older patients to encompass the complete spectrum of musculoskeletal injury and osteoarthritis in the community. Our goal at Banff Sport Medicine is to broaden access and develop an integrated versus silo-based model for acute musculoskeletal injuries by combining clinical care, research and education. BSM strives to provide excellence in orthopaedic care by developing outcomes evidence and practicing evidence-based care. Success in these endeavours requires inte-

grating a multi-disciplinary team that is able to get the patient to the right care provider at the right time. This model of triage, early diagnosis, and collaborative care can improve clinical outcomes, enhance the physical and mental wellbeing of our patients, and reduce overall health care and societal costs. References 1. https://d10k7k7mywg42z.cloudfront.net/assets/569821a 0d4c9612e3f019ed0/E_Referral_Summary_Report_FINAL. pdf 2. http://waittimes.cihi.ca/ 3. https://d10k7k7mywg42z.cloudfront.net/assets/569821a 0d4c9612e3f019ed0/E_Referral_Summary_Report_FINAL. pdf 4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5686957/ 5. http://banffsportmed.com/research/ 6. http://healthydebate.ca/2017/02/topic/wait-times-specialists 7. www.banffsportmed.ca 8. https://www.cbc.ca/news/canada/calgary/innovativeknee-injury-clinic-saving-money-doctor-says-1.2423389

COA Endorsement of the CPSI Position Statement Supporting a Surgical Safety Checklist

L’ACO appuie l’énoncé de position de l’Institut canadien pour la sécurité des patients en faveur de l’utilisation d’une liste de vérification d’une chirurgie sécuritaire

Led by the Canadian Patient Safety Institute (CPSI), the COA joins a chorus of health care voices in support of a call for Surgical Safety Checklists to be made a standard part of every surgical procedure performed in Canada. In addition to an updated CPSI Joint Position Statement in support of surgical safety checklists, numerous resources are available to health care providers, including the Surgical Safety Checklist, a detailed explanation of checklist items and a how-to guide for implementation. We encourage all COA members to familiarize themselves with these protocols and to consider local implementation as appropriate, as part of our ongoing commitment to highquality and safe patient care.

L’ACO s’est jointe à un concert d’organismes en santé, dirigé par l’Institut canadien pour la sécurité des patients (ICSP), préconisant qu’une liste de vérification d’une chirurgie sécuritaire devienne un élément normalisé lors de toute intervention chirurgicale au Canada. En plus d’une mise à jour de l’Énoncé de position commune : Promotion et soutien de l’utilisation d’une [l]iste de vérification d’une chirurgie sécuritaire, un éventail de ressources sont à la disposition des fournisseurs de soins de santé, dont la Liste de vérification d’une chirurgie sécuritaire, l’Explication détaillée des éléments de la liste de vérification et le Guide d’instructions sur la mise en œuvre de la Liste de vérification d’une chirurgie sécuritaire. Nous invitons tous les membres de l’ACO à prendre connaissance de ces protocoles et à en envisager la mise en œuvre à l’échelle locale, si c’est approprié, conformément à notre engagement envers des soins de grande qualité et sécuritaires.

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Resident Scholarship Opportunity – Call for Applications The Canadian Orthopaedic Foundation is pleased to announce that applications are now being accepted for the 2019 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 2019 : 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 ». 2018 Scholarship Recipient / Lauréat de la bourse d’études 2018 :

Supriya Singh

(Western University / Université Western) for her role in the / pour son rôle dans le

Nyota Project (Project summary) (Résumé du projet)


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New Leadership, Continued Growth at the Canadian Orthopaedic Foundation Pierre Guy, MDCM, MBA, FRCSC Associate Professor and Clinician-scientist Department of Orthopaedics, UBC Vancouver, BC

At its Annual General Meeting held in July 2018 the Canadian Orthopaedic Foundation appointed Dr. Pierre Guy as President and Chair of the Board. Dr. Guy takes over the position from now Past President Dr. Geoffrey Johnston.

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am pleased to step into the role of President and Chair of the Board of the Canadian Orthopaedic Foundation (COF) at this remarkable time in its history. It was just over three years ago that the COA Executive challenged then-President Dr. Geoff Johnston and the rest of the Board to switch its main focus from education to research. With research dollars for orthopaedics becoming increasingly challenging to acquire, they felt that the COF might step forward to fill this niche in Canada, ensuring that Canadian orthopaedic surgeons retained their place on the global stage of leading-edge orthopaedic research. Under Dr.  Johnston’s leadership, and with the support of the Board and staff, the COF has risen to that challenge, growing from an annual research program of about $35,000 to over $240,000 in 2018. The prestigious Samson Award was doubled in value, emphasizing the importance of the COF’s premier award for research. In addition to an increased number of CORL grants (six this year), the COF presented awards named in honour of Drs.  Robert  Salter and Carroll  Laurin. Two new competitions were also introduced this year: Community Innovation Awards, presented to two community researchers, and the Cy  Frank Award for Innovation, in collaboration with CORS. Smaller awards were also granted this year (the best paper award for shoulder/elbow research, in partnership with CSES, and the Bones and Phones scholarship presented to a promising resident.) For information on all of this year’s awardees, visit the COF web site.

All of our successes are only possible with the aid of critical supporters. We are proud to announce that we have enlisted the support of Dr. Cecil Rorabeck as our Patron. Dr.  Rorabeck, a respected leader in Canadian orthopaedics, takes over the role of Patron from Dr. Pierre Guy, Dr.  Marvin  Tile, who President and Chair of completed his Patron term this year. The the COF Board COF is grateful to merit the support of two such orthopaedic legends. Coming up for the COF: we will not sit back on our laurels. We are proud to introduce a new award for the coming year. The Robin Richards Award for Upper Extremity Research will be presented on an annual bases for the best UE paper at the COA AGM. This is made possible by a six-figure donation from Dr.  Robin  Richards to establish an endowment to fund the award. Our Foundation is humbled and grateful to merit Dr.  Richards’ support and we look forward to presenting the first award in June 2019.

An impressive array of researchers accepted their COF research awards at the COA AGM, June 2018. The COF Research Program and other programs are supported by the Powering Pain Free Movement campaign, a fundraising campaign aimed at raising significant donations to advance the COF’s mandate. Thanks to Powering Pain Free Movement partners: Zimmer Biomet, DePuy Synthes, Bayer Healthcare, Sunnybrook Associates and Wright Medical. COA Bulletin ACO - Fall / Automne 2018


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(continued from page 49)

At the same time as we grow our research program, the COF is acutely aware that it has a role to play in patient education and care. Our education program, centred around our virtual library of patient resources, will grow this year with the introduction of a new resource for shoulder patients. Our GLA:D program, proven to benefit patients with hip or knee OA, continues to grow across Canada. In my tenure as President and Chair of the Board, I commit to working with the Board to build on the successes of the COF to date. We must continue to demonstrate the importance of research support to encourage increased donations from our surgeon colleagues and industry. We, as surgeons, have a unique opportunity and a strong influence: if we don’t demonstrate our own support of research, through the COF’s programs, why would industry feel the need to do so? In the coming months and years, the COF will work hard with Canada’s orthopaedic surgeons to advance our shared dedication to the COF vision: Pain free mobility for all Canadians. Visit the COF web site for more information on the COF Patron.

Nouveau leadership et croissance soutenue à la Fondation Canadienne d’Orthopédie Pierre Guy, MDCM, MBA, FRCSC Professeur agrégé et clinicien-chercheur Département d’orthopédie, Université de la Colombie-Britannique Vancouver (Colombie-Britannique)

À l’assemblée générale annuelle de la Fondation Canadienne d’Orthopédie, en juillet dernier, le  Dr  Pierre  Guy a accédé à la présidence du conseil d’administration de l’organisation. Il prend donc le relais du Dr Geoffrey Johnston, président sortant.

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e suis heureux d’endosser le rôle de président du conseil d’administration de la Fondation Canadienne d’Orthopédie à un moment si remarquable de son histoire. Il y a un peu plus de trois ans, le Comité de direction de l’ACO lançait un défi au président de l’époque, le Dr Geoff Johnston, et au reste du conseil d’administration  : faire de la recherche la grande priorité de la Fondation, dont les efforts étaient jusquelà axés sur la sensibilisation et la formation. Le financement de la recherche en orthopédie se faisant de plus en plus rare, le Comité de direction était d’avis que la Fondation pouvait occuper ce créneau au pays, et ainsi s’assurer que les orthopédistes canadiens maintiennent leur position sur la scène internationale de la recherche de pointe en orthopédie.

COA Bulletin ACO - Fall / Automne 2018

We are pleased to announce that Dr. Cecil Rorabeck has accepted the role of Foundation Patron. Dr. Rorabeck practiced joint replacement surgery at London Health Sciences Centre for 30 years before moving on to Interim Chief Executive Officer and Scientific Director of the Robarts Research Institute. He was appointed an officer Dr. Cec Rorabeck: new Patron of the of the Order of Canada in 2012 for Canadian Orthopaedic advancing orthopaedic medicine and became president of the Royal College Foundation of Physicians and Surgeons of Canada Le Dr Cecil Rorabeck, in 2013. “The Canadian Orthopaedic nouveau président d’honneur de la Foundation funds impressive research projects and provides direct support to Fondation Canadienne d’Orthopédie our orthopaedic patient community. I’m sure others will want to join me in supporting the Foundation,” says Dr. Rorabeck. Nous sommes heureux d’annoncer que le Dr Cecil Rorabeck a accepté la présidence d’honneur de la Fondation. Le Dr Rorabeck est spécialiste des arthroplasties au Centre des sciences de la santé de London pendant 30 ans, puis président-directeur général et directeur scientifique intérimaire du Robarts Research Institute. Il est fait officier de l’Ordre du Canada en 2012 pour avoir repoussé les frontières dans le domaine des soins orthopédiques. En 2013, il devient président du Collège royal des médecins et chirurgiens du Canada. « La Fondation Canadienne d’Orthopédie finance des projets de recherche impressionnants, en plus de soutenir directement nos patients en orthopédie. Je suis persuadé que d’autres voudront suivre mon exemple et appuyer la Fondation », déclare le Dr Rorabeck. Sous la direction du Dr  Johnston, et avec le soutien du conseil d’administration et du personnel, la Fondation s’est montrée à la hauteur, faisant passer son programme de financement de la recherche d’environ 35 000 $ par an à plus de 240 000 $ en 2018. La valeur du prestigieux Prix J.-Édouard-Samson a doublé, donnant plus de poids à la récompense phare de la Fondation. De plus, la Fondation a augmenté le nombre de bourses de recherche du programme de l’Héritage de la recherche orthopédique au Canada  (HROC)  – elle en a octroyé six cette année  – et remis les bourses Robert-B.-Salter et Carroll-A.-Laurin, qui rendent hommage à ces orthopédistes de renom. L’année a aussi été marquée par le lancement de deux prix  : le Prix  d’innovation communautaire, remis à deux chercheurs communautaires, et le Prix Cy-Frank pour l’innovation en recherche orthopédique, remis en partenariat avec la Société de recherche orthopédique du Canada. D’autres distinctions ont aussi été remises, soit le Prix du meilleur précis en orthopédie de l’épaule et du coude, accordé en partenariat avec la Société canadienne de l’épaule et du coude  (CSES), et la Bourse d’études Bones  and


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(suite de la page 50)

Phones, attribuée à un résident d’exception. Pour de plus amples renseignements sur les lauréats de cette année, consultez le site Web de la Fondation. Une telle réussite n’est toutefois possible que grâce au soutien d’alliés inestimables. Nous sommes d’ailleurs fiers d’annoncer que le Dr Cecil Rorabeck a accepté de devenir notre président d’honneur. Leader respecté du milieu orthopédique canadien, le Dr Rorabeck succède au Dr Marvin Tile, dont le mandat à ce titre vient de prendre fin. La Fondation est privilégiée d’obtenir ainsi le soutien de deux piliers du milieu. Mais il ne faut pas croire qu’on s’arrêtera là! Nous sommes fiers d’offrir une nouvelle distinction cette année  : le Prix Robin  Richards de la recherche sur les membres supérieurs sera remis chaque année au meilleur précis sur les membres supérieurs présenté à la Réunion annuelle de l’ACO. Ce prix est le fruit d’un don dans les six chiffres effectué par le Dr Robin Richards en vue de la création d’un fonds de dotation. Nous sommes on ne peut plus reconnaissants au Dr  Richards pour son soutien et avons hâte de remettre le premier prix en son honneur en juin 2019. Tout en faisant fructifier notre programme de financement de la recherche, nous sommes tout à fait conscients que nous avons un rôle à jouer dans la sensibilisation des patients et dans leurs soins. Notre programme de sensibilisation, axé sur notre catalogue virtuel de ressources à l’intention des patients, se verra

bonifié cette année d’une nouvelle ressource sur la chirurgie de l’épaule. Notre programme GLA:D, dont les bénéfices pour les personnes atteintes d’arthrose aux genoux ou aux hanches sont éprouvés, continue de prendre de l’ampleur au pays. En tant que président du conseil d’administration de la Fondation, je m’engage à Le Dr Pierre Guy, œuvrer de pair avec le conseil de sorte à président du conseil miser sur les réussites de notre organisa- d’administration de la tion à ce jour. Afin d’inciter les orthopé- Fondation distes et l’industrie à donner davantage, il est primordial de montrer encore et toujours l’importance de soutenir la recherche. En tant qu’orthopédistes, nous avons une position unique et une influence certaine : si nous ne soutenons pas la recherche, par l’intermédiaire des programmes de la Fondation, pourquoi l’industrie le ferait-elle? Au cours des mois et années à venir, la Fondation travaillera sans relâche avec les orthopédistes canadiens à la concrétisation de notre vision, soit une mobilité sans douleur pour toute la population canadienne. Pour plus de renseignements sur le président d’honneur de la Fondation, consultez le site Web de la Fondation.

Un groupe impressionnant de chercheurs ont reçu leur prix ou bourse de recherche de la Fondation à la Réunion annuelle de l’ACO, en juin dernier. Le programme de financement de la recherche de la Fondation, entre autres programmes, est soutenu par sa campagne Misons sur une vie sans douleur, qui vise à recueillir des sommes importantes afin de concrétiser le mandat de la Fondation. Merci à nos partenaires de la campagne Misons sur une vie sans douleur : Zimmer Biomet, DePuy Synthes, Bayer Healthcare, Sunnybrook Orthopaedic Associates et Wright Medical. COA Bulletin ACO - Fall / Automne 2018


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Using the CanMEDS Roles in Your Practice

The Medical Expert Role: There’s more to it than you think Wade Gofton, M.D., MeD, FRCSC Director of Education, University of Ottawa Ottawa, ON Tyson Gofton, PhD

care individually, locally, nationally and internationally. As you can see, each of these CanMEDs Roles are integral parts of being MEs.

ME is also an important part of continuing professional development (CPD). The Royal Kevin Smit, M.D., FRCSC College allows maintenance of compeAssistant Professor, University of Ottawa tence points in ME from any learning secThe Children’s Hospital of Eastern Ontario tions. For example, researching and develOttawa, ON oping Medical Council of Canada (MCC) questions for the Royal College examination is an easy opportunity to not only update knowlhen thinking about CanMEDs in clinical edge, but also to maintain ME (Section 2). ME practice, the Medical Expert (ME) role is can also be maintained by reviewing teaching generally the role we think of first. After feedback from students or peers, audits of perforall, expertise is central to our identity and practice mance within your practice or participating in a 360 as specialist and subspecialist orthopaedic surgeons. review or reviewing feedback from peer-reviewed Copyright © 2015 However, our expertise is about much submissions (Section 3 points). In CPD more than just what takes place in The Royal College of Physicians and Surgeons of Canada. too, maintenance of ME is closely conReproduced with permission. the operating room. Building our own nected to other intrinsic roles, such as competencies as MEs, and helping Scholar, Collaborator and Professional. trainees develop in the ME role requires The CanMEDS framework is a tool used for teaching an understanding of how the ME role Teaching ME and for our continuing medical education. It is fits into our whole practice. There may There are several common misconwell established, benefits our profession and has be more to ME than you think. ceptions that trainees have about ME. been integrated into the Royal College’s programs Trainees tend to focus on the tools and including Maintenance of Certification. The seven ME in practice technical aspects of our specialty, priorroles of the CanMEDS are: As specialists or subspecialists we have itizing the need to ‘learn to operate’. We medical expertise that differentiates us can reframe their thinking by remind• Medical Expert (the integrating role) from other specialties and is usually ing them that patients care about how • Communicator the primary reason a patient is coming our expertise contributes to address• Collaborator to us for care. However, while the ME ing their needs. Our expertise is about • Leader role is at the centre of medical practice, more than operating; it is understand• Health Advocate this role in isolation is not sufficient for ing ‘who needs the operation’, ‘which • Scholar practice of patient-centred care in the operation’, and perhaps when ‘not oper• Professional 21st century. ME must integrate and ating’ best addresses patient needs. incorporate with the other six Intrinsic Trainees may also confuse the ME role Roles to optimize patient care. with an authoritative role in patient Over the next few editions of the COA Bulletin, care, however, the patient-physician various members of the COA will define each of the ME is the core role that defines our clinirelationship is defined by patient prefroles and how they can be used in day to day practice cal scope of practice, while integraterence. Key skills are often learned outand education. This series will provide guidelines on ing all CanMEDs roles. As orthopaedic side of the operating room and, when how to use the CanMEDS roles to their full advantage surgeons, we are experts in muscuincorporated with the other intrinsic in your orthopaedic practice. Drs. Wade Gofton, Kevin loskeletal function and pathology. As Smit and Tyson Gofton have kindly agreed to examine roles, develop the patient-centered surScholars, we continuously enhance our geon that patients seek. Trainees also the role of Medical Expert in this edition’s feature. medical expertise with ongoing learnneed to learn that there are no siming and critical evaluation of ongople answers to complex problems. ME Enjoy – Ed. ing research. As Communicators, we requires comfort working with uncerconvey our orthopaedic expertise to tainty and communicating that uncerpatients, which results in improved patient satisfaction and tainty to patients. Finally, trainees often consider other roles to fewer medical errors. We are Collaborators as experts conbe secondary to ME. A training program’s explicit curriculum tributing to safe, high-quality, patient-centered care teams. As (teaching and training) and implicit curriculum (the way faculty Professionals, we draw on our expertise through ethical pracpractice) that integrates all seven CanMEDS roles can correct tice and high standards to represent our subspecialty. We are this misperception. Leaders ensuring that our clinical and operating teams achieve optimal outcomes for every patient. We are Health Advocates When asked to observe trainees and document performance, when we draw on our expertise to advocate for our patients we intuitively comment on aspects of the Medical Expert role.

W

COA Bulletin ACO - Fall / Automne 2018


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

While our intentions are good, our feedback is often limited to ‘read more around this’ or ‘you need to see and do more of these’. However, as we move towards Competence by Design (CBD), we also need to rethink how we teach ME. By reconceptualizing time as a resource rather than a limitation, CBD focuses training on individual learners, ensuring competence progression through a fixed training period. Learning milestones are layered onto training experience to provide learners with a clear path towards competence. Workplace-based assessment (WBA) also provides instructors with practical tools for assessing progress towards medical expertise in the context of deliberate practice, where ME is closely integrated with other Intrinsic Roles.

ees, medical students or allied health workers, you need to provide patient-centered care and continuously develop your competencies in all seven Intrinsic Roles. It is often not what you teach but how you practice that provides the example and the model for trainees.

Perhaps the most important way you can teach trainees about the ME role is by example. Whether in the academic environment or in the community, whether to the orthopaedic train-

2. Royal college web site: CPD activities you can record: http://www.royalcollege.ca/rcsite/cpd/moc-program/ cpd-activities-can-record-e

References 1. F. Bhanji, K. Harris, M. Goldszmiidt, S. Glover Takahashi: CanMEDS Teaching and Assessment Tool Guide. Medical Expert. Royal College of Physicians and Surgeons of Canada; Oct 2015.

Do You Know How to Protect Your Assets?

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ne of my colleagues recently told me about being embezzled, and reported that 30% of physicians are victims of embezzlement at any one time. Orthopaedic surgeons run practices that have relatively high costs and financial turn over.   We are busy, and often poorly educated in money matters making us all targets for fraud.  Shortly after learning about the volume of embezzlement in medicine, I talked to one of my patients, Constable Bruce Brown, who works for the RCMP in the White Collar Crime division.   My conversation with Constable Brown confirmed that an ounce of prevention was worth a pound of cure.  The best way to avoid having your cell phone stolen from your car is not to leave it there in the first place, rather than expect it to be returned if it is taken. Similarly, it is much better to be educated and avoid fraud in the first place, rather than try and recover the cash from the crooks later. After being persuaded to invest in a scam through parents of children in my kids’ kindergarten class when I was a junior consultant, I wish I had had this guidance earlier.  Constable Brown’s advice is based on years of prosecuting fraudsters. I would like to thank him for providing this article for our membership, and for the ongoing work he does through the RCMP. His job is invaluable and like much detective work, goes unrecognized.  In due course, we will feature an article by

Dr. Jeff Nacht on embezzlement in medicine in an upcoming edition of the COA Bulletin.

Article submissions to the COA Bulletin are always welcome!

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

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

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

This edition also includes an article by Adam O’Neill, who manages COAplan, which focuses on how to ensure that your financial goals are achieved through proper planning. I would like to thank them both for their valuable contributions to our journal. Alastair Younger, Editor in Chief COA Bulletin

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Avoiding Investment Fraud Bruce Brown Special to the COA Bulletin

Tips for Avoiding Investment Fraud: • Don’t judge a person or company by their presentation or web site. • Don’t invest in anything you are not sure about. Do your homework on the investment and the company to ensure that they are legitimate. • Check out other web sites regarding the person/company you are considering investing with. • Be cautious when responding to special investment offers, especially through unsolicited e-mails or cold calls. • Be cautious when dealing with individuals/companies from outside of Canada. • Inquire about all the terms and conditions of the investment. Do a background check on the company and the person giving the presentation and ask questions before you invest. Don’t be Afraid to Ask! Confirm Identification ost investment advisors are required to complete a “Know your Client” form. This person is asking you to trust them and invest tens of thousands of dollars or more. They should not have a problem with you knowing their true identity. Ask to see their government issued picture identification, (Provincial Driver’s Licence, Passport), take out your smart phone, snap a picture of the identification and a facial photo of them. This simple step will help with the background checks or bring the person to justice if they turn out to be a fraudster!

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The Most Common Frauds The continuing integration of global capital markets has created unprecedented opportunities for Canadians to access investments and diversify their portfolios. This growth has led to a corresponding rise in the amount of fraud and misconduct seen in these markets. The creation of complex investment vehicles and the tremendous increase in the amount of money being invested have created greater opportunities for individuals and businesses to perpetrate fraudulent investment schemes.

The following are the most prevalent types of securities and commodities fraud schemes: • Investment fraud: These schemes are sometimes referred to as “high-yield investment fraud. They are characterized by offers of low- or no-risk investments, guaranteed returns, overly-consistent returns, complex strategies, or unregistered securities. These schemes often seek to victimize affinity groups—such as groups with a common religion or ethnicity—to utilize the common interests to build trust to effectively operate the investment fraud against them. The perpetrators range COA Bulletin ACO - Fall / Automne 2018

from professional investment advisers to persons trusted and interacted with daily, such as a neighbor or sports coach. The fraudster’s ability to foster trust makes these schemes so successful. Investors should use scrutiny and gather as much information as possible before entering any new investment opportunities. Ponzi schemes: These schemes involve the payment of purported returns to existing investors from funds contributed by new investors. Ponzi schemes often share common characteristics, such as offering overly consistent returns, unregistered investments, high returns with little or no risk, or secretive or complex strategies. Pyramid schemes: As in Ponzi schemes, money collected from new participants is paid to earlier participants. In pyramid schemes, however, participants receive commissions for recruiting new participants into the scheme. Pyramid schemes are frequently disguised as multi-level marketing programs. Promissory note fraud: These are generally short-term debt instruments issued by little-known or nonexistent companies. The notes typically promise a high rate of return with little or no risk. Fraudsters may use promissory notes to avoid regulatory scrutiny; however, most promissory notes are securities and need to be registered with the Securities and Exchange Commission and the provinces in which they are being sold. Commodities fraud: Commodities fraud is the illegal sale or purported sale of raw materials or semi-finished goods that are relatively uniform in nature and are sold on an exchange (e.g., gold, pork bellies, orange juice, and coffee). The perpetrators of commodities fraud entice investors through false claims and high-pressure sales tactics. Often in these frauds, the perpetrators create artificial account statements that reflect purported investments when no such investments have been made. Instead, the money has been diverted for the perpetrators’ use. Additionally, they may trade excessively merely to generate commissions for themselves (known as “churning”). Two common types of commodities fraud include investments in the foreign currency exchange (Forex) and into precious metals (e.g., gold and silver). Broker embezzlement: These schemes involve illicit and unauthorized actions by brokers to steal directly from their clients. Such schemes may be facilitated by the forging of client documents, doctoring of account


Training & Practice Management / Formation et gestion d’une pratique (continued from page 54)

statements, unauthorized trading/funds transfer activities, or other conduct in breach of the broker’s fiduciary responsibilities to the victim client. • Market manipulation: These “pump and dump” schemes are based on the manipulation of lower-volume stocks on small over-the-counter markets. The basic goal of market manipulation fraud is to artificially inflate the price of the penny stocks so that the conspirators can sell their shares at a large profit. The “pump” involves recruiting unwitting investors through false or deceptive sales practices, public information, or corporate filings. Many of these schemes use boiler room methods where brokers—who are bribed by the conspirators—use highpressure sale tactics to increase the number of investors and, as a result, raise the price of the stock. Once the target price is achieved, the perpetrators “dump” their shares at a huge profit and leave innocent investors to foot the bill. Fraud schemes will continue to grow as investors remain susceptible to the uncertainty of the global economy. Protect yourself: get investment advice from trusted sources, ask questions, and be sure you understand the risks. Remember, it never hurts to get a second opinion. Investment scammers may guarantee extremely high returns on your investment or tell you that you must act fast to get in on “the opportunity of a lifetime.” These tricks can lead you to make an impulsive decision. Slow down, take enough time to: (a) read the contract, (b) understand the investment, and (c) obtain an independent second opinion about the investment (particularly for unsolicited investment opportunities). You are entitled to use as much time as you need to understand the investment before making the decision to invest. What You Can Do to Avoid Investment Fraud • Ask questions. Fraudsters are counting on you not to investigate before you invest. It’s not enough to ask for more information or for references, take the time to do your own independent research. • Research before you invest. Unsolicited emails, message board postings, and company news releases should never be used as the sole basis for your investment decisions. Understand a company’s business and its products or services before investing. Look for the company’s financial statements on the Security Exchange. • Know the salesperson. Spend some time checking out the person touting the investment before you invest — even if you already know the person socially. Always find out whether the securities salespeople who contact you are licensed to sell securities in your province and whether they or their firms have had run-ins with regulators or other investors. You can check out the disciplinary history of brokers and advisers with the Provincial Security Commission. • Be wary of unsolicited offers Be especially careful if you receive an unsolicited pitch to invest in a company, or see it praised online, but can’t find current financial information about it from independent sources.

• Be wary if someone recommends foreign or “off-shore” investments. If something goes wrong, it’s harder to find out what happened and to locate money sent abroad. • Protect yourself online. Online and social marketing sites offer a wealth of opportunity for fraudsters. Protect yourself online, learn how to protect your social media accounts. • Know what to look for. Make yourself knowledgeable about different types of fraud and red flags that may signal investment fraud. Red Flags for Fraud and Common Persuasion Tactics How do successful, financially intelligent people fall prey to investment fraud? Researchers have found that investment fraudsters hit their targets with an array of persuasion techniques that are tailored to the victim’s psychological profile. Here are red flags to look for: • If it sounds too good to be true, it is. Watch for “phantom riches.” Compare promised yields with current returns on well-know stock indexes. Any investment opportunity that claims you’ll receive substantially more could be highly risky – and that means you might lose money. Be careful of claims that an investment will make “incredible gains,” is a “breakout stock pick” or has “huge upside and almost no risk!” Claims like these are hallmarks of extreme risk or outright fraud. • “Guaranteed returns.” Every investment carries some degree of risk, which is reflected in the rate of return you can expect to receive. If your money is perfectly safe, you’ll most likely get a low return. High returns entail high risks, possibly including a total loss on the investments. Most fraudsters spend a lot of time trying to convince investors that extremely high returns are “guaranteed” or “can’t miss.” They try to plant an image in your head of what your life will be like when you are rich. Don’t believe it. • Beware the “halo” effect. Investors can be blinded by a “halo” effect when a con artist comes across as likeable or trustworthy. Credibility can be faked. Check out actual qualifications. • “Everyone is buying it.” Watch out for pitches that stress how “everyone is investing in this, so you should, too.” Think about whether you are interested in the product. If a sales presentation focuses on how many others have bought the product, this could be a red flag. • Pressure to send money RIGHT NOW. Scam artists often tell their victims that this is a once-in-a-lifetime offer and it will be gone tomorrow. But resist the pressure to invest quickly and take the time you need to investigate before sending money. • Reciprocity. Fraudsters often try to lure investors through free investment seminars, figuring if they do a small favour for you, such as supplying a free lunch, you will do a big favour for them and invest in their product. There is never a reason to make a quick decision on an investment. If you attend a free lunch, take the material home and research both the investment and the individual selling it before you invest. Always make sure the product is right for you and that you understand what you are buying and all the associated fees.

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(continued from page 55)

Rules for Avoiding Investment Fraud • Rule 1 – Only Deal with Registered Advisors. In Canada, investment firms and advisors are licensed to sell investments by a process called “registration”. A provincial or territorial securities commission regulates each registered firm and advisor. Some are also governed by investment industry self-regulatory organizations (SROs). The two SROs in Canada are the Investment Industry Regulatory Organization of Canada (IIROC) and the Mutual Fund Dealers Association (MFDA). • Registration – You can check registration at  AreTheyRegistered.ca. For further information about  conducting background checks, see FAIR Canada’s web site. • Discipline – You can review disciplinary history records on the Disciplined Persons List. If the advisor has a history of disciplinary action, this is a red flag. You should make sure you fully understand any proceedings brought against them before investing or find an advisor who does not have a disciplinary history. Advisors and firms governed by SROs are subject to a closer level of regulation and supervision. An additional advantage of dealing with an advisor or firm regulated by an SRO is that they are required to participate in a compensation fund (the Canadian Investor Protection Fund or the Investor Protection Fund). The compensation fund may provide coverage to investors in the event of firm insolvency. • Rule 2 – Be Aware of Fraud ‘Warning Signs’ and red flags mentioned previously. • Rule 3 – Cheques Payable to Registered Firms, Not Individuals or Other Companies. Only hand over money in the name of registered firms.

• Rule 4 – Stick to Registered Investments. Unsophisticated investors should only invest in products that securities regulators have given some scrutiny to. Investments in unregulated private real estate offerings and “bulletin board listed” (over-the-counter) companies have often turned out to be scams. To find out whether a particular investment has a prospectus, call your provincial securities regulator. • Rule 5 – Ask Questions, Verify, and ‘Just Say No’. If you do not understand an investment after discussing it with your advisor, do not buy it. Never sign a blank document or one that you do not understand. Provincial securities regulators have contact centres to answer inquiries. If you think that an investment opportunity is a scam or is not suitable for you, don’t be afraid or embarrassed to just say no. For more information see: • BC Securities Commission • Ontario Securities Commission • Canadian Securities Administrator • faircanada.ca • Financial and consumer Services Commission • RCMP - Canadian Anti-Fraud Centre (www.antifraudcentre.ca) • FBI - Fraud advisory **This article was written using information from the above organizations.

Planning in the New Tax Regime Adam O’Neill, CFP, CLU, CHS, MBA, BSc Special to the COA Bulletin

T

he ICL on tax management presented by COAplan this summer at the COA Annual Meeting in Victoria dealt with the changes in the most recent federal budget, and how those changes impact orthopaedic surgeons. The (very) condensed answer is that many of the most beneficial and “easy win” strategies have been disallowed, leaving fewer and often more complex strategies available. This, in turn, necessitates a greater degree of efficiency and attention to both personal and professional financial management for Canadian surgeons, the bedrock of which is a financial plan. Incomplete or Partial Plans Far too often I encounter individuals in my practice who are confident that they have a financial plan, which upon further investigation ends up being only a very limited part of a plan (usually an investment plan). Any effective financial plan must be holistic as well as comprehensive (taking into account protection, investment, tax and estate issues). These areas are all COA Bulletin ACO - Fall / Automne 2018


Training & Practice Management / Formation et gestion d’une pratique (continued from page 56)

interrelated and addressing them together ensures that these areas are in alignment and where possible, create additional efficiency. Designations (CFP & CLU) There are very loose regulations in Canada around financial planning, but there is an easy way to ensure that your plan meets certain standards and guidelines. The two main professional designations for financial planners are CFP® (Certified Financial Planner) and CLU® (Certified Life Underwriter). The individual or entity designing your plan should have one or both of these designations or have those that do in their employ. Aside from ensuring a level of competency, those designations also demand additional ethical and educational requirements of holders, as well as laying out certain parameters and best practices for the planning process. These include the foundation of any plan: the assumptions. Assumptions The assumptions used in a financial plan largely determine the resulting recommendations and outcomes. In order to forecast and project into the future, assumptions need to be made on interest rates, cost of borrowing, rates of return for different types of investments and portfolios, life expectancy, and many more. These assumptions should be in line with industry norms, and erring on the side of conservatism where possible. Comprehensiveness A financial plan needs to address all aspects of your financial wellbeing, while also encompassing your broader life, legacy goals, and overall philosophy. The following are areas which should be addressed in any effective plan: Income What is your current income and expected income progression (both during your full-time career years and after), and what are your retirement income needs? These all need to be estimated, and the planning process itself often greatly informs and shapes the expectations for retirement. Tax What combination of investment vehicles and investment types can provide the best corporate and personal tax sheltering? How do you most efficiently shelter non-registered assets and estate values? Is there a place or need for trust structures, segregated funds, insurance or other tools in your plan for optimal tax protection? Protection What are the implications of the three main controllable risks (death, disability, disease) on your plan? How can these risks best be managed and mitigated? Legacy What charitable or legacy goals do you have, and what are the different strategies to achieve them? Can these legacy goals be combined or addressed in concert with other goals and concerns in your plan?

What goals do you have for your children and grandchildren, or less fortunate family members? With significant wealth transfer, how can you prevent undesirable behaviour and decisions in future generations? How can you protect the assets you are leaving your children and grandchildren against marital breakdown? Corporate Assets and Entities How best should you wind down your corporation, and extricate your corporate assets? What share structures and strategies are available to minimize tax? Can you take advantage of the LCGE (lifetime capital gains exemption)? Is your business saleable? Contingency Planning What impact will different scenarios have on your plan? How could changes in mortality, morbidity, care needs, financial markets, and more impact you and your family? How recent and effective are your wills and powers of attorney? Are corporate wills and powers of attorney needed? What events might trigger a review of these documents? Recommendations What concrete steps can be taken and in what priority to materially improve your financial security and situation? What alternatives are there for each area? What events or changes might trigger or provoke the implementation of these strategies? These above topics all have potentially very significant impacts on how your life may unfold, and how your plan should be designed. Any plan which neglects any of these areas should be treated with suspicion and revisited. Conclusion While the big four banks, MD, and several other large institutions should also provide some level of these services under certain situations, all COA members have access to Sun Life Financial’s EFPS (Estate and Financial Planning Services) through the COAplan initiative, which ensures impartial, armslength planning from some of the best planners in the country to all Canadian orthopaedic surgeons and their families. Don’t be shy about requesting planning services, nor about asking reasonable and responsible questions such as the accreditation of the planners involved, their compensation, and what further services are or are not offered. The new reality is that there is now more attention and efficiency required for surgeons in Canada in order to ensure the security and outcomes enjoyed by your predecessors. The clearest and most effective way to achieve this is to undertake a comprehensive financial plan, designed by a competent, ethical planner using the most up-to-date tools and strategies. The information in the article has been provided to the COA by O’Neill Financial Inc. and COAplan Inc. It is always recommended to seek independent advice related to your particular circumstances as necessary.

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ICORS

2nd Meeting of the

International Combined Orthopaedic Research Societies (ICORS) Deuxième réunion des

International Combined Orthopaedic Research Societies (ICORS)

Montréal 2019 June 19-22 Du 19 au 22 juin www.2019icors.org

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COA Bulletin #121 - Fall 2018  

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

COA Bulletin #121 - Fall 2018  

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

Profile for coa-aco