Spring 2015 COA Bulletin #108 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie Spring / Printemps 2015 Publication Mail Envoi Poste-publication Convention #40026541 4150 O. Ste-Catherine W., Suite 450 Westmount QC H3Z 2Y5

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

BULLETIN

108

Photo: Super, Natural British Columbia is a trade-mark of Destination BC Corp

Welcome to Vancouver! Special feature section on the upcoming 2015 Annual Meeting ......................................... p.16 Soyez les bienvenus à Vancouver! Section spéciale sur la Réunion annuelle 2015 Alberta’s Bone and Joint Health Institute - bridging MSK care’s knowledge-to-action gap � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37 Clinical Feature - Paediatric Physeal Ankle Fractures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 28 Debate: What is the best way to achieve needed reform in our health-care system? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 41 La Fondation Canadienne d’Orthopédie célèbre son cinquantième anniversaire � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 50

Complimentary online subscription to The Bone & Joint Journal and Bone & Joint 360

Form e know rly n as JBJS ( Br)

Editor-in-Chief Mr Ben Ollivere

Editor-in-Chief Prof Fares Haddad

If you’re an Associate or Active Member (practicing in Canada) of the COA, your membership benefits now include a complimentary online subscription to The Bone & Joint Journal (formerly JBJS Br) and Bone & Joint 360

To activate your subscription go to www.tiny.cc/COA If you do not know your login details to activate your subscription please email subs@boneandjoint.org.uk

Stop by The Bone & Joint Journal‘s table during the COA Annual Meeting if you have any questions on activating your online subscription or would like to ‘top-up’ to receive a print subscription to either The Bone & Joint Journal or Bone & Joint 360

www.boneandjoint.org.uk

Follow us on twitter @BoneJointJ and @BoneJoint360 The British Editorial Society of Bone & Joint Surgery. Registered Charity No. 209299

Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 108 Spring / Printemps 2015 COA / ACO Dr. Bas Masri President / Président Dr. John Antoniou Secretary / Secrétaire Mr. Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4150 Ouest, rue Sainte-Catherine West Suite 450, Westmount, QC H3Z 2Y5 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Dr. Marc Isler Editor-in-Chief / Rédacteur en chef Dr. Peter Lapner Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

Get Ready for Vancouver Bas A. Masri, M.D., FRCSC President, Canadian Orthopaedic Association

ith a very long cold winter now behind us and with spring in the air, this is the time of year when we look forward to getting together as colleagues, friends, and collaborators to share our thoughts, experiences, and to reconnect. The COA Annual Meeting is the time that I look forward to every year for this purpose. This event gives us the opportunity to see colleagues we might not have seen all year, and this is where we share our experiences, success and potential concerns from across the country. It is also the event that precedes our short and long awaited summer. To me, both are highlights of the year. There is no better place than my hometown of Vancouver to celebrate the beginning of summer. After the gray of the fall and winter, the beauty of Vancouver in the summer is magical. It is a true inspiration for an excellent Annual Meeting. I would like to encourage all members to attend the meeting in Vancouver, and to bring your families. Spend some extra time in British Columbia and explore the quiet beauty of Vancouver Island, the magic of Whistler, the warmth and charm of the Okanagan Valley or the majestic Rocky Mountains. The summer truly highlights the beauty of the entire province. I would like to also challenge all COA members to identify any non-members and invite them to attend this year’s Meeting. You can learn more about what is being offered at the upcoming Annual Meeting in the special feature section we have put together for you beginning on page 16 of this edition of the COA Bulletin. Updated program information is always available at www.coaannualmeeting.ca. My wife, Dr. Rola Masri, and I look forward to hosting you in Vancouver this coming June at what will hopefully be our most successful meeting ever. I would like to thank all of our members for their support over the past year, and look forward to an even stronger Canadian Orthopaedic Association. The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450, Westmount, Quebec, H3Z 2Y5. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450 Westmount, Quebec, H3Z 2Y5

Le Bulletin de l’Association Canadienne d’Orthopédie est publié au printemps, été, automne, hiver par l’Association Canadienne d’Orthopédie, 4150, rue Ste-Catherine Ouest, Suite 450, Westmount, Québec H3Z 2Y5. 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 : l’Association Canadienne d’Orthopédie, 4150, rue Ste-Catherine Ouest, Bureau 450, Westmount, Québec H3Z 2Y5

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

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

COA Bulletin ACO - Spring / Printemps 2015

Your COA / Votre association

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 25 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 37 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 54

Soyez prêts pour Vancouver Bas A. Masri, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

ous avons connu un hiver très long et froid et, maintenant que le printemps est là, nous avons hâte de renouer avec nos collègues, amis et collaborateurs pour échanger idées et expériences. Et c’est à la Réunion annuelle de l’ACO que ça se passe! Cette manifestation est l’occasion de côtoyer des collègues de partout au pays qu’on ne voit pas du reste de l’année et d’échanger avec eux sur nos expériences, nos réussites et de possibles préoccupations. C’est aussi notre façon d’accueillir l’été, aussi court qu’attendu! Pour moi, il s’agit là de moments forts de l’année. Et il n’y a pas de meilleur endroit que ma ville pour célébrer l’arrivée de l’été. Après la grisaille de l’automne et de l’hiver, la beauté estivale de Vancouver est féérique; une véritable source d’inspiration pour une excellente réunion annuelle. J’invite donc tous les membres à assister à la Réunion annuelle de

Vancouver et à y emmener leur famille. Prolongez ensuite votre séjour en Colombie-Britannique et explorez la beauté tranquille de l’île de Vancouver, la magie de Whistler, la chaleur et l’accueil de la vallée de l’Okanagan ou encore toute la majesté des Rocheuses. L’été met vraiment en valeur la province. Je lance un défi à tous les membres de l’ACO : trouvez un collègue qui n’est pas membre et invitez-le à la Réunion de Vancouver. Vous pouvez en apprendre davantage sur ce que vous réserve la prochaine réunion annuelle à la section spéciale colligée pour vous au début de la page 16 du présent numéro du Bulletin de l’ACO. Des renseignements à jour sur le programme sont toujours accessibles à www.coaannualmeeting.ca. La Dr Rola Masri, mon épouse, et moi-même avons hâte de vous accueillir à Vancouver, en juin, à l’occasion de ce que nous espérons être la Réunion la plus réussie à ce jour. Permettezmoi de remercier tous les membres pour leur soutien au cours de la dernière année; j’espère que l’ACO continuera sur sa lancée.

New COA Bulletin Format – Online & Better Defined Marc Isler, M.D., FRCSC Editor in Chief, COA Bulletin

his edition of the COA Bulletin marks the journal’s very first online only edition. This new format offers a few additional features that were not available in the print edition:

1. Timelier access to the articles. Eliminating print and mail production times allows us to issue each Bulletin at least three weeks earlier. 2. Full colour design. No longer restricted by expensive colour print costs, the entire journal is now in full colour. COA Bulletin ACO - Spring / Printemps 2015

3. Live links. Hyperlinks, web sites and email addresses are all linked to their external sites within the journal. 4. Mobile friendly. You can access the online COA Bulletin on your Smart Phone or tablet whenever you wish. 5. Responsible. The COA is reducing its carbon footprint with this alternative paperless and inkless format. 6. Searchable. Use the search feature to find a specific article, author or reference without having to flip through every page. 7. Better Connected. Each of the ads that are included by our industry partners is linked to their company web site. Learn more about the products and companies that are featured in the Bulletin simply by clicking on their ads.

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If an online version is not for you, the Bulletin can be printed out from your home or office by first downloading the journal to your computer. Click on the download feature and either save or print out the Bulletin after the download is complete. We have kept the journal to a size and format that can easily be printed out without compromising its design and layout. New Sections You will also note that the articles are now classified in different sections related to their content. Each section is identified at the top of the page by a different header and colour. These new categories better define and represent the articles that appear within them. Some of the new sections include: Your COA In this section you will find messages from the president, COA news, information about our Annual Meeting, travelling fellowships and membership services announcements, committee news as well as in memoriam obituaries. Clinical Features, Debates & Research Our former “Themes” section articles will be included in this area along with clinical point/counterpoint debates and research articles. Advocacy & Health Policy Position statements, models of care, information about

the Canadian Joint Replacement Registry and government relations articles are what will be featured in this section. Training & Practice Management Resident-specific articles, retirement and financial planning, practice transition, medicolegal and billing/fee negotiation articles and a CME calendar of events can be found under this header.

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

BULLETIN

108

Photo: Super, Natural British Columbia is a trade-mark of Destination BC Corp

Welcome to Vancouver! Special feature section on the upcoming 2015 Annual Meeting Soyez les bienvenus à Vancouver! Section spéciale sur la Réunion annuelle 2015 Alberta’s Bone and Joint Health Institute - bridging MSK care’s knowledge-to-action gap � � � � � 0 0 Clinical Feature - Paediatric Physeal Ankle Fractures � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0 0 Debate: What is the best way to achieve needed reform in our health-care system? � � � � � � 0 0 Canadian Orthopaedic Foundation Celebrates 50 Years � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 0 0

Foundation Articles and information about the Canadian Orthopaedic Foundation and its various programs will be located in this section. Additional sections will be added when required as this new online COA Bulletin continues to evolve, improve and develop. What do you think about this new format? Send me your feedback: marcisler@videotron.ca

Nouveau format pour le Bulletin de l’ACO – Version électronique et mieux définie Marc Isler, MD, FRCSC Rédacteur en chef du Bulletin

e présent numéro du Bulletin de l’ACO est le tout premier numéro exclusivement électronique. Ce nouveau format comporte des avantages que ne pouvait pas offrir la version papier : 1. Accès plus rapide aux articles. L’élimination de l’impression et de l’envoi postal nous permet de publier chaque numéro du Bulletin au moins trois semaines plus tôt. 2. Mise en page toute en couleur. Les coûts prohibitifs de l’impression couleur ne posant plus problème, toute la revue est maintenant en couleur. 3. Liens actifs. Tous les liens, sites Web et courriels dans la revue mènent directement aux sites et programmes externes. 4. Compatibilité avec les téléphones intelligents. Le Bulletin de l’ACO est toujours accessible sur votre téléphone intelligent ou votre tablette. 5. Publication responsable. L’ACO réduit son empreinte carbone en éliminant papier et encre.

6. Fonction de recherche. La fonction de recherche permet de trouver un article, un auteur ou une référence en particulier sans consulter toutes les pages. 7. Connectivité accrue. Chaque publicité de nos partenaires de l’industrie mène à leur site Web. Il suffit de cliquer sur l’une d’elles pour en apprendre davantage sur les produits et entreprises qui figurent dans le Bulletin. Si vous préférez une version papier, vous n’avez qu’à télécharger le Bulletin sur votre ordinateur, à la maison ou au bureau, et à l’imprimer. Cliquez sur la fonction de téléchargement et sauvegardez le document ou imprimez-le. Nouvelles sections Vous remarquerez également que les articles sont maintenant classés selon leur contenu. Chaque section est identifiée par une couleur et un en-tête. Ces nouvelles sections définissent et représentent mieux les articles. En voici quelques-unes : Votre association C’est là que vous trouverez les messages du président, les nouvelles de l’ACO, les renseignements sur la Réunion annuelle, les annonces sur les bourses de voyage et les services aux membres, les nouvelles des comités et les avis de décès.

COA Bulletin ACO - Spring / Printemps 2015

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Débats, recherche et articles cliniques Les articles de notre défunte section « Thèmes » figureront dans cette section, de même que les débats sur des questions cliniques et les articles de recherche. Défense des intérêts et politiques en santé On y regroupe les énoncés de position, les modèles de soins, les renseignements sur le Registre canadien des remplacements articulaires et les articles sur les relations gouvernementales. Formation et gestion d’une pratique L’endroit où trouver les articles relatifs aux résidents, à la retraite et à la planification financière, à la transition en fin de carrière, à la médecine légale et aux négociations sur la facturation ou les honoraires, de même que le calendrier des activités des programmes d’éducation médicale continue (ÉMC).

Fondation On y trouve les articles et renseignements sur la Fondation Canadienne d’Orthopédie et ses divers programmes. D’autres sections s’ajouteront au besoin, au fil de l’évolution, de l’amélioration et du perfectionnement de la version électronique du Bulletin de l’ACO. Que pensez-vous de ce nouveau format? Faites-moi part de vos impressions à marcisler@videotron.ca.

In Memoriam Cy Frank, C.M., MD, FRCSC 1949-2015

he Canadian Orthopaedic Association was devastated to learn of the sudden passing of Dr. Cy Frank on Thursday, March 5.

Dr. Frank was a true leader and spent more than three decades devoting his life to improving health outcomes. His many contributions to medicine as a surgeon, teacher, mentor, world-renowned researcher and advocate for positive change in public health care have profoundly impacted the lives of Canadians. Previously, Dr. Frank held the positions of President of the Canadian Orthopaedic Association, Canadian Orthopaedic Foundation and Canadian Orthopaedic Research Society. He was awarded an Order of Canada last year for his contributions to advancing orthopedic health care services in Alberta, and for his scientific contributions to bone and joint repair research. His complete obituary can be found here: http://v1.theglobeandmail.com/servlet/story/Deaths.20150314.93357904/ BDAStory/BDA/deaths Donations in his memory can be made to support the Cy Frank Memorial Fund in Bone & Joint Health. Please send cheques payable to the University of Calgary with a memo indicating Cy Frank Memorial Fund to the Cumming School of Medicine Fund Development Office, 3330 Hospital Dr. N.W., Calgary, AB, T2N 4N1 or make your donation online: https://netcommunity. ucalgary.ca/CyFrank

COA Bulletin ACO - Spring / Printemps 2015

A tribute to Dr. Frank will be held during the Opening Ceremonies of the upcoming COA Annual Meeting on Wednesday, June 17 at 17:30. Please join us in remembering our friend and colleague. “I am inspired by what the future holds for orthopaedics and how innovation can continue to progress and evolve to better serve the citizens of this great country” – Cy Frank

Your COA / Votre association

The Pursuit of Progress

COA Committees Assemble at 2015 Mid-Winter Meeting Doug Thomson Chief Executive Officer Canadian Orthopaedic Association

he leadership of the COA convened in Toronto in early January for the annual two-day Mid-Winter Meeting. This year, face-to-face conferences included the Practice Management Committee, (Chaired by Dr. Ken Hughes), Standards Committee (Co-Chaired by Drs. Tracy Wilson and Eric Bohm), the Committee on Continuing Professional Development (Chaired by Dr. John Murnaghan), as well as the Executive and Board of Directors (both Chaired by Dr. Bas Masri, COA President). A wide range of issues were discussed, and what follows is a brief summary of some of the decisions and discussions most relevant to the membership. Membership Services Update After consultation with the membership, the Board of Directors has voted to adopt an updated membership dues structure, reflecting the trend within a number of professional organizations to package Annual Meeting registration costs into membership fees. Effective in 2016, annual membership dues for Active members will provide full access to the Annual Meeting at no additional cost. More information about the new Active member dues rate and benefits will be featured in an upcoming Bulletin. For questions about your membership status, contact Cynthia Vezina at cynthia@canorth.org or 514-874-9003 x 3. In a bid to gain strength in numbers, the Membership Committee hopes that all Canadian orthopaedic surgeons will join the COA by 2020. The lucky surgeon who becomes the 1000th Active Canadian member will be granted free membership for three years, including all benefits and Annual Meeting registration. Help us celebrate this achievement and spread the word to your colleagues. In addition, two current Active members, who have paid their 2015 dues by the end of April, will be selected by random draw for a full reimbursement. These two members will enjoy free annual dues for this year as a thank you for their continued support and commitment to the Association. Stay tuned to find out if you are one of the winners.

access to current information, searchability, full-colour design, multimedia opportunities and a greener alternative to paper. With the launch of this inaugural edition of the eBulletin, the COA is committed to progressing our communications in keeping with the forward-thinking technology that defines today’s successful professional organizations. What’s New in Events? In 2020, the COA will commemorate its 75th anniversary. Our members can look forward to celebrating this milestone birthday in East Coast style at the Annual Meeting in beautiful Halifax, Nova Scotia. Seafood and sea breeze coming your way! For more information and updates about the 2015 Annual Meeting in Vancouver, BC, please refer to the feature section on page 16 of this edition. Advocacy and Committee Progress Formulating a response plan for unemployment and underemployment of orthopaedic surgeons continues to be a priority for COA committees. The Practice Management Committee presented preliminary results of a health human resources survey to all hospitals in the country related to orthopaedic hiring in the next five years, and will present final results at the Annual Meeting in June. Concurrently, the Orthopaedic Human Resources Committee is surveying Program Directors related to job status of recent graduates from 2010 onwards, as well as surveying R3, R4, R5 residents and recent graduates with the goal of gathering up-to-date and detailed employment data, including full-time orthopaedic positions, fellowships, locums, subspecialty aspirations, and more. Results will help to inform the COA’s advocacy program, gauge the depth of the current underemployment problem, provide information to surgeons looking for work or nearing the end of their training, estimate the appropriate number of annual training spots and project what subspecialties are likely to be in higher demand. For inquiries about this initiative, contact Trinity Wittman trinity@canorth.org or 514-874-9003 x 2.

The COA has formed a subscription agreement with The Bone and Joint Journal (formerly JBJS British Edition) and is pleased to offer Active and Associate members, practicing or training in Canada, a complimentary online subscription to The Bone & Joint Journal and Bone & Joint 360. Activation instructions were sent by individual e-mail, but any questions related to this new membership benefit can be directed to subs@boneandjoint.org.uk.

The COA is one of thirty-nine health care organizations that comprise the Health Action Lobby (HEAL), a non-partisan coalition dedicated to improving the health of Canadians. On December 2, 2014, HEAL issued a consensus statement, ‘The Canadian Way: Accelerating Innovation and Improving Health System Performance’, calling on the federal government to take a collaborative leadership role in health system performance and urging political parties to identify their health platforms ahead of the next federal election. The full press release and statement can be viewed on the COA web site.

Under the guidance of the Communications Committee, the Executive is pleased to announce that the COA Bulletin will now be published in eJournal format. The eBulletin provides numerous advantages, offering more timely and interactive

In response to the requested expansion of scope of practice for podiatrists and chiropodists put forward by the College of Chiropodists of Ontario (CCO), and thanks to financial support provided by the Canadian Orthopaedic Foot and Ankle COA Bulletin ACO - Spring / Printemps 2015

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Society (COFAS), the COA teamed up with COFAS and the Ontario Orthopaedic Association (OOA). Dr. Tim Daniels, COFAS Co-Founder and Past-President, and Dr. Karl-André Lalonde, COFAS President-Elect, submitted a two-part detailed report to the Health Professions Regulatory Advisory Council (HPRAC) outlining concerns on behalf of the three organizations around access to quality foot and ankle care as well as optimal patient outcomes, should the expanded scope request be granted.

both the patients and their care givers. A consistent, unified, evidence-based approach to the issue will benefit all.

Following a 2014 survey of COA and Canadian Arthoplasty Society (CAS) members regarding the American Academy of Orthopaedic Surgeons (AAOS) – American Dental Association (ADA) Clinical Practice Guidelines for antibiotic prophylaxis in THA/TKA patients prior to dental procedures, the COA Standards Committee continues to collaborate with the Canadian Dental Association (CDA) and the Canadian Infectious Disease and Medical Microbiology experts related to best practices. The COA and the CDA ultimately hope to issue a combined position statement regarding clinical guidelines/recommendations for the use of antibiotic prophylaxis in patients with lower extremity arthroplasties undergoing a variety of dental procedures. This is a complicated and often controversial topic, often causing confusion and anxiety for

The next face-to-face Committee Meeting day takes place at the Annual Meeting in Vancouver, on Wednesday, June 17, 2015.

The Practice Management Committee will begin work on a pan-Canadian database that aims to catalogue projects related to improving access to care. All provincial associations will be invited to submit a brief description of relevant projects for inclusion on the COA web site with a link to further information, to allow for sharing of best practices.

If you have any questions about the COA’s Committees and their projects, I invite you to contact me at doug@canorth.org or 514 874-9003 x 5.

L’incessante quête de progrès

Rassemblement des comités à la Réunion d’hiver 2015 de l’ACO Doug Thomson Directeur Association Canadienne d’Orthopédie

’équipe de direction de l’ACO s’est réunie à Toronto début janvier pour sa réunion d’hiver de deux jours. Parmi les réunions en personne au programme cette année, mentionnons celles du Comité sur la gestion de l’exercice (présidé par le Dr Ken Hughes), du Comité sur les normes (coprésidé par les Drs Tracy Wilson et Eric Bohm), du Comité de perfectionnement professionnel (présidé par le Dr John Murnaghan), de même que du Comité de direction et du conseil d’administration (tous deux présidés par le Dr Bas Masri, président de l’ACO). On a abordé un large éventail de questions; vous trouverez ci-après le résumé des décisions et discussions les plus pertinentes pour les membres. Mise à jour sur les services aux membres Après avoir consulté les membres, le conseil d’administration a voté en faveur d’une nouvelle structure de cotisation, qui s’inscrit dans la tendance de nombre d’organisations professionnelles à regrouper les droits d’inscription à la Réunion annuelle et la cotisation annuelle. Ainsi, à compter de 2016, la cotisation annuelle des membres actifs leur donnera plein accès à la Réunion annuelle sans coûts supplémentaires. De plus amples renseignements sur la nouvelle cotisation annuelle des membres actifs et les avantages connexes seront COA Bulletin ACO - Spring / Printemps 2015

fournis dans le prochain numéro du Bulletin. Si vous avez des questions sur votre statut de membre, communiquez avec Cynthia Vezina, à cynthia@canorth.org ou au 514-874-9003, poste 3. Le Comité d’admission espère que tous les orthopédistes canadiens adhèreront à l’ACO d’ici 2020 pour tirer pleinement profit de la force du nombre. Ainsi, l’orthopédiste qui aura la chance d’être le millième membre actif au Canada recevra une adhésion gratuite pendant trois ans comprenant tous les avantages usuels et l’inscription aux réunions annuelles. Aidez-nous à célébrer le chemin parcouru en passant le mot à vos collègues. De plus, deux membres actifs ayant payé leur cotisation 2015 d’ici la fin avril seront choisis au hasard, et leur cotisation sera entièrement remboursée. Ces deux membres profiteront donc d’une adhésion gratuite cette année pour les remercier de leur soutien et de leur engagement envers leur association. Soyez à l’affût : vous pourriez bien être l’un des gagnants! L’ACO a conclu une entente avec le Bone & Joint Journal (anciennement le British Journal of Bone and Joint Surgery), et est ainsi heureuse d’offrir un abonnement en ligne gratuit au Bone & Joint Journal et à Joint 360 à ses membres actifs et associés en exercice ou en formation au Canada. Les directives d’activation vous ont été envoyées par courriel; toutefois, si vous avez des questions sur ce nouvel avantage de l’adhésion à l’ACO, vous pouvez les envoyer à subs@boneandjoint.org.uk.

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S’appuyant sur les conseils du Comité des communications internes et avec les orthopédistes, le Comité de direction est heureux d’annoncer que le Bulletin de l’ACO prendra désormais la forme d’une revue électronique. Le Bulletin version électronique offre de nombreux avantages, dont un accès plus rapide et interactif aux renseignements, une fonction de recherche, une mise en page toute en couleur et des possibilités multimédias, en plus d’être écologique. Par le lancement du premier numéro électronique du Bulletin, l’ACO s’engage à moderniser ses communications à l’aide de la technologie avant-gardiste employée par les organisations professionnelles efficaces. Quoi de neuf du côté des activités spéciales? En 2020, l’ACO fêtera son soixante-quinzième anniversaire. Nos membres pourront souligner ce jalon important à la mode de la côte est à l’occasion de la Réunion annuelle, dans la magnifique ville de Halifax, en Nouvelle-Écosse. Au programme : fruits de mer et air marin! Pour de plus amples renseignements et des mises à jour sur la Réunion annuelle 2015 à Vancouver, en ColombieBritannique, consultez la section spéciale, à la page 16 du présent numéro. Progrès des comités et dans la défense des droits et intérêts L’une des priorités des comités de l’ACO demeure l’élaboration d’une stratégie d’intervention en matière de chômage et de sous-emploi chez les orthopédistes. Le Comité sur la gestion de l’exercice a déposé les résultats préliminaires d’un sondage sur les ressources humaines en santé mené auprès de tous les hôpitaux au pays et portant sur l’embauche en orthopédie au cours des cinq prochaines années; il devrait en présenter les résultats finaux à la Réunion annuelle, en juin. De même, le Comité sur les ressources humaines en orthopédie sonde les directeurs de programme relativement à la situation d’emploi de tous les diplômés depuis 2010 et de tous les résidents de troisième, quatrième et cinquième années afin de recueillir des données à jour et détaillées sur les postes à temps plein en orthopédie, la formation supérieure, la suppléance, les sous-spécialités qui les intéressent et plus encore. Les résultats viendront étayer le programme national de défense des droits et intérêts de l’ACO; contribueront à évaluer l’ampleur du problème actuel de sous-emploi; fourniront des renseignements aux orthopédistes qui cherchent du travail ou devraient terminer leur formation sous peu; permettront d’estimer le nombre adéquat d’orthopédistes à former; et donneront une idée des sous-spécialités où la demande devrait être la plus importante. Si vous avez des questions sur cette initiative, communiquez avec Trinity Wittman, à trinity@canorth.org ou au 514-8749003, poste 2. L’ACO fait partie des trente-neuf associations de la santé membres du Groupe d’intervention action santé (GIAS), une coalition apolitique vouée à l’amélioration de la santé de la population canadienne. Le 2 décembre 2014, le GIAS a publié une déclaration de consensus intitulée Le modèle canadien : Accélérer l’innovation et améliorer le rendement du système de santé, exhortant le gouvernement fédéral à assumer un rôle de leadership de collaboration dans l’amélioration du ren-

dement du système de santé et incitant les partis politiques à faire connaître leur position en matière de santé avant les prochaines élections fédérales. On peut consulter le communiqué et la déclaration du GIAS sur le site Web de l’ACO. En réponse à la demande du College of Chiropodists of Ontario (CCO), qui souhaite l’élargissement du champ d’activité des podiatres et podologues, et grâce au soutien financier de la Société Orthopédique Canadienne pour le Pied et la Cheville (SOCPC), l’ACO s’est associée à la SOCPC et à l’Ontario Orthopaedic Association (OOA) pour étudier la question. Le Dr Tim Daniels, cofondateur et président sortant de la SOCPC, et le Dr Karl-André Lalonde, président élu de la SOCPC, ont soumis un rapport détaillé en deux parties au Conseil consultatif sur la réglementation des professions de la santé (CCRPS), dans lequel ils insistent sur les préoccupations des trois organisations quant à l’accès à des soins du pied et de la cheville de qualité ainsi qu’à l’obtention de résultats optimaux pour les patients dans l’éventualité où on accèderait à la demande du CCO. Dans la foulée du sondage de 2014 auprès des membres de l’ACO et de la Société canadienne d’arthroplastie (CAS) sur les lignes directrices cliniques de 2012 de l’American Association of Orthopaedic Surgeons (AAOS) et de l’American Dental Association (ADA) en matière d’antibioprophylaxie chez les patients ayant une prothèse totale de la hanche ou du genou qui subissent une procédure dentaire, le Comité sur les normes de l’ACO poursuit sa collaboration sur les pratiques exemplaires avec l’Association dentaire canadienne (ADC) et des spécialistes canadiens en infectiologie et microbiologie médicale. Au bout du compte, l’ACO et l’ADC espèrent pondre un énoncé de position conjoint sur les lignes directrices et recommandations cliniques en matière d’antibioprophylaxie chez les patients qui ont une prothèse articulaire à un membre inférieur et doivent subir diverses procédures dentaires. Il s’agit d’un sujet complexe et controversé, qui provoque souvent de la confusion et de l’anxiété tant chez les patients que les soignants. Une approche commune, uniforme et fondée sur des données probantes ne peut qu’être que bénéfique pour tous. Le Comité sur la gestion de l’exercice se penchera sur une banque de données pancanadienne qui a pour but de répertorier les projets d’amélioration de l’accès aux soins. Toutes les associations provinciales seront invitées à soumettre une brève description des projets pertinents en vue d’une publication sur le site Web de l’ACO, où un lien permettra d’obtenir de plus amples renseignements, de sorte à favoriser le partage des pratiques exemplaires. La prochaine journée de réunions en personne des comités aura lieu à la Réunion annuelle de Vancouver, le mercredi 17 juin 2015. Si vous avez des questions sur les comités de l’ACO et leurs projets, je vous prie de communiquer avec moi, à doug@canorth.org, ou au 514 874-9003, poste 5.

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Bringing Together Canadian Surgeons to Promote Bone and Joint Health Around the World The Canadian Orthopaedic Association Global Surgery (COAGS) Program Paul J. Moroz, M.D., FRCSC Chair, COAGS Committee Ottawa, ON

anadian orthopaedic surgeons have had a long history of working in some of the poorest regions of the world. In the past these regions were called the Third World, then the Developing World and are now often referred to as the more politically correct Low and Middle Income Countries (LMIC). Global Health and Global Surgery are other terms used to describe opportunities and programs whereby surgeons donate their time and surgical expertise to help with the huge burden of MSK problems in LMIC. Twenty-two days after the devastating 2010 earthquake in Haiti, there is a shortage of drapes, and no pillows. Under a spinal anaesthetic, this young woman is having her proximal femur nailed in the lateral position by Dr. Neil White’s team (Foundation of Orthopaedic Trauma). Blood from the reamer is splashing the patient’s neck.

lamation by the United Nations of the 2011-2020 Decade of Action for Road Safety, a resolution co-sponsored by more than 90 countries. However, above and beyond UN proclamations, many orthopaedic surgeons wish to use their hands-on surgical skills to directly address MSK problems attributable to absent or inadequate surgical care. Several Canadians have made notable headway into assisting regions with vast surgical needs. Dr. Andrew Furey from St. John’s, NL Co-Founded Team Broken Earth in 2010 following the devastating earthquake which killed more than 200,000 Haitians and left many with largescale medical and surgical problems. Currently, Team Broken Earth sends regular missions to Haiti to help rebuild their medical and surgical capacity.

Drs. Andrew Furey and Will Moores teaching Haitian residents how to perform acetabular fixation in a 2014 Team Broken Earth trip to Haiti.

With the advent of better surveillance of disease in LMIC, the true burden of bone and joint disease has also come to bear. While this was known by orthopaedic surgeons working in the field1, only recently have the major organized health organizations such as the WHO recognized the need to become more involved in the surgical burden of MSK problems2. This is especially true as it relates to the worldwide pandemic of motor vehicle crashes (MVC), where 90% of worldwide mortality and morbidity from crashes occur in LMIC, where there are few trained orthopaedic surgeons and a lack of even simple implants for fracture care. This was the impetus for the procCOA Bulletin ACO - Spring / Printemps 2015

Norgrove Penny is a paediatric orthopaedic surgeon from Victoria, BC who has spent a lifetime working in the developing world with a number of organizations and NGOs, including the Canadian Network for International Surgery (CNIS). Norgove has lived in Africa, operated on thousands of patients there, taught clubfoot care around the world and recently developed a two-day certificate course for surgeons in LMIC through the CNIS on the surgical care of osteomyelitis, an extensive problem in poor countries throughout the world. Many other Canadian orthopaedic surgeons are doing remarkable work and making significant contributions worldwide. While most professional associations have a specific committee for surgeons doing work in austere environments, the COA has not had a formalized committee in place for the last two decades. In the 1960’s and 1970’s, CARE-MEDICO gave surgeons opportunities to collaborate on working in developing coun-

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Dr. Peter O’Brien operates with two residents from Uganda and a resident from UBC at Mulago National Referral Hospital in Kampala in 2013 as part of the Uganda Sustainable Trauma Orthopaedic Program (USTOP).

Dr. Norgrove Penny teaching techniques of sequestrectomy surgery during an osteomyelitis course he developed under the auspices of the CNIS and CURE. The course took place in December 2014 at the Muhimbili Orthopaedic Institute in Dar es Salaam, Tanzania.

tries. In 1979, an ad hoc COA global committee was formed, later becoming a COA special committee named “Orthopaedics Overseas Canada”, which later disbanded. Despite this, many Canadian orthopaedic surgeons have utilized the Orthopaedics Overseas infrastructure maintained by the American Academy of Orthopaedic Surgeons (AAOS), an excellent entry level resource for practicing surgeons to spend a month in a wellplanned program in a developing country. As more and more Canadian orthopaedic surgeons are using their surgical, educational and research talents in developing countries, the COA Executive has recognized the need for the COA to formally resurrect a means whereby Canadian orthopaedic surgeons can bring together their ideas. As such, Dr. Bas Masri, COA President, invited an ad hoc committee to move forward on a new COA program addressing humanitarian orthopaedic care to vulnerable populations.

A new global orthopaedics committee consists of Drs. Paul Moroz (Ottawa), Andrew Furey (St. John’s), Neil White (Calgary), and Peter O’Brien (Vancouver). Each of these members have years of experience working in developing countries. Infrastructure support from the COA office consists of the invaluable assistance of Trinity Wittman, Cynthia Vezina and Doug Thomson. The committee has tentatively called itself the COA Global Surgery Committee, or “COAGS” for short. The mandate is to develop a program under the auspices of the COA whereby Canadian orthopaedic surgeons can gain opportunities to provide orthopaedic services in “alternative or austere” environments addressing the MSK problems of vulnerable populations including: a) Low and Middle Income Countries where orthopaedic services are absent or deficient, b) Disaster relief orthopaedics, e.g. the Emergency Response Unit of the Canadian Red Cross, Doctors Without Borders, support for Canadian Forces initiatives. c) Other vulnerable populations recognized as having limited access to orthopaedic care, e.g. residents of Nunavut, refugees to Canada, etc. COAGS will mark its beginning with a special symposium at the COA 2015 Annual Meeting in Vancouver, profiling a number of surgeons who have worked and/or are currently working in Global Surgery. The forum is meant to not only attract those with experience in Global Surgery, but also those wanting to learn how they can become involved. Join us on Saturday, July 20 from 08:45 – 10:45 at the Fairmont Hotel Vancouver. COA members wishing to donate funds to COAGS, as they might have in the past for Orthopaedics Overseas Canada when they renew their COA annual membership, can anticipate that their donations will be utilized in a transparent fashion to promote and foster the goals of COAGS.

Orthopaedic surgery residents from the Muhimbili Orthopaedic Institute (MOI) in Dar es Salaam, Tanzania receiving their certificates of completion of the CNIS/CURE Osteomyelitis Course. Instructors included (in the front row) Dr. Norgrove Penny, Dr. Samuel Swai (paediatric orthopaedic surgeon, MOI) and Dr. Paul Moroz.

Future editions of the Bulletin will profile various international orthopaedic outreach involving COA members. For more information about this initiative, please contact Trinity Wittman at trinity@canorth.org or 514-874-9003 x 2. COA Bulletin ACO - Spring / Printemps 2015

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References 1. Beveridge M., Howard A. The burden of orthopaedic disease in developing countries. J Bone Joint Surg 2004; 86-A: 1819 – 22.

2. Moroz P.J., Spiegel D.A. The World Health Organization’s Action Plan on the Road Traffic Injury Pandemic: Is there Any Action for Orthopaedic Trauma Surgeons? Journal of Orthopaedic Trauma, 2014 Jun; 28 Suppl 1: S 11 - 4.

The COA’s 2015 NATF Fellow Dr. Bashar Alolabi

Pascal-André Vendittoli, M.D., FRCSC Chair, COA Exchange Fellowships Committee Montreal, QC

r. Bashar Alolabi of Hamilton, Ontario has been selected as the COA’s 2015 North American Travelling Fellow (NATF). Dr. Alolabi obtained his M.D. from McMaster University and completed his orthopaedic surgery residency and Masters degree at Western University. He pursued subspecialty training in shoulder and elbow surgery at the Cleveland Clinic under the supervision of Dr. Joseph Iannotti, followed by a fellowship in trauma and lower extremity reconstruction/ arthroplasty at the University of Toronto with Drs. Richard Jenkinson and Markku Nousiainen. Dr. Alolabi currently practices at the Hamilton General Hospital and has a strong commitment to clinical outcomes research and upper extremity biomechanics. He will represent the COA over the course of a four-week tour beginning in October visiting orthopaedic centres in both Canada and the U.S. Please join us in congratulating Dr. Alolabi on this achievement.

Une expérience inoubliable

A summary of the 2014 CFBS Travelling Fellowship tour Nathan Urquhart, M.D., M.Sc., FRCSC 2014 CFBS Fellow Dartmouth, NS Alex Soroceanu, MD CM, MPH, FRCSC 2014 CFBS Fellow Calgary AB

ast fall we had the wonderful opportunity to represent the Canadian Orthopaedic Association on the CanadianFrench-Belgian-Swiss Travelling Fellowship (CFBS). The CFBS Travelling fellowship is an exchange between the COA and various European orthopaedic societies. On alternating years, one representative from each of France, Belgium, and COA Bulletin ACO - Spring / Printemps 2015

Switzerland travel to Canada and two Canadian representatives travel to the three countries the subsequent year. This year Dr. Alex Soroceanu and I were the fortunate ones chosen by the COA’s Exchange Fellowships Committee as the 2015 Canadian CFBS Fellows. Currently Alex is working in Calgary at the Foothills Medical Centre doing adult spinal surgery while I am working in Halifax (across the bridge at Dartmouth General Hospital) doing arthroscopy and sports medicine. We were pretty excited when we found out that were selected, however, what made it even more exciting was finding out that we would be co-fellows travelling together since we are good friends from orthopaedic residency at Dalhousie University. We spent four weeks travelling to nine hospitals and many towns steeped in history.

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Our first week was in Paris. Alex spent her time doing spine surgery. Alex’s first day was spent at St-Joseph Hospital with Dr. Wolf, scrubbing in for a scoliosis surgery. The rest of the week was spent at the Bicetre Hospital, with Professor Charles Court. She then had the opportunity to scrub in for several surgeries (ALIF, MIS lumbar fusions), and participated in daily ward rounds, and daily conferences where all of the elective operative cases of the upcoming weeks were presented and a surgical plan was made with input from all of the surgeons in the division. I spent my time split between Hôpital Ambrose-Paré in Paris with Professor Philippe Hardy and L’Hôpital André Mignot in Versailles with Professor Philippe Beaufils. These two stops were very interesting for me from a sports medicine perspective. I was a little surprised with the similarities in how we all approach ACL reconstruction, not just in France but in all three countries. Much more entertaining was debating about shoulder instability while in France “the home of the Latarjet”. I was very impressed with the speed in which they could do their Latarjets. Versailles is considered the “City of Kings” and it is of great offense is to call someone from Versailles a “Parisian” as residents of Versailles are of much higher noble blood. When not talking meniscal repair and transplant with the group, I had a great opportunity to do some running on the Palace grounds. From Paris we then joined back up and travelled north to Brussels. In Brussels we were graciously met by Professor Cornu from the University Clinics of St Luc. When Professor Cornu finishes his orthopaedic career, he certainly could go into the tourism/sight seeing business with his great hospitality!

We had a number of academic sessions here and also had a tour of their tissue bank. Working in Halifax I am spoiled with the quality and access of our regional tissue bank. I was very surprised to learn that few of the Western European countries have their own tissue banks. Belgium, in fact, supplies tissue to many of the countries and is part of the business model for a number of the larger hospitals. Not unlike Canada, Belgium is starting to run into a workforce over supply issue. This is happening at a much earlier stage for medical students trying to enter residency programs due to very high intake numbers of medical students (financial benefit for the universities) despite the governments clamping down and reducing the number of residency and practice positions. From what we were explained, even though the decrease in the number of residency positions was expected for a few years, the universities did not reduce the number of medical students being trained to match the expected number of residency spots. Consequently, the students graduating this year will not have a guaranteed residency position at the end of their medical school training and were organizing protests to bring attention to the issue. We spent two days in Liege with Professor Gillet and Dr. Allington. The hospital was located a few kilometers out of town, on the university campus, and was surrounded by beautiful parks and gardens. We had the opportunity to observe a few spine cases, both adult and paediatric. For Alex, our next stop in Liege was extremely exciting, and probably the highlight of her trip, as it was a mere 13km from where she lived for five years as a child. She was able to spend a weekend in the small village where she grew up, and had a chance to catch up with several elementary school and family friends that she only gets the chance to see every few years. Highlights included a magic show, the local village fair, meeting her friend’s two year old daughter, and lunch with everyone organized by family friends at their restaurant. Our visit to Hôpital Universitaire Erasme was highlighted by their anatomy and biomechanics labs. The have a very advanced gait lab and anatomy lab for testing muscle function and upper limb biomechanics. We had the opportunity to see many of the projects they were working on. Their anatomy lab is one of the oldest in Europe and had many amazing prosections and specimens - some over 150 years old.

Dr. Cornu showing us around Brussels.

Alex eating the famous waffles of Liege bringing back childhood memories of the County Fair.

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One of the surprising but fun aspects of our time in Switzerland was how many surgeons had trained in Canada, particularly at McGill and the Université de Montréal. This was great, as Alex had spent much of her training in the McGill system and had actually met some of the surgeons when they were doing their fellowship, and I had worked in Montreal for a short time on an elective during medical school. Our first stop was Hôpitaux Universitaires de Genève (HUG) where we were met by Dr. Hoffmayer and his team. They are the only public hospital in Genève and had a very wellequipped hospital, large ORs and many beds and were still undergoing expansion. Genève is an interesting city carved out of a small tract of land nearly completely surrounded by France with many people who work in Genève actually living in nearby France due to the price difference in housing. I also had a great opportunity to do some running around the city exploring the lake and the United Nations including the ‘Broken Chair” monument to landmine and cluster bomb opposition.

Our final stop of the tour before heading back to Paris for the Société Française de Chirurgie Orthopédique et Traumatologiqe (SOFCOT) meetings was the Lausanne University Hospital. Again, we were treated warmly and there were many Canadian connections in their training. As such a high number of attendings had trained in Canada or the US, they were active in modifying their residency training system to integrate some of the positive features they experienced and witnessed in Canada. They had a very nice collaborative inpatient ward for all their infections regardless of the cause (acute infected or infected non unions, diabetic, prosthesis). Their inpatient ward is an integrated ward when ortho, vascular, and infectious disease all round together usually two times per week. It gives them a very focused and consistent approach. They also had clinics on the floor for management of the outpatient infections. It was an impressive example of multi-disciplinary collaborative practice.

Broken Chair monument to landmine and cluster bomb opposition in Genève.

We also had time to visit the Olympic museum in Lausanne. Keep training Alex.

Our next stop was a short one in Fribourg, a few hours train ride northeast of Genève. We arrived and left under the cloak of rain and darkness but had good hospitality and conversation about new innovations in spine fracture management and acute ACL repair/reconstruction.

One thing that surprised us was their perioperative bed management. In my practice, arthroscopic ACL or shoulders are essentially outpatient day procedures - with exceptions being for patients with medical issues who may need overnight observation. Many of the places we visited, while they have decreased their hospital stays, still keep ACL or rotator cuff repairs for a day or two and implement fairly long stays for

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total joint patients. When we discussed this with the staff in Switzerland, they told us that overnight or lengthy hospital stays are the patient’s expectation since they pay taxes for their health care. While there are certainly variations across our country, I think we likely have more rapid discharge. Our final week was back in Paris for the SOFCOT Annual Meeting. Alex delivered a few presentations on complications in spine surgery while I attended sessions on shoulder instability and knee arthroscopy. Alex’s Fiancée, Phil and my wife Robin and two girls Asia (6) and Victoria (2) came to meet us for the remainder of our tour. My girls ate crepes for every meal and enjoyed touring around Paris and a trip to Disneyland Paris. Overall, we had a great experience that we will never forget. It was made even better because we had the opportunity to do it together and catch up after a couple of years working in different locations. Many thanks goes out to the COA’s Exchange Fellowships Committee, chaired by Dr. Pascal-André Vendittoli as well as Cynthia Vezina from the COA who always rocks and is totally on top of things! Also much thanks to all the European societies for their hospitality and to Eléonore Brackenbury from SOFCOT for her support and coordination.

Alex’s fiancée Philippe and I supporting her during her spine talk.

Welcome 2015 CFBS Fellows We look forward to hosting Drs. Frédéric Paternostre from Brussels, Belgium and Eric Nectoux from Lille, France this June as the visiting CFBS fellows. Drs. Paternostre and Nectoux will visit orthopaedic centres in Hamilton, Montreal, Sherbrooke and Calgary before attending the COA Annual Meeting in Vancouver. Please take the time to introduce yourselves to them and extend our Canadian hospitality when they travel through your centres or during the Annual Meeting - Ed. Nous avons hâte de recevoir les Drs Frédéric Paternostre, de Bruxelles (Belgique), et Eric Nectoux, de Lille (France), lauréats de la Bourse de voyage canado-franco-belge-suisse (CFBS), en juin. Les Drs Paternostre et Nectoux visiteront les centres orthopédiques de Hamilton, de Montréal, de Sherbrooke et de Calgary, en plus d’assister à la Réunion annuelle de l’ACO à Vancouver. Nous vous prions de prendre un instant pour les saluer et de les accueillir chaleureusement au pays si vous les croisez dans votre centre ou à la Réunion. – La rédaction

Alex and my girls at Disneyland Paris.

COA Bulletin ACO - Spring / Printemps 2015

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Welcome to Vancouver!

Learn more about the upcoming COA, CORS and CAOS Annual Meeting in this special feature section

n behalf of the 2015 COA Annual Meeting planning committee, we look forward to welcoming you in Vancouver this coming June. Our Program Committee has put together a dynamic educational program this year offering COA members the best opportunities for learning, development and sharing best practices – all within one of the most beautiful cities in Canada. We hope that you will take a moment to consider all that is being offered at the meeting by reviewing the Preliminary Program found in the Menu > Scientific Sessions area of www.coaannualmeeting.ca. COA President, Dr. Bas Masri, looks forward to greeting you at the Opening Ceremonies on Wednesday, June 17. These ceremonies will also include a special address by Deputy Health Minister, Dr. Robert Bell who will speak about the Appropriateness of Health Care. Dr. Masri will also present the COA’s distinguished awards of merit and excellence and deliver his state of the union address. We will also take this opportunity to present a special tribute to the late Dr. Cy Frank in honour of his many contri- Kishore Mulpuri, MBBS; M.S (Ortho); butions to Canadian ortho- MHSc (Epi) 2015 Program Committee Chair paedics.

We hope that you will bring your families and enjoy some of the many tours and activities that are being offered through the Family & Guest Program. Get to know our incredible host city by signing up for one of these excursions through the online registration system. Finally, no meeting would be complete without a social gathering with all of your colleagues from across our great nation. Friday night, join us at the spectacular Vancouver Aquarium for the Soirée Under the Sea. Enjoy an unforgettable evening of dinner, dancing and visits through the various aquarium exhibits. Purchase your tickets in advance - this event is likely to sell out quickly. We hope you will enjoy this special Annual Meeting preview section which highlights some of the guest lectures, program gems, social activities, and new and innovative features being offered in Vancouver from June 17-20. If you have not yet registered, please go ahead and do so by visiting www.coaannualmeeting.ca. We look forward to seeing you all in Vancouver this June! Bert Perey, M.D., FRCSC 2015 Local Arrangements Committee Chair

Bringing Your Family to Vancouver?

Sign up for the various tours and excursions being offered at the COA Annual Meeting • Foodie Tour & Granville Island Market Tour • Harbour Dinner Cruise • Vancouver City Bus Tour Open to all registered delegates of the Annual Meeting and their families. Register for your tickets through the online meeting registration program

www.coaannualmeeting.ca COA Bulletin ACO - Spring / Printemps 2015

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Soyez les bienvenus à Vancouver!

Apprenez-en plus sur la Réunion annuelle de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’International Society for Computer Assisted Orthopaedic Surgery (CAOS) dans cette section spéciale

u nom du comité organisateur, nous avons hâte de vous accueillir à la Réunion annuelle 2015 de l’ACO, à Vancouver, en juin. Le Comité responsable du programme a conçu un programme de formation dynamique donnant aux membres de l’ACO les meilleures possibilités d’apprentissage, de perfectionnement et d’échange de pratiques exemplaires, et ce, dans l’une des plus belles villes au pays. Nous espérons que vous prendrez un instant pour considérer tout ce qui vous est proposé à la Réunion en jetant un coup d’œil au programme provisoire, à « Séances scientifiques », dans « MENU », sur le site www.coaannualmeeting.ca. Le président de l’ACO, le Dr Bas Masri, a hâte de vous accueillir aux cérémonies d’ouverture, le mercredi 17 juin. Ces cérémonies comprendront entre autres une allocution spéciale du sous-ministre de la Santé, le Dr Robert Bell, intitulée Pertinence des soins de santé. Le Dr Masri remettra aussi les prestigieux Prix du mérite et Prix d’excellence du président de l’ACO, en plus de donner son allocution sur l’état de la situation. L’ACO profitera également de l’occasion pour rendre hommage au regretté Dr Cy Frank et souligner son énorme contribution à l’orthopédie au Canada. Nous espérons que vous serez accompagné de votre famille et que vous profiterez des visites et activités du programme

des conjoints et invités. Découvrez une ville hôte incroyable en vous inscrivant à l’une des excursions proposées à partir du système d’inscription en ligne. Enfin, aucune réunion n’est complète sans une activité sociale réunissant tous vos collègues de partout au pays. Le vendredi soir, soyez des nôtres au spectaculaire Aquarium de Vancouver pour la Soirée sous la mer. Profitez de cette soirée inoubliable où bonne bouffe, danse et visite des aquariums sont au menu. Achetez vos billets à l’avance; cette activité devrait afficher complet très vite. Nous espérons que cette section spéciale vous plaira; vous y trouverez des détails sur certaines des conférences spéciales, les incontournables au programme, les activités sociales et les nouveautés offertes à la Réunion annuelle de Vancouver, du 17 au 20 juin. Si vous n’êtes pas encore inscrit, rendez-vous à www.coaannualmeeting.ca. Au plaisir de tous vous voir à Vancouver en juin! Bert Perey, MD, FRCSC Président du Comité organisateur 2015 Kishore Mulpuri, MBBS; M.S. (Ortho); M.Sc.S. (Épi) Président du Comité responsable du programme 2015

Votre famille vous accompagne à Vancouver? Inscrivez-vous aux diverses visites et excursions proposées à l’occasion de la Réunion annuelle de l’ACO : • Foodie Tour et Granville Island Market Tour • Souper-croisière • Tour de ville en autobus Ces activités sont offertes à tous les participants inscrits à la Réunion annuelle de même qu’à leur famille. Réservez vos billets par l’intermédiaire du système d’inscription en ligne à la Réunion annuelle.

www.coaannualmeeting.ca COA Bulletin ACO - Spring / Printemps 2015

Your COA / Votre association

What’s New at the Annual Meeting This Year?

he COA Annual Meeting evolves with the needs of its membership. New program components, eposters, paperless evaluation forms, onsite membership recognition and shared sessions with a partnering society are just some of the exciting new features being offered at the Vancouver meeting this June. New Program Components Posters will be presented this year in electronic format. Please visit our e-poster stations located in the exhibit hall foyer from Wednesday, June 17 at 17:00 to Friday, June 19 at 16:00. The 25 top scoring posters from the COA and CORS submissions will be on physical display in the corridor outside the Plenary Hall (Pacific Ballroom) for the duration of the meeting. Questions to the authors are always welcome; they will be available during the President’s Reception Wednesday evening. Experts from Sunlife Financial Group will be putting on an ICL on Thursday morning on Transition Planning: An Evolution in Financial Planning Best Practices in Response to a Changing Landscape. This ICL will offer an overview of the shifting landscapes of career progression, life goals, and regulations, which are affecting the wealth and planning of surgeons at every career phase. Also, a broad look at the evolving planning tools, strategies and best practices in reaction to those changes, specifically the move towards “transition planning” in replacement of the historic retirement planning model. All attendees will leave with a copy of the case study that will illustrate the covered concepts, as well as a checklist to guide their current planning. Advance registration is required. Select “ICL 1” that is scheduled for Thursday, June 18 from 7:00-8:30 when registering online. There is no charge to attend this session. We would like to welcome participants of the International Society for Computer Assisted Orthopaedic Surgery (CAOS) Meeting running in conjunction with the COA Annual Meeting this year in Vancouver. Symposium 2: Orthopaedics and Technology will review the history of the development of computer-assisted surgical technologies, explore a range of pressing surgical problems, and discuss the potential for addressing these problems using technological approaches. All COA meeting participants are invited to attend this shared symposium with our CAOS colleagues on Thursday, June 18 from 13:00-14:30. Pre-registration is not required. A foot and ankle cadaver lab on arthroscopy and minimally invasive techniques will be held offsite at the Centre of Excellence for Simulation Education and Innovation at Vancouver General Hospital on Thursday afternoon from 13:3017:00. This workshop is designed for practicing surgeons, fellows and residents to learn from master surgeons on techniques to reduce invasiveness of foot and ankle surgery. Advance registration is required through the COA’s online registration program. Space is limited. COA Bulletin ACO - Spring / Printemps 2015

End off your Thursday afternoon with one of the brand new “Fireside Chats” sessions. Bring in your tough cases during these casual subspecialty-specific discussion sessions. Space is very limited and preregistration is required for the Trauma, Arthroplasty, Foot and Ankle, Sports or Paediatric case sessions. The Fireside Chats sessions are being held on June 18, from 17:00-18:00. How are we doing? Evaluate the sessions through the COA App All session evaluation forms will be paperless this year and available through the COA App. Download the App before heading to Vancouver by searching for the Canadian Orthopaedic Association in the App Store or in Google Play. Select the Session Evaluation tab after clicking on the navigation icon in the top left corner. Your input and feedback are much appreciated. Take a moment after each session to complete the evaluation form. Show your colours! The delegate badge holders will be colour-coded this year to reflect the number of years that each attendee has been a member of the COA. Registrants wearing a red badge are our new members who have joined the Association over the past year. Bronze badges represent one to five years of COA membership, while silver badges represent six to fifteen years of membership. Meeting participants wearing gold badges have been members of the COA for more than fifteen years. Look for the surgeon wearing a gold ribbon on their badge – they are the longest serving COA member in attendance at the Annual Meeting. Shake their hand – they deserve to be congratulated indeed! Exhibitors will be wearing blue badges and non members will be wearing clear badges. Encourage the non members to join your COA today!

Article submissions to the COA Bulletin are always welcome! Contact: Cynthia Vezina Tel: (514) 874-9003 ext. 3 E-mail: cynthia@canorth.org

Les contributions au Bulletin de l’ACO sont toujours les bienvenues! Contacter : Cynthia Vezina. Tél. : 514-874-9003, poste 3 Courriel : cynthia@canorth.org

Your COA / Votre association

2015 COA & CORS Annual Meeting Keynote Speakers / Conférenciers principaux de la Réunion annuelle 2015 de l’ACO et de la SROC Visit www.coaannualmeeting.ca for speaker biographies – select Scientific Sessions > Guest Speakers in the Menu tab

Vous trouverez la notice biographique des conférenciers principaux à www.coaannualmeeting.ca. Cliquez sur « MENU », puis « Séances scientifiques » et « Conférenciers invités ».

Opening Ceremonies Guest Speaker Conférencier aux cérémonies d’ouverture

Macnab Lecture Conférencier Macnab

Appropriateness in Canadian Health Care Pertinence des soins de santé au Canada Robert S. Bell, MDCM, M.Sc., FRCSC, FACS During the Opening Ceremonies / Aux cérémonies d’ouverture Wednesday, June 17 • 17:30 / Le mercredi 17 juin • 17 h 30 Pacific Ballroom (Plenary Hall), Conference Floor / Salle de bal Pacific (salle des séances plénières), étage Conference Fairmont Hotel Vancouver

R.I. Harris Lecture Conférencier R.I. Harris Life Lessons Leçons de vie Robert B. Bourne, C.M., MD, FRCSC Thursday, June 18 • 16:30 / Le jeudi 18 juin • 16 h 30 Pacific Ballroom (Plenary Hall), Conference Floor / Salle de bal Pacific (salle des séances plénières), étage Conference Fairmont Hotel Vancouver

Implant Innovation and Quality Assessment Les prothèses : Innovation et évaluation de la qualité Pr Rob Nelissen Leiden, The Netherlands / Leyde, Pays-Bas Thursday, June 18 • 15:00 / Le jeudi 18 juin • 15 h Waddington Room, Conference Floor / Salle Waddington, étage Conference Fairmont Hotel Vancouver

Presidential Guest Speaker Conférencier invité par le président The Times They Are A-Changin’ Car le monde et les temps changent... Brian Day, MRCP (UK), FRCS (Eng), FRCSC Friday, June 19 • 11:00 / Le vendredi 19 juin • 11 h Pacific Ballroom (Plenary Hall), Conference Floor / Salle de bal Pacific (salle des séances plénières), étage Conference Fairmont Hotel Vancouver

President Elect Address Allocation du président élu Moving Forward – Together Avancer, ensemble Robin Richards, MD, FRCSC COA President Elect / Président élu de l’ACO Friday, June 19 • 11:30 / Le vendredi 19 juin • 11 h 30 Pacific Ballroom (Plenary Hall), Conference Floor / Salle de bal Pacific (salle des séances plénières), étage Conference Fairmont Hotel Vancouver COA Bulletin ACO - Spring / Printemps 2015

Your COA / Votre association

Soirée under the Sea

Soirée sous la mer

COA Gala and Dinner at the Vancouver Aquarium

Souper-réception de l’ACO à l’aquarium de Vancouver

Friday, June 19 oin your friends and colleagues at the Vancouver Aquarium for an unforgettable evening of cocktails, dinner, dancing and access to various exhibits and galleries. This casual evening is a great opportunity to catch up with colleagues from across the country. Purchase your tickets for Soirée under the Sea through the COA’s online meeting registration system at www.coaannualmeeting.ca. Tickets are limited and will not be available for sale on site.

Le vendredi 19 juin oignez-vous à vos amis et collègues à l’aquarium de Vancouver pour une soirée inoubliable avec cocktails, souper, danse et accès à diverses expositions et galeries! Cette soirée décontractée est une excellente occasion de renouer avec vos collègues de partout au pays. Procurezvous des billets pour la Soirée sous la mer par l’intermédiaire du système d’inscription à la Réunion annuelle de l’ACO, à www.coaannualmeeting.ca. Le nombre de billets disponibles est limité, et il ne sera pas possible de s’en procurer sur place.

COA Bulletin ACO - Spring / Printemps 2015

Your COA / Votre association

Annual Meeting Registration Closes on June 12

egister for the COA Annual Meeting, as well as the CORS and CORA meetings by June 12. Visit www.coaannualmeeting.ca to register today. Don’t forget to buy your Soirée under the Sea tickets before June 12. Tickets may not be available to purchase in Vancouver. Limited space remains available for the guest tours – book your tickets online before it’s too late! If you are a presenter (poster or podium), moderator or speaker, you also must register before June 12. See you in Vancouver!

Inscrivez-vous à la Réunion annuelle d’ici le 12 juin!

ous avez jusqu’au 12 juin pour vous inscrire à la Réunion annuelle de l’ACO, de même qu’à la Réunion annuelle de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO). Rendez-vous à www.coaannualmeeting.ca et inscrivez-vous dès aujourd’hui. N’oubliez pas d’acheter vos billets pour le gala Soirée sous la mer avant le 12 juin. Il n’y aura pas nécessairement de billets disponibles à Vancouver. Il reste un nombre limité de billets pour les visites guidées – réservez en ligne avant qu’il ne soit trop tard! Si vous présentez une affiche ou un exposé, êtes modérateur ou conférencier, vous devez aussi vous inscrire avant le 12 juin. Au plaisir de vous voir à Vancouver!

Graduation Ceremony Honouring R5 Residents

OA members are encouraged to attend a special ceremony honouring the R5 residents who will be completing their Royal College Fellowship Examinations this year. The ceremony will be held during the upcoming COA Annual Meeting on Thursday, June 18 at 11:00. PGY5 Residents will be presented with a certificate by their Program Director and congratulated by the COA Executive. Join us in congratulating the Class of 2015 at this special event.

Cérémonie spéciale de fin de résidence pour tous les résidents de cinquième année

ous les membres de l’ACO sont conviés à une cérémonie spéciale en l’honneur des résidents qui passent leur examen au titre d’associé du Collège royal des médecins et chirurgiens du Canada cette année. La cérémonie aura lieu le jeudi 18 juin, à 11 h 00, à l’occasion de la Réunion annuelle de l’ACO. Les résidents recevront les félicitations de la direction de l’ACO et un certificat des mains de leur directeur de programme. Soyez des nôtres pour féliciter la cohorte de 2015 à cette occasion spéciale.

COA Bulletin ACO - Spring / Printemps 2015

Your COA / Votre association

2015 Annual Business Meeting Notice

his year’s Annual Business Meeting will be held on Thursday, June 18 at 11:00 in the Pacific Ballroom of the Fairmont Hotel Vancouver.

All COA members are asked to attend this meeting to receive and consider the financial statements, the auditor’s report, to elect the Association’s directors and other committee members, and to discuss other pertinent COA business matters. Open discussion is encouraged. This is your opportunity to bring your suggestions in person to the COA Executive. We look forward to seeing you there.

Avis de convocation à la séance de travail de la Réunion annuelle 2015

a séance de travail de la Réunion annuelle aura lieu le jeudi 18 juin, à 11 h, dans la salle de bal Pacific du Fairmont Hotel Vancouver. Nous demandons à tous les membres de l’ACO d’assister à la séance, qui a pour objet de présenter et d’examiner les états financiers et le rapport du vérificateur, d’élire les membres du conseil et des comités et de discuter d’autres questions d’intérêt liées à l’ACO. On favorise les discussions franches. Ces séances sont une occasion de présenter en personne vos suggestions à la direction de l’ACO.

Au plaisir de vous y voir! John Antoniou, MD, FRCSC COA Secretary/Secrétaire de l’ACO

COA Bulletin ACO - Spring / Printemps 2015

Your COA / Votre association

Get the Best Access to the Annual Meeting

Profitez d’un accès optimal à la Réunion annuelle

Through the COA App

Avec l’application de l’ACO

• Daily programs • Session Evaluation Forms • Meeting Updates • Eposter Listings

Search for the Canadian Orthopaedic Association in the App Store or in Google Play or scan the QR codes below. Download the update before you head to Vancouver.

• Programme quotidien • Formulaires d’évaluation de la formation • Mises à jour sur la Réunion • Liste des affiches électroniques

Pour vous procurer l’application de l’ACO, recherchez « Canadian Orthopaedic Association » dans l’App Store d’iTunes ou dans Mes applis Android de Google Play, ou balayez l’un des codes QR ci-dessous. Téléchargez la mise à jour de l’application avant de partir pour Vancouver.

On Twitter @CdnOrthoAssoc

Sur Twitter, @CdnOrthoAssoc

Follow along using #COAVan2015

Suivez la Réunion en utilisant le mot-clic #COAVan2015

By visiting www.coaannualmeeting.ca

À www.coaannualmeeting.ca

• Preliminary Program • Keynote speaker bios • Social event & family program information • AV & Poster Guidelines • Online registration

• Programme provisoire • Notice biographique des conférenciers principaux • Renseignements sur les activités sociales et familiales • Directives sur les techniques audiovisuelles et pour les affiches • Inscription en ligne COA Bulletin ACO - Spring / Printemps 2015

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

A (Practical Guide) to the Critical Appraisal of Randomized Clinical Trials Michael D. McKee, M.D., FRCSC Professor of Orthopaedic Surgery, Division of Orthopaedic Surgery, Department of Surgery, St. Michael’s Hospital and the University of Toronto, Toronto, ON

t is well-accepted that randomized clinical trials (RCT) represent the gold standard of research studies for the practicing clinician, and rightly so1. A properly performed RCT is free of bias, large enough (“powered adequately”) that the findings can be relied upon to be accurate, investigates a clinically relevant outcome, and can affect surgeon behavior. A timely RCT can change surgical practice: plating of displaced clavicle fractures is increasing following the publication of the Canadian Orthopaedic Trauma Society’s (COTS) 2007 study showing clear advantages of surgical fixation compared to non-operative treatment2 (Figure 1). Similarly, extracranial to intracranial bypass was a very popular surgical procedure in the early 1980’s until a large RCT published in the New England Journal of Medicine in 1985 revealed that, when compared to the nonoperative group, the surgical group had a 14% increase in the rate of strokes that it was supposed to prevent3. Overnight the procedure fell into disfavour and was largely abandoned. There are scores designed to assess RCT’s and I would highly recommend the Detsky score to readers of this article: it is an excellent, objective measure that can rapidly evaluate the qual-

ity of an RCT4. Although I have no formal training in advanced statistics or epidemiology, I have designed, managed, participated in, reviewed, and published dozens of RCT’s and thus feel justified in describing some of the potential pitfalls of RCT’s that may be of interest. Lacking the space for a comprehensive review, I will focus on several (practical) contemporary aspects of these studies that are of interest. Randomization Randomization has three main advantages. First and perhaps most importantly, it eliminates selection bias5. In non-randomized trial designs, treatment allocation may be prejudiced, either consciously or unconsciously, which may favour a particular treatment outcome. By eliminating selection bias, the likelihood increases that the known and unknown confounders are equally distributed between groups6. Second, randomization lends itself to the use of probably theory, which allows for a determination of the likelihood that any difference between groups has only occurred due to chance7. Third, randomization facilitates the blinding of investigators, participants, and evaluators, which reduces the chance for bias after treatment allocation8. Blinding in itself is an important consideration, considering that both patients and evaluators, if unblinded, may provide differential reporting of marginal treatment effects. There are instances when randomization was “circumvented” so that unequal, or biased, groups resulted. For example, in one orthopaedic fracture study patients were “randomized”

Figure 1 COA Bulletin ACO - Spring / Printemps 2015

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 25)

by their odd/even admission number, and residents rapidly realized they could enter the patient into a favoured group by calling the admission department and having a corresponding admission number assigned. Similarly, “sealed” envelopes have been tampered with and other irregularities have occurred. I recently reviewed an RCT where, despite a 1:1 randomization schedule, there were 58 patients in the experimental group and 37 in the control group. This is highly unlikely (less than one in a million) to have occurred by chance alone: something else is in play. The gold standard randomization method is an off-site, central call in number that randomly dictates the treatment arm. The reader needs to be aware of these potential problems with randomization. In trials with greater than 200 participants, simple randomization can usually be relied upon to produce equal group allocations. Other strategies can be used to minimize unequal group allocation in smaller trials. Blocking ensures that equal numbers of participants are allocated between groups at any time during the study. Each block (block sizes of four, six, and eight are common) has an equal number of assignments to each group; this comes at the disadvantage of the possibility of predicting future group assignments. Randomly varying block sizes, and keeping investigators blinded to block size, reduces this possibility.9 Were All Patients Enrolled in the Trial Accounted for at its Conclusion? Every patient enrolled in a prospective trial should be accounted for at its conclusion. If a significant number of patients are “lost to follow-up”, the validity of the study results may be called into question. Patients may not return for follow-up because they have favorable treatment outcomes, or because they have adverse outcomes (or even death). Not completing follow-up may bias the results of trial. When evaluating a RCT, one can determine if the loss to follow-up is excessive in positive trials by assuming that all patients lost to follow-up in the treatment group did badly and all patients lost to follow-up in the control group did well. If this assumption does not change the results of the study, the loss to follow-up is not excessive. However, if the results of the trial change based on this assumption, the strength of the study’s conclusions are diminished9. In addition, one has to consider whether patients assigned to the treatment or control groups were analyzed in the group to which they were randomized; an “intention to treat” analysis. In surgical trials, patients assigned to the surgical group may never undergo the operation because they are too sick or suffer from a medical complication before they have the intervention. If these patients are analyzed as part of the control group, even a useless surgical therapy would appear to be effective. Inclusion / Exclusion Criteria The practicing surgeon must apply information from an RCT specifically to the group included in the study. For example, in a Canadian RCT, total elbow arthroplasty (TEA) was shown to be a superior treatment for severe intra-articular distal humeral fractures, but only patients over 65 years of age were included (the mean age of the patients in the study was 78 years)10. I have seen this study misinterpreted to justify TEA in significantly younger patients where longevity of the prosthesis becomes very uncertain: this is not the way to use this information. COA Bulletin ACO - Spring / Printemps 2015

Similarly, a study comparing arthroscopic versus open shoulder stabilization for recurrent instability revealed little difference in recurrence rates, but the study excluded patients with any evidence of bony Bankart injuries or Hill-Sachs lesions (both of which are recognized to increase the failure rate of arthroscopic repairs). Thus, a surgeon performing an arthroscopic repair on a patient with these bony lesions may be unpleasantly surprised to find a higher failure rate than anticipated from the results of said study. These (devilish) details are usually buried in the “fine print” of the Methods section, and are important to read and understand. Once the inclusion and exclusion criteria are established, the reader should also consider two other factors: 1) whether the two groups are similar at the beginning of the trial, and 2) whether patients in both groups were treated in a similar fashion in all respects other than the treatment intervention under study. One can look for documentation in the study to confirm that groups were similar at baseline. Given that randomization does not necessarily guarantee that all prognostic variables are evenly distributed between groups, the more groups differ at the beginning of the trial, the more the study conclusions may be called into question. Statistical techniques can be applied to account for uneven group allocation for prognostic variables; if the conclusions of the study do not change once these differences are accounted for, the strength of the conclusions are not diminished. Once randomization has occurred, it is important to consider whether either group received any “co-interventions”. If differential treatment or follow-up occurs between groups other than the treatment under study, the results of the trial may be questioned given that co-interventions may be highly effective and have the potential to bias study results. Any permissible co-interventions should be documented in the study methodology. (Under) Power Orthopaedic RCT’s are dwarfed in size by similar studies in other fields such as cardiology that may include 10,000 or more patients. In this larger setting, it is possible to show a statistical difference between two groups of very small magnitude (i.e. an event rate of 3.4% versus 4.1% may be statistically significantly different). We rarely have the luxury of enrollment of this size in orthopaedic studies, so one must be wary of the conclusions reached in studies that have small numbers11. This so called “beta-error” means missing a true difference between two groups because the study has too few patients to demonstrate statistical differences (i.e. it is “underpowered”). In the TEA study referenced earlier, the re-operation rate was 3/25 (12%) in the TEA group and 4/14 (27%) in the fixation group, but this was not statistically different (p=0.20). However, as Dr. Bernard Morrey pointed out in a JBJS commentary on this study, most of us would consider a re-operation rate difference of 12% versus 27% clinically relevant12. The probability is that a larger study would have demonstrated this to be a true difference statistically. Industry Bias Given the scarcity of peer-reviewed research funding for practical orthopaedic research, industry-funded studies are critical to our profession, and I have participated in many such trials. However, Dr. Mohit Bhandari and colleagues have shown that studies funded by industry are much more likely to have “posi-

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 26)

tive” results, and be subsequently published, than studies with other funding sources13. In fact, large pharmaceutical companies are infamous for “burying” results from “negative” RCT’s that do not show their products in a favourable light. While I stress that industry funding does not negate the findings of an RCT, it is important for the reader to have a clear understanding of the role that a company played in a study: in this regard full disclosure (for example, the handling of the data, whether “approval” of the company was required prior to publication, any proprietary interests of the authors) is critical. I always carefully examine this information, which most orthopaedic journals now publish with the article. In conclusion, RCT’s remain the unrivalled Level 1, gold standard in evidence-based orthopaedic research. However, as with all other types of studies, there are potential problems that the reader needs to be aware of, and hopefully this article has clarified some of these issues. References 1. Bhandari M., Joensson A. Clinical research for surgeons. New York: Thieme Publishing Group, 2009. 2. Canadian Orthopaedic Trauma Society. A randomized, clinical trial of plate fixation versus non-operative treatment of displaced midshaft fractures of the clavicle. J Bone Joint Surg(A), 2007, 1-7. 3. The EC/IC Bypass Group. Failure of extracranial-intracranial arterial bypass to reduce the risk of ischemic stroke. Results of an international randomized trial. N Engl J Med. 1985 Nov 7;313(19):1191-200. 4. Bhandari M., Richards R.R., Sprague S., Schemitsch E.H. The quality of reporting of randomized trials in the Journal of Bone and Joint Surgery from 1988 through 2000. J Bone Joint Surg Am. 2002 Mar;84-A(3):388-96 5. Kleijnen J, Gøtzsche PC, Kunz R, Oxman AD, Chalmers I. So what’s so special about randomisation. In: Maynard A, Chalmers I, eds. Non-random reflections on health services research BMJ Books, 1997:93-106. 6. Schulz K.F. Randomized controlled trials. Clin Obstet Gynecol 1998;41:245-56. 7. Greenland S. Randomization, statistics, and causal inference. Epidemiology 1990;1:4218. Armitage P. The role of randomization in clinical trials. Stat Med 1982;1:345-52. Dec 1, 1993 Vol 270 no. 21. 9. Users’ Guides to the Medical Literature II. How to Use an Article About Therapy or Prevention A. Are the Results of the Study Valid? Gordon H. Guyatt, MD, MSc; David L. Sackett, MD, et al.

10. McKee M.D., Veillette C.J., Hall J.A., Schemitsch E.H., Wild L.M., McCormack R., Perey B., Goetz T., Zomar M., Moon K., Mandel S., Petit S., Guy P., Leung I. A multicenter, prospective, randomized, controlled trial of open reduction--internal fixation versus total elbow arthroplasty for displaced intra-articular distal humeral fractures in elderly patients. J Shoulder Elbow Surg. 2009 Jan-Feb;18(1):3-12. 11. Lochner HV., Bhandari M., Tornetta P. 3rd. Type-II error rates (beta errors) of randomized trials in orthopaedic trauma. J Bone Joint Surg Am. 2001 Nov;83-A(11):1650-5. 12. Morrey B.F. Total elbow arthroplasty did not differ from open reduction and internal fixation with regard to reoperation rates. J Bone Joint Surg Am. 2009 Aug;91(8):2010. 13. Bhandari M., Busse J.W., Jackowski D., Montori V.M., Schünemann H., Sprague S., Mears D., Schemitsch E.H., Heels-Ansdell D., Devereaux P.J. Association between industry funding and statistically significant pro-industry findings in medical and surgical randomized trials. CMAJ. 2004 Feb 17;170(4):477-80.

ADVERTISING SPACE AVAILABLE 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. By placing your advertisement in the COA Bulletin, you will be communicating with the largest number of Canada’s leading orthopaedic specialists. 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: cynthia@canorth.org and details will be forwarded to you.

ESPACE PUBLICITAIRE 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. Placer une annonce dans le Bulletin de l’ACO assure une visibilité inégalée auprès des orthopédistes les plus influents au pays. 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 cynthia@canorth.org.

COA Bulletin ACO - Spring / Printemps 2015

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

Paediatric Physeal Ankle Fractures

An Introduction to this Edition’s Clinical Feature

aediatric ankle injuries are extremely common. The majority are soft tissue injuries or minor fractures, which heal without any long-term sequelae. However, special attention must be made to fractures that involve the physis of the distal tibia. These are among the most common physeal injuries in the paediatric population, second in incidence only to physeal fractures of the wrist and hand. The pattern of physeal fracture and risk of physeal arrest are closely associated with patient age and mechanism of injury. Surgeons must consider the potential long-term complications related to premature physeal closure and articular malreduction. In this edition of the COA Bulletin, paediatric orthopaedic surgeons from across Canada will discuss common paediatric physeal ankle fractures with a focus on management and avoidance of long-term complications. Dr. Debra Bartley will present the extra-articular (Salter-Harris I and II) fractures of the distal tibia, and highlight the significant rate of growth

arrest. I will discuss intra-articular and higher energy (SalterHarris III and IV) medial malleolar fractures. The unique group of transitional fractures (Tillaux and triplane) will be covered by Dr. Carrie Kollias. And, finally, Dr. Luke Gauthier and Dr. Karl Logan will discuss premature physeal arrest after distal tibia physeal fracture. I would like to thank the authors for their contributions, as well as the COA, Dr. Marc Isler, Dr. Peter Lapner and Cynthia Vezina for the opportunity to guest-edit this section. Megan Cashin, M.D., FRCSC Guest Editor Assistant Professor, Western University Paediatric Orthopaedic Surgery Children’s Hospital of Western Ontario, London Health Sciences Centre London, ON

Extra-articular Paediatric Distal Tibia Fractures: Is the treatment really as straightforward as we think? Debra Bartley, M.D., FRCSC Assistant Professor, Western University Paediatric Orthopaedic Surgery Children’s Hospital of Western Ontario, London Health Sciences Centre London, ON

physeal injury representing 38% with an average age of 12 years, seven months. Subsequent studies support Salter-Harris II fractures being the most common distal tibia physeal fracture, comprising approximately 40% in most series1,3,4,6.

reating distal tibia physeal injuries is a common part of every paediatric orthopaedic surgeon’s practice. Many surgeons will recognize that managing Salter-Harris III and IV injuries, Tillaux fractures and the “tricky triplane” requires careful attention to restoring joint congruity for long-term function. However, Salter-Harris I and II fractures of the distal tibia have historically been considered innocuous injuries; but should they be treated with more caution and long-term follow-up? When considering acceptable reduction parameters for distal tibia Salter-Harris I and II fractures, the literature continues to be controversial. The risk of premature physeal closure was previously reported as 2-5% following Salter-Harris II fractures, however, more recent authors caution that it is significantly higher, at 25-40%1-4. This review will outline current treatment guidelines, risk factors for premature physeal closure and recommendations for long-term management of distal tibia Salter-Harris I and II fractures. Spiegel et al5 reported on 237 distal tibia physeal injuries, the largest series in the literature. In his series, Salter-Harris I fractures comprised 15% with an average age of ten years, six months, while Salter-Harris II fractures were the most common COA Bulletin ACO - Spring / Printemps 2015

Figure 1 AP (A), mortise (B) and lateral (C) radiographs of a nine year-old girl with a significantly displaced Salter-Harris II fracture of the distal tibia.

Distal Tibia Salter-Harris I Fractures Undisplaced or minimally displaced distal tibia Salter-Harris I fractures are treated with immobilization in a below knee cast or walking boot for three to four weeks. All displaced distal tibia Salter-Harris I fractures require closed reduction and immobilization in a below knee cast. Radiographic

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

follow-up is recommended at one week post-injury to confirm reduction. Transition to a below knee walking cast or boot can be considered at three to four weeks. Acceptable reduction remains controversial but the majority of series agree with less than 3mm gap or displacement at the physis1,3,7. Salter-Harris I fractures of the distal tibia are rarely severely displaced unless associated with a concomitant fibula fracture6. The risk of premature physeal closure is very low following a distal tibia Salter-Harris I physeal fracture, and ranges from 0-5%3,5. Distal Tibia Salter-Harris II Fractures Similar to Salter-Harris I fractures, undisplaced or minimally displaced Salter Harris II fractures of the distal tibia are treated in a below knee cast or walking boot for three to four weeks. Controversy remains regarding acceptable reduction criteria for a displaced Salter-Harris II fracture (Figure 1). Most recently, Blackburn et al6 recommended open reduction to remove blocks to reduction when greater than 2-3mm of physeal widening remains after reduction. These recommendations for acceptable reduction focus on the association between residual gap and the risk of premature physeal closure versus long-term function and biomechanics of the ankle joint1,3. Following closed reduction for a displaced Salter-Harris II distal tibia fracture, an above or below knee cast is used to maintain the reduction (Figure 2). Radiography is used to confirm reduction at one week follow-up. Transition to a below knee cast or walking boot can be considered at three to four weeks postclosed reduction.

Figure 2 AP (A), mortise (B) and lateral (C) radiographs of the same girl, postclosed reduction and immobilization.

Summary Points • Undisplaced and minimally displaced Salter-Harris I and II distal tibia fractures can be managed with immobilization. • Distal tibia Salter-Harris II fractures have a significant risk of premature physeal closure, and is higher than previously reported. The risk of premature physeal closure is increased with a residual gap of greater than 3mm. • Closed reduction should be attempted in all displaced distal tibia Salter-Harris I and II fractures. • Consider open reduction for residual fracture gap of greater than 2-3mm. • Salter-Harris II fractures in children with greater than two years of growth remaining should be followed for a minimum of one year after injury. • It is important to inform parents of the risk of premature physeal closure at initial visit.

For patients who require open reduction, retrograde smooth wire cross pinning should be considered for fixation7. If a fibular fracture is associated, it is often stable once the tibial physis is reduced and stabilized. If it is persistently unstable, fixation is indicated.

References

Recent studies indicate that the risk of premature physeal closure subsequent to Salter-Harris II distal tibia fracture is alarmingly high at 25-40%, as compared to previous reports of 2-5%1-4,7. Therefore, in children with more than two years of growth remaining, a minimum of one to two years followup is recommended with repeat radiographs to prevent leg length discrepancy, angular deformity and altered ankle joint mechanics.

2. Rohmiller M.T., Gaynor T.P., Pawelek J., et al. Fractures of the distal tibia: does mechanism of injury relate to premature physeal closure? J Pediatr Orthop. 2006;26:322-328.

Many of the perceived risks of premature physeal closure of the distal tibia have not been supported in the literature on Salter-Harris II fractures. Barmada et al1 and Rohmiller et al2 found that residual displacement greater than 2mm was the only factor associated with a significant increased incidence of early physeal closure. However, it remains unclear whether surgery to remove entrapped periosteum for residual gaps of more than 2-3 mm will decrease the incidence of premature physeal closure1,2,4 . Dr. Luke Gauthier and Dr. Karl Logan will further discuss post-traumatic distal tibia physeal arrest.

1. Barmada A., Gaynor T., Mubarak S.J. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23:733-739.

3. Leary J.T., Handling M., Talerico M., et al. Physeal Fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop. 2009; 23:356-61. 4. Russo F., Molly B.A., Moor A., et al. Salter-Harris II fractures of the distal tibia: does surgical management reduce the risk of premature physeal closure? J Pediatr Orthop. 2013;33:524-529. 5. Spiegel P.G., Cooperman D.R., Laros G.S. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am. 1978;60:1046-1050. 6. Blackburn E.W., Aronsson D.D., Rubright J.H., et al. Current Concepts Review: ankle fractures in children. J Bone Joint Surg Am. 2012;94:1234-44. 7. Podeszwa D.A., Mubarak M.D. Physeal fractures of the distal tibia and fibula: Salter-Harris type I, II, III, and IV fractures. J Pediatr Orthop. 2012;32:S62-S68. COA Bulletin ACO - Spring / Printemps 2015

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

Intra-articular Distal Tibia Physeal Fractures

he intra-articular distal tibia physeal fractures will be discussed in two sections; 1) Salter-Harris III and IV medial malleolar fractures, and 2) transitional fractures.

Distal Tibia Salter-Harris Type III and IV Fractures (Medial Malleolar Fractures) Megan Cashin, M.D., FRCSC Assistant Professor, Western University Paediatric Orthopaedic Surgery Children’s Hospital of Western Ontario, London Health Sciences Centre London, ON

alter Harris type III and IV fractures have been reported to be approximately 25% of paediatric distal tibia fractures1-3. The majority are medial malleolar fractures that occur as a result of a higher energy supination-inversion mechanism4. The goals of treatment are to restore articular congruity and reduce the risk of premature physeal closure. Long-term management must include close monitoring for signs of subsequent growth arrest. Undisplaced or minimally displaced fractures are treated with A immobilization in a below knee Figure 1A cast for six to eight weeks. Early Radiographs of an 11 year-old follow-up is necessary within boy with a Salter Harris III medithe first two weeks to ensure al malleolar fracture. the fracture does not displace. Transition to a below knee walking cast or boot can be considered at four weeks4,5. It is difficult to significantly improve and maintain the alignment of a displaced Salter Harris III or IV medial malleolar fracture by closed reduction and immobilization (Figure 1, Figure 2). All fractures with greater than 2mm of intra-articular displacement should be treated with open reduction and internal fixation, to decrease the risk of degenerative joint disease and premature physeal closure6. This so-called “2mm rule” has become dogma within the literature despite the absence of clear scientific evidence that the risk of degenerative disease increases with more than 2mm of articular displacement5. While it has been challenging to quantify how residual displacement affects the rate of premature physeal closure, it is known that fractures with greater displacement have a higher COA Bulletin ACO - Spring / Printemps 2015

rate of premature physeal closure1,2,6. Surgical treatment of fractures displaced greater than 2mm have consistently shown good long-term outcomes5-7. Operative treatment of Salter Harris III and IV medial malleolar fractures consists of arthrotomy with direct visualization and anatomic reduction of the articular surface, including removal of entrapped periosteum if present. The location of incision is dependent on the fracture pattern, typically anterior or medial. This is followed by fixation with one or two epiphyseal screws, depending on fracture fragment size (Figure 2). Epiphyseal screws are most easily done with a cannulated screw system, should not cross the physis and, if necessary, may be inserted through separate percutaneous incisions. For fixation of a Salter Harris IV fracture with a large metaphyseal fragment, a metaphyseal screw may be added. Comminuted or small fractures may require transphyseal fixation with smooth K-wires, alone or in a tension-band construct, with planned later removal (Figure 1). Note that associated distal fibular fracture must be addressed once the tibial physis is reduced and stabilized. If the distal fibula remains unstable, fixation is indicated. Postoperative care includes immobilization with a below-knee cast and non-weight-bearing for six weeks4. There is no general consensus regarding planned screw removal, although one cadaveric study demonstrated increased ankle joint contact pressures in the setting of in situ epiphyseal screws8.

Figure 1B,C AP (B) and lateral (C) radiographs of the same boy post-open reduction and K-wire fixation.

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

Reported rates of premature physeal arrest after Salter Harris III and IV fractures are variable, from between 13% to 50%1-3,6,7. This wide variation is due to variations in mechanism of injury, pattern of fracture, type of treatment and length of follow-up. Recent studies have attempted to determine specific predictive factors for this complication in distal tibia physeal fractures2. This will be discussed in the following article by Dr. Luke Gauthier and Dr. Karl Logan. Regardless of the true incidence of premature physeal arrest, long-term follow-up is necessary for all patients to ensure its timely detection before the onset of significant deformity or limb length discrepancy. Therefore, radiographs should be repeated every six months for a minimum of two years4,6.

3. Spiegel P.G., Cooperman D.R., Laros G.S. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am.1978;60:1046-1050. 4. Podeszwa D.A., Mubarak M.D. Physeal fractures of the distal tibia and fibula: Salter-Harris type I, II, III, and IV fractures. J Pediatr Orthop. 2012;32:S62S68.

Figure 2B

Figure 2A Radiographs of a nine year-old girl with a Salter-Harris IV medial malleolus fracture.

References 1. Barmada A., Gaynor T., Mubarak S.J. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. J Pediatr Orthop. 2003;23:733-739. 2. Leary J.T., Handling M., Talerico M., et al. Physeal Fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest. J Pediatr Orthop. 2009;23:356-61.

5. Blackburn E.W., Aronsson Radiographs of the same girl D.D., Rubright J.H., et al. post-open reduction and epiCurrent Concepts Review: physeal screw fixation. ankle fractures in children. J Bone Joint Surg Am. 2012;94:1234-44. 6. Kling T.F. Jr, Bright R.W., Hensinger R.N. Distal tibia physeal fractures in children that may require open reduction. J Bone Joint Surg (Am). 1984;66:647-657. 7. Cass J.R., Peterson H.A. Salter-Harris type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. J Bone Joint Surg (Am). 1983;65:1059-70. 8. Charlton M., Costello R., Mooney J.F. 3rd, Podeszwa D.A. Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthop. 2005;25(5):63540.

Transitional Fractures of the Distal Tibia Carrie Kollias, M.D., FRCSC Paediatric Orthopaedic Surgeon Chinook Regional Hospital Lethbridge, AB

his group of intra-articular fractures accounts for 2.5-6% of all paediatric ankle fractures1. They occur in older children nearing skeletal maturity, and are labeled as ‘transitional fractures’ since they are neither classically paediatric fractures nor adult patterns of injury. The distal tibial physis closes over a period of 18 months with a well-described pattern of closure beginning centrally and then in the following order: anteromedial, posteromedial and then lateral.

Figure 1 (A) X- ray of Tillaux fracture. (B) CT scan of Tillaux fracture with 3mm of displacement. (C) Tillaux fracture after percutaneous arthroscopic assisted reduction and internal fixation.

Tillaux fractures are the simpler of the two types of transitional fractures and typically occur in adolescents as the rest of the physis is often closed. Tillaux fractures are a Salter Harris III

type of injury involving the anterolateral distal tibial epiphysis through an avulsion mechanism (Figure 1A,B). This is thought to occur in supination and external rotation when the anterior tibiofibular ligament pulls off the anterolateral epiphysis of the COA Bulletin ACO - Spring / Printemps 2015

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

distal tibia through an area of relative weakness at the unclosed physis (remember that the lateral physis is the last to close)2. Triplane fractures represent a subtype of Salter Harris IV injuries and typically occur in older children and early adolescents with relatively less physeal closure compared to Tillaux fractures3. Depending on the relative maturity of the physis, these injuries can have two to four parts4. Two-part fractures are the most common and have three fracture lines: one seen on the AP view through epiphysis, a second fracture line extending anterior to posterior through the physis, and a third fracture line travelling coronally up through the metaphysis. Two-part fractures look like a Salter Harris III fracture on the AP view and Salter Harris II fracture on the lateral view (Figures 2A,B,C). Three-part fractures differ from two-part fractures in that the coronal fracture line of three-part fractures also crosses the posterior epiphysis in addition to the metaphysis. Four-part fractures extend medially in the transverse plane and this creates an additional medial malleolus piece, in addition to the posterior epiphysis piece, anterolateral epiphysis fragment, and metaphyseal portion. When a transitional fracture is suspected, a closed reduction should first be attempted prior to obtaining any cross-sectional imaging. In cases where the amount of displacement is suspected to be borderline for operative treatment, a CT scan is recommended to evaluate the true extent of the fracture and to quantify displacement in an accurate manner. In a recent study comparing X-rays and CT scans in 24 transitional fracture cases, CT scan changed the original diagnosis of fracture type of Tillaux to triplane fracture in 4.9% of cases; however the CT did not significantly change the initial impression of the amount of displacement per case. Furthermore, more patients were reassigned to non-operative treatment after evaluation of the CT5. Thus despite X-rays being a fairly accurate tool for quantifying displacement, we still recommend use of CT scan for evaluation to assist with clinical decision-making in cases that require surgery. Intra-articular fracture lines in Tillaux and triplane fractures that have less than 2 to 2.5mm of displacement can be treated nonoperatively by placing the foot in plantarflexion to relax the gastrocsoleus along with traction and internal rotation. For reduction of triplane fractures, the additional manouvres of sustained traction, internal rotation, followed by anterior translation and dorsiflexion can be helpful6. The traditional recommendation of up to 2mm of displacement dates back to a retrospective study in 1988 of 23 patients with triplane fractures which found suboptimal clinical outcomes in patients with intra-articular displacement of 2mm or greater displacement7. However, a recent study demonstrated that residual displacement up to 2.4mm have a uniformly good result with no difference in Foot and Ankle Outcomes Score subscales nor the Marx Activity Scale8. Classically, patients receiving conservative management are placed in an above knee cast initially to minimize the pull of the gastrocnemius6, however, immobilization in a below the knee cast may be considered. The patient should be non-weightbearing for six weeks. It has been shown that fractures with 3mm or greater displacement are not typically amenable to closed reduction as there is interposed periosteum blocking reduction7.

COA Bulletin ACO - Spring / Printemps 2015

Figure 2 (A) Two-part triplane fracture AP view (B) lateral view. Note that there are three fracture lines visible: one through the epiphysis, another through the physis and a third up through the metaphysis. (C)This fracture was fixed with open reduction and internal fixation.

Moderately displaced transitional fractures (Figure 1) requiring surgery may be amenable to percutaneous reduction +/- arthroscopic assisted reduction9-11, however, gross displacement typically requires a formal open reduction through anterior arthrotomy overlying the intra-articular fracture line. Depending on fracture pattern of the triplane fracture, this may require multiple approaches. For both Tillaux and triplane patterns, we recommend interfragmentary cannulated compression screws. Where possible, screw placement parallel with the physis is advised. However, in cases where growth is virtually complete, screws may cross the physis if required for biomechanical reasons (Figure 2C). Note that there is some cadaveric evidence of increased contact pressures across the tibiotalar joint when transepiphyseal screws are placed12. As such, screw removal can certainly be justified when possible. Postoperative management consists of non-weight-bearing immobilization in a below knee cast for six weeks. In summary, transitional fractures of the distal tibia require careful imaging and preoperative planning for an optimal result. Particularly in younger patients with moderate amounts of growth remaining, it is essential these fractures be followed to avoid any harm that may occur with premature physeal arrest. Further discussion regarding physeal arrest will occur in the following section by Dr. Luke Gauthier and Dr. Karl Logan. Summary Points for Intra-articular Distal Tibia Physeal Fractures • Intra-articular fractures of the distal tibia require specific management to restore articular congruity and identify premature physeal closure. • Transitional fractures of the ankle occur in older children and adolescents nearing skeletal maturity and have welldescribed fracture patterns. • Closed reduction should be attempted in all displaced intra-articular fractures. • CT scan after closed reduction has been attempted is recommended for transitional fractures that are still not anatomic. This will allow for an accurate measurement of displacement and operative planning.

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

• Surgery is recommended for all intra-articular distal tibial fractures with intra-articular displacement greater than 2mm. • There is biomechanical evidence to support removal of screws in the epiphysis in order to prevent increased joint contact pressures. References 1. Spiegel P.G., Cooperman D.R., Laros G.S. Epiphyseal fractures of the distal ends of the tibia and fibula. A retrospective study of two hundred and thirty-seven cases in children. J Bone Joint Surg Am. 1978;60:1046-1050. 2. Tillaux P.: Traite d’anatomie Topographique Avec Applications a la Chirurgie. Paris, France, Asselin et Houzeau, 1892. 3. Cooperman D.R., Speigel P.G., Laros G.S. Tibial fractures involving the ankle in children: The so-called triplane epiphyseal fracture. J Bone Joint Surg (Am). 1978;60(8):1040-1046. 4. Brown S.D., Kasser J.R., Zurakowski D., Jaramillo D. Analysis of 51 tibial triplane fractures using CT with multiplanar reconstruction. Am J Roentgenol. 2004; 183(5):1489-95. 5. Liporace F.A. et al. Does adding computed tomography change the diagnosis and treatment of Tillaux and triplane pediatric ankle fractures? Orthopedics. 2012;35(2):e208-12.

6. Weinberg A.M., Jablonski M., Castellani C., Koske C., Mayr J., Kasten P. Transitional fractures of the distal tibia. Injury. 2005;36(11):e1371-8. 7. Ertl J.P., Barrack R.L., Alexander A.H., VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. J Bone Joint Surg (Am). 1988;70(7): 967-76. 8. Choudhry I.K. et al. Functional outcome analysis of triplane and tillaux fractures after closed reduction and percutaneous fixation. J Pediatr Orthop. 2014;34(2):139-43 9. Whipple T.L., Martin D.R., McIntyre L.F., Meyers J.F. Arthroscopic treatment of triplane fractures of the ankle. Arthroscopy. 1993;9(4):456-63. 10. McGillion S., Jackson M., Lahoti O. Arthroscopically assisted percutaneous fixation of triplane fracture of the distal tibia. J Pediatr Orthop B. 2007;16(5):313-6. 11. Jennings M.M., Lagaay P., Schuberth J.M. Arthroscopic assisted fixation of juvenile intra-articular epiphyseal ankle fractures. J Foot Ankle Surg. 2007;46(5):376-86. 12. Charlton M., Costello R., Mooney J.F. 3rd, Podeszwa D.A. Ankle joint biomechanics following transepiphyseal screw fixation of the distal tibia. J Pediatr Orthop 2005; 25(5):63540.

Premature Physeal Closure After Distal Tibia Physeal Fracture Luke Gauthier, M.D., FRCSC Assistant Professor, Dalhousie University Paediatric Orthopaedic Surgery IWK Health Centre Halifax, NS Karl J. Logan, MBChB, FRCS (Tr and Orth) Assistant Professor, Dalhousie University Paediatric Orthopaedic Surgery IWK Health Centre Halifax, NS

L’art de la médecine consiste à distraire le patient tandis que la nature guérit la maladie - Voltaire (1694-1778)

his statement by Voltaire in the 18th century applies to the practice of paediatric orthopaedics like no other branch of medicine. Most adult orthopaedic surgeons will readily point this out to their paediatric colleagues! Physeal fractures can be your friend or foe; your friend with their relative propensity for rapid healing and remodeling1, your foe as physeal arrest, though relatively uncommon, can cause significant long-term functional issues for our patients.

Predicting Growth Arrest Prognosticating the potential for growth arrest in the distal tibial physis, the treating orthopaedist should ask oneself whether the fracture is of a transitional type, such as a Tillaux2 or triplane? Although some cases have been reported, the developmental pathoanatomy that allows transitional fractures to occur indicates a stage of skeletal maturation where a physeal arrest has a largely A negligible clinical impact3-5. Figure 1A

9 year-10 month old male

The epiphyseal development sequence with Salter Harris IV medial of the distal tibia is thought to explain distal tibia fracture. the transitional fracture patterns that are commonly seen6. Undulations of the distal tibial physis occur with skeletal maturation, most obvious anteromedially (known as Poland’s hump7, and often misinterpreted as an injury or premature epiphysiodesis). The ossification centre appears centrally, proceeds into the medial malleolus before extending laterally. Fracture patterns associated with a growth disturbance are Salter-Harris8 (SH) I, II or V, resulting in complete physeal arrest COA Bulletin ACO - Spring / Printemps 2015

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

and SH III and IV causing angular deformity although there is some crossover9. In contrast with sites, such as the distal femur, even small distal tibial growth disturbances may result in an angular deformity, adversely affecting ankle biomechanics without significant leg length discrepancy. Complete arrest B of the distal tibia can cause Figure 1B symptoms simply due to fibular After open reduction internal overgrowth and lateral impinge- fixation. ment10. The SH IV fracture of the medial distal tibia (Figure 1A) is most likely to produce a growth arrest with angular deformity4. Premature physeal closure can be related to indirect trauma in high-energy injuries making recognition of higher energy patterns with potential collateral physeal damage helpful in predicting a growth arrest11,12,13. Whether the number of attempts, or the accuracy and maintenance of fracture reduction alters the rate of physeal arrest is unclear. Podeszwa et al. concluded that open reduction of SH III/ IV distal tibia fractures (Figure 1B,C) helped to restore joint congruity and minimize the risk of physeal arrest14. Initial fracture displacement and injury mechanism, rather than residual displacement or number of reductions, have been shown to be more predictive of growth disturbance in some studies. In other studies, no significant correlation has been demonstrated between premature physeal closure with fragment displacement, mechanism of injury or treatment modality9,15. The hypothetical idea that periosteum or tissue trapped within the fracture site can cause premature physeal closure has been shown in animal models but not in humans3. Russo found that surgery to remove interposed tissue and anatomic reduction may be necessary to improve joint alignment, but did not reduce the rate of physeal arrest16. In a large study by Rohmiller of 91 SH I and II fractures, there was a high rate of physeal closure in patients with residual post-reduction displacement, prompting the authors to recommend more operative management to achieve an anatomic reduction, which was similar to other authors3,17. In a recent current concepts review regarding the prevention of premature physeal arrest in distal tibial physeal fractures, the following grades of evidence18 have been given: Grade B 1. all paediatric ankle fractures or high axial load injuries should be followed for at least one year; 2. surgeons should remove interposed periosteum in SH II distal tibia fractures with greater than 3mm of post-reduction physeal widening; Grade C 1. no more than two closed fracture reduction attempts should be performed19. Workup The treating orthopaedic surgeon should obtain a thorough clinical history of the symptoms, evolution of the deformity, as well as previous treatment. Physical examination includes COA Bulletin ACO - Spring / Printemps 2015

gait observation and clinical assessment of leg length discrepancy. Local deformity of the leg, ankle and foot should be noted. A standard imaging protocol would include plain films of the ankle, standing C lower limb alignment views with the affected Figure 1C limb on the appropri- After five years lost to follow-up, now age ate corrective blocks 14 years-2 months. where applicable, as well as CT scan to assess presence and extent of a physeal bar. Recognizing the convergence of Harris growth arrest lines20 with the physis can be useful in early detection and ongoing monitoring of an angular deformity. Total absence of periphyseal growth arrest lines after six months may suggest a complete growth arrest. Assessment of skeletal age should be performed as prediction of growth remaining is central to the decision-making process. Treatment The first step in management of a post-traumatic distal tibial physeal arrest is its detection via frequent early follow-up. This enables the appropriate assessment and early surgical management. Inadequate follow-up could result in the need for more extensive treatment, as deformity and leg length inequalities progress unchecked21,22. Estimation of growth remaining at the distal tibial and other lower limb physes dictates the treatment plan. At least one year of estimated growth remaining in the limb is required to justify a physeal bar resection, but most surgeons prefer two years to optimize treatment effectiveness23,24. D Physeal bar size directs resection versus completion of epiphysiodesis. Figure 1D Successful restoration of longitudinal After completion of epigrowth is less likely when the physeal physiodesis and acute corbar size is greater than 40-50% of rective osteotomy. the total physeal size25,26. Peripheral bars are technically easier to resect when compared to central bars, which necessitate resection through a metaphyseal fenestration. An arthroscope to visualize the bone cavity can be a helpful adjunct in these cases. Fat and polymethylmethacrylate are the most common interposition materials used, but more important are measures taken to ensure the interposition material stays with the physis rather than migrating24. Even with appropriate patient selection, failures can occur because of incomplete physeal bar excision, bar recurrence, or poor function of the remaining physis27. Fibular epiphysiodesis must be considered if completing epiphysiodesis of the distal tibial physis in a younger patient. Angular deformity of

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

greater than 10° requires considering concomitant corrective osteotomy (Figure 1D) of the distal tibia with physeal bar resection28. Acute corrective osteotomy may be performed after careful preoperative planning. Similar meticulous planning is required before gradual correction with an external ring fixator such as the Taylor Spatial Frame, which has the advantage of ongoing changes in the deformity correction based on the peri-treatment radiographs. Summary Points • Physeal arrest is an infrequent occurrence but has a significant impact when it occurs. • The ability to prevent physeal arrest in the acute phase is controversial. • Early, frequent follow-up for early detection is the most practical effective step in the overall management if there is a suspicion for physeal arrest. • Estimation of the patient’s skeletal development is the basis from which the potential treatment options are determined. References 1. Dugan G., Herndon W.A., McGuire R. Distal tibial physeal injuries in children: a different treatment concept. 1987. J Ortho Trauma;1:63-7. 2. Tillaux P.: Traite d’anatomie Topographique Avec Applications a la Chirurgie. Paris, France, Asselin et Houzeau, 1892. 3. Barmada A., Gaynor T., Mubarak S.J. Premature physeal closure following distal tibia physeal fractures: a new radiographic predictor. 2003. J Pediatr Orthop; 23:733-9 4. Cass J.R., Peterson H.A. Salter-Harris type-IV injuries of the distal tibial epiphyseal growth plate, with emphasis on those involving the medial malleolus. 1983. J Bone Joint Surg Am; 65:1059-70. 5. Ertl J.P., Barrack R.L., Alexander A.H., VanBuecken K. Triplane fracture of the distal tibial epiphysis. Long-term follow-up. 1988. J Bone Joint Surg Am; 70:967-76 6. Love S.M., Ganey T., Ogden J.A. Postnatal epiphyseal development: the distal tibia and fibula. 1990. J Pediatr Orthop; 10:298-305

12. Beals R.K. Premature closure of the physis following diaphyseal fractures. 1990. J Pediatr Orthop; 10:717-20. 13. Letts M., Davidson D., McCaffrey M. The adolescent pilon fracture: management and outcome. 2001. J Pediatr Orthop; 21:20-6. 14. Podeszwa D., Mubarak S.J. Physeal fractures of the distal tibia and fibula (Salter-Harris Type I, II, and III, and IV fractures). 2012. J Pediatr Orthop;32(Suppl 1):S62-8 15. Leary J.T., Handling M., Talerico M., Yong L., Bowe J.A. Physeal fractures of the distal tibia: predictive factors of premature physeal closure and growth arrest. 2009. J Pediatr Orthop; 29:356-61. 16. Russo F., Moor M.A., Mubarak S.J., Pennock A.T. Salter-Harris II fratures of the distal tibia: does surgical management reduce the risk of premature physeal closure? 2013. J Pediatr Orthop; 33:524-9 17. Rohmiller M.T., Gaynor T.P., Pawelek J., Mubarak S.J. SalterHarris I and II fractures of the distal tibia: does mechanism of injury relate to premature physeal closure? 2006. J Pediatr Orthop; 26:322-8 18. Wright J.G., Einhorn T.A., Heckman J.D. Grades of recommendation. J Bone Joint Surg Am. 2005 Sep;87(9):1909-10. 19. Blackburn E.W., Aronsson D.D., Rubright J.H., Lisle J.W. Ankle fractures in children. 2012. J Bone Joint Surg Am; 94:1234-44. 20. Harris H.A. Lines of arrested growth in the long bones in childhood: The correlation of histological and radiographic appearance in clinical and experimental conditions. 1931. Br J Radiol; 4:561-588. 21. Lalonde K.A., Letts M. Traumatic growth arrest of the distal tibia: a clinical and radiographic review. 2005. Can J Surg; 48:143-7 22. Abbo O., Accadbled F., Laffosse J.M., Sales de Gauzy J. Reconstruction and anticipatory Langenskiöld procedure in traumatic defect of tibial medial malleolus with type 6 physeal fracture. 2012. J Pediatr Orthop B; 21:434-8. 23. Langenskiöld A. Surgical treatment of partial closure of the growth plate. 1981. J Pediatr Orthop; 1:3-11

7. Poland J.: Traumatic separation of the epiphyses. London, Smith, Elder and Co.,1898,926 pp

24. Khoshal K., Kiefer G. Physeal Bridge Resection. 2005. J Am Acad Orthop Surg; 13:47-58.

8. Salter R.B., Harris W.R.: Injuries involving the epiphyseal plate. 1963. J Bone Joint Surg Am; 45(3):587-622.

25. Ogden J.A. The evaluation and treatment of partial physeal arrest. 1987. J Bone Joint Surg Am; 1297-302.

9. Seel E.H., Noble S., Clarke N.M., Uglow M.G. Outcome of distal tibial physeal injuries. 2011. J Pediatr Orthop B. 2011; 20:242-8

26. Peterson H.A. Partial growth plate arrest and its treatment. 1984. J Pediatr Orthop; 4:246-58.

10. Kay R.M., Matthys G.A. Pediatric ankle fractures: evaluation and treatment. 2001. J Am Acad Orthop Surg; 9:268-78.

27. Hasler C.C., Foster B.K. Secondary tethers after physeal bar resection: a common source of failure? 2002. Clin Orthop Rel Res; 405:242-9.

11. Navascués J.A., González-López J.L., López-Valverde S., Soleto J., Rodriguez-Durantez J.A., García-Trevijano J.L., Premature physeal closure after tibial diaphyseal fractures in adolescents. 2000. J Pediatr Orthop; 20:193-6.

28. Williamson R.V., Staheli L.T. Partial physeal growth arrest: treatment by bridge resection and fat interposition. 1990. J Peditr Orthop; 10:769-76. COA Bulletin ACO - Spring / Printemps 2015

Right from the Start. External rotation and instability were historical challenges in reverse TSA—factors that drove the design of the Equinoxe® Shoulder System. In a two-year multicenter clinical study of 200 patients, the average active external rotation for the rTSA patients was >32 degrees with zero instances of instability.1

These are the results of the cited studies. Individual results may vary. In vitro (bench) test results may not necessarily be indicative of clinical performance.

Ten years of clinical use and 34 peer-reviewed studies prove we had it right from the start.

n STABILITY / ROTATION n SCAPULAR

NOTCHING

n COMPONENT LOOSENING

The Equinoxe system is designed to lateralize the humerus to create a more anatomic deltoid wrap (which aids stability) and better tension the remaining cuff (to improve active rotation).1,2 Equinoxe (green) vs. Grammont-style implant shown

n REVISABILITY

Go to www.exac.com/equinoxestudies to view the research. 1. Flurin PH. et al. Comparison of Outcomes Using Anatomic and Reverse Total Shoulder Arthroplasty. Bulletin of the Hospital for Joint Diseases. 2013; Vol 71, Supp 2. 2. Roche C. et al. Impact of Inferior Glenoid Tilt, Humeral Retroversion And Bone Grafting on Muscle Length and Deltoid Wrapping in Reverse Shoulder Arthroplasty. Bulletin of the Hospital for Joint Diseases. 71(4):284-93. 2013.

www.exac.com 905-765-1117

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

Alberta’s Bone and Joint Health Institute bridging MSK care’s knowledge-to-action gap Dennis Jeanes Manager, Communications & Advocacy Canadian Orthopaedic Association

t’s been called the “Switzerland of data,” and there’s more than a little truth to the notion.

The Alberta Bone and Joint Health Institute (ABJHI) is indeed a neutral, independent entity that, like the alpine confederation, excels at protecting privacy and keeping data secure. As a result, the Institute enjoys the trust of all the key stakeholders in the province’s musculoskeletal community – patients, community workers, health professionals, hospital administrators and government health authorities – all of whom create and collect copious amounts of data. Privacy legislation, however, deters sharing this information, and so it often accumulates in health-system silos as single-use, dormant data. But no more. After much negotiation with all concerned parties, the Alberta Bone and Joint Health Institute has achieved the near-impossible. Within its safe confines, ABJHI staff now have permission to “liberate the data” and let the different sources commingle to great effect as never before. Different streams of data can be used, for example, to create a detailed account of one patient’s journey along the MSK care path, or to produce a high-definition overview that picks up a path’s overall strengths and weaknesses. Individual performance and comparative peer data have led to a successful continuous improvement program for Alberta’s hip and knee arthroplasty surgeons. “We have formal affiliation agreements with the physician community and with Alberta Health Services,” says Chris Smith, ABJHI’s chief operating officer, “so we can serve as an independent party that connects patient and community data to administrative and clinical data. Since we’re focused exclusively on bone and joint health, we can build up our capacity to learn and innovate in this area. We’re really here to bridge that knowledge-to-action gap, take what is known and put it into practice now to improve health care.” If seizing the moment embodies the spirit of the place, it’s not much of a stretch to note that the Institute, itself, seems configured to tick along with the elegance and precision of a fine Swiss watch. Designing and launching care paths requires many elements to come together in a timely, clockwork fashion – everything from a customized tool kit of best practices to need and demand modeling to conceptual frameworks for measuring outcomes, not to mention gap analysis and continuous improvement reporting. The ABJHI’s multidisciplinary teams mesh like gearwheels to deliver services, collaborate on long-term projects and conduct research. As we shall see, project teams with their embedded data analysts continue to mine new insights from the ABJHI’s model of care for hip and knee replacement, the Institute’s most mature program. And

virtually all of Alberta’s hip and knee arthroplasty surgeons are now enrolled in the Institute’s continuous improvement reporting initiative. “We went to great pains,” says Smith, “working with the Alberta Orthopaedic Association and Alberta Health Services to develop a governance model that everybody was comfortable with. We don’t do practice audits or billing reviews. We’re here to give information and data back to the clinicians to improve their own practice. And I have to say that, without exception, every surgeon we interact with – once you reveal to them an opportunity for delivering higher quality care – not one of them resists. The bell curve is much narrower now than it used to be in terms of variability of outcomes. And most changes have to do with process.” The Institute may be unique, but it is not alone. ABJHI is a cog in a larger knowledge-translation undertaking that ultimately seeks to mobilize continuous improvement across the full spectrum of musculoskeletal patient care. The mainspring behind this endeavour is the Bone and Joint Health Strategic Clinical Network, which operates under the aegis of Alberta Health Services (AHS). The Network is tasked with assessing the needs of the province’s MSK community for the next three decades and then designing care paths to deliver health services in an appropriate and timely fashion. It’s a mission that meshes perfectly with ABJHI’s expertise. “The strategic clinical network,” says Dr. Don Dick, its medical director, “goes to the Bone and Joint Institute if, say, we want to work on our fragility-fracture program or our low-back and spine program. Then we sit down with Institute staff to figure out what we can do, how we’re going to do it, and how we’re going to evaluate it.” (In passing, it’s worth noting that Alberta Health Services, based on the success of the bone and joint prototype, has another nine strategic clinical networks in other medical fields up and running.) Bench-to-bedside research is the other prime mover. Following an initial multi-disciplinary capacity-building grant from Alberta Innovates Health Solutions in 2008, osteoarthritis research has flourished. The Alberta Osteoarthritis Team, under the leadership of Drs. Walter Herzog and Linda Woodhouse, now numbers more than 50 principal investigators and 100 trainees who

COA Bulletin ACO - Spring / Printemps 2015

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 37)

are exploring different sub-types of the disease and identifying interventions best suited for each sub-type. Peer-reviewed support from the Network and the McCaig Institute for Bone and Joint Health ensures continuity. Thus, new knowledge to improve patients’ health and mobility is transferred from the OA Team to the Institute for evaluation and to the Network for possible implementation, and then those findings are fed back to the OA researchers for further consideration in an ongoing cycle of innovation. “Health care just doesn’t change overnight,” says Don Dick. “It’s a process that takes years. One advantage of having an organization like the Institute is that it can take the long view and say, ‘Suchand-such will likely take five years to fully implement, but in the meantime the Institute can continue to measure and evaluate the process. And we can show you the millions of dollars that have been saved along the way for use in other areas of health care.’” At this juncture, it seems most fitting – all the more so because of his sudden passing in March – to acknowledge Dr. Cy Frank, the gentle visionary who patiently assembled this remarkable knowledge enterprise and attracted the talented people who bring it to life and make it productive. (For more reflections on Cy Frank’s legacy, see “Friendly Persuasion and Clarity of Purpose”) “I came from Ontario in large part because of Cy,” says Dr. Linda Woodhouse, who, in addition to co-directing the Alberta Osteoarthritis Team, is scientific director of the Bone and Joint Health Strategic Clinical Network and holds the David Magee Endowed Chair in Musculoskeletal Health. “His vision was to have established researchers embedded in these strategic clinical networks, using the best evidence to drive innovation. And he felt that network decisions should be made by large teams with broad regional and stakeholder representation.” In keeping with that inclusive approach, the Network has placed patient engagement researchers at the centre of its management committee. These are individuals with arthritis and various MSK disorders who have taken a university-level course on how to design and conduct qualitative research. The training allows them to write their own ethics proposals for approval, lead focus groups and do analyses of their findings. “So when the patient engagement researchers come back to the committee,” says Woodhouse, “and they report that they’ve interviewed a hundred or more patients and this is what they told us about the health-care system and what they need in terms of OA management, it’s not something trivial. It’s the latest evidence from the frontline.” Others on the clinical network committee include rheumatologists, orthopaedic surgeons, primary-care physicians from rural and remote areas, government health-policy experts, health-services zone directors and administrators, IT experts, and ABJHI staff. Lynn Mansell, a senior provincial director for AHS, anchors the government side of the group and shares network leadership responsibilities with Don Dick and Linda Woodhouse. Executive director Mel Slomp operationalizes strategic decisions. In addition to the 30-plus individuals who comprise the Network’s core committee, says Woodhouse, “we have about eight to ten other working groups in key areas such as low-back pain, RA and OA that report to us. We probably COA Bulletin ACO - Spring / Printemps 2015

have 400 to 500 people across the province connected to the Bone and Joint Health Strategic Clinical Network, of which 200 or so are researchers who feed back to the core group. “When Cy was vice-president of research at AHS, he’d meet monthly with the scientific directors for the different strategic clinical networks. We’d talk about how to get the research networks more integrated, more effective. I had a sense of what Cy wanted to accomplish, but until it all comes together, you don’t realize what he’s actually convinced everyone to do. It’s a bit of a surprise to suddenly find you have some 200 people across the province reporting to you about arthritis research.” And what about funding for all this research? It turns out that Cy Frank had his own ideas about that, too. Woodhouse recalls that, when he became president and CEO of Alberta Innovates Health Solutions (AIHS) in 2013, one of Cy Frank’s first actions was to merge the organization with Alberta Health. Next, he negotiated a $5-million annual research fund from AIHS and a matching yearly investment from Alberta Health Services, which together were used to spur competitive research applications from the 10 strategic clinical networks. A review committee of distinguished scientists with backgrounds in knowledge translation and health systems determined which of the projects submitted by the clinical networks would deliver best value and reduce waste within Alberta’s health-care system. Says Woodhouse, “Cy’s idea was, we should optimize the efficiency of the health-care system through the six dimensions of quality needed to measure outcomes, and the monies saved through increased efficiency would flow back to the research fund. So each of the projects was funded in such a way that you could save the health-care system some money – and the more money you saved, the more money would become available to you to do other projects.” Currently, Woodhouse is using a health-innovation grant to more closely examine Alberta’s five largest centralized intake clinics in Edmonton, Calgary, Red Deer, Medicine Hat and Lethbridge to assess how their services might be optimized: “Every patient in the province that needs to consult about a joint replacement comes through one of these central intake clinics. And the comprehensive data collected there by some 40 field researchers are analyzed by the ABJHI to get a sense of how much gain is really achieved by a central intake mechanism.” Her chief collaborator on this project is Dr. Deborah Marshall, the Institute’s Director of Health Technology Assessment, and the Canada Research Chair of Health Services and Systems Research. She, too, was recruited by Cy Frank from Ontario. Marshall is overseeing the development of performance objectives based on the evidence and is using the six dimensions of the Alberta Measurement Framework for Quality Care – acceptability, accessibility, appropriateness, effectiveness, efficiency and safety – to analyze outcomes. “You have to set out a care pathway so that everybody knows what they should be doing, figure out how you’re going to measure performance and establish baselines,” says Marshall. “Then you have to continually monitor and measure according to those predefined metrics so that you can see what’s happening and have a truly comprehensive view over time.”

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 38)

A key dimension of quality – appropriateness – will command Marshall’s particular attention as co-principal investigator of the CIHR-supported BEST-Knee Study (Best Evidence for Surgical Treatment for Total Knee Arthroplasty), a collaboration with principal investigator Dr. Gillian Hawker, who in addition to her highly regarded OA research is currently Chair of the University of Toronto’s Department of Medicine and the FM Hill Chair in Academic Women’s Medicine. That Cy Frank gently nudged each one separately to get to know the other better should come as no surprise. So, when does a person tip from being conservatively managed to requiring a joint replacement? And how can one consistently make that determination and predict whether the patient will benefit? “One of Cy’s key messages,” says Marshall, “was, ‘get the right care to the right people at the right time.’ He was a strong believer in the public health-care system, but he really disliked how money was wasted treating the wrong people.” The ABJHI’s research team conducted focus groups and interviews with patients, orthopaedic surgeons and policy makers to get their perspectives on the question of appropriateness. “Viewpoint matters. People define ‘appropriateness’ differently,” says Marshall. “From that qualitative work we developed a conceptual framework based on four criteria: demonstrated need for knee replacement; a patient ready, willing and able to undergo surgery; realistic patient expectations about the outcome; and whether the benefit outweighs the risk of surgery. We’re now testing these criteria empirically in a prospective study to see whether they can predict with any accuracy which patients will or will not benefit from kneereplacement surgery. Based on these initial outcomes, we can further refine the algorithm.”

“Frail elderly people, who make up much of the patient population with fragility and stability problems, are a complex group,” says Chris Smith, “with lots of co-morbid conditions. Their needs are acute and difficult to manage compared to elective patients. And that really tests our resources to follow them and measure the care path’s outcomes.” On another front, the Institute has initiated a working group on inflammatory arthritis, and a project on soft-tissue knee injury is at the planning stage. Smith anticipates that the knowledge gained from the hip- and knee-replacement care path will widen the Institute’s scope of activity to include more surgical procedures and MSK care. He also expects that data collection and analysis will move “further and further upstream into primary care and self-management. Are there best practices to slow down the progression of osteoarthritis and perhaps avoid its end stage? That’s where the future lies, and that presents a whole new test of our skills.” And despite the current economic slump in Alberta due to low oil prices, he remains optimistic that the Institute will weather the current hard times: “Our role becomes even more important, because we’ve got the data that can reveal opportunities for improvement, and better patient outcomes are what is going to drive sustainability in the health-care system.”

Currently, ABJHI is in the midst of assisting the strategic clinical network deploy a continuum of care that concentrates on fractures and stability. “We have three parts to the program,” says Don Dick. “At the front end, we’re identifying fragility fractures among older patients at fracture clinics and starting them on appropriate osteoporosis treatment and fall prevention. The second part involves acute surgical care for fractured hips. And then we have postoperative care after hospital discharge. It’s taken a couple of years to get going and the program isn’t fully implemented across the province. It is a bit of a challenge to implement a full continuum of care, but that’s our goal.”

COA Bulletin ACO - Spring / Printemps 2015

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

Friendly Persuasion and Clarity of Purpose In Memorium Cy Frank - 1949-2015

y Frank was the soul of modesty and would have shrugged off any notion that he was somehow the mastermind behind the Alberta Bone and Joint Health Institute, likely commenting that “many hands make light work.” True, the best and the brightest gravitated toward him to make it happen, but there can be no doubt that Cy Frank was the magnetic personality at the centre of it all. His deeply held core belief – deliver the best care to patients based on the best evidence – is what gave him clarity of purpose and determination to act. Through the institute, clinical network and OA research team, he has left us a working model of how

these interlocking organizations can rapidly propel innovation and create better outcomes for patients.

Don Dick “I connected with Cy about 18 years ago. Cy had organized a meeting in Red Deer. He wanted to bring all the doctors together so we could talk about how we would all change the health-care system. I decided to go. It wasn’t greatly attended. In those days we had a Calgary Health Region and an Edmonton Health Region, and they were fighting all the time. I came up to him and said, ‘Cy, I hear what you’re saying. If you want me to help you, I’ll try to get Edmonton on side.’ As always, Cy was gracious, but I’m not sure he really believed me. So we started meeting about every six weeks in Red Deer. He would drive from Calgary, and I would drive from Edmonton. Cy would sit down and he’d have this white board and would draw all over it, and we would talk: ‘Who do we need to get involved? How would we do this, and what role would this new structure play?’ Those were fun days of dreaming a dream.”

“While his professional guidance was invaluable, his personal impact on me and my staff cannot be overstated. If ever I felt frustrated, stymied, or discouraged, he could find a way to encourage me, refocus my energies, and recharge my batteries through his always gentle, always positive outlook. His optimism was unbeatable. He truly believed that engaging and partnering with stakeholders would always yield a better, stronger, more resilient and sustainable change than any top-down directive.”

“We presented a proposal for an institute to the Alberta Medical Association. There were concerns from the AMA on the organizational structure that Cy had proposed. Originally there was a feeling that this should be doctor owned. Cy would have none of that. He argued that ‘it just has to be an independent organization. The institute can’t be owned by the health system or the doctors. We’re going to have a lot more buy-in by the different groups, whether it’s government, whether it’s regional leadership or other stakeholders.’ Eventually we convinced government and got some funding, although that could be precarious at times. Fortunately, Cy had developed a relationship with Bud McCaig, and Bud had much the same vision as Cy about patient-centred research and treatment working side by side in the same clinic. We wrote and wrote papers and proposals. I remember reading some of the stuff that Cy had done, and as always I thought of myself as two years behind him.” Chris Smith “I remember speaking with Cy several years ago about a report on quality that we had recently produced and distributed to some one hundred stakeholders. He asked me a simple question: ‘Who is doing anything about these findings?’ This seemingly casual question fundamentally changed our way of doing things. Perhaps without realizing it (although I suspect Cy knew very well what he was doing), he impressed on me the simple notion that all findings must be actionable and put into the local context. It became a call to action within our walls that stimulated our growth from passive quality monitoring to active engagement with clinical and administrative partners to drive the quality agenda.” COA Bulletin ACO - Spring / Printemps 2015

We were in the midst of developing the article about the ABJHI when we learned of Cy Frank’s sudden passing. At this bittersweet time, the COA Bulletin dedicates this article to his memory and the many great things he achieved. Below are some reflections and fond memories from some of his friends and colleagues we interviewed at the Institute:

Linda Woodhouse “Cy called one day and said, ‘I know you’re really busy but could we meet for a GOW meeting every two weeks?’ So I put in my book ‘GOW,’ and the meetings were all set up. After about three or four meetings, his assistant Judy Crawford asked me, ‘Do you know what a GOW meeting is?’ and I confessed, ‘No, I have no idea.’ ‘Glass Of Wine.’ So I’ve shared a glass with Cy all across Canada at different restaurants every two weeks, and we would talk about his vision, what he wanted to accomplish. He never actually told you what to do. He simply shared information.” “He was always about three steps ahead of us at the strategic clinical network. By the time we told him we were ready to do something, lo and behold, all the mechanisms were in place to make it happen — whether it was data, an agreement for sharing information, something inside the health system or something that needed the minister’s approval. He had all the players on board already. Honestly I’ve never worked with anyone else like him.” Deborah Marshall “Cy was truly dedicated to young people and fostering their growth. As part of the osteoarthritis team grant, he encouraged the computer folks to talk to the bench scientists, and vice versa. In fact, my next meeting is with a young PhD scientist who is working with Walter Herzog on the relationship between body fats and osteoarthritis. She came up to me at a team meeting and said, ‘You know that Statistics Canada has this data set of anthropometric measures? I wonder how they use it?’ We connected her with a colleague at Statistics Canada, and so, completely apart from her PhD, which is all about rats and fat, she’s working with me. She is genuinely interested in how you translate bench science into practice and how that influences clinical decisions. I have in front of me the latest version of her paper on this work. It’s totally out of her world and her training. But she’s really smart, and she’s working with me because of Cy.”

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

Introduction to this Edition’s Debate: What is the best way to achieve needed reform in our health-care system? Peter Lapner, M.D., FRCSC Scientific Editor, COA Bulletin

ublic hospital care was first implemented in Saskatchewan (1947) and Alberta (1950). In 1984, The Canada Health Act was passed, an amalgamation of the Hospital Insurance and Diagnostic Services Act and the Medical Care Act. It established five founding principles: • Public administration on a non-profit basis • Comprehensiveness: insurance of medically necessary services • Universality: guarantee that all Canadian residents have access to care on uniform terms • Portability across provinces • Accessibility: reasonable and uniform access to insured health services, free of financial or other barriers.

Health care in Canada is facing very significant challenges and is in urgent need of reform. Many Canadians wait too long for care, in general and for elective surgical treatment, in particular. Health-care providers feel increasingly overworked. Mechanisms for monitoring system performance are lacking. Access to other essential health-care services outside the range of medically necessary services is inconsistent. We have an aging population. The current system has staggering inefficiencies. The importance of the decisions that we make as a profession on how our health-care system is reformed cannot be overstated. The approach that we take today will have serious and lasting consequences for us as care providers and for all Canadians. It is imperative that we participate in the discussion and in the development of solutions. Our decisions must be well-informed and well-considered and we must advocate for the interests of those to whom we have dedicated ourselves: our patients.

Debate: What is the best way to achieve needed reform in our health-care system? System changes should take place within our publicly funded Medicare system Danielle Martin M.D., CCFP, MPubPol Women’s College Hospital, University of Toronto Founding Board Chair, Canadian Doctors for Medicare Toronto, ON Cy Frank C.M., M.D., FRCSC President and Chief Executive Officer, Alberta Innovates – Health Solutions McCaig Professor in Joint Injury and Arthritis Research Professor, Department of Surgery, Section of Orthopaedics University of Calgary Calgary, AB Robert Y. McMurtry C.M., M.D., FRCSC, FACS Professor Emeritus, Western University Visiting Specialist, Prince Edward Family Health Team Expert, Evidence Network of Canadian Health Policy Founding Board Member, Canadian Doctors for Medicare London, ON

veryone agrees that Canadian health care needs reform. In spite of the many ways in which the system functions well, we and our patients often experience problems in accessing and providing effective care. The question is not whether the system needs to be improved. Rather, it is how we can best improve and expand Medicare to meet the needs of all Canadians – not just those who can afford to pay or buy private insurance. System challenges should be addressed based on solid evidence and values, not anecdotes and preferences, in ways that benefit all patients. That is the challenge we collectively face. Reforms that would divert resources from the public health care system would solve problems only for a minority of patients, exacerbating existing system weaknesses for the vast majority. This is contrary to the ethical framework underpinning the practice of medicine, particularly the principle of justice1.

Authors’ note: our article is dedicated to the late Dr. Cy Frank, who committed to co-author this piece before his sudden and untimely passing in March. Dr. Frank was a giant in the field of orthopaedics and Canadian health-care reform. He will be greatly missed.

COA Bulletin ACO - Spring / Printemps 2015

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 41)

I. Why is it best to maintain a single-payer model for medically necessary services? Canada does not have a single tier in health-care delivery. Virtually all medically necessary care is delivered by private entities – physicians and hospitals - and fully 30% of health spending is private2,i. Physicians are not state employees, but rather private entrepreneurs. We earn high incomes by international standards3. We enjoy substantial clinical autonomy, certainly more than our American colleagues whose freedom to practice medicine is limited by private insurance companies that pay (or refuse to pay) for the majority of care.

Allowing private payment for hospital and physician care would lengthen waits in the public system. A privately-funded second tier would siphon resources away from the public sector. Physicians, nurses, administrative staff, technicians and other human resources would have to come from the public sector. When Australia’s previously single-payer system was opened up to private payment, wait times in the public system increased6.

Duckett, S.J. Private care and public waiting. Australian Health Review. 2000; 29.1: 87-93.

World Health Organization National Health Account database. Health expenditure, public (% of total expenditure). 2013.

Thanks to our single-payer public payment plans, our patients are all covered by comprehensive publicly-funded insurance for the care we provide in our offices and hospitals. In areas of the system where there is a mix of public and private payment, such as for prescription drugs4 and dentistry5, there are vast inequities in access to care and soaring costs. At the same time, there is a misconception that physicians are compelled to practice in the publicly-funded system. In fact, in most provinces, physicians are free to unenroll from Medicare ii, and, in some provinces such as BC, those who do so can charge patients as much as the market will bear so long as they work outside the public system. However, few among us unenroll, given the stability and security Medicare provides for us, and for our patients. Most of us accept that it is a flawed option to place patients rendered vulnerable by disability and disease at the mercy of market forces. COA Bulletin ACO - Spring / Printemps 2015

Allowing dual practice would increase waits for most. Physicians in other countries who are permitted to split their time and income between the public and private sectors (dual practice) tend to prioritize their more lucrative for-profit work. This has been well documented in many jurisdictions, including New Zealand7. The OECD cautions that allowing dual practice by surgeons “may encourage some surgeons to lengthen the public queues to boost the demand for their private practices8.” Single-payer systems are vastly more efficient than multipayer systems. Fewer payers in a system means less waste on administrative “bean counters”. In extreme multi-payer systems, like the US, administration accounts for 30% of the health-care budget and 25% of its workforce9,10,11. In Canada, less than 2% of our health-care expenditures support administration in our public plans12. I. How can we best address challenges to benefit all patients?

CMA Task Force on the Public–Private Interface. It’s about access. 2006.

The solutions to our challenges are not magical, nor are they unknown. Across Canada and elsewhere in the world, dozens of projects have been highly successful in improving equitable access to care. We need to spread and scale-up those models. Two examples illustrate the point:

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 42)

1. Reduce wait times for procedural and surgical services through efficient centralized intake and assessment projects.

undergo surgery in vain17,18,19,20. These critiques offer opportunity to reduce inappropriate interventions.

The global burden of musculoskeletal disease is growing, up 45% from 1990 to 201013. Of several successful Canadian initiatives underway to address this growth, none is more deserving of praise than Alberta’s Hip and Knee Replacement Project, a joint effort between the Alberta Bone and Joint Health Institute (ABJHI), orthopaedic surgeons, and government. Using a centralized referral system, waits dropped to 21 working days from 145. Using alternative providers rather than surgeons to assess patients, 80% of consultations end in conservative non-surgical intervention. Waits for the 20% needing surgery declined to just 37 working days from 29014. This landmark project demonstrates that change based on sound evidence can solve seemingly intractable problems within the public system.

Conclusion As physicians and surgeons, our obligation is to our patients based on their need, not their ability to pay. Part of the reason we face challenges in Canadian health care is that physicians and surgeons have not been engaged enough in evidenceinformed system-level analysis and consultation. We can lead change locally, and at the system level, to address these challenges, none of which would be served by a multi-payer financing system. Let’s spend our collective energy tackling the challenges together, rather than advocating for changes that would only benefit a few patients – and their doctors leaving the rest of us to pick up the pieces. Acknowledgements: The authors thank Professor Karen Palmer for her assistance in the preparation of this piece. Notes i. Detractors of Medicare sometimes make preposterous claims about the Canadian health-care system resembling those of Cuba and North Korea. Such claims are not based in fact. The Cuban and North Korean systems are government-funded and government-delivered health systems. Canadian physicians are independent entrepreneurs, not state employees. ii. Excluding Ontario. References 1. Beauchamp, T.L., Childress, J.F. Principles of biomedical ethics. Toronto, ON: Oxford University Press; 2001. 2. Canadian Institute for Health Information. Health Spending in 2013. 2013. 3. Fujisawa, R., Lafortune, G. The remuneration of general practitioners and specialists in 14 OECD countries: What are the factors influencing variations across countries? OECD health working papers no. 41. 2008.

In another successful example, physicians and government worked together in the Richmond BC Hip and Knee Reconstruction Project to design publicly-funded innovations that reduced median wait times from 20 months to five15. Efficiencies and simple innovations, such as staggered surgical start times with patients scheduled between adjoining rooms so surgeons can “swing” between rooms, illustrate the ability of health care to learn from other industries. Standardized surgical procedures and practices reduce variations and enable bulk purchases. 2. Reduce inappropriate interventions and waste. The Choosing Wisely Canada campaign urges physicians and patients to engage in conversations about unnecessary tests, treatments and procedures, facilitating smart and effective choices to ensure high-quality care16. Orthopaedics has seen a number of serious challenges to the validity of popular surgical procedures, resulting in the conclusion that patients often

4. Tamblyn, R. , Eguale, T., Huang, A., Winslade, N., Doran, P. The incidence and determinants of primary nonadherence with prescribed medication in primary care: A cohort study. Annals of Internal Medicine.160.7: 441-450, 2014. 5. Grignon M., Hurley J., Wang L., Allin S. Inequity in a marketbased health system: Evidence from Canada’s dental sector. Health Policy. 2010; 98.1: 81-90. 6. Duckett, S.J. Private care and public waiting. Australian Health Review. 2000; 29.1: 87-93. 7. Flood, C.M. Chaoulli’s Legacy for the future of Canadian health care policy. Osgoode Hall Law Journal. 2006; 44.2: 273-310. 8. Organization for Economic Cooperation and Development. Towards high-performing health systems. 2004. COA Bulletin ACO - Spring / Printemps 2015

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(continued from page 43)

9. Woolhandler, S., Himmelstein, D.U. National health insurance or incremental reform: Aim high, or at our feet? American Journal of Public Health. 2003; 93.1: 102-105.

15. Priest, A., Rachlis, M., Cohen, M. Why wait? Public solution to cure surgical waitlists. Vancouver, BC: BC Health Coalition; 2007.

10. Woolhandler, S., Campbell, T., Himmelstein, D.U. Costs of health care administration in the United States and Canada. N Engl J Med 2003; 349:768-775.

16. Choosing Wisely Canada. What is CWC? N.D.

11. Himmelstein, D.U., Jun, M., Busse, R., Chevreul, K., Geissler, A., Jeurissen, P., Thomson, S., Vinet, M., Woolhandler, S. A comparison of hospital administrative costs in eight nations: US costs exceed all others by far. Health Aff. 2014; 33.9: 15861594. 12. Woolhandler, S., Campbell, T., Himmelstein, D.U. Costs of health care administration in the United States and Canada. N Engl J Med 2003; 349:768-775. 13. Storheim, K., Swart, J-A. Musculoskeletal disorders and the global burden of disease study. Annals of Rheumatic Diseases. 2014; 73: 949-950. 14. Alberta Bone and Joint Health Institute. Alberta hip and knee replacement pilot project patient results one year following surgery. 2008.

17. Frobell, R.B., Roos, E.M., Roos, H.P., Ranstam, J., Lohmander, L.S. A randomized trial of treatment for acute anterior cruciate ligament tears. N Engl J Med. 2010; 363.4:331-42. 18. Buchbinder, R., Osborne, R.H., Ebeling, P.R., Wark, J.D., Mitchell, P., Wriedt, C., et al. A randomized trial of vertebroplasty for painful osteoporotic vertebral fractures. N Engl J Med. 2009; 361.6: 557-68. 19. Kirkley, A., Birmingham, T.B., Litchfield, R.B., Giffin, J.R., Willits, K.R., Wong, C.J., et al. A randomized trial of arthroscopic surgery for osteoarthritis of the knee. N Engl J Med. 2008; 359.11:1097-1107. 20. Aspenberg, Per. Overtreatment of cruciate ligament injuries. SA Orthopaedic Journal. 2011; 10.3: 61.

Debate: What is the best way to achieve needed reform in our health-care system? A privately-funded multi-payer health-care tier is the best way to achieve system reform Brian Day, MRCP (UK), FRCS (Eng), FRCSC Vancouver, BC

hould you have the right to pay for care you desperately want?” was the question asked of panelists in a recent CBC National newscast. “No” was the response from supporters of the current Canadian health-care system. They would have one believe (wrongly) that long wait lists are not harmful to patients and that they exist in other highly-developed countries. For reasons that defy logic, they believe that Canadians should accept state control over their bodily health. They endorse the fact that we are the only country on earth that legally prohibits its citizens from spending on their own health. Hypocritically, they accept their own private insurance and use the private sector themselves. I can forgive ignorance and lack of insight, but not hypocrisy. “

In our upcoming trial, they will argue that long waits are a worthwhile price for maintaining the status quo and that we should not have a constitutional right to protect ourselves from harm. We differ in believing that government cannot be COA Bulletin ACO - Spring / Printemps 2015

allowed to promise care, fail to deliver it appropriately, and then outlaw the right to use one’s own funds to insure against personal suffering or hardship. We will ask that every Canadian be given the same legal rights that the Supreme Court of Canada granted to Quebec residents. We will show that allowing patients to suffer on wait lists does not justify the present state of affairs. In a court of law, the propaganda and ideology of our opponents will be countered by evidence and factual data. Canada’s health-care system is controlled by a bloated bureaucracy, determined to retain and control its massive budget and the control that goes with it. We will argue it is irrational that workers’ compensation, armed forces, federal prisoners, and non-residents are exempt from the draconian laws we are challenging. We will demand that if Terry Lake’s animal patients (our current BC Health Minister, one of three defendants, is a vet) can lawfully benefit from private insurance, then humans should have similar rights. We will present evidence to refute discredited and factually bankrupt reports submitted by our opponents.

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 44)

Ethical arguments will feature in the trial. With one exception, those who support the current infringement on patient rights are in violation of all ethical standards. That exception applies to lawyers acting for the defendants, who have a duty to argue in support of their clients. The exception does not apply to physicians and government (so-called) experts who will attempt to justify the pain, and suffering of the plaintiff patients and their families. Two of the three adult plaintiffs with cancer have died. One of three children is paralyzed for life (www.charterhealth.ca). They are the “tip of an iceberg” that comprises over a million Canadians on wait lists. The Supreme Court of Canada has already ruled that patients are “suffering and dying on wait lists”, and that “access to a wait list is not access to care”. The denial of a patient’s right to obtain timely access outside the system, when it is not available within the system, is unethical. An ethical physician must advocate for quality health care that is appropriate, effective, and timely. When laws, policies, or regulations conflict with that role, we must reject them. The CMA Code of Ethics preamble states: “Physicians may experience tension between different ethical principles, between ethical and legal or regulatory requirements, or between their own ethical convictions and the demands of other parties”, but requires that we “Consider first the well-being of the patient.” A citizen’s right to spend their own after-tax dollars on the care of themselves or their loved ones is a human right that physicians must defend. Unethical laws and regulations are not uncommon. Legalized apartheid in South Africa and slavery in North America are relatively recent examples. Laws that made homosexuality a criminal offence, and others that allowed racial and sexual discrimination, are examples that have existed in my lifetime. Recent examples in Canada include those relating to abortion, same sex marriage, prisoners’ rights, safe-injection sites, and assisted suicide.

We will focus our case on a simple question: should residents be legally prevented from protecting their health or survival by a government that has promised, but failed to provide, timely access to care? One point we will not make is that ours is a socialist system. All socialist countries (even communist China, Vietnam, Laos and Cuba, and the more radical North Korea) embrace a hybrid private system alongside the public system. The Commonwealth Fund recently ranked Canada’s system 10th of 11 developed countries (US was 11th). We need to learn from those ranked ahead of us, all of which embrace patient choice and competition for their public systems. With respect to our court challenge, we are “David” challenging “Goliath” in terms of our financial resources. Like David, our cause is just, and we will not give up until this battle is concluded. If government’s strategy is to force us to abandon our action by escalating our costs, they will fail. Recently, just six days before trial, government lawyers announced that they had failed to disclose (as required by law) “thousands” of documents. This was a great shock. Astonishingly, this number quickly grew to several hundred thousand documents. No wonder our health-care system is under duress when its operation is controlled by individuals such as those responsible. During the more than six years this challenge has taken to reach the courts, two of six patient plaintiffs have died. Wait-listed patients will now be condemned to suffer longer, as the trial is again delayed while we review materials which I presume bureaucrats hoped we would never see. The government went to court in the recent assisted suicide trial to argue against the rights of terminally ill patients to die without pain and suffering. In our trial they, and the intervening unions and Canadian Doctors for Medicare, will argue against the rights of living patients to live without pain and suffering. In our battle for patient rights, we are grateful for the support of the Canadian Constitution Foundation (www.theccf.ca).

What’s coming up in the next edition of the COA Bulletin? Stay tuned for the Summer edition #109 of the COA Bulletin next month which will include Dr. Bas Masri’s last article to the membership as President of the COA, a debate on primary fixation of ankle syndesmotic disruption, more detailed information about the new annual dues

structure, a clinical feature on the use of bone graft and substitutes in orthopaedics and much more. Keep your eye on your inbox for a link to the Summer 2015 edition when it’s posted online.

COA Bulletin ACO - Spring / Printemps 2015

The Canadian Orthopaedic Foundation is pleased to have awarded the following research grants for 2014:

La Fondation Canadienne d’Orthopédie est heureuse d’accorder les prix et bourse de recherche suivants pour 2014 :

J. EDOUARD SAMSON AWARD

PRIX J.-ÉDOUARD-SAMSON

Dr. Paul E. Beaulé (Ottawa, ON)

Dr Paul E. Beaulé (Ottawa, ON)

“Understanding the Etiology and Cause of Osteoarthritis of the Hip: A Multi-Disciplinary Approach”

« Understanding the Etiology and Cause of Osteoarthritis of the Hip: A Multi-Disciplinary Approach »

As part of the Foundation’s commitment to increase the support of orthopaedic research in Canada, we are pleased to award two CORL grants this year:

Dans le cadre de son engagement à accroître le soutien à la recherche en orthopédie au Canada, la Fondation est heureuse d’accorder deux bourses cette année :

CANADIAN ORTHOPAEDIC RESEARCH LEGACY (CORL) Award

BOURSE DE L’HÉRITAGE DE LA RECHERCHE ORTHOPÉDIQUE AU CANADA

Dr. George Athwal Dr. David O’Gorman

Dr George Athwal Dr David O’Gorman

(London, ON)

“The effects of Proprionibacterium acnes infection on the integration of primaryhuman cells into 3D models of shoulder tissue repair”

« The effects of Proprionibacterium acnes infection on the integration of primaryhuman cells into 3D models of shoulder tissue repair »

Dr. Peter Lapner (Ottawa, ON)

Dr Peter Lapner (Ottawa, ON)

“Diagnostic Accuracy of Synovial Biopsy for Implant-Related Shoulder Infections”

« Diagnostic Accuracy of Synovial Biopsy for Implant-Related Shoulder Infections »

The Canadian Orthopaedic Foundation opens its annual research grant process in the summer. Please visit www.canorth.org for more information.

La Fondation Canadienne d’Orthopédie lance son processus annuel d’octroi de prix et bourses de recherche à l’été. Veuillez consulter le site www.canorth.org pour obtenir plus de renseignements.

Foundation / Fondation

Canadian Orthopaedic Foundation Celebrates 50 Years: COF’s 5Ws Geoffrey Johnston, M.D., FRCSC President, Canadian Orthopaedic Foundation

or 50 years your Foundation has been supporting orthopaedic surgeons and their patients through funding research, providing education and enhancing patient care. At this critical time in our development, as we plan to grow our surgeon support programs, we invite you to learn more about us, and to see how YOU can help us to support YOU and YOUR patients. Read more about COF’s 5Ws. WHO? We are Canada’s patient voice for bone and joint health. Our mission is “To achieve excellence in bone and joint health, mobility and function for all Canadians through the advancement of research, education and care”. As a national charity, we invest in communities across the country. We provide hospital grants that help to improve patient care, fund local researchers, and deliver free patient resources to hospitals nationally.

The COF supports Canadian orthopaedic surgeons directly through our awards’ program, support of the R.I. Harris and Macnab lectureships, and indirectly through patient education and support. In 2013 the COA urged the Canadian Orthopaedic Foundation to be more supportive of the surgical community. The COF responded, and in 2014 the COA Executive endorsed the COF’s proposal to expand its surgeon support initiative. The changes we propose are: Budget ($) A. Research Grants

We are a lean organization, with a committed staff team, governed by a volunteer Board of Directors and supported by hundreds of volunteers across the country. Volunteers are our life blood, delivering peer support, organizing fundraising activities and delivering our mission nationally. We have helped to improve the lives of Canadians over 50 years, having provided: • Close to $1 million in research grants • $10 million in community grants in 61 regions across the country • Surgeons and hospitals with patient booklets reaching more than 200,000 Canadians • Peer support to many of the tens of thousands of people on the wait list for surgery WHAT? … Canada’s only orthopaedic charity. The Canadian Orthopaedic Foundation has four objectives: 1. Patient Education: Provide resources to surgical and nonsurgical patients, and to the general public interested in disease prevention. 2. Surgeon Support: Fund research by orthopaedic surgeons, support education and innovation and improve clinical practice. 3. Health Policy: Build public awareness of the impact of bone and joint conditions on society, and opportunities for prevention, self-management, patient education and service improvements. 4. Build Capacity: Improve funding, partnerships, community and volunteer networks, to deliver services.

Canadian Orthopaedic Research Legacy Award (seed funding for research)

20,000

100,000

J. Édouard Samson Award (recognizes career orthopaedic research over 5 years)

15,000

25,000

Robert Salter Award (for outstanding new research)

10,000

16,000

B. Education Grants Visiting Professor Grants Travelling Educational Grants

C. Community & Innovation Award D. Fellowships and Scholarships for Residents and Fellowships TOTAL

Target ($)

Clinical Fellowship Grants Bones and Phones Scholarship

8,000

20,000

100,000

1,000

46,000

280,000

WHERE? … across Canada. The Canadian Orthopaedic Foundation was founded in 1965, evolving from the Canadian Orthopaedic Charitable Organization (1956) and the subsequent Canadian Orthopaedic Organization, with a goal to fund research and to support special prizes, lectureships and Orthopaedics Overseas. The COF Founding Members included J.L. McDonald, L.W. Black, H.M. Coleman, J.C. Favreau, J.C. Kennedy, R.N. Lofthouse, W.J. Melvin, W.B. MacKinnon, F.P. Patterson, G.F. Pennal, R.G. Townsend and R.I. Harris.

COA Bulletin ACO - Spring / Printemps 2015

Foundation / Fondation

(continued from page 47)

Since its inception, the COF has responded to an ever-evolving environment, which saw our Foundation transform from a small orthopaedic research organization into a national fundraising body with a primary focus on patient education. Last year we implemented a new soccer injury prevention program which contributes to bone and joint health at an early age; and a new smoking cessation program which prepares people for optimal recovery following surgery. Most recently we broadened our orthopaedic surgical profile by expanding research, innovation and learning awards for Canadian orthopaedic surgeons. While it was necessary to establish the COF as an independent charitable Foundation in 2008, the COA and COF continue to work together, sharing values and objectives. WHEN? … now. Funding comes from three main sources: patients (supporting education), surgeons (supporting surgical initiatives) and industry (supporting specific programs). Fundraising is critical to the Foundation. In 2012 the COF implemented a new fundraising event called the “Bad to the Bone” golf tournament. This year’s tournament will take place on June 8, and among the hockey players in attendance, Connor McDavid will make a repeat visit. This tournament is the brainchild of Sherry Bassin, General Manager of the OHL Erie Otters and an ardent advocate of the COF. I am sure orthopaedic surgeons would not want to miss this event. Last year we re-launched Hip Hip Hooray!, which many surgeons will recall as an event that ran from 1992 to 2008. The 2014 event resulted in $15,000 distributed to three Canadian orthopaedic communities, and additional funds supported the COF’s mandate. This money reflects the esteem that patients hold for orthopaedic surgeons. As well, a new pedometer challenge raised $70,000. Over the last three years, however, surgeon donations have been rapidly declining. This has left the COF unable to rely on its core of orthopaedic surgeons to fulfil its surgeon support mandate, a mandate endorsed by the COA. We need all orthopaedic surgeon hands on deck, now. WHY? … because your orthopaedic surgical colleagues, your profession, and your patients need you. We are all keenly aware of the burden of musculoskeletal treatment and the rising need for orthopaedic surgery. Orthopaedics has to take advantage of the rapidly changing technology and health-care environments, which drive innovation. Innovation only comes from bright ideas which can translate to the bedside – but many of our ideas die on the vine for lack of funding. Funding by governments for research is increasingly scarce and difficult to access. Nevertheless, we cannot afford to let good ideas go to waste – indeed, we have recently heard of Toronto orthopaedic surgeons committing substantial amounts of their own earnings to fund their own research program in the absence of adequate external funding.

COA Bulletin ACO - Spring / Printemps 2015

The Canadian Orthopaedic Foundation, recognizing that Canada’s orthopaedic surgeons’ excellent research ideas are not being funded, wants to provide seed funding that they so direly need. To do this, we need to expand our grants to surgeons to kindle the research and innovation ideas that our surgeons propose. Over its first fifty years the COF has achieved a rich legacy of support for Canadian orthopaedic research, investing close to $1 million. See the impressive list of more than 60 COF-funded distinguished surgeons on our website at Geoffrey Johnston, M.D., FRCSC www.canorth.org (About President, Canadian Orthopaedic Us> Research Awards and Foundation Educational Grants). Recent awardees through COF programs attest to the value of their awards. Brian Kwon (2013 Samson awardee) writes, “The Samson Award has been extremely valuable for enabling pilot experiments that can be leveraged into further larger-scale extramural funding.” Nadr Jomha (2012 Samson awardee) writes, “Being presented with the J. Édouard Samson award in 2012 was a significant milestone in my research career. It formally recognized my position as a leading orthopaedic researcher in Canada. This has been important in furthering my research career by enabling reviewers of my grant applications and nominations to realize that a national organization has independently reviewed my work and bestowed this honour on me. I am very grateful to the Canadian Orthopaedic Foundation for this honour.” Albert Yee (2011 Samson awardee) writes, ”The award has significant history in orthopaedic research in Canada, with several past recipients being key mentors who have inspired me over the years as I established my early academic career. This award has enabled me to continue to support the research of promising trainees who will be our future generation of surgeon-scientists.” Douglas Naudie (2013 CORL co-awardee) adds, “Grant funding continues to be more difficult to come by. The Canadian Orthopaedic Foundation is one of the only agencies making orthopaedic research a priority. The amount of the award is sufficient to cover our needs with a single grant. We are very grateful that there is a competition like the CORL Award, and look forward to presenting and publishing our research with the support of the COF”. Mohit Bhandari and Olufemi Ayeni (2012 CORL awardees) say: “The CORL grant was critical early support for our trial. It enabled a strong rationale to other funders, like CIHR, to leverage grants that provided over 20 times return on CORL’s initial financial investment.” Steven MacDonald and Sharon Culliton (2011 CORL awardees) write, “The Canadian Orthopaedic Research Legacy Grant has provided the opportunity to develop an innovative and unique patient educational tool for patients undergoing total knee replacement surgery.”

Foundation / Fondation

(continued from page 48)

COF awards represent vital seed-funding for Canadian orthopaedic research ideas, and act as springboards to other funding agencies. COF’s awards list reads as a Who’s Who of Canadian orthopaedic research. But the list should be much larger. For every CORL winner there are 10-20 submissions that cannot be funded. Are they rejected on the basis of merit? No. This past year the Foundation received 19 CORL funding-worthy applications. The Foundation opted to fund two awards, despite the value of the awards being in excess of Canadian orthopaedic surgeons’ donations in that year. What about the majority that did not receive COF funding? As one of those who were unfunded I will relate my own sad story! For the last seven years I have followed systematically the clinical, radiographic and patient-rated outcomes of 2,000 distal radial fractures in adults, treated surgically and nonoperatively. From that experience I carefully devised a novel surgical implant for adult distal radial fractures designed to capitalize on the strengths and minimize the weaknesses of present day methods. In addition to submitting requests for peer-reviewed local and provincial funding, I submitted a grant application to the COF. It was one of the seventeen that could not be funded. Provincial funding failed too. Maybe my idea will be stamped one of those “it was not meant to be”; who will ever know? Certainly, I don’t think so. But such is the similar fate of our colleagues’ many bright ideas – pity. Orthopaedic surgeons in Canada know each other, and there is mutual trust. We ought to be willing to take a risk on investing in the ideas of our colleagues. In my mind, Canadian orthopaedic surgeons’ present willingness to invest, manifested by their donations, in just 5% of their colleagues’ ideas is astonishingly timid, and is so low as to risk the future of orthopaedic research in Canada. The Foundation is determined to support your good ideas, the many opportunities enabled by scientific discovery. More than ever we need to reach out to our donors amongst the public and surgical communities, appealing to their generosity to fuel these initiatives. Last year surgeons donated just $35,000 for these initiatives. In order for the COF to deliver on what you want, we need widespread, if not universal, support from you. The arithmetic is easy, but unfortunately the giving has not been. If all 1,500 orthopaedic surgeons in Canada contributed in 2014, the average donation would have been $23; if only Active COA members (900) contributed, the average donation amount would have been $38. All in all we’re talking about one or two weeks of coffee money. It is hard to see that as investing in our colleagues. Were each and every one of the 1,500 orthopaedic surgeons practicing in Canada to contribute just $190, or each and every one of the 900 COA Active members to contribute $310, we would reach our target of $280,000. Unfortunately our reality has been that we have always relied on a fraction of the mem-

bership for our funding, akin to Churchill’s “never was so much owed by so many to so few”, so we would be most grateful for a more generous donation. Your research colleagues will not disappoint! South of the 49th parallel, the Orthopaedic Research and Education Fund (OREF) in 2013 reported the year’s donations as being $1.8M, almost exclusively from 2,000 orthopaedic surgeons (an average of $US 900 per donor), and targeted for research purposes. This amount is more than 50 times the 2014 Canadian giving. We can do better. The rich legacy of Canadian orthopaedic research deserves better. The Foundation needs your support. Encourage your colleagues to join you in giving, for the Foundation serves all orthopaedic surgeons in Canada by facilitating advances in education and research. Encourage them to make an annual donation, or pledge to monthly deductions. I have personally pledged the value of just one orthopaedic consultation per month. I ask you, my fellow surgeons, to be similarly generous. The Canadian Orthopaedic Foundation is celebrating its 50th anniversary. We continue to support your orthopaedic patients’ educational needs and, at the strong encouragement of the COA, have expanded our orthopaedic research and educational roles to meet the needs of COA members. We have responded, and we need you to share in the COA’s and COF’s mutual missions to foster innovation and discovery in the Canadian orthopaedic community. The Canadian Orthopaedic Foundation is your Foundation. Together we can stand out and achieve excellence in bone and joint health, mobility and function for all Canadians through the advancement of research, education and care. In another 50 years we will look back at the accomplishments of your Foundation and say “We did the right thing.”

Just as the COA lost a true leader by Cy Frank’s sudden death on March 5, so too did the Canadian Orthopaedic Foundation in which he was both a long-standing Director and Chair of the Governance and Nominating Committee. We will remember Cy’s passion for orthopaedic surgical research, and for Canadians’ improved access to orthopaedic care. He truly lived the part of an orthopaedic research scientist and innovator to the fullest. Together our organizations must continue his legacy. We shall all miss him.

COA Bulletin ACO - Spring / Printemps 2015

Foundation / Fondation

La Fondation Canadienne d’Orthopédie célèbre son cinquantième anniversaire : La Fondation en cinq questions Geoffrey Johnston, MD, FRCSC Président de la Fondation Canadienne d’Orthopédie

epuis 50 ans, la Fondation Canadienne d’Orthopédie soutient les orthopédistes et leurs patients en finançant la recherche, en sensibilisant les patients, en offrant de la formation aux orthopédistes et en améliorant les soins. En cette période critique dans le développement de la Fondation, qui planifie actuellement l’expansion de ses programmes de soutien aux orthopédistes, nous vous invitons à en apprendre davantage sur la Fondation et à considérer la façon dont VOUS pouvez nous aider à soutenir VOS patients et VOTRE travail. Voici donc la Fondation en cinq questions : QUI SOMMES-NOUS? Nous sommes la voix des patients en matière de santé des os et articulations. Nous avons pour mission d’« atteindre l’excellence en matière de santé des os et des articulations, de mobilité et de fonction pour tous les Canadiens, en faisant progresser la recherche, l’éducation et les soins ». En tant qu’organisme de bienfaisance national, nous investissons dans les collectivités d’un bout à l’autre du pays. Pour ce faire, nous versons aux hôpitaux des bourses et subventions contribuant à améliorer les soins aux patients, finançons des projets de recherche locaux et distribuons des ressources gratuites dans les hôpitaux canadiens. Nous sommes une organisation allégée, dotée d’un personnel dévoué, administrée par un conseil bénévole et soutenue par des centaines de bénévoles de tout le pays. Par le soutien qu’ils offrent à leurs pairs, l’organisation d’activités de collecte de fonds et leur rôle dans la concrétisation de notre mission à l’échelle nationale, les bénévoles sont notre souffle vital. En un demi-siècle, nous avons contribué à améliorer la vie des Canadiens grâce : • au financement de bourses de recherche de près de 1 million de dollars; • au financement de subventions communautaires d’environ 10 millions de dollars dans plus de 61 régions au pays; • à la distribution dans les cabinets d’orthopédie et hôpitaux de livrets qui ont permis de joindre plus de 200 000 patients; • à l’offre de soutien par les pairs à bon nombre des dizaines de milliers de patients en attente d’une chirurgie. QUE FAISONS-NOUS? Nous sommes le seul organisme de bienfaisance canadien qui se consacre à l’orthopédie. Voici les quatre objectifs de la Fondation Canadienne d’Orthopédie : 1. Sensibilisation des patients : Offrir des ressources aux patients en attente d’une chirurgie ou non et à toute personne intéressée par la prévention des maladies. COA Bulletin ACO - Spring / Printemps 2015

2. Soutien aux orthopédistes : Financer des projets de recherche menés par des orthopédistes, soutenir la formation et l’innovation et améliorer l’exercice clinique. 3. Politiques en santé : Sensibiliser la population aux répercussions des troubles des os et des articulations sur la société et faire connaître les possibilités de prévention, d’autogestion, de sensibilisation des patients et d’amélioration des services. 4. Renforcement de la capacité : Améliorer le financement, les partenariats et les réseaux communautaires et bénévoles pour la prestation des services. Nous soutenons les orthopédistes canadiens directement, par l’intermédiaire de nos prix, bourses et subventions ainsi que du financement des conférences R.I. Harris et Macnab, et indirectement, grâce à nos activités de sensibilisation et de soutien des patients. En 2013, l’ACO a incité la Fondation à soutenir davantage la communauté orthopédique. Nous avons répondu à cet appel : en 2014, la direction de l’ACO a approuvé notre proposition d’accroître notre soutien aux orthopédistes. Voici les changements que nous proposons : Budget ($) A. Bourses de recherche

B. Subventions à l’éducation

Bourse de recherche du programme de l’Héritage de la recherche orthopédique au Canada (HROC) : Financement de démarrage pour la recherche Prix J.-Édouard-Samson : Recherche en orthopédie menée sur une période de plus de cinq ans Bourse Robert-B.-Salter : Nouveaux projets de recherche exceptionnels Bourses de professeur invité Bourses de voyage

C. Prix d’innovation communautaire Bourses de formation clinique D. Bourses de recherche et Bourses d’études Bones and d’études pour Phones résidents et boursiers TOTAL

Cible ($)

20 000

100 000

15 000

25 000

10 000

0 0 0

16 000 8 000 20 000

0 1 000

100 000 1 000

46 000 280 000

Foundation / Fondation

(continued from page 50)

OÙ ŒUVRONS-NOUS? Nous œuvrons partout au Canada. La Fondation Canadienne d’Orthopédie a été fondée en 1965, succédant à la Canadian Orthopaedic Charitable Organization (1956) et à la Canadian Orthopaedic Organization. Elle a pour but le financement de la recherche ainsi que de prix spéciaux, de conférences et d’Orthopédie Outre-Mer Canada. Les membres fondateurs comprenaient J.L. McDonald, L.W. Black, H.M. Coleman, J.C. Favreau, J.C. Kennedy, R.N. Lofthouse, W.J. Melvin, W.B. MacKinnon, F.P. Patterson, G.F. Pennal, R.G. Townsend et R.I. Harris. Depuis sa création, la Fondation s’est adaptée à un milieu en constante évolution : elle est passée d’une petite organisation axée sur la recherche en orthopédie à un organe de financement national mettant l’accent sur la sensibilisation des patients. L’an dernier, nous avons mis en œuvre un programme de prévention des blessures au soccer qui favorise la santé des os et des articulations à un jeune âge et un programme de renoncement au tabac qui prépare les patients à un rétablissement optimal à la suite d’une chirurgie. Plus récemment, nous avons élargi nos visées en chirurgie orthopédique en augmentant les prix, bourses et subventions de recherche, d’innovation et de formation à l’intention des orthopédistes canadiens. Même s’il a fallu faire de la Fondation un organisme de bienfaisance indépendant en 2008, l’ACO et la Fondation poursuivent leur collaboration et partagent toujours les mêmes valeurs et objectifs. QUAND DEVONS-NOUS AGIR? Nous devons agir maintenant. Nous avons trois grandes sources de financement : les patients (soutien à la sensibilisation), les orthopédistes (soutien aux initiatives en chirurgie) et l’industrie (soutien à des programmes donnés). La collecte de fonds est essentielle à nos activités. En 2012, nous avons lancé une nouvelle activité de collecte de fonds, la classique de golf Bad to the Bone. Cette année, elle aura lieu le 8 juin et, entre autres joueurs de hockey présents, Connor McDavid sera de retour. Ce tournoi est une idée de Sherry Bassin, directeur général des Otters d’Érié, de la Ligue de hockey de l’Ontario, et grand défenseur de la Fondation. Je suis persuadé que les orthopédistes ne voudront pas manquer ce tournoi. L’an dernier, nous avons également relancé la campagne Hip Hip Hourra!, dont bon nombre d’orthopédistes se souviendront pour les activités organisées de 1992 à 2008. La campagne de 2014 a permis de recueillir 15 000 $ au profit de 3 centres orthopédiques canadiens, en plus de fonds affectés à la concrétisation de notre mandat. Ces fonds reflètent l’estime des patients pour les orthopédistes. Le Défi podomètre, une nouveauté, a en outre permis de recueillir 70 000 $. Depuis trois ans, par contre, les dons des orthopédistes chutent, et nous ne pouvons plus nous fier à notre noyau d’orthopédistes pour remplir notre mandat de soutien envers eux, mandat qui est d’ailleurs endossé par l’ACO. Tous les orthopédistes doivent mettre l’épaule à la roue dès maintenant!

POURQUOI DEVONS-NOUS AGIR? Nous devons tous agir parce que nos collègues orthopédistes, notre profession et nos patients ont besoin de nous. Nous connaissons tous trop bien le fardeau associé aux soins de l’appareil locomoteur et à la demande croissante en chirurgie orthopédique. Le milieu de l’orthopédie doit profiter de l’évolution rapide de la technologie et des milieux de soins, qui est au cœur de l’innovation. L’innovation n’est possible que lorsque de bonnes idées sont transposées au chevet des patients; mais bon nombre de nos idées Geoffrey Johnston, MD, FRCSC n’aboutissent jamais en rai- Président de la Fondation son d’un manque de fonds. Canadienne d’Orthopédie Le financement gouvernemental en recherche se fait de plus en plus rare et inaccessible. Nous ne pouvons toutefois pas nous permettre un tel gaspillage d’idées; d’ailleurs, nous avons récemment appris que des orthopédistes torontois ont investi personnellement des sommes substantielles afin de financer leur propre programme de recherche, faute de financement externe adéquat. La Fondation Canadienne d’Orthopédie, consciente du fait que les excellentes idées de recherche des orthopédistes canadiens ne sont pas soutenues, souhaite assurer le financement de démarrage dont ils ont désespérément besoin. Pour ce faire, nous devons accroître la valeur des prix, bourses et subventions remis à nos orthopédistes de sorte à stimuler leurs idées en matière de recherche et d’innovation. En 50 années d’existence, la Fondation a bâti un riche legs de soutien à la recherche en orthopédie au Canada grâce à des investissements de près de 1 million de dollars. Pour consulter l’impressionnante liste de plus de 60 orthopédistes financés par la Fondation, consultez son site Web, à www.canorth.org (cliquez sur « À propos de nous », puis « Bourses de recherche et subventions à l’éducation »). Les derniers lauréats des prix, bourses et subventions de la Fondation confirment leur valeur : Le Dr Brian Kwon, lauréat du Prix J.-Édouard-Samson en 2013, explique : « Le Prix s’est avéré extrêmement précieux dans la mise en œuvre d’expériences préliminaires qui peuvent attirer des fonds externes à plus grande échelle ». Selon le Dr Nadr Jomha, lauréat du Prix J.-Édouard-Samson en 2012, la réception du Prix J.-ÉdouardSamson en 2012 a marqué un jalon dans sa carrière de chercheur, puisqu’elle est venue officialiser son leadership dans la recherche en orthopédie au Canada. « Le Prix a été important dans l’avancement de ma carrière de chercheur, car il permet aux responsables de l’évaluation de mes demandes de financement et de mes nominations de constater que mes travaux ont été évalués et reconnus par une organisation nationale indépendante. Je suis très reconnaissant envers la Fondation COA Bulletin ACO - Spring / Printemps 2015

Foundation / Fondation

(continued from page 51)

Canadienne d’Orthopédie pour l’honneur qu’elle m’a fait. » De son côté, le Dr Albert Yee, lauréat du Prix J.-Édouard-Samson en 2011, écrit : « Le Prix a joué un rôle important dans l’histoire de la recherche en orthopédie au Canada, plusieurs de ses lauréats étant des mentors clés qui m’ont inspiré pendant les premières années de ma carrière universitaire. Grâce à cette distinction, j’ai pu continuer d’appuyer les travaux de stagiaires prometteurs qui composent la prochaine génération de chercheurs-orthopédistes. » Le Dr Douglas Naudie, colauréat de la Bourse du HROC de 2013, ajoute : « Les subventions sont de plus en plus difficiles à obtenir. La Fondation Canadienne d’Orthopédie est l’une des seules organisations qui fait de la recherche en orthopédie une priorité. On peut couvrir nos frais avec une simple bourse, et nous sommes très reconnaissants de pouvoir poser notre candidature dans le cadre d’un programme comme celui du HROC; nous avons hâte de présenter et publier nos recherches grâce au soutien de la Fondation. » Quant aux Drs Mohit Bhandari et Olufemi Ayeni, lauréats de la Bourse du HROC en 2012, ils déclarent que la Bourse du HROC a été d’une aide essentielle au tout début de leurs essais : « Elle nous a donné de solides arguments pour convaincre d’autres sources de financement, comme les Instituts de recherche en santé du Canada, de sorte à obtenir des subventions 20 fois supérieures à l’investissement financier initial du HROC. » Le Dr Steven MacDonald et Sharon Culliton, lauréats de la Bourse du HROC en 2011, écrivent : « La Bourse de recherche du programme de l’Héritage de la recherche orthopédique au Canada nous a donné l’occasion de développer un outil à la fois novateur et unique pour la sensibilisation des patients en attente d’une arthroplastie totale du genou ». Les prix, bourses et subventions de la Fondation constituent un financement de démarrage crucial dans la réalisation de projets de recherche en orthopédie au Canada. Ils servent de tremplins vers d’autres organes de financement. La liste des lauréats de la Fondation regroupe l’élite de la recherche en orthopédie au pays, mais elle reste trop courte. Pour chaque lauréat de la Bourse du HROC, de 10 à 20 candidatures ne reçoivent pas de financement. Et ce n’est pas par manque de mérite. L’an dernier, la Fondation a reçu 19 candidatures pour des projets dignes d’être financés dans le cadre du programme du HROC. La Fondation a choisi de doter deux bourses malgré le fait que leur valeur dépassait le montant des dons recueillis auprès des orthopédistes canadiens au cours de l’année. Qu’advient-il donc de la majorité des projets, soit ceux qui ne bénéficient pas du financement de la Fondation? Voici ma triste histoire de non-lauréat! Depuis 7 ans, j’effectue un suivi systématique des résultats cliniques, radiographiques et autodéclarés pour 2 000 fractures du radius distal traitées par chirurgie ou non chez des adultes. Fort de cette expérience, j’ai soigneusement conçu une nouvelle prothèse chirurgicale pour les fractures du radius distal chez les adultes qui mise sur les forces des interventions actuelles et en minimise les faiblesses. En plus de soumettre des demandes pour du financement local et provincial attribué en fonction d’une évaluation par des pairs, j’ai soumis ma candidature pour une bourse de la Fondation. Je figure parmi les 17 candidatures qui n’ont pas pu être financées, et ma demande de financement provincial a également été rejetée. Peut-être dira-t-on de mon idée qu’elle n’était pas destinée à voir le jour, qui sait? Je n’en crois rien, COA Bulletin ACO - Spring / Printemps 2015

bien sûr. Mais nombreuses sont les bonnes idées qui subissent le même sort, et c’est dommage. Les orthopédistes canadiens se connaissent et se font confiance. Nous devrions être prêts à prendre le risque d’investir dans les idées de nos collègues. En sachant que les dons actuels des orthopédistes canadiens ne permettent d’investir que dans 5 % des idées de leurs collègues, je suis d’avis que leur volonté d’investir est bien timide, et que cela met carrément en péril l’avenir de la recherche en orthopédie au pays. La Fondation est décidée à appuyer nos bonnes idées et les nombreuses possibilités découlant des découvertes scientifiques. Plus que jamais, il faut rallier nos donateurs au sein de la population et du milieu chirurgical, et faire appel à leur générosité afin de nourrir ces initiatives. L’an dernier, les orthopédistes ont donné à peine 35 000 $ pour ces projets. Pour que la Fondation puisse nous offrir ce que nous voulons, elle a toutefois besoin de notre soutien généralisé, voire universel. Le calcul est simple, mais sa concrétisation n’est malheureusement pas évidente. Si chacun des 1 500 orthopédistes canadiens avait fait un don en 2014, le don moyen aurait été de 23 $; si seuls les 900 membres actifs de l’ACO l’avaient fait, le don moyen aurait été de 38 $. Bref, c’est l’équivalent d’une à deux semaines de cafés. Il est difficile de voir un tel don comme un investissement dans nos collègues. Si chacun des 1 500 orthopédistes exerçant au pays donnait seulement 190 $, ou si chacun des membres actifs de l’ACO donnait 310 $, nous atteindrions notre cible de 280 000 $. Malheureusement, la réalité est toute autre, et notre financement a toujours été tributaire des dons d’une fraction des membres. « Jamais tant de gens n’ont dû autant à si peu », disait Churchill. Nous vous serions donc très reconnaissants de donner plus généreusement. Vos collègues chercheurs ne vous décevront pas! Au sud du 49e parallèle, l’Orthopaedic Research and Education Foundation (OREF) déclarait en 2013 des dons d’une valeur de 1,8 million de dollars pour la recherche, provenant presque exclusivement de 2 000 orthopédistes, pour une moyenne de 900 $US par donateur. Ce montant est près de 50 fois supérieur aux dons faits par les orthopédistes canadiens en 2014. Nous pouvons faire mieux. Le riche legs de soutien à la recherche en orthopédie au Canada doit se poursuivre. La Fondation a besoin de votre soutien. Invitez vos collègues à donner eux aussi, car la Fondation soutient tous les orthopédistes au pays en favorisant l’avancement de la recherche, de la formation et de la sensibilisation. Incitez-les à faire un don annuel ou par prélèvements mensuels. Je me suis personnellement engagé à donner l’équivalent d’une seule consultation en orthopédie par mois. Je vous demande donc, chers collègues, d’être aussi généreux.

Foundation / Fondation

(continued from page 52)

La Fondation Canadienne d’Orthopédie a 50 ans. Nous continuons de soutenir les besoins en information de vos patients et, avec l’appui indéfectible de l’ACO, nous avons accru notre soutien à la recherche, à la formation et à la sensibilisation de sorte à répondre aux besoins des membres de l’ACO. Nous nous sommes adaptés, et nous avons besoin que vous vous appropriiez la mission commune de l’ACO et de la Fondation, qui est de favoriser l’innovation et la découverte dans le milieu de l’orthopédie au Canada. La Fondation Canadienne d’Orthopédie vous appartient. Ensemble, nous pouvons atteindre l’excellence en matière de santé des os et des articulations, de mobilité et de fonction pour tous les Canadiens, en faisant progresser la recherche, l’éducation et les soins. Dans 50 ans, nous considérerons les réalisations de notre fondation et nous pourrons dire que nous avons fait ce qu’il fallait.

Tout comme l’ACO, la Fondation Canadienne d’Orthopédie est durement éprouvée par la mort soudaine de Cy Frank, le 5 mars dernier, puisqu’elle perd un véritable leader, un membre du conseil de longue date ainsi que le président de son comité des candidatures et de la gouvernance. Nous garderons tous en mémoire la passion de Cy pour la recherche en chirurgie orthopédique et l’amélioration de l’accès aux soins orthopédiques pour l’ensemble de la population canadienne. Chercheur et innovateur dans l’âme, il a parfaitement assumé sa vocation en chirurgie orthopédique. Ensemble, l’ACO et la Fondation doivent aujourd’hui poursuivre son œuvre. Il nous manquera tous énormément.

And the Winners Are…. Free Membership Dues Contest Results Congratulations are extended to Drs. Mario Corriveau from Saint-Jean-sur-Richelieu and Gwyneyth deVries from Fredericton for being the two lucky winners of our membership dues contest. Both Drs. Corriveau and deVries will have their 2015 COA membership dues reimbursed. This contest was open to all Active members whose accounts were in good standing by May 1. The winners were selected by random draw. Stay tuned for more incentive contests in the future!

Et les gagnants sont… Résultats du tirage des cotisations gratuites Félicitations aux Drs Mario Corriveau, de SaintJean-sur-Richelieu, et Gwyneth deVries, de Fredericton, les heureux gagnants de notre concours, qui verront ainsi leur cotisation de 2015 à l’ACO remboursée. Ce concours était ouvert à tous les membres actifs dont les comptes étaient en règle au 1er mai. Les gagnants ont été désignés par tirage au sort. Restez à l’affût! Nous avons d’autres concours du genre en vue!

COA Bulletin ACO - Spring / Printemps 2015

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

37th National CONA Conference Reaching New Horizons in Orthopaedics May 24-27 mai Fredericton, NB Web Site/Site Int. : http://www.cona-nurse.org/ 16th Congress of the European Federation of National Associations of Orthopaedics and Traumatology (EFORT) May 27-29 mai Prague, Czech Republic Web Site/Site Int. : https://www.efort.org/prague2015/ Bethune Round Table 2015 - Meeting Local Needs: Socially Accountable Surgical Care Hosted by the Centre for Global Surgery at the University of Calgary June 4-7 juin Calgary, AB E-mail/Courriel : brt2014@mcmaster.ca Web Site/Site Int. : http://www.ucalgary.ca/cgs/bethune Annecy Live Surgery International Shoulder Advanced Course June 11-13 juin Annecy, France Web Site/Site Int. : http://www.lafosseshoulder-annecy.com/ CORA Annual Meeting June 17 juin Vancouver, BC E-mail/Courriel : coraweb@canorth.org Web Site/Site Int. : http://www.coraweb.org/ South African Orthopaedic Association (SAOA) 61st Annual Congress August 31 août-September 3 septembre Drakensberg, South Africa Web Site/Site Int. : http://www.saoa.org.za/

2016

European Orthopaedic Research Society (EORS) 23rd Annual Meeting September 2-4 septembre Bristol, UK Web Site/Site Int. : http://eors2015.org/ British Orthopaedic Association (BOA) Annual Scientific Congress September 15-18 septembre Liverpool, UK Web Site/Site Int. : http://congress.boa.ac.uk/ 36th SICOT Orthopaedic World Congress September 17-19 septembre Guangzhou, China Hip Symposium Brochure 2015_2013 2015-01-26 9:57 AM Page 1 E-mail/Courriel : congress@sicot.org Web Site/Site Int. : http://www.sicot.org/guangzhou

JOINTS Shoulder Course January 28-29 janvier Ottawa, ON E-mail/Courriel : cpd@toh.on.ca Web Site/Site Int. : http://www.coa-aco.org/joints/joints-meetings/

13th Meeting of the Combined Orthoaedic Associations April 11-15 avril Cape Town, South Africa

12th Biennial Canadian Orthopaedic Foot & Ankle (COFAS) Symposium April 14-16 avril Wet lab on April 14 Eaton Centre Marriott Toronto, ON E-mail/Courriel : cofas@canorth.org Web Site/Site : http://www.canadafoot.com/

th SYMPOSIUM on 1 1

Australian Orthopaedic Association (AUST.OA) 75th Annual Scientific Meeting October 11-15 octobre Brisbane, Australia Web Site/Site Int. : http://asm.aoa.org.au/

Joint Preserving and Minimally Invasive Surgery of the Hip

New Zealand Orthopaedic Association (NZOA) ANNUAL Scientific Meeting October 18-21 octobre Te Papa, Wellington, New Zealand Web Site/Site Int. : http://www.nzoa.org.nz/

World renowned faculty, interactive format including case base discussions on hip arthroscopy techniques, open hip surgery, FAI, dual mobility cups, short stems, anterior approach surgery as well as a hands on skills laboratory for hip arthroscopy, osteotomy and less invasive total hip replacements.

28th Annual COA Basic Science Course October 24-30 octobre Ottawa Conference Centre Ottawa, ON Web Site/Site Int. : http://www.orthobasicscienceacademy.org/

The Classic for Hip Courses

June 4-6, 2015

CAS 4th Annual Meeting November 26-27 novembre Ottawa, ON E-mail/Courriel : cas@canorth.org Web Site/Site Int. : http://www.coa-aco.org/cas/cas/

Office of Continuing Professional Development Loeb Research Building, Main Floor, Room 158 725 Parkdale Avenue, Ottawa, ON K1Y 4E9

Fairmont Chateau Laurier, and University Of Ottawa Skills and Simulation Centre, Ottawa, ON, Canada

COA Bulletin ACO - Spring / Printemps 2015

2017 June 16-18 juin Ottawa, ON

Fairmont Chateau Laurier, and University Of Ottawa Skills and Simulation Centre, Ottawa, ON, Canada

2016 June 16-19 juin Québec City, QC

2015 June 17-20 juin Vancouver, BC

Come learn from the experts in your field

Upcoming COA/CORS Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO et de la SROC Eleventh Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip

2018 June 21-23 juin Victoria, BC

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Active for Life From June 17-20, 2015, the Canadian orthopaedic community will come together in beautiful Vancouver, British Columbia. Iconic landscapes and breathtaking views will provide an ideal setting for those who enjoy an active lifestyle. It’s why we chose Vancouver to represent our 2015 theme: Active for Life. Orthopaedics is one of the most optimistic disciplines in medicine, where patient outcomes are often dramatic and quality of life soars. Our common goal is to ensure that our skills contribute to an active life for those we care for, and the lifestyle orthopaedics for Canadians.

coaannualmeeting.ca

Plan to join us June 17-20, 2015.

Actif pour la vie Du 17 au 20 juin 2015, la communauté orthopédique canadienne se réunira dans le cadre enchanteur de Vancouver, en Colombie-Britannique. Les paysages emblématiques et personnes privilégiant un mode de vie actif. C’est pourquoi nous

L’orthopédie est l’une des disciplines médicales les plus optimistes, puisque les patients obtiennent souvent des résultats spectaculaires, retrouvant une excellente qualité de vie. Notre objectif commun est de veiller à ce que nos compétences permettent à ceux que nous soignons d'avoir une vie active, et le mode de vie caractéristique de Vancouver est tout à fait désigné canadienne. Soyez des nôtres du 17 au 20 juin 2015.

COA Annual Meeting Réunion annuelle de l’ACO CANADIAN ORTHOPAEDIC ASSOCIATION ASSOCIATION CANADIENNE D'ORTHOPÉDIE

CANADIAN ORTHOPAEDIC RESEARCH SOCIETY SOCIÉTÉ DE RECHERCHE ORTHOPÉDIQUE DU CANADA

CANADIAN ORTHOPAEDIC RESIDENTS ASSOCIATION ASSOCIATION CANADIENNE DES RÉSIDENTS EN ORTHOPÉDIE

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