COA Bulletin #125 - Fall 2019

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


Canadian Orthopaedic Association Association Canadienne d’Orthopédie DOES THE NEW CANADA FOOD GUIDE SUPPORT A HEALTHY SKELETON?. . . . . . . . . . . . . . . . . . . p. 30 LE NOUVEAU GUIDE ALIMENTAIRE CANADIEN FAVORISE-T-IL LA SANTÉ DE L’APPAREIL LOCOMOTEUR?.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . p. 30

Fall Automne 2019



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

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1. Statement based on x-ray based imaging, imageless case option, and reduced instrumentation through pre-operative imaging. 2. *Meta-Analysis of Navigation vs Conventional Total Knee Arthroplasty Bandar M. Hetaimish, MD, & al , The Journal of Arthroplasty Vol. 27 No. 6 2012 All content herein is protected by copyright, trademarks and other intellectual property rights, as applicable, owned by or licensed to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or in part, without the express written consent of Zimmer Biomet. This material is intended for health care professionals. Distribution to any other recipient is prohibited. For indications, contraindications, warnings, precautions, potential adverse effects and patient counselling information, see the package insert or contact your local representative; visit for additional product information. Check for country product clearances and reference product specific instructions for use. Not for distribution in France. Š 2019 Zimmer Biomet

Your COA / Votre association

Bulletin Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 125 - Fall / Automne 2019 COA / ACO Mark Glazebrook President / Président Brendan Sheehan 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: Web site/Site internet: COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Paul A. Martineau Scientific Editor / Rédacteur scientifique William Weiss Current Issues Editor Rédacteur, questions d’actualité Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Lexie Bilhete Editorial Assistant / Adjointe à la rédaction Dan Cohen Contributor / Contributeur Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: 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® (, 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., 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.


Sail with Your COA to the Future Mark Glazebrook, MD, FRCSC President, Canadian Orthopaedic Association


ime is flying by, as we approach the end of the year and are well into planning the 2020 Annual Meeting in Halifax, NS. I am happy to report that the COA Board, committees, and staff, along with the membership are all working together and making progress on many of the Association’s projects and initiatives. First and foremost, preparations are currently underway for the upcoming COA Strategic Retreat. In line with its 75th anniversary, the COA is undergoing an important review, with the aim to analyze its mission and vision, restructure its core values and goals, as well as prioritize support for upcoming changes and new projects. This month, all COA members were contacted to participate in a very brief survey asking for their input, which will Dr. Mark Glazebrook, greatly assist the Board and steering committee with COA President this process. Your suggestions lead our discussions and I encourage your involvement. Additionally, a cross-section of members representing the diverse COA membership will also participate in a two-day retreat organized by the COA Executive and staff, early in the New Year. Diversity remains a priority for the COA and our efforts have been recognized by several of the international orthopaedic associations I visited throughout the Fall. This is due to accomplishments such as a publication1 by Hiemstra et al. revealing current gender statistics in the COA and the importance of strong female role models in leadership positions and on the podium at meetings and conferences. We are continuing this momentum alongside Dr. Pascale Thibaudeau (McGill University) researching maternity and parental leave within the Canadian orthopaedic community. Thank you to our COA members for their active work on these projects. I encourage future involvement of our membership as we pursue initiatives related to all aspects of diversity. Unfortunately, the orthopaedic manpower dilemma continues to be the COA’s most daunting challenge; many of our surgeons are left unemployed in the face of growing wait times for our patients’ orthopaedic care. Progress has been made by involved COA members through diverse strategies such as exploring job-sharing models of employment, and raising awareness at local and national government. Your COA continues to monitor the number of unemployed surgeons and resident training positions, and track all progress made in these areas. The Practice Management Committee is working on establishing retirement transition and job-sharing models with Committee Chair, Dr. Greg Clarke, along with Drs. Ross Leighton, Nathan Urquhart, 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:

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 :

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

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Andrew Hayward and I currently soliciting the cooperation of Nova Scotia’s government to establish a framework for more immediate surgeon employment, synchronised with a plan for gradual retirement of senior surgeons. The implementation of this framework within Nova Scotia can also serve more broadly as a blueprint for other orthopaedic surgeons to approach their provincial leaders. In order to keep moving forward, significant progress requires elevating public awareness that Canada has some of the longest waitlists for orthopaedic care among the developed nations, yet paradoxically has a high number of unemployed surgeons largely due to a lack of government resources. The COA is working with affiliate stakeholder organizations on rolling out public awareness initiatives into the next year. Addressing the orthopaedic manpower dilemma requires innovations in multiple areas, including patient care, resource allocation, and private care. The COA Executive realizes that this issue has no quick fix and can’t expect to be resolved during my mandate, but calls upon the engagement of the COA membership to reach solutions faster. Please get involved in your Association’s fight to improve the orthopaedic speciality in Canada by reaching out to Finally, I urge all COA members to mark your calendars and come sail with your COA to Halifax for the Annual Meeting, June 3-6, 2020. The upcoming Meeting promises to be an inno-

vative experience, including additional interaction opportunities with industry representatives during specialized lunchtime sessions. Further, the heart of your COA’s success will be in full swing with academic and community educators highlighted in the scientific program under the direction of the 2020 Program Co-chairs, Drs. Glen Richardson and Ivan Wong. Dr. Chad & Ms. Jodi Coles are busy assuring the Meeting represents a true maritime experience featuring East Coast music and lobster on the beautiful Halifax waterfront! Registration opens in the New Year and we can’t wait to see you next June.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 19 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 37 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 43

Venez voguer vers l’avenir avec votre ACO Mark Glazebrook, MD, FRCSC Président de l’Association Canadienne d’Orthopédie


e temps file, et nous voici déjà à la fin de l’année et au beau milieu de la planification de la Réunion annuelle 2020, à Halifax, en Nouvelle-Écosse. J’ai le plaisir de confirmer que le conseil d’administration, les comités et le personnel de l’ACO, tout comme ses membres, travaillent tous ensemble de sorte à faire progresser bon nombre de ses projets et initiatives. Tout d’abord, les préparatifs vont bon train pour la prochaine retraite stratégique de l’ACO. Dans le cadre de son 75e anniversaire, l’ACO procède à un important examen, dans l’intention d’analyser sa mission et sa vision, de reformuler ses valeurs fondamentales et objectifs, ainsi que de prioriser le soutien pour les changements et projets à venir. Ce mois-ci, on a invité tous les membres de l’ACO à répondre à un très court sondage afin d’obtenir leur rétroaction, qui sera fort utile au conseil d’administration et au comité directeur dans ce processus. Vos suggestions guideront nos discussions, et je vous incite à participer au sondage. De plus, un groupe représentatif de la diversité des membres de l’ACO prendra part à une retraite de deux jours organisée par la direction et le personnel de l’ACO en début d’année. COA Bulletin ACO - Fall / Automne 2019

La diversité demeure une priorité pour l’ACO, et ses efforts en ce sens ont été reconnus par plusieurs des associations en orthopédie que j’ai visitées dans le monde cet automne. Cette reconnaissance découle de réalisations telles qu’une publication d’Hiemstra et al.1 révélant les statistiques ventilées selon le sexe à l’ACO et l’importance de modèles féminins forts bien visibles dans des rôles de leadership et sur le podium dans les congrès et conférences. Nous poursuivons sur cette lancée avec la Dre Pascale Thibaudeau (Université McGill), qui fait des recherches sur les congés de maternité et parental au sein de la communauté orthopédique canadienne. Merci aux membres de l’ACO pour leur travail acharné dans ces projets. J’invite nos membres à participer à nos initiatives actuelles et futures liées à tous les aspects de la diversité. Malheureusement, l’enjeu de la main-d’œuvre en orthopédie continue de représenter le défi le plus redoutable pour l’ACO; beaucoup de nos orthopédistes sont sans emploi malgré des temps d’attente croissants pour les soins en orthopédie. Des progrès ont été réalisés par des membres concernés de l’ACO grâce à diverses stratégies, comme l’essai de différents modèles de partage des tâches et la sensibilisation d’administrations locales et nationales.

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Votre ACO continue de faire le suivi du nombre d’orthopédistes sans emploi et de places en résidence, ainsi que des progrès réalisés à cet égard. Le Comité sur la gestion de l’exercice travaille à l’établissement de modèles de transition vers la retraite et de partage des tâches avec le Dr Greg Clarke, président du comité, et les Drs Ross Leighton, Nathan Urquhart, Andrew Hayward et moi-même sollicitons actuellement la coopération du gouvernement néo-écossais afin de créer un cadre pour une embauche plus immédiate d’orthopédistes, synchronisé avec un plan de retraite progressive des orthopédistes âgés. La mise en œuvre de ce cadre en Nouvelle-Écosse peut également servir de modèle aux autres orthopédistes qui doivent approcher leurs leaders provinciaux. Pour continuer d’avancer, de réaliser des progrès considérables, il faut sensibiliser les gens au fait que les listes d’attente pour les soins orthopédiques au Canada figurent parmi les plus longues des pays développés, mais que, paradoxalement, on y trouve un nombre élevé d’orthopédistes sans emploi, principalement en raison d’un manque de ressources gouvernementales. L’ACO collabore avec des organisations d’intervenants affiliées au déploiement d’initiatives de sensibilisation l’an prochain. La gestion de l’enjeu de la main-d’œuvre en orthopédie nécessite des innovations dans de nombreux domaines, dont les soins aux patients, l’affectation des ressources et les soins

privés. La direction de l’ACO reconnaît qu’il n’existe pas de solution facile à cet enjeu et ne peut s’attendre à ce qu’il soit résolu pendant mon mandat; mais elle demande l’engagement des membres de l’ACO de sorte à trouver des solutions plus rapidement. Prenez part à la lutte menée par votre association afin d’améliorer la profession au Canada en écrivant à Enfin, j’invite tous les membres de l’ACO à faire une croix à leur calendrier du 3 au 6 juin et à venir voguer avec leur association à Halifax à l’occasion de la Réunion annuelle 2020. La prochaine réunion annuelle promet d’être une expérience novatrice, avec entre autres des possibilités d’interactions supplémentaires avec des représentants de l’industrie pendant des dîners-conférences spécialisés. De plus, la raison même du succès de votre ACO sera bien visible, grâce aux intervenants des milieux universitaires et communautaires mis en vedette dans le programme scientifique élaboré sous la direction des Drs Glen Richardson et Ivan Wong, coprésidents du Comité responsable du programme de la Réunion annuelle 2020. Le Dr Chad Coles, président du Comité organisateur, et sa femme, Jodi, veillent à ce que la Réunion offre une véritable expérience des Maritimes, avec de la musique de la côte Est et du homard, le tout dans le superbe secteur riverain de Halifax! Vous pourrez vous inscrire dès le début de l’année. Au plaisir de vous y voir en juin!

Diversity in the COA: Spotlight on Women in Orthopaedics with Dr. Marcia Clark Lexie Bilhete Coordinator, Membership Services & Affiliate Programs Canadian Orthopaedic Association


r. Marcia Clark is an orthopaedic surgeon and Clinical Associate Professor at the University of Calgary and the Site Lead for Surgery at the South Health Campus Hospital. Her academic interests are in Simulation Based Medical Education (SBME), National and Global Medical Education, and the intersection of health and technology. Dr. Clark’s practice is focused on surgical arthritis care and sport medicine. She provides medical care to several athletic teams including Calgary Wolfpack Rugby, the University of Calgary Dinos, International Speed Skating, Formula One Motor Racing (Montréal) and the Canadian Alpine Ski Team. For leisurely pursuits, she has goals that include: being outside in daylight, alpine skiing, snowshoeing, hiking and biking. All activities that get her off concrete. 1) What drew you to orthopaedics (and your subspecialty)? In medical school, I gravitated toward specialities that reflected my experiences, and surgery’s potential to create positive, quick results appealed to my instinct to try and fix problems when I saw them. I was also in awe, and still am, at the profound trust surgical patients give me to heal their bodies. My ath-

letic background in particular led me to focus on orthopaedics. Years spent training to achieve athletic goals and occasionally going in for my own repairs left me fascinated by the body’s ability to heal and its mechanisms of healing. As an orthopaedic resident, I was immediately drawn to arthroplasty when I saw the joy patients experienced after a successful hip or knee replacement. 2) Can you recount a defining moment in your career thus far? As an arthroplasty surgeon, my patients have given me a stream of defining moments – hugs from family members or spouses, tears as they thanked me for giving them back their parent, partner, or sibling. On one occasion, a patient who had lost three family members in a terrible motor vehicle accident thanked me for saving his foot so he could walk again.

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3) What does diversity mean to you? Diversity is important for inclusivity, decision making, and better outcomes (this is certainly true in the business literature). It manifests when we do not let our assumptions about the identity or lived experiences of a colleague, team member or patient define our interactions. Diversity flourishes and makes us resilient in an environment where there is a broad scope of appreciation for the people around you and their backgrounds. Diversity allows us to use curiosity and learning to confront the biases of our own identity and lived experiences; a place where a trans-gendered patient was comfortable enough to answer my questions and teach me about their gender and identity while I treated the soft-tissue injury.

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

4) What advice would you give to orthopaedic residents? Remember to focus on all the key learning you acquire in residency training, in addition to developing your medical knowledge and skills. The non-technical skills really matter. Teaching, working with team members, and communicating with colleagues, patients and family members are all skills you will need to foster throughout your career. Learning does not stop after residency and so much of it comes when you seek a deeper understanding of where people are coming from at all times.

5) What is one professional goal and one personal goal you hope to achieve in the next five years? My professional goal is to become a key advisor in how health, technology and innovations can improve the health of Canadians in a positive and ethical way. My personal goal is to take a one-year sabbatical to both learn some new skills (technical and non-technical) and deepen my relationship with my family.

6) Name one of your go-to tricks or hacks that has helped you in your day to day life? I start visits with patients by asking what their goals for the consultation are. It helps me avoid assumptions and leads to more focussed discussions. Not every patient who walks in the door is seeking surgery. Every visit, I give my patients some form of homework to ensure they are taking an active role in their care. After surgery, I try to call a patient’s designated family member to talk about how the operation went. I find it minimizes anxiety for the family and helps establish communication during the long, post-surgery period.

Diversité au sein de l’ACO : Pleins feux sur les femmes en orthopédie avec la Dre Marcia Clark Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés Association Canadienne d’Orthopédie


a Dre Marcia Clark est orthopédiste et professeure clinicienne agrégée à l’Université de Calgary, de même que responsable d’établissement pour la chirurgie à l’hôpital South Health Campus. Ses intérêts de recherche portent sur la formation médicale par simulation, la formation médicale à l’échelle nationale et internationale, et la conjugaison de la technologie et des soins de santé. Dans sa pratique, la Dre Clark se concentre sur les soins chirurgicaux de l’arthrite et la médecine sportive. Elle soigne plusieurs équipes sportives, y compris les Wolfpack de Calgary (rugby), les Dinos de l’Université de Calgary et l’équipe canadienne de ski alpin, en plus de faire partie de l’équipe médicale de compétitions internationales de patinage de vitesse et de l’équipe médicale du Grand prix du Canada de Formule 1, à Montréal. Dans ses loisirs, ses objectifs sont entre autres de profiter du soleil et de faire du ski alpin, de la raquette, de la randonnée et du vélo, bref des activités qui l’éloignent du béton.

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1) Qu’est-ce qui vous a amenée à choisir l’orthopédie (et votre sous-spécialité)? À l’école de médecine, je m’intéressais à des spécialités qui faisaient écho à mon expérience, et la possibilité d’obtenir des résultats positifs rapidement grâce à la chirurgie m’a interpellée, puisque je cherche d’instinct à remédier aux problèmes qui se présentent. Aussi, l’immense confiance que les patients m’accordent pour traiter leur corps m’éblouissait et continue de m’émerveiller. Mon intérêt pour l’orthopédie me vient en particulier de mon expérience sportive. J’ai passé des années à m’entraîner pour atteindre des objectifs sportifs, et comme j’ai moi-même eu à subir des interventions, j’étais fascinée par la capacité de guérison du corps et ses mécanismes de guérison. Pendant ma résidence, quand j’ai vu la joie des patients après une arthroplastie de la hanche ou du genou réussie, j’ai tout de suite été intéressée par la procédure.

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

2) Racontez-nous un moment marquant de votre carrière. En tant qu’orthopédiste spécialisée dans les arthroplasties, mes patients m’ont procuré un éventail de moments marquants, que ce soit les câlins de membres de leur famille ou de leur conjoint, les remerciements émus parce que je leur avais rendu leur parent, leur conjoint, leur frère ou leur sœur. Par exemple, un patient qui avait perdu trois membres de sa famille dans un tragique accident de la route m’a remerciée d’avoir réussi à lui sauver le pied, ce qui lui a permis de marcher de nouveau.

est suffisamment à l’aise pour répondre à mes questions et m’en apprendre davantage sur son genre et son identité tandis que je traite sa blessure aux tissus mous. 4) Quels conseils donneriez-vous aux résidents en orthopédie? N’oubliez pas de miser sur tous les apprentissages clés de votre résidence, en plus de perfectionner vos connaissances et compétences médicales. Les compétences non techniques sont vraiment importantes. Enseigner, travailler avec les membres de son équipe et échanger avec ses collègues, ses patients et leur famille sont toutes des compétences à cultiver durant sa carrière. Loin de s’arrêter après notre résidence, notre apprentissage s’effectue en bonne partie parce que nous cherchons toujours à mieux comprendre l’expérience des autres.

5) Pouvez-vous me parler d’un objectif professionnel et d’un objectif personnel que vous voulez atteindre au cours des cinq prochaines années? Mon objectif professionnel est de devenir une conseillère clé dans l’amélioration de la santé des Canadiens et Canadiennes de façon positive et éthique grâce aux soins de santé, à la technologie et à l’innovation. Mon objectif personnel est de prendre une année sabbatique pour acquérir de nouvelles compétences (techniques et autres) et approfondir mes liens avec ma famille.

3) Pour vous, que signifie la diversité? La diversité est un aspect important de l’inclusivité, du processus décisionnel et de résultats améliorés (ce qui est on ne peut plus évident dans les ouvrages de gestion). Elle éclot quand nos interactions avec un collègue, un membre de notre équipe ou un patient ne sont pas influencées par nos suppositions liées à leur identité ou à leur expérience. La diversité s’épanouit et nous rend plus résilients dans un milieu où l’on témoigne de moult façons notre appréciation pour les personnes qui nous entourent et leur bagage. La diversité nous permet de regarder en face les préjugés associés à notre identité et à notre expérience en nous appuyant sur notre curiosité et notre capacité d’apprendre; la diversité, c’est lorsqu’un patient transgenre

6) Nommez le truc ou l’astuce que vous appliquez au quotidien pour vous faciliter la vie. Quand mes patients arrivent à mon cabinet, je veux d’abord connaître leurs objectifs, ce qui me permet d’éviter les suppositions et de mieux cibler nos échanges. La chirurgie n’est pas toujours ce que le patient souhaite. Je donne en quelque sorte des devoirs à chaque patient qui vient me voir pour veiller à ce qu’il prenne une part active dans ses soins. Après la chirurgie, j’essaie d’appeler un membre de la famille du patient pour lui donner des nouvelles de l’opération; j’ai constaté que cela diminue l’anxiété familiale et contribue à de bonnes communications pendant la longue période de rétablissement.

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:

Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : COA Bulletin ACO - Fall / Automne 2019

Your COA / Votre association


Welcome Aboard the COA Team

Bienvenue au sein de l’équipe de l’ACO

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



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

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

We are proud to highlight the newest members* of the COA’s various committees, announced at the Annual Meeting in Montréal this past June 2019. The COA looks forward to working with all our committees toward the positive future and advancement of Canadian orthopaedics.

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

Stay tuned! This year, the COA welcomes 22 new committee members, who will be highlighted in upcoming Bulletin editions.

Gardez l’œil ouvert! Cette année, l’ACO accueille au sein de ses comités 22 nouveaux membres, qui seront présentés dans les prochains numéros du Bulletin.

*French biographies for those listed below available upon request to:

* Les notices biographiques en français des membres suivants sont disponibles sur demande à

Continuing Professional Development Committee Chair, Ted Tufescu, MD, FRCSC Dr. Tufescu currently practices at the Health Sciences Centre in Winnipeg, where he focuses on complex orthopaedic trauma and post-traumatic problems. He is Assistant Professor at the University of Manitoba, and serves as Fellowship and Research Director for orthopaedic trauma. He is also currently the orthopaedic residency Program Director for the University of Manitoba.

Continuing Professional Development Committee Vice-Chair, Glen Richardson, MD, MSc, FRCSC Dr. Glen Richardson is a full-time Associate Professor of orthopaedic surgery at Dalhousie University, specializing in adult hip and knee arthroplasty. Dr. Richardson completed his medical degree (1996) and orthopaedic residency training program (2001) at Dalhousie University. He subsequently completed fellowships in adult reconstruction surgery (2002) at Duke University, North Carolina and in sports medicine (2003) at the University of Ottawa. He also holds a Master’s degree in Health Information Sciences from the University of Victoria (2011). Prior to his current position with the Division of Orthopaedic Surgery at Dalhousie University, he practiced orthopaedic surgery in Saint John, NB (20032008). He is a member of the American Academy of Hip and Knee Surgeons, American Academy of Orthopaedic Surgeons, Canadian RSA Network, Canadian Arthroplasty Society and the Canadian Orthopaedic Association. His research interests utilize RSA, gait analysis, and patient-reported outcome measures for hip and knee replacements. He has supported numerous national collaborative research projects.

Dr. Tufescu has an undergraduate degree in pharmacology from the University of Toronto, and a medical degree from Queen’s University. He completed his orthopaedic training at the University of Saskatchewan and obtained subspecialty fellowship training in orthopaedic trauma at Sunnybrook Health Sciences Centre in Toronto, where he also began his practice. Dr. Tufescu also supports orthopaedic education through his service to the Canadian Orthopaedic Association as past academic Program Chair and current Chair of the Continuing Professional Development Committee. He has served as Royal College examiner and currently is a member of the Royal College Specialty Committee in Orthopaedic Surgery. He has also served as AO faculty at numerous fracture care courses for nursing staff, residents and surgeons, and he chairs a fracture care course in Winnipeg. COA Bulletin ACO - Fall / Automne 2019

Within the COA, Dr. Richardson has been an active member since 2001, and particularly involved with the Continuing Professional Development Committee.

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Nominating Committee BC Representative, Peter Dryden, MSc, MD, FRCSC Dr. Peter Dryden was born and raised in Victoria, British Columbia where he currently practices orthopaedic surgery. Dr. Dryden completed his medical degree and orthopaedic residency training at the University of British Columbia, and continued on to a fellowship in foot and ankle surgery with Dr. Tim Daniels at St. Michael’s Hospital, University of Toronto. Dr. Dryden’s clinical interests include foot and ankle surgery, adult hip and knee replacement, orthopaedic trauma surgery and general orthopaedics. He holds the position of Section Chief Division Orthopaedics and Clinical Instructor at the University of British Columbia. He is also Past President of the British Columbia Orthopaedic Association (BCOA) and is currently on the Executive of the BCOA. Dr. Dryden has been heavily involved with the COA over the past few years. After participating as an active member of COFAS, he is now the COFAS President Elect. He was also formerly on the Program Committee for the COA’s 2019 Annual Meeting. Dr. Dryden works closely with the Canadian Orthopaedic Foundation, sitting on their Medical and Scientific Review Committee. As an active member of his community, Dr. Dryden is also part of the COFAS Ankle Arthritis Research Group as well as a Royal College orthopaedic examiner.

COAGS Resident Representative, Laura Morrison, MD Dr. Laura Morrison is a second-year resident at the University of Calgary. When not on call, you can find her flipping tires (also known as Crossfit), drinking flat whites, or going on adventures. Dr. Morrison’s interest in global surgery stemmed from volunteering with Right To Play, a non-profit organization aimed at using sport and play as a tool for education in underserved communities around the world. Through this, she learned the importance of utilizing the local community to impart lasting change, and the value of education in preventative medicine. Dr. Morrison hopes to gain more knowledge and expertise that she can apply during the completion of her Masters of Community Health Sciences with a Specialization in Medical Education. Dr. Morrison looks forward to helping connect the orthopaedic resident body with opportunities to have an impact on bone health on a global scale.

Stay tuned!

This year, the COA welcomes 22 new committee members, who will be highlighted in upcoming Bulletin editions.

Gardez l’oeil ouvert!

Dr. Dryden’s personal hobbies include golfing, playing basketball, and cycling around beautiful Victoria.

Cette année, l’ACO accueille au sein de ses comités 22 nouveaux membres, qui seront présentés dans les prochains numéros du Bulletin.

COA/ICORS 2019 Meeting Photos Available!

Photos de la Réunion 2019 de l’ACO et du congrès des ICORS disponibles!


hank you to all COA and ICORS members for making the Montréal Meeting from June 19-22 a success! You can review the Meeting photo gallery by clicking here. You can then download images of your choice. Questions? Contact


erci à tous les membres de l’ACO et des ICORS d’avoir fait de la manifestation de Montréal, du 19 au 22 juin, un grand succès! Vous pouvez consulter la galerie de photos de la manifestation en cliquant ici. Vous pourrez ensuite télécharger des photos. Des questions? Écrivez à

COA Bulletin ACO - Fall / Automne 2019

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Congratulations to the 2019 Recipients of the COA Awards of Merit and Presidential Award for Excellence John Antoniou, M.D., FRCSC Immediate Past President Canadian Orthopaedic Association


would like to congratulate this year’s winners of the COA awards of distinction, which were presented at the Opening Ceremonies of the 2019 Annual Meeting in Montréal, QC.

Dr. Masri served as Surgeon-in-Chief of VGH and UBC Hospitals from 2011 until 2018. He founded the UBC Centre for Surgical Innovation in 2006 and was its head until it was absorbed as a part of UBC Hospital in 2017. He served as the Regional Medical Director for Surgical Services for The Vancouver Coastal Health Authority, which involved the primarily urban areas of the Greater Vancouver area, from 2015-2018. He served as President of the Canadian Orthopaedic Association in 2014-2015.

This year, the COA honoured Drs. Emil Schemitsch and Bas Masri with the Award of Merit, which pertains to outstanding contributions to the COA, service to the people of Canada in raising the standards of orthopaedic care, and contributions to the advancement of orthopaedic research, education, and healthcare organization.

He is a member of a number of prestigious scholarly societies.

The recipient of the COA’s Presidential Award of Excellence, as it pertains to a lifetime of exceptional contributions to the advancement of the art and science in the field of orthopaedics, is awarded posthumously to Dr. Peter Roughley. Dr. Roughley’s wife Sheila and son Simon Roughley accepted the award on his behalf.

Congratulations Dr. Masri.

Dr. Bas Masri– Award of Merit Dr. Masri migrated to Canada in 1981 from Lebanon. He graduated from UBC medical school in 1988 and UBC orthopaedics in 1994. He completed adult reconstructive orthopaedic and musculoskeletal oncology fellowships at UBC and HSS prior to returning on staff at UBC in 1995. He is now a full Professor at UBC and he is the Head of the Department of Orthopaedics at the University of British Columbia, VGH, and UBC Hospitals.

In November 2017, Dr. Masri was the recipient of the Pier Giorgio Marchetti, M.D. Lifetime Achievement Award by an International Alumnus from the Hospital for Special Surgery in New York.

Dr. Emil Schemitsch – Award of Merit A University of Toronto graduate in medicine, Dr. Schemitsch completed his orthopaedic training at the University of Toronto. He then trained at the University of Washington (Harborview Medical Centre) and Harvard University as a clinical fellow. Dr. Schemitsch is now the Richard Ivey Chairman of the Department of Surgery at the University of Western Ontario. He is also a Professor of Surgery at the University of Toronto, Scientist at the Keenan Research Centre of the Li Ka Shing Knowledge Institute and past Head of the Division of Orthopaedic Surgery at St. Michael’s Hospital.

Dr. Masri has been very prolific throughout his career with over 400 invited presentations, 274 scientific presentation, 233 peerreviewed published articles, and 57 book chapters. He has been invited professor or speaker on 199 occasions.

He has been extremely prolific with over 480 publications and hundreds of guest lectures. He has received numerous accolades including the J. Edouard Samson Award, the CORS Founder’s Medal four times, the Bovill Award for best paper from the OTA eight times, the Neer Award from the

Dr. Bas Masri receives the Award of Merit from Dr. John Antoniou

2019 Award of Merit Recipient, Dr. Emil Schemitsch

COA Bulletin ACO - Fall / Automne 2019

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American Shoulder and Elbow Surgeons, the Best Poster Award from the Orthopaedic Trauma Association twice, the Best Paper Award from the International Society for Fracture Repair twice, the CORE/ACORE Award from the Canadian Orthopaedic Association, the Lister Award, the George Armstrong Peters Award from the University of Toronto, and the Kappa Delta Award. He is recipient of the North American Travelling Fellowship and the ABC Travelling Fellowship. Dr. Schemitsch is Past President of the Canadian Orthopaedic Association, the Canadian Arthroplasty Society and the Medical Staff Association of St. Michael’s Hospital. Congratulations Dr. Schemitsch. Dr. Peter Roughley – Presidential Award for Excellence Dr. Roughley is a Past President of CORS and mentor to many across the Canadian and international orthopaedic research landscape. He was chosen for this award shortly before his untimely passing a few months ago.

Peter with Sheila and their children Simon and Fiona

Dr. Peter Roughly was born in Doncaster, Britain in 1947 and studied chemistry at Nottingham University, UK where he received both a BSc and a PhD. He completed a post-doc with Roger Mason in London and then with Alan Barrett in Cambridge. Dr. Roughley went on to work at the Strangeways Research Laboratory and arrived with his wife Sheila in Montréal in October, 1977. Dr. Roughley had many great strengths, including but not limited to being extremely organized with an analytical mind, an outstanding teacher and mentor, and very systematic in his work. He was extremely productive as a collaborator and published his research findings in a timely manner. He became full Professor at McGill University and secured excellent funding throughout his career with technicians, graduate students and post-docs working under his supervision. Some of Dr. Roughley’s most important research was centered on the role played by extracellular matrix proteoglycans and collagens in the function of human connective tissues, particularly articular cartilage and later intervertebral disc. This includes the involvement of proteoglycan and collagen degradation in the onset and progression of arthritis and disc degeneration, and the involvement of gene mutations in the development of skeletal dysplasias. His work involved the use of biochemical techniques to study changes in protein structure and metabolism, and molecular biological techniques to study changes in gene structure and expression. Dr. Roughley was a keen bridge player and enjoyed playing badminton for his university and in Cambridge, UK. He was an avid reader of adventure stories, such as those by Robert Ludlum and Bill Clancy. He was a sailor for the last ten years of his life, out on the water having fun. Unfortunately, this is where he died of a heart attack.

Sheila and Simon Roughley accept the award from Drs. John Antoniou and Fackson Mwale

This award was presented by CORS Past President, Dr. Fackson Mwale, to Dr. Roughley’s wife Sheila and their son Simon. COA Bulletin ACO - Fall / Automne 2019

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The 2019 ABC Travelling Fellowship Tour Diary: Building Leadership and Wellness Through Connection


he American-British-Canadian (ABC) Travelling Fellowship began in 1948 during Canadian Robert I. Harris’ term as President of the American Orthopaedic Association (AOA). It is an important tradition in cultivating leadership in orthopaedics which promotes international cooperation and advancement through knowledge exchange, mentorship and networking. In April and May 2019, we had the honour of travelling to the United Kingdom, Australia and New Zealand, representing the COA on the latest iteration of the ABC tour along with our five counterparts from the AOA. The 2019 ABC travelling fellows are: Antonia F. Chen M.D., MBA - Brigham and Women’s Hospital, Boston, MA (Arthroplasty) Sukhdeep Dulai M.D., MHSc, FRCSC - Stollery Children’s Hospital, Edmonton, AB (Paediatrics) Ruby Grewal MSc, M.D., FRCSC - Roth|McFarlane Hand and Upper Limb Centre, London, ON (Upper limb) Derek Kelly M.D., FAOA - Campbell Clinic, Memphis, TN (Paediatrics) Michael Lee M.D., FAOA - University of Chicago Medical Centre, Chicago, IL (Spine) Philipp Leucht M.D., PhD - New York University Langone Orthopedic Hospital, New York, NY (Trauma) Hassan Mir M.D., MBA, FACS, FAOA – Florida Orthopaedic Institute, Tampa, Florida (Trauma) The fellowship is a unique and inspiring experience that helped us build a collaborative network to navigate the challenges of orthopaedic practice. Over the course of the five-week tour, we met over 45 former ABC fellows and countless orthopaedic staff and trainees, visited 23 orthopaedic sites/scientific meetings and gave 82 lectures discussing our research and leadership experiences. For detailed accounts of our daily activities including the places we visited and the people we had the privilege of meeting, please refer to our travel diary and our fellowship blog. The following is a taste of our experience and the insights we gained. United Kingdom After a warm reception, our tour began in London. We were introduced to the unrelenting pace, unparalleled hospitality and unprecedented access that characterizes the ABC tour. Over the course of our three weeks in the UK, we travelled to prominent orthopaedic centres in London, Oxford, Wrightington, Leeds, Edinburgh, Northeast England and Nottingham. COA Bulletin ACO - Fall / Automne 2019

During our time in the UK, the challenges and benefits of delivering orthopaedic care in a mixed public-private system were debated. A variety of important issues were discussed including standardizing care, optimizing patient and staff experiences, development of UK registries and the structure, funding and implementation of clinical trials in orthopaedics. Despite a wide spectrum of practice environments and payment structures, we witnessed a consistent commitment to excellence. It was apparent that the NHS not only demands fiscal respon- COA ABC fellows atop the Cow and sibility but supports cost- Calf rock formation in Yorkshire effective health care by providing significant funding for well-designed and purposeful clinical research programs. We engaged in discussions with prominent academic surgeons on conducting research in orthopaedics. Traditional academic practices of using metrics that reward volume rather than quality were challenged in favour of alternative value structures. The importance of asking important, impactful research questions was reinforced and we were inspired to embed research throughout our clinical care. With the editorial board of the Bone and Joint Journal, we discussed the impact of health-care and academic systems on research support and developed a deeper understanding of the intense, thorough and iterative editing process employed at one of the leading international orthopaedic journals. Key high-level surgeon administrators in NHS England shared with us their thoughts and experiences demonstrating how government, clinicians and academia can work together to effectively implement meaningful transformative change in health care and how politics can and will impact the future of our profession. They shared with us the principles of efficacious programs developed to ensure consistent, safe, high-quality and compassionate care within financially sustainable local health systems. The humble yet inspirational beginnings of modern-day orthopaedics were explored, including a visit to the Charnley Museum at the Centre for Hip Surgery. We saw how the tradition of innovation and excellence is being carried forward. Novel models of delivering surgical care while maintaining fiscal responsibility were encountered, challenging many of

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our prior assumptions. National leaders in the development of the UK’s national joint registry discussed the importance and limitations of national registries and the implications of using this data to monitor surgeon performance. Ubiquitously, we were warmly welcomed by our predecessors in the ABC fellowship. With them, we discussed our research and leadership interests, challenges in our own clinical practices, the significance of the ABC fellowship and comparisons of our various health-care systems and practice models. It was clear that regardless of when they completed the ABC tour, they continue to feel the positive impact of the fellowship and the networks and friendships that began on the tour. We were encouraged to pay it forward by sharing our experiences with junior staff and trainees and inspiring them to become future leaders. Aside from our academic events, every host site treated us to both unique and classic local cultural experiences and ensured that we had an opportunity to visit famous landmarks in the region. These informal events offered the opportunity for valuable networking and mentorship discussions and more importantly, contributed to well-being. Australia In Australia, we continued our tour visiting Brisbane, Gold Coast and Melbourne in a well-balanced mix of networking, scientific exchange, teambuilding and cultural exploration. Hospital administrators discussed with us the benefits, drawbacks and intricacies of the mixed public-private Australian health-care system. The importance of strong orthopaedic leadership and advocacy was reinforced as we visited worldclass public facilities built to optimize the patient experience and facilitate growth while remaining mindful of the importance of physician well-being. We explored alternative approaches to encouraging diversity, promoting physician well-being and advancing orthopaedic care. The innovative clinical and basic science research shared with us was inspiring and the importance of humility and integrity in clinical research and medicine was demonstrated and reinforced. New Zealand We crossed the Tasman Sea to conclude our tour in New Zealand with visits to Queenstown, Christchurch and Auckland. Our scientific discussions focussed on trauma care, health systems and mass casualty management. We had an opportunity to compare infrastructure and care delivery models in New Zealand’s universal health-care system to those at our home institutions. Our itinerary was flush with networking activities promoting teambuilding and well-being. It was apparent to us that New Zealand has a friendly and tight-knit orthopaedic community, with many similarities to Canada. There is a strong culture of mentorship and the ABC fellowship has played a significant role in their orthopaedic leadership development strategy. The importance of maintaining healthy work-life balance and physician well-being for a long and productive career in orthopaedics was impressed upon us.

Attending Morning Trauma Report at the Royal London Hospital

Post-tour The conclusion of the fellowship was bittersweet. We were overjoyed to be reunited with our loved ones but leaving our new friends and the nurturing and inspirational environment of the fellowship to return to the routine of our practices has been an interesting challenge. We are armed and emboldened with new ideas, priorities and opportunities, renewed energy and enthusiasm and the support of our new friends and colleagues around the world. Reconciling this with the expectations and demands of a surgical practice and family obligations, especially in light of having taken a five-week “hiatus”, has been an imposing task that we continue to work through daily. The privilege of being an ABC fellow is also a responsibility to ensure that we share our experiences with those around us and mentor junior colleagues and trainees to reach for more. We have been tasked with contributing to the meaningful growth of orthopaedics and committing to surgeon well-being. Our first such initiative has been to analyze the results of our ABC fellows’ research project, a multinational physician well-being survey that we look forward to publishing and presenting in the near future. Applying for the ABC fellowship should be considered by every eligible orthopaedic surgeon who wants to make contribution extending beyond their direct patient base. The fellowship gives an opportunity to build strategic collaborations with key international orthopaedic centres and individuals. The experience emphasizes the strength of working together as a united group rather than fractioning our influence through our differences. The exposure to alternative health-care delivery models and strategies is invaluable for future leaders. The access to international leaders in thought and initiative is above that of any other venue available to the junior or mid-career orthopaedic surgeon. We are thankful for our mentors who encouraged us to apply for this fellowship. We are eternally grateful to the COA and AOA for giving us this priceless opportunity and are humbled by the gracious hospitality that was bestowed on us by the BOA, BJJ, AOA (Australian), NZOA and especially, all our hosts and former ABC fellows. We look forward to paying it forward. Finally, we would be remiss without acknowledging the unwavering and selfless support of our families, colleagues and staff at home, without whom participation in the fellowship would not have been possible. COA Bulletin ACO - Fall / Automne 2019

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The Complexities of Simple Pelvic Surgery Yet more often than not, it is not actually me performing the orthopaedic procedures, which include amputations, tendon repairs, debridements, external fixation, skin grafting, and many closed reductions. Burundi, like many countries around the world and particularly in sub-Saharan Africa, does not here’s a postoperative have enough surgeons, orthoX-ray of which I’m particupaedic and otherwise, to meet larly proud, from a case I the basic needs of its populadid this summer. I have been tion. And while MSF could draw struggling to decide whether on its pool of international I’m allowed to feel this way surgeons to staff this hospital about what is, ultimately, a simday and night, that’s an entirely ple pelvic ex-fix. unsustainable model. So over the last two and a half years, I am, according to my curricueighteen-odd local doctors lum vitae, a subspecialist orthohave completed a course of onThe COA Global Surgery (COAGS) Committee is pleased to share paedic trauma surgeon with felthe-job training that has turned Canadian global health initiatives. If you are interested in COAGS lowship training in pelvic and half of them into GP-intensivists featuring your organization in the Bulletin, or if you are a resident acetabular surgery. Yet simultawho manage the emergency and you would like to share an essay about your global surgery neously, this feeling – a sense of room and ICU, and the rest experience, please contact for details. accomplishment, blended with into GP-surgeons who perform relief – is not the result of a almost all the procedures in our complex case done well, but rather of a procedure that I first two operating rooms, and who take care of the patients preperformed nine years ago as a junior resident at the AO Basic and postop on the ward and in the outpatient department. course, with a sawbones model wrapped in a garbage bag. My colleagues who attended that same course are several years into I’m here to help with continuing medical education and to clinical practice now, and when we talk about work, their stresses provide back-up for the complex cases – which is daunting, stem from multihour paediatric spine surgeries, complex pelvic since I’m keenly aware that most of my general practitioner osteotomies, and difficult revision arthroplasties. And then here I colleagues have put on far more ex-fixes than I have over my am, congratulating myself over a few Steinman pins. career, and also have the added advantage of being much more familiar with the equipment, not hampered by the dependence The ‘here,’ however, is the key. Right now, ‘here’ for me is on technology that is a natural and necessary part of modern Bujumbura, Burundi, where I’m a few weeks into my fifth Canadian surgical training. It’s an interesting variation on the placement with Médecins Sans Frontières/Doctors Without roles I have filled in other MSF projects: on call around the Borders (MSF). It’s a vastly different environment from that in clock, almost always without a local counterpart, caring for which I trained, and although I still depend on the knowledge patients injured by car crashes, gunshots, and improvised and skills from my Canadian surgical background, actually explosive devices in Northern Syria; scheduled for ward and applying them is more of a stretch. Fortunately, I’m part of OR shifts alongside the other members of a ten-strong orthoa sizeable team: the staff at L’Arche Medical de Kigobe, an paedic team, headed by an expert local surgeon, at a trauma MSF trauma hospital, number around 250, and are almost all referral centre in Port-au-Prince, Haiti; and in the Gaza Strip, local recruits – just ten of us are international hires who call Bujumbura home for now. What I lack in practical techniques is more than made up for by my colleagues’ hands-on expertise and their knowledge of low-tech work-arounds that I never had to develop at the well-resourced centres where I trained. Deirdre Nunan, M.D., FRCSC Bujumbura, Burundi Médecins Sans Frontières (MSF)


Like all MSF orthopaedic projects, I can depend on this one having a well-functioning OR with all the equipment I need – for the context, at least. Our set-up doesn’t allow for surgical implants, and anyway, a lot of the soft tissue injuries generated from the road traffic accidents that make up the bulk of our surgical cases are too severe to be appropriate for early (if any) internal fixation. So, the orthopaedic tool-kit consists of an external fixator set with a hand drill; good-quality pre- and postop X-rays but nothing in theatre; basic surgical sets and an amputation tray – a bona fide Satterlee saw along with a Gigli; two types of sutures in various sizes; and lots and lots of Plaster of Paris.

COA Bulletin ACO - Fall / Automne 2019

© Evrard Ngendakumana/MSF. There’s a constant flow of traffic at the MSF hospital in Bujumbura, where trauma care is provided free of charge

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where once again, my national staff colleagues were every bit as skilled as I, and where I found an unexpected satisfaction in filling some of the more administrative roles in our bone-defect and osteomyelitis project. Here in Bujumbura, the patient with the nice postop films was the first of a string of patients with open-book pelvic fractures. Thanks to strong work by the team combined with a little bit of luck, they’re doing well. A little girl, the youngest patient I’ve ever ex-fixed, has shown herself to be a real joker, charming all of us on the daily ward round. The young man with a vertical shear pelvic fracture has a perfect reduction, thanks to a com-

bination of skeletal traction and external fixation – and to the X-ray technicians, who have confirmed that “inlet” and “outlet” views are the same in French, just with a different accent. Another adult, who was unlucky enough to dislocate her hip at the same time as sustaining a B-1 pelvic fracture, has been excelling with physiotherapy since the second I somewhat nervously let her out of bed. The older patient with associated abdominal injuries is out of the ICU. One ex-fix is © Michael Ward/MSF. Dr. Deirdre Nunan actually ready to come with an experienced OT nurse, Abdon off. And treating pelvic Isango, both breaking into a sweat after and acetabular frac- finishing a pelvic ex-fix tures with the bare minimum of equipment is starting to seem very normal. Which is, in a way, is the very essence of surgical work with MSF: doing ordinary things, in extraordinary circumstances.

© Evrard Ngendakumana/MSF. Patients in one of the wards at L’Arche de Kigobe Trauma Centre

In Memoriam The COA extends sympathies to friends and families of the following members:

L’ACO offre ses sincères condoléances aux amis et à la famille des membres suivants :

M. André Perreault 1954 - 2019


’est avec une profonde tristesse que nous vous informons du décès de Dr André Perreault, M.D., FRCSC, survenu le 19 septembre 2019, à l’âge de 65 ans.

Il laisse dans le deuil son épouse Nicole Savard. Il laisse également dans le deuil ses sœurs, Lise (Peter Jones), Micheline (Pierre Angers), son frère Philippe (Suzanne Masse), ses tantes Marie-Claude, Fleurette et Fernande, sa belle-famille Lise (Philippe) Gilles (Carmen), Colette (Robert) ses neveux, nièces : Catherine, Sophie, Véronique, Marie-Pièr, Annie, Raphaël, Geneviève, Laurent, Marie-Pierre, Marilaine et Pierjean et ses nombreux amis (es).

Médecin orthopédiste dévoué, il était un être de générosité et de chaleur humaine. Très attentionné auprès des siens, sa présence, son soutien indéfectible, sa sensibilité vont manquer à tous ses proches. Vos témoignages de sympathie pourraient se traduire par un don à l’Institut de Cardiologie de Montréal.

COA Bulletin ACO - Fall / Automne 2019

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First Meeting of the Canadian Orthopaedic Limb Lengthening Association & Deformity Correction (COLLA)


he first ever COLLA meeting took place during the COA Annual Meeting on Friday, June 21, 2019. During the meeting, the Executive Committee was introduced made up of: Drs. Marie Gdalevitch, President; Simon Kelley, Treasurer/ Industry relations; and Caroline Forsythe, Education/Membership. Dr. Maryse Bouchard was later appointed Research Chair. The Mission of COLLA is to help advance the field of limb lengthening and deformity correction in Canada. We are hoping to facilitate the collaboration within and across specialties, including paediatric and adult surgeons and mid-level providers. We want to promote awareness of our group for colleagues and patients. Our future endeavors include the development

of Canadian limb deformity and lengthening courses for residents and surgeons, and establishing a patient database to enable multicentre research. We are also hoping to collaborate with other subspecialties to have a conjoint symposium at the 2020 COA Annual Meeting in Halifax next June. COLLA is dedicated to creating mentorship opportunities and developing resources for patients, therapists and surgeons to facilitate deformity planning and perioperative care. If you would like to be a member or get involved with COLLA, please see our web site by clicking here or e-mail for more information.



The COA Bulletin, the official journal of the Canadian Orthopaedic Association, has been declared by our membership as one of the most valuable membership services.

Le Bulletin, publication officielle de l’Association Canadienne d’Orthopédie (ACO), a été désigné par nos membres comme l’un des services les plus utiles que nous leur offrons.

By placing your advertisement in the COA Bulletin, you will be communicating with the largest number of Canada’s leading orthopaedic specialists.

Placer une annonce dans le Bulletin de l’ACO assure une visibilité inégalée auprès des orthopédistes les plus influents au pays.

Don’t miss out on this kind of opportunity! Become a part of our publication cycle by contacting Cynthia Vezina at the COA Office Tel: (514) 874-9003 ext. 3 or e‑mail: and details will be forwarded to you.

Ne manquez pas cette occasion! Pour faire partie de notre cycle de publication, communiquez avec Cynthia Vezina, au bureau de l’ACO, au 514-874-9003, poste 3, ou à

COA Bulletin ACO - Fall / Automne 2019

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

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

What Do the Experts Say? Achilles Tendon Treatment Options Debate Dan Cohen Med 4, McGill Faculty of Medicine MDCM Program Contributor, COA Bulletin Montréal, QC Paul A. Martineau, M.D. FRCSC, ABOS Scientific Editor, COA Bulletin


n this edition’s debate, we have the opportunity to learn how some of the experts in Canadian orthopaedics would manage Achilles tendon repairs. Drs. Brad Petrisor and Mohit Bhandari discuss nonoperative management in their very informative and thorough article that clearly defines what the best evidence supports. Drs. Andrea Veljkovic, Anna-Kathrin Leucht and Emilie-Ann Downey defend surgical management of Achilles tears providing interesting views that support operative intervention for Achilles injuries. They also question the practical applicability of structured rehab protocols for all nonoperatively treated patients. Finally, we have a summary of the results of our very first COA readership pre-debate survey. Overall, 136 surgeons responded to our survey. The survey consisted of short clinical vignettes presenting 22 alternate patient-specific variables and seven surgeon-specific variables that we thought could influence decision making whether to offer operative or nonoperative management for Achilles injuries. This is where things got really interesting! It seems that surgical management is being offered around 40% of the time for most variables, and thus nonoperative management is being performed 60% of the time. Nonoperative management is favoured, but surgery is still being performed fairly routinely despite strong evidence (some of this evidence coming from Canada) recommending nonoperative management for Achilles ruptures. Table 1a: Treatment decision based on variable Operative management Young 61.8% Elderly 5.9% Acute 39.7% Chronic 57.4% Smoker 11.8% Non smoker 41.9% Athlete 84.6% Sedentary 14.7% Lawyer 36.8% Non lawyer 37.5% Increased billing codes 37.5% Decreased billing codes 32.4% Healthy 37.5% Sick 3.7% Patients wants surgery 80.9% Patient does not want surgery 2.9% Yes available OR time 36.0% No available OR time 37.5% Tendon well aligned and well 14.0% opposed on ultrasound Tendon not well aligned and well 55.1% opposed on ultrasound Male 41.9% Female 36.0%

Some variables clearly swung the pendulum one way or another. For example, patient preference for surgery (81%), or a patient athlete (85%) dramatically affected surgeon preference for surgery. Whereas, being sick (4%) or elderly (6%) swung the pendulum back in favour of nonoperative management. The numbers for the sick and elderly are much more in line with current evidence-based medicine (EBM), although EBM would suggest this allocation for most patients. Athletic status is often anecdotally quoted by many, including myself, as an operative indication. This variable certainly affected surgeons’ choice for surgery, but as Drs. Petrisor and Bhandari elegantly discuss in their article, there is very little evidence to support surgical management for athletes. In fact, many elite athletes have a quite dismal return to play after surgical management of an Achilles injury. Finally, I was under the impression that foot and ankle specialists would be the most reticent to operate on Achilles tear given their referral bias likely includes some of the most dreaded surgical complications. However, the survey did not show many differences in management preferences between foot and ankle surgeons and the rest of the specialty. I would like to thank the COA Bulletin readers and association members for their participation in the predebate survey. I think the survey quite nicely highlights one of the larger issues in orthopaedics today. Evidence-based medicine should be providing us with the best rationale for a given treatment, in this case nonoperative management of Achilles tears. However, there is a major disconnect between the recommendations of EBM and actual surgical practice profiles. EBM seems to hitting a hurdle in changing the practice of surgeons. We need to find out why. Table 1b: Influence of variable on treatment decision

Nonoperative management 38.2% 94.1% 60.3% 42.6% 88.2% 58.1% 15.4% 85.3% 63.2% 62.5% 62.5% 67.6% 62.5% 96.3% 19.1% 97.1% 64.0% 62.5% 86.0% 44.9% 58.1% 64.0%

Influence (1-5) Young 3.85 Elderly 4.32 Smoker 3.93 Non smoker 3.12 Athlete 4.19 Sedentary 3.94 Lawyer 2.28 Non lawyer 2.28 Increased billing codes 1.92 Decreased billing codes 2.14 Acute 3.5 Chronic 4.24 Healthy 3.40 Sick 4.37 Patients wants surgery 3.80 Patient does not want surgery 4.02 Yes available OR time 1.84 No available OR time 1.88 Tendon well aligned and well opposed on ultrasound 3.41 Tendon not well aligned and well opposed on ultrasound 3.32 Male 2.57 Female 2.51 *Note the variables are ranked from least to most influential with 1 representing least influential and 5 representing most influential COA Bulletin ACO - Fall / Automne 2019



Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 19)

Table 2a: Treatment decision based on variable and specialty Foot and ankle All other specialties Operative Nonoperative Operative Nonoperative management management management management Young 73.3% 26.7% 60.0% 40.0% Elderly 0% 100% 6.6% 93.4% Smoker 0% 100% 13.2% 87.8% Non smoker 5.0% 95.0% 42.1% 57.9% Athlete 80% 20% 85.1% 14.9% Sedentary 6.7% 93.3% 15.7% 84.3% Lawyer 33.3% 66.7% 37.2% 62.8% Non lawyer 33.3% 66.7% 38.0% 62.0% Increased billing codes 40.0% 60.0% 37.2% 62.8% Decreased billing codes 26.7% 73.3% 33.1% 66.9% Acute 33.3% 66.7% 40.5% 59.5% Chronic 53.3% 46.7% 57.9% 42.1% Healthy 40.0% 60.0% 42.1% 57.9% Sick 0% 100% 4.1% 95.9% Patients wants 86.7% 13.3% 80.2% 19.8% surgery Patient does not 0% 100% 3.3% 96.7% want surgery Yes available OR time 26.7% 73.3% 37.2% 62.8% No available OR time 33.3% 66.7% 42.1% 57.9% Tendon well aligned and 20.0% 80.0% 15.7% 84.3% well opposed on ultrasound Tendon not well aligned and 60.0% 40.0% 62.0% 38.0% well opposed on ultrasound Male 40.0% 60.0% 42.1% 57.9% Female 26.7% 73.3% 37.2% 62.8%

P Value 0.486539 0.587489 0.756267 0.808192 0.889248 0.585355 0.993339 0.943654 0.943654 0.836388 0.798687 0.954564 0.943654 0.893603 0.798006 0.940318 0.606079 0.943654 0.74985 0.900161 0.905831 0.606079

Table 3: Influence of surgeon specific factors on treatment decision

Table 2b: Influence of variable and surgeon specialty on treatment decision Foot and All other Mean ankle specialties Difference P Value Influence (1-5) Influence (1-5) Young 4.47 3.37 1.10 0.03156 Elderly 4.67 4.21 0.46 0.24604 Smoker 4 3.93 0.07 0.88866 Non smoker 3.27 3.10 0.17 0.5552 Athlete 4.47 4.16 0.31 .09102 Sedentary 4.40 3.88 0.52 0.0271 Lawyer 2.53 2.25 0.28 0.30302 Non lawyer 2.20 2.29 -0.09 0.85716 Increased billing codes 1.93 1.93 0 0.8181 Decreased billing codes 2.07 2.15 -0.08 0.61006 Acute 3.87 3.45 0.42 0.1902 Chronic 4.67 4.19 -0.48 .01684 Healthy 3.47 3.39 0.08 0.60306 Sick 4.53 4.35 0.18 0.58232 Patients wants surgery 3.87 3.79 0.08 0.47152 Patient does not want 4.13 4.01 0.12 0.28014 surgery Yes available OR time 2.07 1.81 0.26 0.33204 No available OR time 1.87 1.88 -0.01 0.95216 Tendon well aligned and 2.93 3.47 -0.54 0.18352 well opposed on ultrasound Tendon not well aligned and 3 3.36 -0.36 0.37346 well opposed on ultrasound Male 2.53 2.53 0 0.9442 Female 2.53 2.51 0.02 1 *Note the variables are ranked from least to most influential with 1 representing least influential and 5 representing most influential Table 4: Demographics Sex M F Other/Non-Binary Age 31-40 41-50 51-60 61-70 71+ Years in practice 0-10 11-20 21-30 31-40 41+ Specialization General Orthopaedics Orthopaedic Trauma Foot and Ankle Sports Other Workplace Academic Community Both

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104 31 1

76.5% 22.8% 0.74%

60 38 25 12 1

44.1% 27.9% 18.4% 8.8% 0.74%

58 35 24 10 0

42.6% 25.7% 17.6% 7.4% 0%

51 10 15 24 36

37.5% 7.35% 11.0% 17.6% 26.5%

59 62 15

43.4% 45.6% 11.0%

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

Achilles Tendon Ruptures: Nonoperative Management Brad A. Petrisor, MSc, M.D., FRCSC1 Mohit Bhandari, M.D., PhD, FRCSC2 Professor, McMaster University Professor, McMaster University, Canada Research Chair, Musculoskeletal Trauma and Surgical Outcomes Hamilton, ON 1 2


chilles tendon injuries are commonly seen throughout an orthopaedic practice, with some evidence suggesting that they may be increasing in number1,2. The average age of patients sustaining these injuries has been reported to be between 37 and 44 indicating that the “weekend warrior” may be the patient profile most commonly associated with these ruptures3. The debate has been raging for a number of years on whether or not Achilles tendon ruptures benefit from surgical fixation. Indeed, the overall debate hinges on the trade-off between a higher re-rupture rate in those treated nonoperatively, versus a higher complication rate in those treated operatively, namely wound healing problems and infection and also, depending on technique, nerve injury. Multiple randomized trials and multiple meta-analyses of randomized trials have been done over the years highlighting this particular trade-off, and clinical practice guidelines have also been developed4–7. With the addition of more recent trials incorporating functional rehabilitation protocols (in both the operative and nonoperative groups) and stronger methodology, it is thought that the observed re-rupture rates following nonoperative management are declining4,8. It is increasingly difficult to ascertain how significant the difference really is between re-rupture rates amongst those patients treated operatively and nonoperatively as the evidence is conflicting at times. Ochen et al. have one of the most recently published meta-analyses on the subject, and highlight the aforementioned issues as they systematically review both randomized and non-randomized data to understand the risks associated with both operative and nonoperative management of Achilles tendon ruptures4,8. Thus, our side of the debate will focus on this most recent and well-done meta-analysis. Ochen et al. identified ten randomized controlled trials and 19 nonrandomized trials4. There are pros and cons to including observational data in meta-analyses, however this is the subject of a different debate. Suffice it to say that the authors suggest the addition of a significant number of patients with the observational studies (14,918 patients for analysis) increased the ability to detect events, and may better reflect clinical practice. The often stringent criteria required for inclusion into an RCT may not reflect who we see clinically. Again, another argument for a different debate. When looking at the randomized data alone, the average size of each trial was consistently small (average of 94 patients with a range of 50–144 patients) and event rates within each was consistently small ranging from zero up to 8 or 11 events4. These numbers alone indicate that there may be significant fragility with the findings of each study, and that there may be considerable imprecision surrounding the estimate of treatment effect within each trial9,10. Consistent with the literature to date, both randomized

and observational data sets within this meta-analysis favoured operative management with regard to re-rupture and favoured nonoperative management with respect to complications4. Interestingly, on closer inspection, while the data suggested a ~60% risk reduction in re-rupture rate, ranging from 31% to 76%, the absolute re-rupture rate including all data sets was 2.3% after operative management compared to 3.9% after nonoperative management, with an absolute risk difference of 1.6%4. To reiterate, re-rupture rates in those managed operatively from all of the pooled data to date indicated there was a 2.3% re-rupture rate in those managed operatively and 3.9% managed nonoperatively, suggesting that for every 62 patients we operate on, we prevent one re-rupture. Conversely, the complication rate observed was 4.9% after operative management compared to 1.6% after nonoperative management with an absolute risk difference of 3.3%, meaning that for every ~30 patients we operate on, we create one complication4. Interestingly, there was no significant difference in effect measures between the randomized and nonrandomized data sets. Based on our personal opinion and bias from practice, this may not be such a fair trade off, as anyone who has dealt with infections following fixation of an Achilles tendon knows. Conversely, those of us who have operated on re-ruptures find that surgery, while still not without complication, is definitely not more technically demanding than fixing an Achilles tendon tear acutely [BP, MB personal opinion]. If operative management lowers re-rupture rates marginally but comes at a cost, an operation must make people functionally better. If not why do it? That is our goal, of course: get people back to work, sport and life. In both the randomized and observational cohort, functional outcome was assessed in some studies, certainly not all of them4. However, no significant differences in functional outcome was identified4. Thus, what are the gains we are getting with operative management? It begs the question: why would one proceed with operative intervention? It seems that, our particular bias over the past few years has been to increasingly treat Achilles tendons in a nonoperative fashion with a functional rehabilitation protocol. Admittedly we have been using the protocol based on the trial by Willits et al.11 However, other recent rehabilitation protocols have been developed and it is unclear which one may be the best.12 There still seems to be some discord when treating the athletic community As Ochen et al. go on to say, “…Athletic people may prefer operative treatment to enhance and expedite their outcomes, where as a sedentary person with limited functional outcome expectations may prefer nonoperative treatment.”4 It is quite difficult to ascertain why this may be so, and so much for us “weekend warriors” if it is the case. It may be that high-end athletic patients are not involved in some of these randomized controlled trials as nonoperative management is apparently just not for them. However, this statement is really not supported by any of the literature thus far, and if we as an orthopaedic community feel that this treatment modality is better functionally for professional athletes, then it should be better for the population, and this does not seem to be so at the moment. Thus, our particular bias is to continue with nonoperative management. Indeed, many studies have looked at COA Bulletin ACO - Fall / Automne 2019



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

return to play for professional athletes and the most recent and largest by Yang et al. suggests that only ~61% of NFL athletes may return to play and in those that did, the average time to get there was ~11mths13. They used an established database of Achilles tendon tears in NFL athletes and the assumption of the authors was that all players received operative treatment [personal communication JaeWon Yang, lead author], interestingly they reported a 15% re-rupture rate in their study cohort13. Furthermore, some studies suggest that professional athletes actually take longer to return to play than non-professional athletes13,14. With ~40% of professional players not returning to sport, even with operative intervention, should we not also be offering nonoperative management to them? Just asking…

7. Chiodo C.P., Glazebrook M., Bluman E.M., Cohen B.E., Femino J.E., Giza E., et al. American Academy of Orthopaedic Surgeons clinical practice guideline on treatment of Achilles tendon rupture. J Bone Joint Surg Am. 2010;

It remains unclear which functional rehab protocol may be the better and secondly, whether or not percutaneous methods of fixation may help decrease the complication rates associated with operative treatment. Further work on this may alter our opinion. However, the trials to date serve to provide numbers for cogent discussions surrounding the treatment strategy of Achilles tendon ruptures with our patients, such that together we can incorporate both our expertise, patient’s values and preferences and the use of the best available evidence. Remember however, the best available evidence would tell us that surgical intervention decreases the absolute risk of rerupture by 1.6% and increases the absolute risk of infection by 3.3%, with no obvious functional benefit clearly observed with operative management. If this was your tendon, is this risk/ benefit profile worth it to you?

10. Khan M., Evaniew N., Gichuru M., Habib A., Ayeni O.R., Bedi A., et al. The Fragility of Statistically Significant Findings from Randomized Trials in Sports Surgery: A Systematic Survey. Am J Sports Med. 2017;

References 1. Egger A.C., Berkowitz M.J. Achilles tendon injuries. Current Reviews in Musculoskeletal Medicine. 2017. 2. Ganestam A., Kallemose T., Troelsen A., Barfod K.W. Increasing incidence of acute Achilles tendon rupture and a noticeable decline in surgical treatment from 1994 to 2013. A nationwide registry study of 33,160 patients. Knee Surgery, Sport Traumatol Arthrosc. 2016; 3. A.C. E, M.J. B. Achilles tendon injuries. Curr Rev Musculoskelet Med. 2017; 4. Ochen Y., Beks R., van Heijl B.M., Hietbrink F., Leenen L.P., van der Velde D., Heng M., van der Meijeden O., Groenwold R.H.H., Houwert R.M. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: Systematic review and meta-analysis. BMJ. 2019; 5. Donaldson P.R. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: Commentary. Clinical Journal of Sport Medicine. 2012. 6. Soroceanu A., Glazebrook M., Sidhwa F., Aarabi S., Kaufman A. Surgical versus nonsurgical treatment of acute achilles tendon rupture: A meta-analysis of randomized trials. J Bone Jt Surg - Ser A. 2012;

COA Bulletin ACO - Fall / Automne 2019

8. Twaddle B.C., Poon P., Monnig J. Randomised prospective study of surgical vs non-surgical treatment of Achilles tendon rupture - clinical results. J Bone Jt Surgery, Br Vol. 2005; 9. Walsh M., Srinathan S.K., McAuley D.F., Mrkobrada M., Levine O., Ribic C., et al. The statistical significance of randomized controlled trial results is frequently fragile: A case for a Fragility Index. Journal of Clinical Epidemiology. 2014.

11. Willits K., Amendola A., Bryant D., Mohtadi N.G., Giffin J.R., Fowler P., et al. Operative versus Nonoperative Treatment of Acute Achilles Tendon Ruptures. J Bone Jt SurgeryAmerican Vol. 2010; 12. Glazebrook M., Rubinger D. Functional Rehabilitation for Nonsurgical Treatment of Acute Achilles Tendon Rupture. Foot and Ankle Clinics. 2019. 13. Yang J.W., Hodax J.D., Machan J.T., Krill M.K., Lemme N.J., Durand W.M., et al. Factors Affecting Return to Play After Primary Achilles Tendon Tear: A Cohort of NFL Players. Orthop J Sport Med. 2019; 14. Parekh S.G., Wray W.H., Brimmo O., Sennett B.J., Wapner K.L. Epidemiology and Outcomes of Achilles Tendon Ruptures in the National Football League. Foot Ankle Spec. 2009;

Look out for the next pre-debate survey on proximal humerus fractures in the Winter edition! Thanks for participating!

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

Operative Treatment of Achilles Tendon Ruptures Emilie-Ann Downey, M.D., FRCSC¹ Anna-Kathrin Leucht, M.D.¹ Andrea Veljkovic, M.D., MPH, BComm, FRCSC² Vancouver, BC ¹Foot & Ankle Fellow, Department of Orthopaedics ²Associate Clinical Professor Department of Orthopaedics St. Paul’s Hospital, UBC


or several decades, acute Achilles tendon ruptures have been treated safely and effectively with surgical repair. Like many other orthopaedic conditions, the pendulum has swung back and forth with regards to the management of this condition operatively versus nonoperatively. In addition, the surgical techniques of acute Achilles tendon repair are numerous, and involve open and minimally invasive techniques. In more recent years, we have seen a positive change in the way that Achilles tears are treated nonoperatively, with the introduction of early accelerated rehabilitation protocols. These protocols, when followed rigorously and when studied in randomized control trials with stringent inclusion criteria, lead to good clinical outcomes. However, we wonder how well these well-executed randomized control trials represent the real patients that walk into our offices. We believe that there remains a role for surgical management of acute Achilles tendon ruptures. As orthopaedic surgeons, it is our role to take into consideration our patients’ expectations with regards to their care, patient specific factors, present our patients with the current best available data, and involve them in a shared decisionmaking process regarding their care. In the appropriate patient, does surgical management of acute Achilles tendon injuries remain an acceptable option? Prior to answering this question, let’s focus first on the nonoperative rehabilitation protocol. It is well known that former protocols emphasized immobilization of the limb and nonweight bearing. When patients are treated without robust suture fixation that surgery guarantees, it was believed that more caution should be taken to allow healing of the tendon, which led to a higher rate of Achilles re-rupture. This is traditionally why surgical management of Achilles tendon injuries had its role to lower this risk (3.1% (surgery) vs. 13% (nonop); (p<0.005))1. With support from research on the biology of tendon healing, early accelerated rehabilitation protocols were developed and have been introduced. They have been the focus of many studies since, and compared to surgical treatments. There are many different variations of functional rehabilitation protocols, but studies are clear to show that if weight bearing is not initiated before the four-week mark, re-rupture rate is increased compared to surgery1. These protocols work, and lead to a good outcome in the right patient treated in the right centre. Patients must be compliant, must present in timely fashion after injury, obtain the right diagnosis and be referred appropriately to the team able to carry out this program. The treating centre must be able to provide rigorous, frequent, well-supervised

follow-up. It is easy to drop out of this program, and these “drop out patients” may not be represented well in the current studies. We are concerned that these patients may have bad outcomes, which are more difficult to treat in a delayed fashion. These studies also probably represent well the prototypical “weekend-warrior” patients, but may not be a clear representation of the outliers; for example, the young athletes, or professional athletes. We also wonder whether these protocols are too generic, and do not take into consideration specific patient characteristics; for example, anatomic variation in a patient’s normal Achilles tendon length which may require a different, or adjusted heel wedge height. In contrast to this “one size fits all” approach, surgery provides an opportunity to dial in the appropriate resting tension for each individual, as compared to their contralateral limb. Proponents of nonoperative treatment often say that the risks of surgical management of acute Achilles tendon tears outweigh the benefits. The most commonly reported risks include infection, wound complications, sural nerve irritation and deep venous thrombosis. It is encouraging to see that with the introduction of newer minimally invasive techniques (MIS), the risks of surgery have gone down significantly2. A meta-analysis comparing minimally invasive versus open repair for acute Achilles tendon ruptures found that for the above-mentioned complications, the risk ratio was reduced (RR 0.18, p=0.00001, relative risk reduction 82%) in the MIS group, which correlates to a NNT of four patients. In particular, a decreased risk ratio was noted for the dreaded problem of wound infections (RR 0.13, p=0.00001, relative risk reduction 87%)2. Some may fear that the MIS techniques may increase the risk of sural nerve damage. However, this study showed an equal low risk of sural nerve-related complications between the MIS and open approaches2. Finally, nonoperative treatment does not equal no risk. Deep venous thrombosis is a known complication associated with acute Achilles tendon ruptures, which was commonly seen in previous rehabilitation protocols. The incidence of DVT has fortunately gone down with the early accelerated rehabilitation protocol, with now comparable risk to surgical management3. Furthermore, we believe that there are studies to suggest trends towards better function, faster return to work, and better patient reported outcomes in patients treated surgically. Thus, in certain patients, the benefits of surgery may outweigh the associated risks. For example, there is RCT evidence to suggest a trend towards better function in patients treated surgically. In one study, all test results with regards to jumping ability, power and endurance were higher in the surgical group 12 months postoperatively, with a significant difference in the drop countermovement jump, as well as hopping4. Another RCT study seemed to suggest a faster recovery of muscle strength in the surgical group. This group had up to 24% higher results than the nonoperative group in peak torque and angle specific peak torque testing at six months. This strength difference was found to persist at the 18-month COA Bulletin ACO - Fall / Automne 2019



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

mark5. This trend towards faster recovery of muscle strength in the surgical group is further supported by another RCT. This study demonstrates higher functional performance with concentric strength, heel-rise work/height and hopping ability in the surgical group at the six-month mark, with the heel-rise work test remaining significantly better in the surgical group at the 12-month mark6. There is also evidence to suggest that nonoperative management has a greater impact on soleus muscle atrophy than surgical treatment. In the nonoperative group, there was a significant decrease in the soleus muscle volume (compared to the uninjured side) from three months to 18 months post injury. In contrast, patients treated surgically had an insignificant change in muscle volume during the same time period7. Moreover, there is evidence to suggest that Achilles tears treated nonoperatively may heal in an overlength position compared to Achilles tears treated surgically7. Whether the difference in strength shown in these studies is relevant to most patients remains unknown, and a subject for future studies. A quoted strength of the surgical repair of acute Achilles tendon ruptures has always been the ability to reduce the risk of tendon re-rupture. A meta-analysis found that compared to the nonoperative group without functional rehabilitation, the risk for re-rupture is reduced by 8.8% with surgical repair of the Achilles tendon (NNT of 12). If functional rehabilitation is implemented, an overall risk reduction for re-rupture is noted with a risk difference of 1,7%, still favouring the surgical group8. Again, whether the good results seen in patients treated nonoperatively with the functional rehabilitation protocol can be reproduced in a nonoptimal clinical setting with possible low adherence to the protocol remains unknown, in our opinion. Finally, in four studies of one meta-analysis, the return to work was examined and found to be significantly different between the nonoperative and operative groups. Patients with surgical repair returned to work on average 19 days earlier than their counterparts8. Another study, which studies the quality of life measurement scores (RAND-36) in patients treated for acute Achilles tendon ruptures, showed significantly higher physical functioning and bodily pain scores in patients who underwent surgery5. In conclusion, surgical repair of acute Achilles tendon injuries remains a safe and reliable treatment for acute Achilles tendon ruptures. With the current best available evidence, surgery favours a slightly lower rate of re-rupture, as a trade-off for a slightly higher, but acceptable (for most patients) risk of complications. Further studies are required to measure clinically relevant differences in function following nonoperative versus operative management of this injury. Until this data is available, we believe the current best available evidence should be presented to our patients, who should decide which risk profile is most suitable to them.

COA Bulletin ACO - Fall / Automne 2019

References 1. Bhandari M., Guyatt G.H., Siddiqui F., Morrow F., Busse J., Leighton R.K., et al. Treatment of acute Achilles tendon ruptures: a systematic overview and metaanalysis. Clin Orthop Relat Res. 2002(400):190-200. 2. Grassi A., Amendola A., Samuelsson K., Svantesson E., Romagnoli M., Bondi A., et al. Minimally Invasive Versus Open Repair for Acute Achilles Tendon Rupture: MetaAnalysis Showing Reduced Complications, with Similar Outcomes, After Minimally Invasive Surgery. J Bone Joint Surg Am. 2018;100(22):1969-81. 3. Ochen Y., Beks R.B., van Heijl M., Hietbrink F., Leenen .LP.H., van der Velde D., et al. Operative treatment versus nonoperative treatment of Achilles tendon ruptures: systematic review and meta-analysis. BMJ. 2019;364:k5120. 4. Olsson N., Silbernagel K.G., Eriksson B.I., Sansone M., Brorsson A., Nilsson-Helander K., et al. Stable surgical repair with accelerated rehabilitation versus nonsurgical treatment for acute Achilles tendon ruptures: a randomized controlled study. Am J Sports Med. 2013;41(12):2867-76. 5. Lantto I., Heikkinen J., Flinkkila T., Ohtonen P., Siira P., Laine V., et al. A Prospective Randomized Trial Comparing Surgical and Nonsurgical Treatments of Acute Achilles Tendon Ruptures. Am J Sports Med. 2016;44(9):2406-14. 6. Nilsson-Helander K., Silbernagel K.G., Thomee R., Faxen E., Olsson N., Eriksson B.I., et al. Acute achilles tendon rupture: a randomized, controlled study comparing surgical and nonsurgical treatments using validated outcome measures. Am J Sports Med. 2010;38(11):2186-93. 7. Heikkinen J., Lantto I., Flinkkila T., Ohtonen P., Niinimaki J., Siira P., et al. Soleus Atrophy Is Common After the Nonsurgical Treatment of Acute Achilles Tendon Ruptures: A Randomized Clinical Trial Comparing Surgical and Nonsurgical Functional Treatments. Am J Sports Med. 2017;45(6):1395-404. 8. Soroceanu A., Sidhwa F., Aarabi S., Kaufman A., Glazebrook M. Surgical versus nonsurgical treatment of acute Achilles tendon rupture: a meta-analysis of randomized trials. J Bone Joint Surg Am. 2012;94(23):2136-43.

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

Arthroscopy Association of Canada (AAC) Position Statement on Intra-Articular Injections for Knee Osteoarthritis Michaela Kopka, M.D., FRCSC, Dip. Sport Med. Brendan Sheehan, M.D., FRCSC, Dip. Sport Med. Ryan Degen, M.D., MSc, FRCSC AAC Executive (at time of statement publication): Ivan Wong M.D., FRCSC, MACM, Dip. Sport Med. Laurie Hiemstra M.D., PhD, FRCSC Femi Ayeni M.D., MSc, PhD, FRCSC, Dip. Sport Med. Al Getgood M.D., FRCS (Tr and Orth), Dip. Sport. Cole Beavis M.D., FRCSC, Dip. Sport Med. Monika Volesky MDCM, FRCSC Ross Outerbridge M.D., FRCSC, Dip. Sport Med. Bogdan Matache, MDCM, FRCSC

Acknowledgements Canadian Orthopaedic Association


he management of knee osteoarthritis and degenerative meniscal tears is multimodal. A key component to the nonoperative management of these conditions involves intra-articular injection therapy. The injections available in Canada include: corticosteroids, hyaluronic acid (HA), platelet rich plasma (PRP), and stem cell injections including bone marrow aspirate concentrate (BMAC). The Arthroscopy Association of Canada, Canadian Arthroplasty Society and Canadian Orthopaedic Association recently reviewed the most up to date evidence on the use of these injections. The following is a summary of their findings and recommendations. The full review, with associated grades of recommendations and references, can be found by clicking here. • Injection of corticosteroid into the knee can provide short-term pain relief and improvement in function. • Injection of hyaluronic acid into the knee can improve pain, function and stiffness for up to six months.

Canadian Arthroplasty Society

• A combined injection of hyaluronic acid and corticosteroid into the knee can relieve pain and acts faster than hyaluronic acid alone. • Certain types of hyaluronic acid are more effective. Specifically, injection of high molecular weight and highly crosslinked hyaluronic acid is more effective than injection with low molecular weight and non-crosslinked hyaluronic acid. • In recent studies, Platelet Rich Plasma (PRP) injection has shown the potential to improve pain and function in patients with knee arthritis. Further research, however, is needed to determine its ideal preparation and true efficacy in treating patients with knee OA. • Injection of corticosteroid, hyaluronic acid, and platelet rich plasma is safe. • The use of stem cell/BMAC injections cannot be recommended at this time. More research is needed to determine if these injections are safe and effective.

COA Bulletin ACO - Fall / Automne 2019



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

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

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

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

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



1) Imaging – up to 5 images

1) Jusqu’à 5 images



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

3) 5 references maximum

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

3) Maximum de 5 références



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

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

COA Bulletin ACO - Fall / Automne 2019

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

This edition’s case was submitted by Dr. Mitchell Bernstein from McGill University

Complex Proximal Tibial Bone Reconstruction Frank DiSilvio Jr., M.D. Department of General Surgery Lahey Clinic Burlington, MA Michael Tripp, M.D. Dept of Anesthesiology, Georgetown University Hospital Washington, DC Mitchell Bernstein, M.D., FRCSC Assistant Professor, Departments of Surgery & Paediatric Surgery, McGill University Head, Paediatric Orthopaedic Trauma, Montréal Children’s Hospital Co-Director, Limb Deformity Unit, Shriners Hospital for Children – Canada Orthopaedic Trauma & Limb Deformity Surgery, Montréal General Hospital Montréal, QC

Figure 2 AP, A and lateral, B standing tibia X-rays at the time of presentation to treating surgeon. This demonstrated a mobile nonunion at the lateral meta-diaphysis of the tibia. Cement spacer is event in the medial metaphyseal bone defect. C, D, coronal CT scans demonstrated small medial articular fragment and bone loss in the metaphysis


his case report describes a 52-year-old male smoker who presented with a type IIIB open bicondylar tibial plateau fracture nonunion with metaphyseal bone loss. His initial surgeries included soft tissue coverage using a medial gastrocnemius flap with split-thickness skin grafting, temporary spanning external fixator with irrigation and debridement, and an open reduction, internal fixation with a lateral locked plate once swelling subsided. A postoperative infected nonunion developed and was unsuccessfully treated at the outside institution with repeat irrigation and debridement, re-plating, staged uniplanar external fixation and cement spacer insertion. The patient had a total of 21 surgeries at the outside institution (Figure 1).

Figure 1 Clinical photograph of the patient’s left leg upon presentation

The patient presented to the senior surgeon with osteomyelitis, metaphyseal bone loss with a small articular fragment, a mobile non-union at proximal meta-diaphysis, and posttraumatic medial compartment osteoarthritis with a malaligned mechanical axis in varus (Figure 2,3). The patient and treating surgeon proceeded with another attempt at limb salvage. The strategy was predicated upon eradication of infection, dead space management, inducible membrane technique for bone loss, and stability without surface implants.

Figure 3 Preoperative standing 51’’ hip-to-ankle X-ray of the patient with limb alignment measurements. Mechanical lateral distal femoral angle (mLDFA) left 88°, right 90° (normal range = 85° to 90°). Medial proximal tibial angle (MPTA) left 84°, right 84° (normal range = 85° to 90°. Joint line congruence angle (JLCA) left 5°, right 1° (normal range = 0° to 2°). Limb length analysis revealed a direct discrepancy of 5 mm, left side long

COA Bulletin ACO - Fall / Automne 2019



Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 27)

Treatment began with flap elevation and removal of the retained antibiotic spacer from the left proximal tibia followed by irrigation and debridement of the bone defect (Figure 4). Diffuse osteomyelitis requires stabilization and dead space management for successful treatment1, 2. External stabilization was utilized to avoid creating an environment for bacteria to grow and create a biofilm, which can occur with internal hardware. The mobile nonunion and the infected metaphyseal bone loss indicated the use of a circular external fixator. Mechanical stability was provided through the Taylor Spatial Frame (Smith and Nephew, Memphis, TN, USA). Re-insertion of an antibiotic cement spacer, application of a circular fixator, and fibular osteotomy were performed. The circular fixator combined with fibular osteotomy allowed for deformity correction and stability. The circular fixator was used to move the mechanical axis into the lateral compartment to unload the patient’s medial compartment OA. Figure 5 Intraoperative photograph of the patient at stage 2 of the reconstruction. The flap has been elevated, cement spacer removed and insertion of iliac crest autograft has been inserted into the defect. Strut #1 (white arrow) has temporarily been moved to allow access to the grafting site

Figure 4 Intraoperative clinical photograph of the patient after the plastic surgeon elevated the medial gastrocnemius flap, A. This allowed for adequate visualization, debridement and insertion of a new antibioticimpregnated cement spacer, B

The patient refused another round of intravenous antibiotics, so Clindamycin, 450 mg PO every six hours was given for a total of six-weeks. The intraoperative cultures were positive for methicillin-resistant Staphylococcus. Ten weeks later the spacer was removed, and iliac crest autograft was placed within the pseudomembrane3 (Figure 5).  The metaphyseal nonunion healed in five months leading to removal of the external fixator (Figure 6). One year after surgery, the patient returned to his previous employment, and ambulated without aids. There was no recurrence of infection. There were no re-fractures or hardware failure during treatment. This case presents a man with a long problem list related to his non-union, bone loss and infection. For effective management, the list must be worked through logically. His non-union was classified as infected4, typically associated with pain, deformity, limited range of motion, nerve dysfunction, and poor overall health. Combining principles of treating infection, bone stability, realignment, and bone defect management made it possible to salvage the patient’s leg function. The treatment strategy involved debridement, infection control, dead space management, and biological stimulation for bone healing and mechanical support.

COA Bulletin ACO - Fall / Automne 2019

Figure 6 Standing hip-to-ankle X-ray five months after the external fixator was removed, A. The mechanical axis line (from the centre of the femoral head to the centre of the ankle has been drawn, demonstrating the valgus alignment of the left lower extremity, B. Lines 3 and 4 indicate the length difference between each leg, accounting for the pelvis and feet height. Final discrepancy utilizing this measurement was 3 mm, left side long. C, same X-ray with the final joint orientation angles, MPTA = 91°; LDFA = 87°; MAD = 7 mm lateral

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

Take Home Messages: • Large bone and soft-tissue voids are best treated with cement spacers or cement beads. The addition of antibiotics may be used in cases of infection treatment or prevention. Typical doses are vancomycin 3 g and tobramycin 2.4 g per 40 g of cement. • Chronic osteomyelitis is surgical if nonviable bone is present. Nonviable bone needs to be excised before reconstruction can be predictably obtained. • Circular external fixators are useful for peri-articular stability as they eliminate the necessity of surface implants or intramedullary rods. They can also be used to obtain complex deformity correction, limb lengthening and sustained compression. They are indicated in cases of infection. • Autograft sources may be obtained using the reamerirrigator-aspirator (RIA) system from the femur or the iliac crest. This is indicated at the surgeon’s discretion. Each has its own advantages and disadvantages. • The inducible membrane technique (Masquelet) is a good option for metaphyseal bone defects, especially when a cement spacer was used a stage one treatment plan.

References 1. Schottel P.C., Muthusamy S., Rozbruch S.R.: Distal tibial periarticular nonunions: ankle salvage with bone transport. J Orthop Trauma 2014. 2. Bernstein M., Fragomen A.T., Sabharwal S., Barclay J., Rozbruch S.R.: Does Integrated Fixation Provide Benefit in the Reconstruction of Posttraumatic Tibial Bone Defects? Clin Orthop Relat Res 2015. 3. Masquelet A.C., Begue T.: The concept of induced membrane for reconstruction of long bone defects. The Orthopedic clinics of North America 2010. 4. Cierny G., 3rd, Mader J.T., Penninck J.J.: A clinical staging system for adult osteomyelitis. Clinical orthopaedics and related research 2003.

Did They Forget About Calcium? Paul A. Martineau, M.D. FRCSC, ABOS Scientific Editor, COA Bulletin


et me first disclose my biases* and conflicts of interest before we take a look at the revised Canada Food Guide that was issued earlier this year. I am not a diary farmer; I am an orthopaedic surgeon. Therefore, by definition, I must be interested in bones. Even at that, I am mainly an arthroscopist, and we don’t tend to talk about osteoporosis as much as ligaments and cartilage. So why am I concerned about dairy products in the Canada Food Guide? Mainly because I have two growing boys and a wife, so the bones of my loved ones are what concern me when I consider the new classification of dairy products in the 2019 version of the Canada Food Guide. The government of Canada web site ( provides statistics on the calcium status of Canadians. Only ~3% of children (aged 1-3) had inadequate intakes of calcium. So far so good. What are kids consuming to meet these requirements? I assume it must have to do with milk and dairy products. However, as children age, one quarter (aged 4-8) had inadequate calcium intake. One third of boys and two thirds of girls (aged 9-18) had inadequate calcium intake. This trend continues into adulthood with inadequate intake in 27-80% of men and 48-87% of women depending on the age group. These statistics are from 2004; so, it seems that even without the current trend away from milk and dairy products, we were not meeting our calcium requirements. What happens now that milk and dairy have been all be removed from the Canada Food Guide? How should my family meet their calcium requirements? This used to be fairly easy: two to three servings of milk and dairy per day for adults, and up to four servings for growing children. Done.

If we consider meeting these same requirements without dairy products, but rather through other food sources that are considered good sources of calcium, things are not as easy. 1) Almonds: Three quarters of a cup contain 300 mg of calcium. Unfortunately, only 60 mg of it will actually be absorbed. That means 4.5 cups of almonds to get one portion worth of calcium. There are considerable calorie implications that come with such a big serving. If I ate that many almonds, I am pretty sure it would go “straight to my hips” much more efficiently than “straight to my bones”. 2) Spinach: Three portions of spinach contain ~300mg of calcium. However, only 5% of which is actually absorbed. I am quite certain I would not be able to convince my kids to eat three portions of spinach, or more precisely 60 portions of spinach (taking into account bioavailability), instead of one glass of milk. 3) Sardines: I won’t even go through the calculations here. My kids will never eat enough sardines to meet their calcium requirements. Not an option for my family. I believe that when they attempted to remove commercial bias from the new Canada Food Guide, they simply overlooked calcium. The impetus was to move away from the classic COA Bulletin ACO - Fall / Automne 2019


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


(continued from page 29)

rainbow of four food groups and recommended portions to a healthier eating holistic approach. However, the new Food Guide can be somewhat patronizing to people who already eat well in alternate ways. It is also a very expensive way to eat and somewhat elitist. Many families could not afford to make a plate that comes anywhere close to looking like the one featured on the cover of this edition of the COA Bulletin. It also makes it increasingly difficult for orthopaedic surgeons to recommend our patients meet their calcium requirements for healthy bones. I am sure following the new Food Guide can lead to improved cardiovascular health, decreased diabetes and decreased obesity. However, the way it is presented, it will come at the expense of our skeleton.

Relabelling the classic milk and dairy group into a calcium rich group may have been more appropriate. Realistic recommendations on how to consume enough calcium should have been included in the new Canada Food Guide as well. A picture of a healthy plate just does not cut it. At least not for our bones. For the sake of brevity in this editorial, I didn’t even mention vitamin D and the challenges in reaching the appropriate amounts for optimal bone health according to the Canada Food Guide’s new recommendations. For now, I invite you to learn more about the regrouping of dairy products and its implications in the following article. *Views expressed are my own and do not necessarily represent those of the Canadian Orthopaedic Association and COA Bulletin.

Does the New Canada Food Guide Support a Healthy Skeleton? Jennifer R. Beaudette1, Wendy E. Ward1, Suzanne N. Morin2 Department of Kinesiology, Faculty of Applied Health Sciences, Brock University St. Catharines, ON 1

Department of Medicine, McGill University; Centre for Outcomes Research and Evaluation, Research Institute of the McGill University Health Centre Montréal, QC 2


ietary calcium and vitamin D are essential nutrients for optimal bone health throughout the lifespan. During childhood and adolescence, the skeleton undergoes rapid changes due to growth, modeling and remodeling processes that maximize bone accrual. In addition to mechanical loading, adequate calcium and vitamin D intake are important for bone development and achievement of peak bone strength in young adulthood, and in the rate of subsequent bone loss in later life. In adults, the body contains approximately 1,000 g of calcium, of which 99% is found as calcium hydroxyapatite in bone, where it provides mechanical strength and contributes to calcium homeostasis. Ingested calcium and vitamin D come from food sources, mostly milk and milk products, and dietary supplements. Canada’s Food Guide Canada’s Food Guide (CFG), through its various versions since the 1940s, has served as a credible source for healthy eating education1. Updated earlier this year, the first time in over a decade, the new CFG is markedly COA Bulletin ACO - Fall / Automne 2019

different from previous iterations. For example, healthy eating habits are highlighted in the updated CFG1 and provide a fresh approach on how to support more healthful eating habits for Canadians. Healthy eating habits are categorized according to the following aspects: being mindful of eating habits, cooking more often; enjoying food, and eating meals with others. Thus, the guide advises how to eat in addition to what to eat, and encourages learning to cook and consciously strive for a social aspect to meal time. A striking difference from previous versions of the CFG is the removal of the four food groups we’re familiar with: fruits and vegetables, grain products, meat and alternatives, and milk and alternatives. Rather, the updated CFG encourages eating vegetables and fruits, whole grains, and protein-rich foods – with advice to choose protein from plant sources more often, and without specific advice on the number of servings. The photo of the ‘Eat Well Plate’ that was released with the food guide (Figure 1) shows the relative proportion of these food categories with half of the plate filled with fruits and vegetables, a quarter plate with whole grains and the remaining quarter of the plate with proteinrich foods. The image of the relatively small portion of yogurt combined with the removal of formal food groups including the “milk and alternatives” group, and emphasis on consuming plant-based proteins, has created confusion and worry as to whether individuals will meet their calcium requirements under the CFG’s new recommendations. In fact, milk and dairy products have not been removed, but, are now Figure 1 The updated “Eat Well Plate” provides an example of the variety of foods Canadians can choose to fill their plates1

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

considered in the “protein-rich foods” category. With respect to calcium-rich foods, the new CFG advises choosing protein options such as “lower fat dairy products” and recommends milk, yogurt, and lower sodium cheeses2. However, without very careful attention to what foods are consumed (or not consumed), the bone health of Canadians may be at risk due to low intakes of calcium. Milk and dairy products represent the richest sources of calcium per serving while also providing other nutrients important for bone health, including protein and vitamin D (Table 1). Plants contain markedly lower levels of calcium than dairy sources; calcium from plant sources also tends to have lower bioavailability and lack vitamin D, which helps with calcium absorption (Table 1)3. Exceptions to this are soy-based products such as soy beverage which is fortified with calcium and vitamin D to the level present in milk.

meal would provide about 70% of a growing child’s recommended daily calcium. In contrast, meeting calcium needs by consuming plant-based sources rather than dairy may require more servings of foods than is realistic to consume, along with careful planning. For example, a cup of chopped kale, 200 g of broccoli, 100 g black beans, and 100 g of oats would need to be consumed to get the same amount of calcium as one serving of dairy. Eating foods such as salmon (particularly from the tin as bones are also consumed) and some soy-based foods such as soy-beverage and tofu can help to meet calcium needs. Though, while soy is fortified with calcium to contain a similar amount as dairy, it contains much lower levels of other nutrients, such as protein. For men over age 70 and women over the age of 50, three servings of dairy in addition to a regular and varied diet meets their RDA of 1200 mg calcium (Tables 1, 2)4.

Table 1: Examples of Commonly Consumed Foods That Can Fill the Eat Well Plate and Help Canadians Meet Their Calcium Needs4 SERVING CALCIUM VITAMIN D PROTEIN FOOD SOURCE SIZE (mg) (IU) (g) Milk (White, 2% Fat) 250 ml 309 103 8.5 Yogurt 100 g 283 34 9.7 (Greek Style, Plain, 2% Fat) Whey Protein Isolate 1 Scoop 200 0 16.7 (Powder) (29 g) Soy Beverage 250 ml 316 86 4.2 (Enriched, Low Fat) Orange Juice 250 ml 310 100 2.1 (Fortified with Added Calcium and Vitamin D) Almonds 25 Count 86 0 6.8 (Dry Roasted, Unsalted) (32 g) Salmon (Sockeye, Canned 75 g 179 557 15.4 with Bones, Unsalted) Tofu (Medium Firm or Firm, 100 g 350 0 8.1 Prepared with Calcium Sulfate) White Beans (Boiled) 100 g 90 0 9.7 Kidney Beans (Red; Boiled) 100 g 28 0 8.7 Black Beans (Boiled) 100 g 55 0 8.2 Chickpeas (Boiled) 100 g 49 0 8.9 Hummus (Prepared) 100 g 38 0 7.9 Edamame (Boiled) 100 g 145 0 12.4 Broccoli (Raw) 100 g 47 0 2.8 Kale (Raw) 250 ml 106 0 3.0 (Chopped) Spinach (Raw) 250 ml 31 0 0.9 Oats (Instant, Plain, Cooked) 100 g 59 0 2.6 Barley (Pearled, Cooked) 100 g 11 0 2.3 Brown Rice (Cooked) 100 g 10 0 2.6

Table 2: Recommended Dietary Allowance (RDA) of Calcium and Vitamin D Across the Lifespan Calcium Vitamin D Protein Age Group RDA RDA RDA Children 1-3 Years 700 mg 600 IU (15 mcg) 1.05 g/kg Children 4-8 Years 1000 mg 600 IU (15 mcg) 0.95 g/kg Children 9-13 Years 1300 mg 600 IU (15 mcg) 0.95 g/kg Children 14-18 1300 mg 600 IU (15 mcg) 0.85 g/kg Adults 19-50 Years 1000 mg 600 IU (15 mcg) 0.80 g/kg Adults 50-70 Years 600 IU (15 mcg) 0.80 g/kg Men 1000 mg Women 1200 mg Adults ≥71 Years 1200 mg 800 IU (20 mcg) 0.80 g/kg*

Calcium, Vitamin D and Protein for Skeletal Health Because many foods contain small amounts of calcium, it is generally assumed that 300 mg of calcium is consumed daily through non-calcium-rich foods. Tables 1 and 2 show the calcium levels of various foods and how much would need to be consumed to meet the recommended dietary allowance (RDA) for calcium. For example, children age 9 to 18 years old require 1300 mg of calcium per day. The challenge of meeting this requirement is particularly evident if dairy is not consumed throughout the day. A serving of dairy contains approximately 300 mg of calcium so integrating one serving of dairy at each

*Older adults might need more protein (1.0-1.2 g/kg body mass) to maintain muscle6 In addition to calcium, adequate protein intake is also integral for maintaining healthy bone matrix throughout the lifespan5. As noted in Table 2, the RDA for both calcium and vitamin D increase with age, but that of protein remains the same throughout adulthood. However, there is evidence that to help attenuate loss of muscle mass and function (sarcopenia), these needs might increase with age to be greater than the RDA of 0.8 g/kg/day to levels closer to 1.0-1.2 g/kg/day6. Vitamin D is also an important nutrient to consider. Fortified foods and supplementation may be useful for most Canadians to meet the RDA for vitamin D since it is very challenging to obtain through diet alone. (Table 1) Challenges Arguably, the new CFG challenges us to reconsider how to meet calcium needs for bone health beyond foods that were traditionally in the ‘milk and alternatives’ group, while still recognizing dairy as a source of protein. Thus, as health-care professionals, it behooves us to remind patients about the importance of adequate calcium, vitamin D, and protein for lifelong musculoskeletal health, and provide them with tools that will facilitate optimal intake. Time will tell the true impact of the new CFG for bone health across the lifespan and whether certain groups, such as the elderly at higher risk of low intake and compromised bone and muscle strength, will require specific attention.

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

Patients can be directed to the following web resources for more information about calcium, vitamin D, and the updated Canada’s Food Guide: • nutrients/calcium.html • food-nutrition/healthy-eating/vitamins-minerals/vitamin-calcium-updated-dietary-reference-intakes-nutrition.html • • • • • Key Points: • Milk and dairy foods have not been removed from the new Canada Food Guide. They are a healthy source of calcium, vitamin D, and protein. Their consumption should be encouraged, as they are among the few common foods in the Canadian diet that have high amounts of each of these nutrients important for supporting bone health throughout life. • The “Calcium Calculator” available through Osteoporosis Canada ( or the International Osteoporosis Foundation (http://www.iofbonehealth. org/calcium-calculator) is a practical tool to help Canadians determine if they are meeting their calcium needs.

• Calcium consumption can be quickly estimated during the clinical encounter: 300 mg from regular (baseline) daily food intake (as many foods contain small amounts of calcium) plus 300 mg for each serving of dairy or calcium fortified food (such as a serving of low-fat yogurt or 100g of tofu prepared with calcium). References 1. Health Canada. Canada’s Food Guide: Canada’s Dietary Guidelines. 2019; Available from: 2. Health Canada. Canada’s Food Guide: Eat Protein Foods. 2019; Available from: healthy-eating-recommendations/make-it-a-habit-to-eatvegetables-fruit-whole-grains-and-protein-foods/eat-protein-foods/. 3. Weaver, C.M., W.R. Proulx, and R. Heaney, Choices for achieving adequate dietary calcium with a vegetarian diet. Am J Clin Nutr, 1999. 70(3 Suppl): p. 543S-548S. 4. Canadian Nutrient File. 2018; Available from: 5. Wallace, T.C. and C.L. Frankenfeld, Dietary Protein Intake above the Current RDA and Bone Health: A Systematic Review and Meta-Analysis. J Am Coll Nutr, 2017. 36(6): p. 481-496. 6. Deutz, N.E., et al., Protein intake and exercise for optimal muscle function with aging: recommendations from the ESPEN Expert Group. Clin Nutr, 2014. 33(6): p. 929-36.

Minimally Invasive Foot and Ankle Surgery Warren C. W. Latham, BSch, M.D., FRCSC, MSc (can) Toronto, ON

Introduction inimally invasive hallux valgus reconstruction techniques have become increasingly popular in the last two decades. The words ‘percutaneous’ and ‘minimally invasive’ are often used interchangeably to highlight procedures performed through a smaller approach than would normally be applied to a similar procedure using an open technique. A 2018 systematic review identified over 278 published studies on the subject since 20011.


Although its origins stem from techniques trialed in the 1940’s, recently the percutaneous techniques for dealing with hallux valgus and lesser toe deformities have become more topical2. Widespread popularization coincided with application of highspeed burrs, custom screw fixation, and larger studies identifying a lack of surgical complications1.

COA Bulletin ACO - Fall / Automne 2019

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. Paul A. Martineau, M.D., FRCSC Scientific Editor, COA Bulletin

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 32)

Figure 1a Bosch technique with K-wire fixation (images courtesy of Dr. Christopher Lu)

Figure 1b Minimally invasive Chevron with screw fixation (images courtesy Dr. Warren Latham)

Currently, there is a paucity of data on each surgical technique to ascertain whether one is more effective than the rest. However, recent prospective and randomized controlled studies have highlighted both a lack of complications as well as overall patient satisfaction with improved AOFAS scores as an outcome measure3.

Procedure Although there are many minimally invasive techniques found within the literature (Bosch technique, MIS Chevron-Akin, Reverdin-Isham, Endolog system)2 which differ primarily in the nature of the osteotomy and fixation technique, the commonality between techniques lies in the percutaneous approach. Whether MIS or open, surgical stabilization maintains the osteotomy position during recovery. Percutaneous fixation is achieved either through Kirschner wires placed through the medial capsule and implanted into the 1st metatarsal shaft (Figure 1a) or custom screws (Figure 1b). Currently, the most stable constructs involve screw(s) oriented from the proximal medial first metatarsal into the laterally translated metatarsal head8. Modern screws are designed for a minimally invasive realignment osteotomy with lower profile heads and custom screw pitches.

In a randomized controlled trial of 47 patients in 2018, Kaufmann and colleagues demonstrated no significant differences between open and percutaneous (MIS) groups in any of the determined outcome parameters. Regarding patient satisfaction, statistically significant differences were found between MIS and open surgery 12 weeks postoperatively in favour of the MIS group (p = 0.022)4. In a 2017, prospective randomized study published in Foot and Ankle International3, Lee et al. compared the percutaneous Chevron-Akin (PECA) to Open Scarf-Akin with a six-month follow-up. Both groups showed comparable clinical and radiologic outcomes. However, the PECA group had significantly less pain in the first six weeks following surgery3. Lai et al. also compared percutaneous Chevron-Akin osteotomy (29 feet) to Open Scarf-Akin osteotomy (58 feet) for hallux valgus at a 24-month follow-up5. The authors concluded that clinical and radiological outcomes of third-generation percutaneous Chevron-Akin osteotomies were comparable with Open Scarf-Akin osteotomies at 24 months but with significantly less perioperative pain, shorter length of operation, and less risk of wound complications5. Primarily the focus of recent publications has been directed towards identifying the goals of percutaneous foot surgery. While equivalent levels of radiographic outcomes and patient satisfaction seem evident5, there is also a suggestion that a patient’s perception of perioperative pain, as well as cosmesis, may be superior with the varied percutaneous techniques4. History In the 1990’s, Bösch et al.6 performed a percutaneous subcapital distal metatarsal while Magnan et al.7 performed the same procedure with a high-speed burr.. Vernois and Redfern’s contribution included a stable screw fixation along with a subcapital osteotomy8.

Prior to commencing percutaneous surgical techniques two technical considerations must be addressed9. First, an adequate number of open procedures independently performed is potentially valuable. Surgical experience provides a clear understanding of anatomy and increases confidence for dealing with potential complications. Even performing a percutaneous osteotomy with a burr using an open incision may be helpful9. Second, adequate training within a cadaveric lab is critical. This experience allows surgeons to understand how the burr responds while cutting within cortical and cancellous bone. When initiating this technique within a surgical practice it may be beneficial to start using the burr for calcaneal osteotomies (as an adjunct to pes planus reconstruction) as the technique is somewhat forgiving. Distal metatarsal osteotomies tend to be more technically demanding with larger potential for error (including metatarsal shortening)9. Smaller hallux vallux deformities, in which translation of the capital fragment is limited, may be the more challenging than more severe deformities with a larger IMA (intermetatarsal angle) (Figures 1a & b). Counterintuitively, the larger deformities, particularly when initially using this technique, provide less technical challenges as the capital fragment can be translated 100% facilitating screw placement. Other technical considerations include minimal osteoarthritis of the 1st metatarsalphalangeal joint, a reducible hallux over the sesamoidal complex and 1st tarsalmetatarsal stability.

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

The common risk factors to orthopaedic surgery still apply to this patient population. Patients who smoke remain at risk for delayed bone healing, while patients with osteopenia, osteoporosis, and diabetic neuropathy may require more frequent follow up an prolonged immobilization2.


Complications In a systematic review of percutaneous osteotomies involving 18 studies and a total of 1,594 feet with hallux valgus, Bia et al.1 identified the following complication rates: infection (1.6%, K-wire cases only), recurrence (1.8%), nonunion (0.4%, K-wire cases only), complex regional pain syndrome (0.9%, K-wire and unfixated cases), transfer metatarsalgia (1.2%, mostly unfixated cases), osteonecrosis (0.1%, K-wire cases only) and joint stiffness (1.9%, K-wire and unfixated cases). The authors concluded the use of screw fixation in minimally invasive bunion surgery appears to offer far fewer complications in comparison to the percutaneous K-wire technique1.

2. Roukis, T.S., Percutaneous and minimum incision metatarsal osteotomies: a systematic review. J Foot Ankle Surg, 2009. 48(3): p. 380-7.

Future Directions Familiarity with percutaneous osteotomy techniques, and increased clinical use of the high-speed burr, allows for the expansion of potential uses. Currently, within my practice, I started using a 12x20 mm burr for midfoot osteotomies in my Charcot neuroarthropathic patients followed by fine wire external fixation (and intramedullary metatarsal fixation)10. Other applications of the high-speed burr may include joint preparation for minimally invasive midfoot and forefoot arthrodesis. Conclusion/Summary A minimally invasive osteotomy with screw fixation may be a better method for hallux valgus correction with improved patient satisfaction and minimal complications. As the prevalence of surgeons using minimally invasive techniques increases, so too will the potential applications of the system.

1. Bia, A., et al., Percutaneous Osteotomies in Hallux Valgus: A Systematic Review. J Foot Ankle Surg, 2018. 57(1): p. 123130.

3. Lee, M., et al., Hallux Valgus Correction Comparing Percutaneous Chevron/Akin (PECA) and Open Scarf/Akin Osteotomies. Foot Ankle Int, 2017. 38(8): p. 838-846. 4. Kaufmann, G., et al., Minimally invasive versus open chevron osteotomy for hallux valgus correction: a randomized controlled trial. Int Orthop, 2019. 43(2): p. 343-350. 5. Lai, M.C., et al., Clinical and Radiological Outcomes Comparing Percutaneous Chevron-Akin Osteotomies vs Open Scarf-Akin Osteotomies for Hallux Valgus. Foot Ankle Int, 2018. 39(3): p. 311-317. 6. Bosch, P., S. Wanke, and R. Legenstein, Hallux valgus correction by the method of Bosch: a new technique with a sevento-ten-year follow-up. Foot Ankle Clin, 2000. 5(3): p. 485-98, v-vi. 7. Magnan, B., et al., Percutaneous distal metatarsal osteotomy for correction of hallux valgus. Surgical technique. J Bone Joint Surg Am, 2006. 88 Suppl 1 Pt 1: p. 135-48. 8. Vernois, J. and D.J. Redfern, Percutaneous Surgery for Severe Hallux Valgus. Foot Ankle Clin, 2016. 21(3): p. 479-93. 9. Jowett, C.R.J. and H.S. Bedi, Preliminary Results and Learning Curve of the Minimally Invasive Chevron Akin Operation for Hallux Valgus. J Foot Ankle Surg, 2017. 56(3): p. 445-452. 10. Botezatu, I. and D. Laptoiu, Minimally invasive surgery of diabetic foot - review of current techniques. J Med Life, 2016. 9(3): p. 249-254.

Did You Book Your Hotel Room in Halifax?


OA Annual Meeting hotel blocks fill up quickly – all members are encouraged to book your accommodations early at the various convention hotels that are located near the Halifax Convention Centre (where Annual Meeting will be held). Visit annual-meeting-2020/hotels/ to make your reservations.

COA Bulletin ACO - Fall / Automne 2019

Avez-vous réservé votre chambre à Halifax?


es blocs de chambres que nous réservons en vue de la Réunion annuelle de l’ACO ont tendance à partir rapidement. Nous invitons donc tous les membres à réserver leur chambre tôt à l’un des hôtels sélectionnés, situés à proximité du Halifax Convention Centre (où la Réunion aura lieu). Rendez-vous à reunion-annuelle-2020/hotels pour réserver.

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As a member of the Canadian Orthopaedic Association (COA), you are directly contributing to the advancement of our specialty. Every membership sustains and develops national and local initiatives for our collective orthopaedic community. Your membership contributions extend far beyond the scope of the Annual Meeting. Instead, consider some of the many recent COA initiatives that your membership dues played a key role in developing.

DIVERSIFYING OUR SPECIALTY Female university and medical students can now participate in an interactive session with leaders in the orthopaedic specialty. This program hopes to increase the number of women applying for residency positions by providing earlier and more comprehensive exposure to orthopaedics.

MENTORSHIP PROGRAM Residents and fellows are matched with active members for a day at the Annual Meeting. This endeavour fosters professional development and career planning, and provides leadership and role modeling opportunities.

ADVOCATING FOR ACCESS TO CARE Lending advocacy support to provincial orthopaedic associations through a lobbyist with expertise in government meetings, drafting briefings/messaging, and gathering intelligence, as well as providing national support to existing provincial advocacy initiatives.

SURGEON EMPLOYMENT Hiring and employment data over a 5-year period has been collected and analyzed for the purposes of strategic discussion related to the ongoing underemployment crisis with orthopaedic training programs, the Royal College, and the media.

CME YEAR-ROUND Accredited learning opportunities through webinars and summarized evidence-based research studies on OrthoEvidence are available to members throughout the year.

SOCIAL RESPONSIBILITY The COA partnered with the Centre for Evidence-Based Orthopaedics at McMaster University to offer members access to EDUCATE, a program that teaches health-care professionals to identify and assist patients who present to the fracture clinic with a history of intimate partner violence.

INTERNATIONAL COLLABORATIONS Educational exchanges and research collaborations are established between the COA and orthopaedic associations in India and Europe, with increasing partnerships developing across the globe. The COA and its members are active participants on the world stage of orthopaedics.

TOGETHER, WE MAKE THE DIFFERENCE Your COA membership is important and your contributions make a difference. These improvements would not be possible without your support. Thank you for being a member.

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

Dissecting Disparity: Improvements Towards Gender Parity in Leadership and On the Podium Within the Canadian Orthopaedic Association

« Dissecting Disparity: Improvements Towards Gender Parity in Leadership and On the Podium Within the Canadian Orthopaedic Association »

embers of the COA Executive Committee and staff analyzed the 15-year trend of women’s involvement in the COA through leadership (committee) positions, membership, Annual Meeting attendance and speaker/presenter opportunities. Though the results show that gender parity is not yet a reality within the COA, the number of females in leadership roles and on the podium is consistent with the gender diversity of our membership. Further efforts will be required to improve gender diversity as well as to encourage female medical students to consider orthopaedics as a specialty. The availability of female role models that are visible on the podium and in leadership positions may be one strategy to encourage the journey towards gender parity.

e Comité de direction et le personnel de l’ACO ont analysé les tendances en matière de participation des femmes au sein de l’organisation ces quinze dernières années, que ce soit à des postes de direction (comités), à titre de membres ou comme participantes et conférencières ou présentatrices à la Réunion annuelle. Bien que les résultats montrent que la parité entre les sexes n’est pas encore une réalité au sein de l’ACO, le nombre de femmes dans des rôles de leadership et sur le podium reflète la diversité des sexes chez les membres de l’ACO. Il faudra déployer davantage d’efforts afin d’accroître la diversité des sexes ainsi que d’inciter les étudiantes en médecine à envisager l’orthopédie. Avoir des modèles féminins bien visibles sur le podium et dans des rôles de leadership pourrait être un moyen stratégique de progresser vers la parité des sexes.

“The presence of greater numbers of female leaders at orthopaedic surgery meetings provides an environment for generating collaboration, improving recognition and respect for female surgeons, and access to opportunity for career advancement.”

« La présence accrue de leaders féminines aux congrès en orthopédie fournit un environnement propice à la collaboration, à la reconnaissance et au respect des femmes orthopédistes et à l’accès aux possibilités d’avancement. »

The paper, authored by Drs. Laurie Hiemstra and Kishore Mulpuri (Executive Committee), Cynthia Vezina and Trinity Wittman (staff ), and Sarah Kerslake (Banff Sport Medicine) was recently published in the Journal of ISAKOS (JISAKOS).

Cet article, rédigé par la Dre Laurie Hiemstra et le Dr Kishore Mulpuri (Comité de direction), Cynthia Vezina et Trinity Wittman (personnel de l’ACO), ainsi que Sarah Kerslake (Banff Sport Medicine), a été publié récemment dans le Journal of ISAKOS (JISAKOS).



Read the entire article by clicking here. Lire l’article en anglais. COA Bulletin ACO - Fall / Automne 2019



En tant que membre de l’ACO, vous contribuez directement à l’avancement de notre profession. Chaque adhésion à l’ACO soutient et stimule des initiatives nationales et locales pour notre communauté orthopédique. Votre contribution à titre de membre va bien au-delà de la Réunion annuelle. En effet, votre cotisation a joué un rôle clé dans de nombreuses initiatives de l’ACO, dont voici quelques exemples récents :

DIVERSIFICATION DE NOTRE SPÉCIALITÉ Des étudiantes en médecine et d’autres étudiantes universitaires participent à une séance interactive avec des leaders en orthopédie. Nous espérons ainsi accroître le nombre de candidatures de femmes pour les places en résidence en les exposant plus tôt et plus exhaustivement à la spécialité.

PROGRAMME DE MENTORAT Les résidents et fellows sont jumelés à des membres actifs pendant une journée à la Réunion annuelle. Ce programme favorise le perfectionnement et la planification de carrière, en plus de constituer une occasion d’exercer son leadership et d’être un exemple.

LUTTE POUR UN MEILLEUR ACCÈS AUX SOINS Soutenir les associations provinciales d’orthopédie dans leurs efforts de défense des droits et intérêts par l’intermédiaire d’un lobbyiste spécialisé dans les réunions gouvernementales, la rédaction de notes d’information et d’autres messages et la collecte de renseignements, et offrir un soutien national à des initiatives provinciales existantes de défense des droits et intérêts.

SITUATION D’EMPLOI DES ORTHOPÉDISTES On a recueilli et analysé des données sur l’embauche et la situation d’emploi sur une période de 5 ans à des fins de discussion stratégique sur la crise persistante du sous-emploi avec les responsables des programmes de formation en orthopédie, le Collège royal et les médias.

ÉDUCATION MÉDICALE CONTINUE À L’ANNÉE Des possibilités de formation agréée grâce à des webinaires et aux résumés de travaux de recherche fondés sur des données probantes publiés dans OrthoEvidence, accessibles toute l’année.

RESPONSABILITÉ SOCIALE L’ACO et le Centre for Evidence-Based Orthopaedics de l’Université McMaster collaborent afin d’offrir aux membres l’accès au programme EDUCATE, qui enseigne aux professionnels de la santé œuvrant dans les cliniques de traitement des fractures à repérer les victimes de violence conjugale et à les aider.

COLLABORATIONS INTERNATIONALES Des programmes d’échange à des fins de formation et des collaborations en recherche ont été établis entre l’ACO et des associations d’orthopédie en Inde et en Europe, et les partenariats du genre sont en croissance partout dans le monde. L’ACO et ses membres jouent un rôle actif sur la scène mondiale.

ENSEMBLE, NOUS AVONS UNE INCIDENCE Votre adhésion à l’ACO est importante, et votre contribution a une incidence. Ces améliorations ne seraient pas possibles sans votre soutien. Merci d’être membre.

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Foundation / Fondation


Dr. Michelle Ghert: Recipient of the Canadian Orthopaedic Foundation’s J. Édouard Samson Award


an orthopaedic oncologists reduce infection rates in limbsalvage surgery by extending the duration of postoperative prophylactic antibiotics? Can the international orthopaedic oncology community work together to improve sarcoma patient care? These are the questions Dr. Michelle Ghert from McMaster University Health Sciences, Hamilton, Ontario, asked as she embarked on a ground-breaking study entitled “The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) Trial: Unprecedented International Collaboration in Orthopaedic Trials.” Sarcoma is rare, and the volume of individual specialized sites precludes large prospective single-centre studies. The orthopaedic oncology literature is dominated by single-centre retrospective case series, so multicentre collaboration is essential for moving the orthopaedic oncologic field forward. Dr. Ghert envisioned a new era of research in orthopaedic oncology through large randomized controlled trials (RCTs). She was inspired by the success of her mentor, Dr. Mohit Bhandari in galvanizing the orthopaedic trauma community into conducting large multicentre RCTs. Armed with optimism, she worked towards developing a research question that could be answered by a collaboration of all orthopaedic oncology surgeons. Bone sarcomas of the femur and tibia can be surgically excised and the limb reconstructed through “limb-salvage”. The most common method involves using endoprostheses. There is a high risk for complications, the most devastating and complicated of which is surgical site infection. This leads to multiple revision surgeries, and at least 50% of patients with an SSI end up with an amputation. A systematic review to determine the overall infection rate, and identify a baseline event rate for PARITY, was conducted, revealing a reported infection rate of 10%. The researchers determined the practices and opinions of orthopaedic oncologists regarding prophylactic antibiotics during and immediately following these procedures. With a 75% response rate, it was determined that 33% of surgeons believed antibiotics should be discontinued after 24 hours but 40% continue antibiotics until the suction drain is removed. 90% of respondents agreed that they would change their practice if a large randomized controlled trial showed clear benefit of an antibiotic drug regimen different from what they currently use. Dr. Ghert and her team approached colleagues across Canada and at several US centres, and formed a Steering Committee to develop the study protocol. Patients with bone tumours undergoing limb-salvage surgery and reconstruction are screened and randomized into one of two study arms: 24 hours of postoperative antibiotics or five days of postoperative antibiotics. The study is fully blinded. COA Bulletin ACO - Fall / Automne 2019

Dr. Michelle Ghert receives her award from Drs. Cec Rorabeck, COF Patron, and Pierre Guy, COF Chair

The first PARITY patient was enrolled in January of 2013. Early success of the trial led to the group receiving additional funding and PARITY attracted international interest, with 21 sites across four countries in the pilot study. PARITY quickly gained international momentum and new sites opened around the world. Now, over 585 patients have been enrolled in PARITY, in 55 sites across 12 countries. PARITY is the largest international collaborative RCT in orthopaedic history in terms of the number of countries collaborating. The study will be completed in 2019 and will provide highlevel evidence to direct clinical practice in the orthopaedic oncology patient population. In answer to Dr. Ghert’s initial questions: Can orthopaedic oncologists reduce infection rates with prophylactic antibiotics? PARITY will answer this question. Can the international orthopaedic oncology community work together to improve sarcoma patient care? PARITY has answered that question. The PARITY team has leveraged its international collaborative network for further research priorities. Optimism for success of these future endeavours is high. For her work on the PARITY project, the Canadian Orthopaedic Foundation was pleased to present the prestigious J. Édouard Samson award to Dr. Michelle Ghert. For further details, visit

Foundation / Fondation


La Dre Michelle Ghert, lauréate du Prix J.-Édouard-Samson de la Fondation Canadienne d’Orthopédie


st-ce que les orthopédistes-oncologues peuvent réduire le taux d’infection à la suite d’une chirurgie de conservation d’un membre en prolongeant le traitement par antibiotiques prophylactiques? Est-ce que les membres de la communauté internationale de l’oncologie orthopédique peuvent œuvrer de concert à l’amélioration des soins aux patients atteints d’un sarcome? Voilà les questions au cœur de l’étude révolutionnaire menée par la Dre Michelle Ghert, du Centre des sciences de la santé de Hamilton, affilié à l’Université McMaster, à Hamilton, en Ontario, intitulée The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) Trial: Unprecedented International Collaboration in Orthopaedic Trials. Le sarcome est une tumeur rare, et le nombre de centres spécialisés empêche toute recherche prospective de grande envergure axée sur un seul établissement. La littérature en oncologie orthopédique est principalement composée d’études de séries de cas rétrospectives menées au sein d’un seul centre, ce qui rend la collaboration multicentre primordiale à l’évolution du domaine. La Dre Ghert envisage une nouvelle ère de recherche en oncologie orthopédique fondée sur les essais cliniques aléatoires de grande envergure, une vision inspirée par son mentor, le Dr Mohit Bhandari, qui a réussi à galvaniser la communauté de l’orthopédie traumatologique à mener des essais cliniques aléatoires multicentres de grande envergure. Forte de son optimisme, elle s’est affairée à formuler une hypothèse de recherche dont la réponse requiert la collaboration de tous les orthopédistes-oncologues. Les sarcomes du fémur et du tibia peuvent être excisés, et le membre reconstruit, grâce à une chirurgie de conservation du membre. La méthode la plus répandue nécessite des endoprothèses, qui sont toutefois associées à de grands risques de complications, dont l’infection du site opératoire est le plus dévastateur et complexe. Il s’ensuit de multiples reprises chirurgicales et, dans au moins la moitié des cas d’infection du site opératoire, une amputation. Une étude systématique des cas menée pour établir le taux global d’infection et le taux d’occurrence de référence dans le cadre de l’essai PARITY a montré un taux d’infection de 10 %. Les chercheurs ont établi les pratiques et opinions des orthopédistes-oncologues par rapport aux antibiotiques prophylactiques pendant ces interventions et immédiatement après. Selon un taux de réponse de 75 %, on a établi que 33 % des orthopédistes estiment que les antibiotiques doivent être arrêtés après 24 heures, mais que 40 % maintiennent le traitement jusqu’au retrait du drain. En outre, 90 % des répondants convenaient de changer leur pratique si des essais cliniques aléatoires de grande envergure montraient les avantages manifestes d’un traitement par antibiotiques différent de celui qu’ils utilisent. La Dre Ghert et son équipe ont communiqué avec des collègues de partout au pays, ainsi que dans plusieurs centres américains, et créé un comité directeur responsable de l’établissement du protocole de recherche. Les patients qui ont des tumeurs osseuses et subissent une chirurgie de conservation d’un membre et une reconstruction sont évalués et répartis aléatoirement dans l’un des 2 volets de l’étude, soit un traitement

La Dre Michelle Ghert reçoit son prix du Dr Cec Rorabeck, président d’honneur de la Fondation, et du Dr Pierre Guy, président du conseil d’administration de la Fondation.

postopératoire par antibiotiques de 24 heures ou un traitement postopératoire par antibiotiques de 5 jours. L’étude est entièrement menée à l’insu. Le premier patient a été inscrit à l’essai PARITY en janvier 2013. Les premières réussites de l’essai PARITY ont permis à l’équipe de chercheurs d’obtenir des fonds supplémentaires, en plus de susciter l’intérêt de la communauté internationale, puisque 21 centres répartis dans 4 pays ont pris part à l’étude pilote. L’essai PARITY a rapidement poursuivi sur sa lancée, de nouveaux centres s’y étant greffés partout sur le globe. Aujourd’hui, plus de 585 patients dans 55 centres répartis dans 12 pays sont inscrits à l’essai PARITY. Du point de vue du nombre de pays participants, il s’agit des essais cliniques aléatoires collaboratifs d’envergure mondiale les plus importants de l’histoire de l’orthopédie. L’étude doit prendre fin en 2019; elle fournira des données probantes très fiables qui orienteront la pratique clinique en oncologie orthopédique. Donc, revenons aux questions de la Dre Ghert à l’origine de l’étude : Est-ce que les orthopédistes-oncologues peuvent réduire le taux d’infection grâce au traitement par antibiotiques prophylactiques? PARITY fournira une réponse. Est-ce que les membres de la communauté internationale de l’oncologie orthopédique peuvent œuvrer de concert à l’amélioration des soins aux patients atteints d’un sarcome? PARITY a fourni une réponse. L’équipe de PARITY a d’ailleurs mis à profit son réseau international de collaborateurs pour d’autres priorités de recherche, et la réussite de ces projets suscite beaucoup d’optimisme. En reconnaissance de son travail dans le cadre de l’essai PARITY, la Fondation Canadienne d’Orthopédie est heureuse de remettre le prestigieux Prix J.-Édouard-Samson à la Dre Michelle Ghert. Pour les détails, consultez wp-content/uploads/2018-Samson-Award-Summary-Ghert.pdf. COA Bulletin ACO - Fall / Automne 2019

Resident Scholarship Opportunity – Call for Applications The Canadian Orthopaedic Foundation is pleased to announce that applications are now being accepted for the 2020 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 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 2020 : 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 et cliquez sur « Fonds de bourses d’études Bones and Phones », dans le menu « Prix, bourses et subventions ». 2019 Scholarship Recipient / Lauréat de la bourse d’études 2019 :

Kayla Cyr

(Memorial University of Newfoundland / l’Université Memorial, à Terre-Neuve-etLabrador) for her role in / pour son rôle dans

EDUCATE : IPV (St. John’s, NL) (Project summary) (Résumé du projet)

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

Canadian Perspectives


n this feature, COA members currently working outside of the country share their insight on various differences they’ve realized working in the United States (US) or abroad in comparison to their orthopaedic training in Canada. These experiences highlight the perspectives of the COA’s growing number of members now working outside of Canada. This issue’s contribution from Dr. Kelly Hynes highlights differences between training exposure in Canada and the US. Trauma exposure is somewhat variable among US training programs, but the consistency in level 1 exposure in Canadian programs prepares our residents to deal with complex trauma. Decreasing exposure to implants like the dynamic hip screw (DHS) is multifactorial. It is clear that practice has shifted to the use of intramedullary nails for various reasons including surgeon comfort, procedure time, equivalent outcomes (when used appropriately), and decreasing cost of intramedullary implants and associated reimbursement. Dr. Hynes and I were co-residents, and as such were trained by faculty who used this implant with success. While the exposure of my US civilian and military residents is similar to that of Dr. Hynes’, this may be more of a function of faculty experience.

My training experience in Canada was similar to what Dr. Hynes describes. I saw no more than a handful of ballistic trauma injuries through my medical and residency training, but these are far more common in the near daily occurrences where I practice now on the US and Mexico border. I will discuss this topic further in the next issue of the COA Bulletin when I share my experience with the recent shooting tragedy in El Paso, Texas. – Dr. William M Weiss, Current Issues Editor

“What Do You Mean, You Haven’t Seen a DHS?” Kelly Hynes, M.D., FRCSC Assistant Professor, UChicago Medicine Chicago, IL


moved to Chicago from Vancouver three years ago to begin practice in the United States (US) due to limited job opportunities available in Canada. The title of this article demonstrates one of the many differences in orthopaedic training that I have observed while working in both countries.

femoral nails simply don’t happen every week or even every month at my centre in Chicago. I became very thankful for the caliber of my own training and really began to focus my energy on ensuring the residents were comfortable with these ‘rare’ cases.

Though I inherently knew the resident experience varied in the US, I didn’t realize how much until I witnessed it firsthand. I am very proud of the top-caliber training available across the country in Canada. It is incredibly consistent and the volume of cases that you’re exposed to is rarely an issue. In a Canadian academic centre, working at a level 1 trauma centre as part of your training is a given. This is not the case south of the border.

Fast-forward two years when another major difference between the Canadian and American health-care systems became very apparent. Only 18 months after I started my staff position at the University of Chicago Medical Centre, a new emergency room and level 1 trauma centre were conceptualized, built and opened. Changes in infrastructure and resource allocation happen much faster in the US. Even though we are an academic institution, we are also a private, not-for-profit business. This means that most of the decisions and funding required for this major project occurred internally. Back home, the long-promised replacement of the aging local hospital in Corner Brook, Newfoundland still hasn’t happened after decades of continued decline and government planning.

Early in my career, it was a challenge to teach senior residents the cases that I took for granted as daily occurrences when I was a resident in Canada. Hip hemi-arthroplasties, DHS’ and

Becoming a level 1 trauma centre had a major impact on our residents’ level of trauma training and exposure, as well as on my orthopaedic practice. We are now seeing regular high-

In Chicago, there are five academic hospitals with their own orthopaedic residency training programs - which is nearly the number in the entire province of Ontario! Each training program in Chicago provides a very different training experience depending on their patient demographics, the expertise of the attending surgeons, and whether or not they are a trauma centre.

COA Bulletin ACO - Fall / Automne 2019



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

energy trauma of a complexity that I rarely saw when training in Canada. With a trauma mix of 60% ballistic injuries and 40% blunt trauma, it is unlike any level 1 trauma centre in Canada. After seeing only one ballistic injury in ten years of medical education in Canada, this new volume remains a little traumatizing. After the expected initial growing pains, our residents are suddenly experts at managing polytrauma patients, putting in traction pins, managing dysvascular limbs, triaging like seasoned veterans. They would not have received this level of training in our program if our hospital had not become a level 1 trauma centre. I believe the change has provided a tremendously valuable experience they couldn’t have foreseen when they started with us as PGY-1s.

If you are a COA member working outside of Canada, and would like to contribute your perspective to this feature, please contact Current Issues Editor, Dr. William Weiss:

While I never envisioned working at a busy level 1 trauma centre in Chicago when growing up in a small town in Newfoundland, my journey has been an incredible educational experience in the extremes of medical care in Canada and the US. I think that in the end, both training systems have their merits, but the stability and consistency of Canadian training is something I will never take for granted.


COA BULLETIN • Dr. William Weiss discusses his experience with the Walmart shooting mass casualty incident in El Paso, Texas • The COA gets ready to celebrate it’s 75th Anniversary in 2020 • Your feedback on the 2019 Annual Meeting • Robotics in Arthroplasty – Is it the future or just a fad? COA Bulletin ACO - Fall / Automne 2019

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

Current Trends in Orthopaedics, Sicily, Italy April 26-May 2, 2020 Paul R. Kim, M.D., FRCSC Course Chair


he University of Ottawa Division of Orthopaedics is pleased to present Current Trends in Orthopaedics in beautiful Sicily, Italy April 26-May 2, 2020. This event follows the incredible success of our inaugural meeting in the Loire Valley, France in 2018. We are now heading to Sicily known for its rich history, delicious food, and magnificent views of the Mediterranean. There will be an in-depth, educational program concentrating on current trends in orthopaedics designed specifically for orthopaedic professionals. First class speakers, interactive sessions including case reviews are all accompanied with ample time for discussion. The academic portion of the meeting is complemented by daily guided cycling and hiking options allowing you to explore the countryside and ancient Roman ruins up close. The program includes accommodation at the stunning beachfront five-star Verdura Resort, gourmet dining, fabulous wines and some of the best hiking and cycling in all of Italy. The resort is also home to three top rated Kyle Phillips golf courses. Please join us to experience this fascinating and unique educational event.

The program is 80% sold out. Click here for information and registration. Space is extremely limited. This University of Ottawa CME event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada and approved by the Canadian Orthopaedic Association.

Upcoming COA/CORS/CORA Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO 2020


June 3-6 juin

June 16-19 juin

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

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

COA Bulletin ACO - Fall / Automne 2019


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


Resetting a Broken Procurement System Tim Wilson Special to the COA Bulletin


rthopaedic surgeons are highly trained medical specialists. In Canada, Royal College certification ensures that our surgeons are among the best in the world. All of them are highly cognizant of their moral duty to deliver the best possible care to their patients. Unfortunately, despite the lack of controversy with regard to the capabilities, commitment, and requirements of Canada’s orthopaedic surgeons, these professionals are often compelled to work in “make-do” scenarios, in which hospital technology procurement practices place more emphasis on direct costs than on overall outcomes, whether these outcomes are medical or financial. “Administrators are paid to look at the short term, not the long term – and that’s a massive problem,” says Douglas Thomson, CEO of the Canadian Orthopaedic Association. “It’s important to make certain that there is clinician input in technology decisions, for them to contribute their knowledge, as it’s difficult, if not impossible, for administrator to make the best call.” That observation stands to reason, but the problem is structural. In Canada, the procurement process is controlled by administrators who are incented to emphasize price over value. As a result, they struggle to assess technologies in the context of downstream effects. “Buying groups are tied to large rebate structures, and discounts are not restructured into the orthopaedic programs,” says Jim Wilson, General Manager at Wright Medical Group. “They get very little return.” There is also a cultural component to this problem. Surgeons “Administrators are paid to and administrators inhabit two look at the short term, not very different worlds. It is not a surgeon’s job to procure medithe long term – and that’s a cal technology; it is not what he massive problem” or she was trained to do. And it is not an administrator’s job to ensure the best possible outcomes; instead, the administrator’s mandate is to control budgets, many of which exist in silos, with few processes in place to track and assess what happens outside of the surgical theatre. What to do? The answer lies in an adjustment in understanding – and in some instances in the behaviour – of both administrators and surgeons. On the administrator front, not much can happen as long as the system mitigates against higher value technologies. Hospital bureaucrats must follow complex rules and processes that are, at least in an administrator’s daily workday, impossible to alter. Requests For Proposals (RFPs) are often cumbersome documents, and as long as the system rewards administrators for buying based on cost, and not outcomes, little will change. Surgeons can play a crucial role, but the trick is to determine what form appropriate surgeon involvement might take. The engagement has to occur in a manner that aligns with the surgeons’ accountability to the patient. However, without a flexible procurement system in place, and with surgeons reluctant to get bogged down in bureaucratic processes, a practical assessCOA Bulletin ACO - Fall / Automne 2019

ment would suggest that, rather than to propose a ready-made model, the most meaningful strategy is for surgeons to hold administrators accountable for more than cost. To do that, a successful strategy would involve communicating with the administrators’ self-interest in mind. New hips and knee procedures drive revenue for a hospital, which is an obvious incentive, whereas revisions are less lucrative. It is also selfevident that revisions represent less-than-optimal outcomes. If surgeons advocate for the best technology to get the job done right the first time, they can appeal to a hospital’s desire to differentiate itself, and to focus on those procedures that represent the optimal return on investment. As hospital employees, administrators are beholden to larger mandates. It is therefore reasonable for surgeons to query administrators as to the extent that procurement procedures accurately reflect the emphasis on four critical pillars: 1) 2) 3) 4)

Improving overall population health Bettering patient care and experience Enhancing overall work satisfaction Reducing per capita costs

Given that RFPs are often structured so that cost is weighted Surgeons can play a to represent about 75% of the crucial role, but the trick tender criteria, it is simply comis to determine what mon sense to ask administrators how their processes are form appropriate surgeon aligned to deliver the best outinvolvement might take. comes for both patients and clinicians. How is it that surgeons are expected to be fully accountable, and potentially liable, for patient outcomes, when surgeons are not appropriately engaged in purchasing decisions? How does that align with a surgeon’s accountability to his or her patient? One answer to these questions is to emphasize choice. As presently structured, prime vendor agreements can create closed loops, with limited competition. An emphasis on lowest Asking Selling Price (ASP) mitigates against technologies that are tied to integrated care models, and that support improved processes for anaesthesia and same-day surgeries. Commodification, with a “one size fits all” approach, ignores the unique requirements of some patients, limiting a surgeon’s ability to deliver care that’s specific to individual need. It is wise to beware “mission creep”. Surgeons want meaningful ways engage, but they are also rightfully wary of being swallowed by bureaucratic processes. If committees are set up, with surgeons expected to commit time to meetings, the best approach would seem to be to place the ball firmly in the administrators’ court. A request for engagement based on value needn’t result in a surgeon getting bogged down by bureaucratic resistance. It can be done. A survey for Bain & Company in the United States has indicated that more than 80% of surgeons and procurement officers in the US work in collaborative partnerships, weighing both clinical and economic value. Clearly, a strategic approach is not about taking power from administrators. It is simply about challenging them to respond to key concerns, and to show results. This article was written on behalf of Medtech Canada, the association representing Canada’s medical technology companies.


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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

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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

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