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

Evolution of Orthopaedic Trauma Care in Canada William N. Dust, M.D., FRCSC, FACS Saskatoon, SK

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rthopaedic trauma care and trauma as a subspecialty have evolved greatly since I was a resident in the early 1980s. In the 1980s there were very few orthopaedic surgeons in Canada with orthopaedic trauma fellowship training, and even fewer who restricted their practices to trauma care. The development of daytime operating room time for fracture care was in its infancy and not available in most centres with much of the routine fracture care being done in the evenings or worse, in the middle of the night. At that time, the standard of care for an open tibia fracture was external fixation and a femoral shaft fracture was 8-12 weeks Dr. William N. Dust in balanced traction in a Thomas splint. Although the array of ropes was aesthetically pleasing sive than conventional plating, and reminded me of rigging on a locking plates are still commonly square rigged sailing ship, it was used and in some cases, the only a long and difficult treatment technique our residents know. The practice of orthopaedic surgery continues to evolve. We that was often met with comare faced with an explosion of information stemming from plications. IM nails had a very published cutting-edge research (bench and clinical). Likewise, Orthopaedic Trauma Future limited role as we were unable an increasingly informed public has rapid access to information Challenges to lock them. In fractures where about novel therapies and surgical techniques. Oftentimes the With the baby boom generainternal fixation was indicated, best way to integrate evidence-based practice and innovative tion now becoming our senior we would spend hours anaand forming an increastomically reducing, inserting lag treatments is unknown or challenging. To add some perspective citizens ing proportion the Canadian screws and neutralization plates, on how to approach emerging and/or controversial topics, we population, it isofexpected that and then be disappointed when have developed this Horizons feature in the COA Bulletin. geriatric fractures, both high and we ended up with an infeclow energy injury, will greatly tion or nonunion. I remember In the Horizons articles, thought leaders from various increase in the upcoming years. Dr. A. Grosse from Strasbourg, subspecialties will provide insights based on their extensive Currently, approximately 30% France coming to McGill to show clinical experience and ongoing research. The goal of this feature of Canada’s population is of us how to use the Grosse-Kempf is to “shed some light” on the best way forward. the baby boom generation; the locking nail. The ability to use youngest of the generation will interlocking screws revolutionFemi Ayeni, M.D., FRCSC be turning 65 around 2030. To ized the management of femoral Scientific Editor, COA Bulletin date we have found, through fractures and markedly improved increasing numbers of high qualpatient outcomes. In addition, ity trials, that the outcomes of many fractures in the over 65 the results of nailing caused us to refocus our thoughts on population are not as good as we thought or expected based internal fixation from a technical exercise to one of biological on outcomes of similar fractures in younger patients. In fact, fracture management. it is difficult to show that the results of surgery are any better than nonoperative care. This is not to say that these fractures Research and Advancements do well, but rather that our current surgical techniques and Orthopaedic surgeons’ understanding of epidemiology and implants don’t work. The reasons are multifactorial and are study design was starting to develop and through higher qualinfluenced by poor bone quality and co-morbid conditions that ity studies, we quickly moved forward revolutionizing the care may impede rehabilitation programs and are associated with of femoral and tibial fractures, open and closed, with locking higher perioperative complication rates. nails. Our Canadian Orthopaedic Trauma Society (COTS) has been a world leader in successfully conducting multi-centered In addition to finding the best management of geriatric fracrandomized controlled trials that have answered many of our tures, perhaps the greatest challenge facing orthopaedics fracture-related questions. and our Canadian health-care system is how to deal with the rapidly increasing volume of geriatric fractures, particularly hip Despite the dramatic advance with locked nails, not all techfractures. Although many centres now have dedicated daynological advances have been as successful. We enthusiastitime operating for fractures, much of this time is in dedicated cally adopted locking plate technology however we’ve been trauma centres. Unfortunately dealing with hip fractures in hard pressed to show that there has been any improvement these centres may be less than ideal as hip fractures are often in patient outcomes. Despite being several times more expen-

Horizons

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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