Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Spring / Printemps 2016 Publication Mail Envoi Poste-publication Convention #40026541 4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3

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

BULLETIN

112

Photo: Jean-François Bergeron, Enviro Foto

Are you ready for the 2016 COA, CORS & CORA Annual Meeting in Québec City? see page 13

Êtes-vous prêt pour la Réunion annuelle 2016 de l’ACO, de la SROC et de l’ACRO, à Québec? Page 12

Militer pour un meilleur accès aux soins � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4 Canadian Research Featured Nationally and Internationally in 2016 � � � � � � � � � � � � � � 18 How to Get your Hip Fracture Patient “Ready for the OR”� � � � � � � � � � � � � � � � � � � � � � � � � � � 27 Wait Time Alliance 2015 Report Card: Another Year of Slow Progress � � � � � � � � � � � � � 34

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Your COA / Votre association

Bulletin

CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 112 Spring / Printemps 2016

The COA has moved!

L’ACO a changé d’adresse!

COA / ACO Dr. Robin R. Richards President / Président

Please remember to update your records with our new address:

N’oubliez pas de mettre vos dossiers à jour :

Canadian Orthopaedic Association (COA) 4060 St. Catherine Street West Suite 620 Westmount, QC H3Z 2Z3

Association Canadienne d’Orthopédie (ACO) 4060, rue Sainte-Catherine Ouest Bureau 620 Westmount (Québec) H3Z 2Z3

Our telephone, fax, web site and e-mail addresses all remain the same. Please update your records.

Nos numéros de téléphone et de télécopieur de même que nos adresses Internet et de courriel demeurent les mêmes.

Thank you!

Merci de noter ces nouvelles coordonnées!

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

Advocacy for Access to Care Robin R. Richards, M.D., FRCSC President, Canadian Orthopaedic Association

ince my previous message in the COA Bulletin, your Board of Directors met in Toronto and discussed access to orthopaedic care. Preparatory to the Board meeting, a Position Statement on Access to Care had been developed for discussion. I am pleased to report that this statement was ratified by the Board and is available on the COA web site for review and use by members and the public (click here to access the statement). All Canadians should have timely access to orthopaedic care irrespective of age, diagnosis and province of residence. What is “timely” access to care? Access to care for the public usually involves an initial wait to see an orthopaedic surgeon. If surgery would be beneficial for the patient, and if the patient wishes to proceed with surgery, there The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4060 St. Catherine Street West, Suite 620, Westmount, Quebec, H3Z 2Z3. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: cynthia@canorth.org

Le Bulletin de l’Association Canadienne d’Orthopédie est publié au printemps, été, Automne, hiver par l’Association Canadienne d’Orthopédie, 4060, rue Ste-Catherine Ouest, Suite 620, Westmount, Québec H3Z 2Z3. Le Bulletin est distribué aux membres de l’ACO, aux gouvernements, aux hôpitaux, aux professionnels de la santé et à l’industrie orthopédique. Veuillez faire parvenir tout changement d’adresse à : cynthia@canorth.org

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

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

COA Bulletin ACO - Spring / Printemps 2016

Your COA / Votre association

(continued from page 3)

is another wait for the surgery to be booked and performed. Sometimes imaging studies are required prior to surgery. In our view, access should depend on the acuity of the problem and should be immediate for urgent cases and available within 90 days for non-urgent cases. As we all know, access to orthopaedic care in Canada is challenging. Recent newspaper headlines speak of “layoffs”, cutting health-care jobs to “save money”, the need to achieve greater “efficiencies” and orthopaedic patients in Montréal waiting up to “two weeks for urgent surgery”. In my last message, I noted that the government posted wait times in Ontario of 314, 220 and 219 days for lumbar disc, forefoot and knee replacement surgery. These times do not include the wait time for an appointment! Lengthy waits for orthopaedic surgery are unacceptable. We all pay for our health-care system with our taxes. Access delayed is access denied. Nothing will change with respect to access to care unless individual patients are made aware of the issue and speak up. Please use the Position Statement to inform your patients and encourage them to advocate for access to orthopaedic care in their jurisdiction. Your Board also has developed a Position Statement on Late Career Transition (click here to access) recognizing that there is no longer a defined retirement age in Canada and that many orthopaedic surgeons wish an evolution, as opposed to a revolution, at the end of their careers. Late career transition is a universal process for all orthopaedic surgeons irrespective of their current age. Some of us, yours truly included, are further along the road than others. Late career transition surgeons have an opportunity to adjust their practices and maintain meaningful involvement as they take less call and use less resource. The key to successful late career transition is planning and communication with colleagues. Late career transition surgeons can and should be involved in the recruitment of their replacement and there may be an opportunity for job sharing with one of our many young orthopaedic surgeons looking for a definitive position. Your Board also refreshed our Position Statement on Orthopaedic Graduate Unemployment (click here to access the statement) noting the need for transparency in the recruitment process and stating that, where qualifications for a job opportunity are equal, that hiring processes should prioritize Canadian citizens or permanent residents to maximize job opportunities for Canadians.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 23 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 34 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 43 We are pleased to have a strong presence at the 13th Meeting of the Combined Orthopaedic Associations (COMOC) in Capetown, South Africa. Dr. Markku Nousiainen has organized a symposium on “The Role of a Competency Based Curriculum in Orthopaedic Training: Bridging the Gap between Theory and Clinical Practice”. Dr. Mohit Bhandari will be presenting a symposium “Clinical Trials (and Tribulations): The Promise of Multinational Research” with Drs. Ross Leighton and Brad Petrisor participating. Dr. James P. Waddell will be presenting a plenary lecture on “An Intergrated Approach to Quality and Access in a Universal Health-care System”. I will be giving the Canadian perspective at an international medicolegal symposium. As President, I am proud of the breadth, depth and quality of our involvement in this meeting. I trust that you have made plans to attend the COA and CORS Annual Meeting in Québec City this June. Remember that your annual membership dues cover the pre-registration fee for the Annual Meeting if you are an Active member. Register before April 29 to take advantage of this benefit. The meeting promises to be a great learning experience in a historic venue and represents a chance to learn, network and meet friends old and new. Refer to page 13 in this edition of the COA Bulletin to learn more about the event, and visit www.coaannualmeeting.ca. Thank you for the honour of serving as your President. You are welcome to contact me directly (robin.richards@sunnybrook.ca) at any time.

Militer pour un meilleur accès aux soins Robin R. Richards, MD, FRCSC Président, Association Canadienne d’Orthopédie

epuis ma dernière intervention dans le Bulletin de l’ACO, le conseil d’administration s’est réuni à Toronto, où il a abordé la question de l’accès aux soins orthopédiques. En prévision de cette réunion, on a rédigé un énoncé de position sur l’accès aux soins orthopédiques. Je suis heureux de vous annoncer que cet énoncé a été adopté par le conseil d’administration, et les membres comme le reste de la popuCOA Bulletin ACO - Spring / Printemps 2016

lation peuvent maintenant le consulter sur le site Web de l’ACO (cliquez ici pour accéder à l’énoncé). Toute la population canadienne devrait avoir accès à des soins orthopédiques en temps opportun, peu importe l’âge, le diagnostic et la province de résidence. Mais qu’entend-on par l’accès aux soins « en temps opportun »? Les personnes qui veulent obtenir des soins doivent attendre un certain temps avant de rencontrer un orthopédiste. Si une chirurgie peut être bénéfique, et si le patient souhaite aller de l’avant, il doit à nouveau attendre avant d’obtenir une date pour l’intervention, puis avant l’intervention comme telle. Il arrive aussi que l’on doive effectuer

Your COA / Votre association

(suite de la page 4)

des examens d’imagerie avant la chirurgie. Nous sommes d’avis que l’accès aux soins devrait dépendre de la gravité du problème et que, dans les cas urgents, il devrait être immédiat; les cas non urgents devraient quant à eux être traités dans les 90 jours. Comme nous le savons tous, l’accès aux soins orthopédiques au pays pose problème. Les manchettes faisaient récemment allusion à des mises à pied, à des coupes de postes en santé afin d’économiser, à la nécessité d’être plus efficaces, et au fait que certains patients montréalais devaient attendre jusqu’à deux semaines avant de subir une chirurgie orthopédique urgente. Dans ma communication précédente, je soulignais que le gouvernement a dévoilé les temps d’attente en Ontario, qui sont de 314 jours pour une chirurgie discale lombaire, de 220 jours pour une chirurgie de l’avant-pied et de 219 jours pour une arthroplastie totale du genou. Et ces temps d’attente ne tiennent pas compte du délai nécessaire à l’obtention d’un rendez-vous! De longs délais en chirurgie orthopédique sont inacceptables. Nous payons tous des impôts pour financer notre système de santé. Les délais dans l’accès aux soins équivalent à une absence de soins. Et rien ne changera à cet égard tant que chaque patient ne sera pas informé du problème et incité à s’exprimer. Nous vous prions donc d’utiliser l’énoncé de position pour informer vos patients et les inciter à militer pour l’accès aux soins orthopédiques dans leur région. Le conseil d’administration a en outre convenu d’un énoncé de position sur la transition en fin de carrière (cliquez ici pour y accéder) qui tient compte du fait qu’il n’y a plus d’âge établi pour le départ à la retraite au Canada et que de nombreux orthopédistes souhaitent finir leur carrière progressivement plutôt que du jour au lendemain. La transition en fin de carrière est un concept universel, peu importe l’âge des orthopédistes. Certains sont plus près de la ligne d’arrivée que d’autres, et j’en suis. Les orthopédistes en fin de carrière ont l’occasion de modifier l’exercice de leur profession tout en y contribuant de manière significative en réduisant leur temps de garde et en mobilisant moins de ressources. La planification et la communication avec ses collègues est au cœur d’une transition réussie. Les orthopédistes en fin de carrière peuvent participer à l’embauche de leur remplaçant et devraient le faire; ce pourrait être l’occasion de partager leurs tâches avec l’un des nombreux collègues de la relève en quête de permanence. Le conseil d’administration a d’ailleurs mis à jour l’énoncé de position sur le sous-emploi des diplômés en orthopédie (cliquez ici pour y accéder), où on insiste sur la transparence du processus d’embauche et précise que, à compétences égales, les processus d’embauche devraient favoriser les citoyens canadiens et résidents permanents afin de maximiser les possibilités d’emploi pour les orthopédistes canadiens. Nous sommes heureux d’être si bien représentés à la 13e réunion conjointe des associations orthopédiques du monde (COMOC), qui aura lieu au Cap, en Afrique du Sud. Le Dr Markku Nousiainen propose un symposium intitulé Le rôle du curriculum fondé sur les compétences dans la formation orthopédique : Réduire l’écart

entre la théorie et la pratique clinique. Le Dr Mohit Bhandari animera un symposium intitulé Essais cliniques (et tribulations) : Les possibilités de la recherche multinationale, auquel participeront les Drs Ross Leighton et Brad Petrisor. Le Dr James P. Waddell prononcera pour sa part une plénière, intitulée Une approche intégrée en matière de qualité et d’accès dans le système universel de soins de santé. Je fournirai quant à moi une perspective canadienne dans le cadre d’un symposium médicolégal international. En tant que président, je suis fier de la portée et de la qualité de notre contribution à cette manifestation. J’espère que vous avez prévu assister à la Réunion annuelle de l’ACO et de la SROC, qui aura lieu à Québec, en juin. N’oubliez pas que votre cotisation annuelle à titre de membre actif englobe les droits d’inscription à cette manifestation, pourvu que vous vous y inscriviez avant le 29 avril. Ce devrait être une belle expérience professionnelle, dans un cadre historique, et une excellente occasion d’apprendre, de réseauter, de revoir de vieux amis et de faire de nouvelles rencontres! Consultez la page 12 du présent numéro du Bulletin de l’ACO pour en savoir plus, et consultez le site www.coaannualmeeting.ca. Je vous remercie pour le privilège que vous m’avez accordé en faisant de moi votre président. Enfin, sachez que vous pouvez toujours me joindre directement à robin.richards@sunnybrook.ca.

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 2016

Your COA / Votre association

Successful Organizations Embrace Change: Committees Position the COA for Growth Doug Thomson Chief Executive Officer Canadian Orthopaedic Association

arlier this year, the COA leadership assembled in Toronto for the Association’s annual Mid-Winter Meeting. Meetings were held by the Practice Management Committee, (Chaired by Dr. Ken Hughes), Standards Committee (Chaired by Dr. Jeffrey Gollish), the Committee on Continuing Professional Development (Chaired by Dr. John Murnaghan), as well as the Executive and Board of Directors (both Chaired by Dr. Robin Richards, COA President). We are pleased to provide the membership with a brief summary of some of the developments that were discussed during these meetings. Update on Membership Services The 2016 membership dues invoices were issued in mid-January of this year allowing Active members ample time to take advantage of the new free Annual Meeting registration benefit by the April 29 deadline. Active members can now immediately register for the COA Annual Meeting at no charge, provided that they pay their outstanding membership dues invoice and register for the meeting by the April 29 pre-registration deadline. For questions about your membership status, contact Cynthia Vezina at cynthia@canorth.org or 514-874-9003 x 3. Members can look forward to a fully refreshed and redesigned COA web site this fall. Our current site will be restructured to better highlight valuable membership services, educational resources and COA position statements. Changes have already been added to the members’ area of the site with the inclusion of a job board and direct access to some of our partnering subscription services. Your COA web site login will now give you access to all online services including: dues payments and profile updates, abstract submissions, meeting registration as well as the job board. The COA continues to offer complementary subscriptions to its Active and Associate members to both the Bone & Joint Journal (formerly JBJS British Edition) as well as to https://www.myorthoevidence.com/. Visit the members’ area at www.coa-aco.org by logging in with your e-mail address and COA password to access these membership benefits. The Membership Committee, led by Dr. Mark Glazebrook, will focus on increasing our resident membership within the Association. The Committee will work closely with the Canadian Orthopaedic Residents’ Association (CORA) to foster stronger ties between the two organizations, as well as encourage the Program Directors across Canada to promote COA membership amongst their residents. A “Membership Path” outlining the benefits and services offered to members throughout their entire orthopaedic career will be the focus of this year’s recruitment and retention strategies. This document can be found on the COA web site at any time. COA Bulletin ACO - Spring / Printemps 2016

Advocacy Initiatives The Practice Management Committee and Board of Directors spent considerable time discussing, editing and ultimately approving the following COA position statements: The Position Statement on Access to Orthopaedic Care in Canada posits that Canadians should have timely access to orthopaedic care, and that adaptation to demographic change is needed, including human resource planning. The COA supports evidence-based practice, responsible use of resources and innovative models of care that will improve access to care. Read the full statement here. The Position Statement on Orthopaedic Graduate Unemployment has been updated in 2016 from a previous version, recognizing that the current level of unemployment among graduates poses a threat to the ability of COA members to adequately serve society and offer appropriate access to orthopaedic care. The statement calls for more effective allocation of government resources, describes responsibilities of orthopaedic surgeons in this context, and outlines potential solutions to reverse the numbers of underemployed surgeons. Read the full statement here. The Guidelines for Late Career Transition encourage Canadian hospitals to work with orthopaedic surgeons to develop individual plans for transitioning systematically towards retirement in late career. Recommendations include gradual decrease in surgical activities while participating meaningfully in other aspects of practice, with optimal patient care of paramount importance. Read the complete guidelines here. The COA Board has sourced Monica Testa-Zanin, a public policy consultant, to assist the Association in evolving our priority on access to care into a comprehensive next phase of advocacy activities. A steering committee made up of Board Members, Drs. Peter MacDonald, Kevin Orrell and Geoffrey Johnston as well as Trinity Wittman and myself from the COA Office will work closely with Monica to determine and define what the COA is hoping to achieve through its advocacy efforts and develop a plan accordingly. Drs. Tracy Wilson and Jeffrey Gollish from the COA’s Standards Committee have worked for a number of years with the Canadian Dental Association (CDA) and the AMMI Antimicrobial Stewardship Group on developing a position statement on the role of antibiotic prophylaxis for orthopaedic patients undergoing dental procedures. The Committee has proposed that the COA consider issuing a joint statement with the CDA and has agreed to support the current CDA guidelines after a few minor proposed revisions. The membership will be provided with an example of a shared decision-making tool for use in patient discussions. Further information about these initiatives will be available this summer. Education and Annual Meeting Program Updates An increased number of ‘Fireside Chats’ sessions will be

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added to the 2016 Annual Meeting program in Québec City. Introduced at last year’s meeting in Vancouver, these small group tough case discussion sessions were overwhelmingly popular and very well-reviewed. Fireside Chat sessions will be offered in Hip, Knee, Paediatrics, Sports, Trauma and Foot & Ankle and held at the end of the program day on both Friday, June 17 and Saturday, June 18. Pre-registration is required through the online Annual Meeting registration process at a cost of $25 per session, and space is very limited. Education-based sessions that will be offered during the upcoming Annual Meeting in Québec City include: ICL 7: Surgical Boot Camp as a Transition to Discipline Intervention The Building Blocks for Boot Camp Success (pre-registration is required) Workshop: Transition into Practice: Now that I Have the Job…. What’s Next? (pre-registration is required) Symposium: What Does the Royal College’s “Competence by Design” Plan Mean for Orthopaedic Surgery Training in Canada? We are pleased to announce that Drs. Peter Lapner and J Pollock will be the 2017 Annual Meeting Program Committee Chair and Local Arrangements Committee Chair respectively. Next year’s Annual Meeting will be held from June 16 to 18 in Ottawa. We look forward to heading back to our nation’s capital for this exciting event.

The COA contributions to the Combined Meeting of the Orthopaedic Associations (COMOC) being held in South Africa from April 11-15, 2016 are strong and substantial. Dr. Mohit Bhandari will be presenting a symposium on “Clinical Trials (and Tribulations): The Promise of Multinational Research”, Dr. Markku Nousiainen will moderate a symposium on “The Role of a Competency-based Curriculum in Orthopaedic Training: Bridging the Gap between Theory and Clinical Practice”, and Dr. James Waddell will be the COA’s keynote speaker. Dr. Richards will also be presenting at a medicolegal panel discussion. More information about this meeting can be found at: www.COMOC2016.org. Logistics Members are reminded that the COA Office moved on April 14 to a nearby building. Please take note of the new office address and update your records accordingly. 4060 St. Catherine Street West, Suite 620 Westmount, QC H3Z 2Z3 The next face-to-face committee meetings take place on Thursday, June 16 prior to the Opening Ceremonies of the Québec City Annual Meeting. If you have any questions about the COA’s Committees and their projects, or would like to volunteer to serve on any COA committee, I invite you to contact me at doug@canorth.org or 514 874-9003 x 5.

One Login for All COA Services

Un guichet unique pour tous les services de l’ACO

Job Board has now been added to the COA Web Site where members can view available career opportunities or post a position to the Job Board.

Log in to the COA web site with your COA username (e-mail address) and password to gain access to the Job Board and other membership services. Get Notified When a New Job is Posted If you would like to receive an e-mail notification when a new job is posted to the job board: 1) Log in to the COA web site 2) Select My Profile in the left menu after login 3) Check off the Job Board Notification option at the bottom of the front page of your profile followed by the Submit button. Your COA username and password now give you access to all of our online services including: 1) 2) 3) 4) 5)

Annual Meeting registration Call for abstracts submissions Membership dues payments Profile management (address updates) Job Board Access

Unsure of your COA login? Use the ‘forgot password’ feature on the COA web site or contact Cynthia Vezina: cynthia@canorth.org for assistance.

e site Web de l’ACO comprend maintenant un babillard des possibilités d’emploi que les membres peuvent utiliser pour chercher un emploi ou soumettre des offres d’emploi.

Ouvrez une session sur le site Web de l’ACO à l’aide de vos nom d’utilisateur (courriel) et mot de passe de l’ACO pour accéder au babillard des possibilités d’emploi et à d’autres services offerts aux membres. Avis d’ajouts au babillard Si vous souhaitez recevoir un avis chaque fois qu’une possibilité d’emploi est affichée sur le babillard, procédez comme suit : 1) Ouvrez une session sur le site Web de l’ACO. 2) Sélectionnez « Mon Profil », dans le menu de gauche. 3) Cochez l’option « Avis d’ajouts au babillard », dans le bas de la page de votre profil, puis cliquez sur le bouton « Soumettre ». Vos nom d’utilisateur et mot de passe de l’ACO vous donnent maintenant accès à tous nos services en ligne, y compris les suivants : 1) 2) 3) 4) 5)

Inscription à la Réunion annuelle Soumission de précis Paiement des cotisations Gestion du profil (mise à jour des coordonnées) Babillard des possibilités d’emploi

Vous avez oublié vos coordonnées de connexion au site de l’ACO? Utilisez le lien « Mot de passe oublié? » ou communiquez avec Cynthia Vezina, à cynthia@canorth.org, pour obtenir de l’aide. COA Bulletin ACO - Spring / Printemps 2016

Your COA / Votre association

Les organisations qui réussissent sont celles qui évoluent : Les comités visent la croissance de l’ACO Doug Thomson Directeur général Association Canadienne d’Orthopédie

lus tôt cette année, l’équipe de direction de l’ACO s’est réunie à Toronto pour sa réunion d’hiver. Parmi les réunions au programme, mentionnons celles du Comité sur la gestion de l’exercice (présidé par le Dr Ken Hughes), du Comité sur les normes (présidé par le Dr Jeffrey Gollish), 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 Robin Richards, président de l’ACO). Nous sommes heureux de communiquer aux membres un aperçu des développements abordés pendant ces discussions. Mise à jour sur les services aux membres Les avis de cotisation à l’ACO pour 2016 ont été envoyés à la mi-janvier, ce qui donne amplement le temps aux membres actifs de se prévaloir d’un nouvel avantage, soit la possibilité de s’inscrire gratuitement à la Réunion annuelle d’ici le 29 avril. Les membres actifs peuvent en effet s’inscrire gratuitement à la Réunion annuelle de l’ACO, à condition de régler toute cotisation impayée, d’ici le 29 avril. 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. Cet automne, les membres de l’ACO auront accès à un site Web entièrement revu. Le site actuel sera restructuré de sorte à mettre davantage en valeur les services aux membres, les ressources en matière de formation et les énoncés de position de l’ACO. La section réservée aux membres a déjà été modifiée afin d’y inclure un babillard des possibilités d’emploi de même qu’un accès direct à des abonnements offerts par des partenaires de l’ACO. Vos coordonnées de connexion au site Web de l’ACO vous donneront désormais accès à tous les services en ligne, y compris le paiement des cotisations et la mise à jour du profil, la soumission de précis, l’inscription à la Réunion annuelle et le babillard des possibilités d’emploi. L’ACO continue d’offrir aux membres actifs et associés un abonnement gratuit au Bone & Joint Journal (anciennement le British Journal of Bone and Joint Surgery) et à https://www.myorthoevidence.com/. Rendez-vous dans la section réservée aux membres en ouvrant une séance sur www.coa-aco.org à l’aide de votre courriel et de votre mot de passe de l’ACO pour bénéficier de ces avantages d’adhésion. Le Comité d’admission, présidé par le Dr Mark Glazebrook, se concentrera sur l’augmentation du nombre de résidents au sein de l’ACO. Il travaillera donc en étroite collaboration avec l’Association canadienne des résidents en orthopédie (ACRO) afin de renforcer les liens entre les deux organisations, en plus d’inciter les directeurs de programme partout au pays à promouvoir l’adhésion à l’ACO auprès de leurs résidents.

COA Bulletin ACO - Spring / Printemps 2016

Le document intitulé L’ACO est là pour vous, à chaque étape de votre carrière en orthopédie, qui précise les avantages et services accessibles aux membres, sera au cœur des stratégies de recrutement et de maintien de l’adhésion cette année. On trouve ce document sur le site Web de l’ACO. Initiatives de défense des droits et intérêts Le Comité sur la gestion de l’exercice et le conseil d’administration de l’ACO ont consacré beaucoup de temps à discuter des énoncés de position ci-après, à les modifier et à les approuver. L’énoncé de position sur l’accès aux soins orthopédiques au Canada établit que la population canadienne devrait avoir accès à des soins orthopédiques en temps opportun et qu’il est nécessaire de s’adapter au changement démographique, entre autres grâce à la planification des ressources humaines. L’ACO appuie les principes de l’exercice fondé sur des données probantes, de l’utilisation responsable des ressources et de l’application de modèles de soins novateurs qui améliorent l’accès aux soins. Cliquez ici pour lire l’énoncé. L’énoncé de position de l’ACO sur le sous-emploi des diplômés en orthopédie a été mis à jour en 2016; il reconnaît que le chômage chez les diplômés en orthopédie compromet la capacité des membres de l’ACO à bien servir la société et à offrir un accès adéquat aux soins orthopédiques. Dans son énoncé, l’ACO demande une affectation plus efficace des ressources gouvernementales, décrit les responsabilités des orthopédistes en ce sens et cerne les solutions possibles au problème de sous-emploi des orthopédistes. Cliquez ici pour lire l’énoncé. Les lignes directrices sur la transition en fin de carrière invitent les hôpitaux canadiens à collaborer avec les orthopédistes à l’élaboration de plans de transition individuels leur permettant d’entamer systématiquement le processus en fin de carrière. Parmi leurs recommandations, on compte une diminution progressive des activités chirurgicales, qui pourrait être associée à une participation significative à d’autres aspects de l’exercice de la profession, la prestation de soins optimaux étant de la plus haute importance. Cliquez ici pour lire les lignes directrices. Le conseil d’administration de l’ACO a retenu les services de Monica Testa-Zanin, conseillère en matière de politique publique, qui l’aidera à intégrer la progression du dossier de l’accès aux soins, une priorité pour l’ACO, à la prochaine phase de ses activités de défense des droits et intérêts. Un comité directeur composé de membres du conseil d’administration (les Drs Peter MacDonald, Kevin Orrell et Geoffrey Johnston) de même que de membres du personnel de l’ACO (Trinity Wittman et moi-même) travaillera en étroite collaboration avec Mme Testa-Zanin pour établir ce que l’ACO souhaite tirer de ses efforts à cet égard et établir un plan en conséquence. Les Drs Tracy Wilson et Jeffrey Gollish, du Comité sur les normes de l’ACO, collaborent depuis plusieurs années avec l’Association dentaire canadienne (ADC) et le Comité sur la résistance aux

Your COA / Votre association

(suite de la page 8)

antimicrobiens et leur gestion de l’Association pour la microbiologie médicale et l’infectiologie Canada (AMMI Canada) afin d’élaborer un énoncé de position sur le rôle de l’antibioprophylaxie chez les patients en orthopédie qui doivent subir une procédure dentaire. Le Comité a proposé que l’ACO envisage la publication d’un énoncé conjoint avec l’ADC et a accepté d’appuyer les lignes directrices de cette dernière en la matière, après de légères modifications. Les membres obtiendront un exemple d’outil de prise de décision partagée à employer dans leurs discussions avec les patients. De plus amples renseignements sur ces initiatives seront disponibles cet été. Mises à jour sur la formation et le programme de la Réunion annuelle Il y aura davantage de « Discussions au coin du feu » à la Réunion annuelle 2016, à Québec. Créées à l’occasion de la Réunion annuelle de 2015, à Vancouver, ces petits groupes de discussion sur des cas complexes ont connu un très grand succès et ont ravi les participants. Les « Discussions au coin du feu » porteront sur la hanche, le genou, la pédiatrie, la médecine sportive, la traumatologie, et la cheville et le pied; elles auront lieu à la fin du programme du jour les vendredi et samedi 17 et 18 juin. Il faut s’inscrire à ces séances en ligne, en même temps qu’à la Réunion annuelle; chacune coûte 25 $, et le nombre de places est très limité. Parmi les séances de formation au programme, mentionnons les suivantes : ICL 7 : Camp d’entraînement chirurgical pour permettre la transition en salle chirurgicale – Le b. a.-ba de la réussite (inscription préalable obligatoire) Atelier : Transition vers l’exercice de l’orthopédie – J’ai un emploi... Et maintenant? (inscription préalable obligatoire) Symposium : Que signifie le plan La compétence par conception, du Collège royal des médecins et chirurgiens du Canada, pour la formation en orthopédie au pays?

Frank Gunston 1923-2016

R. FRANK GUNSTON CM, BSc.Eng(E), MD, FRCS(C), Orthopaedic Surgeon (retired) Frank passed away peacefully at his home in Brandon on Monday, February 15, 2016 at the age of 82. Lovingly remembered by Sharleen, his wife of 47 years, his children John of Brandon and Jennifer of Winnipeg, sisters Joan (Seaforth) Lyle of Naples, FL and Judy (Terrence) Grandstaff of Virginia Beach, VA, his extended family and friends. Born in Flin Flon, MB, the oldest child of Leonard and Myrtle (nee Anderson) Gunston, Frank attended the University of Manitoba, and gained his Engineering degree in 1957, and his MD in 1963. During further study in England, he designed and developed a revolutionary total knee prosthesis. Numerous achievements and accolades followed, including the McLaughlin Travelling Fellowship (Sweden and Finland, 1971-72), Assistant Professorship (Surgery, Orthopaedics) at the U of M Faculty of Medicine, active appointments at Winnipeg

Nous sommes heureux d’annoncer que les Drs Peter Lapner et J Pollock présideront respectivement le Comité responsable du programme et le Comité organisateur de la Réunion annuelle 2017, qui aura lieu à Ottawa, en Ontario, du 16 au 18 juin. Nous sommes emballés de retourner dans la capitale nationale! La contribution de l’ACO à la réunion conjointe des associations orthopédiques du monde, qui aura lieu en Afrique du Sud, du 11 au 15 avril 2016, est fouillée et solide. Le Dr Mohit Bhandari animera un symposium intitulé Essais cliniques (et tribulations) : Les possibilités de la recherche multinationale, tandis que le Dr Markku Nousiainen en modérera un intitulé Le rôle du curriculum fondé sur les compétences dans la formation orthopédique : Réduire l’écart entre la théorie et la pratique clinique. Enfin, le conférencier principal de l’ACO sera le Dr James Waddell. Il y aura aussi une intervention du Dr Richards à un groupe de discussion médicolégal. Pour de plus amples renseignements sur cette manifestation, consultez le site www.COMOC2016.org (en anglais seulement). Logistique On rappelle aux membres que, depuis le 14 avril, les bureaux de l’ACO sont dans un nouvel édifice, à proximité de l’ancien. Veuillez prendre note de nos nouvelles coordonnées et mettre à jour vos dossiers en conséquence : 4060, rue Sainte-Catherine Ouest Bureau 620 Westmount (Québec) H3Z 2Z3 Les prochaines réunions en personne des comités auront lieu le jeudi 16 juin, avant les cérémonies d’ouverture de la Réunion annuelle de Québec. Si vous avez des questions sur les comités de l’ACO et leurs projets, ou si vous souhaitez participer bénévolement à leurs activités, je vous prie de communiquer avec moi, à doug@canorth.org ou au 514-874-9003, poste 5.

General Hospital, the Children’s Centre, the Manitoba Rehab Hospital, and later practice in Orthopaedics and joint replacement at Brandon General Hospital. He received the Principal Manning Award for Innovation (1989) for the knee prosthesis, was named Distinguished Surgeon by the Canadian Orthopaedic Association (1994), received the Order of Canada (1997), and the Manitoba Medical Association Scholastic Award (1998). Following his retirement in 2000, he also received the Queen’s Golden Jubilee Medal in 2002, and the Diamond Jubilee Medal in 2012. Frank’s other passions included building scale live steam engines, restoring antique cars, his love of dogs, and playing music - having played trumpet since high school, and being a long-standing member of many bands and local community ensembles. If friends so desire, donations may be made to the Brandon Humane Society, 2200-17th Street East, Brandon, Manitoba, R7A 7M6 or to Funds for Furry Friends, #208 - 740 Rosser Avenue, Brandon, Manitoba, R7A 0K9. Expressions of sympathy may be made at www.memorieschapel.com. COA Bulletin ACO - Spring / Printemps 2016

Your COA / Votre association

2017 ABC Fellowship Applications – May 1 Deadline

Date limite de soumission des candidatures pour la Bourse de voyage ABC 2017 : Le 1er mai

he COA is accepting applications for the 2017 ABC Travelling Fellowship until May 1, 2016. The tour will take place during the Spring of 2017 over approximately five weeks. This fellowship opportunity is open to candidates who are under 45 years of age as of December 31, 2016 and who are either Canadian citizens or permanent residents with full-time positions in Canadian hospitals. Guidelines, application forms and further information can be found here.

’ACO accepte les candidatures pour la Bourse de voyage américano-britanno-canadienne (ABC) 2017 jusqu’au 1er mai 2016. La tournée aura lieu au printemps 2017 et durera environ cinq semaines. Les candidats doivent être âgés de moins de 45 ans au 31 décembre 2016 et être citoyens canadiens ou résidents permanents, en plus d’occuper un poste à temps plein dans un hôpital canadien. Vous trouverez les lignes directrices, le formulaire de demande et de plus amples renseignements ici.

Past ABC Fellowship Tours Pictured Above COA Bulletin ACO - Spring / Printemps 2016

Heading

ABOUT MEDEC

The innovations of our member companies have helped diagnoses, enhance the treatment and cure of diseases, and transform the delivery of healthcare in Canada. Procedures reduce long-term disabilities. Healthcare institutions often once considered highly invasive can now be performed as day experience greater efficiency, reduced waiting lists and betsurgery with minimal scarring and quick recovery. Every day, ter utilization of human resources thanks to medical devices THE VOICE OF CANADA’S MEDICAL TECHNOLOGY INDUSTRY advances in medical technologies make possible less invasive and technologies. procedures, speedier recoveries, and a quicker return to productivity and independent living. They improve the accuracy of

CANADA’S MEDICAL TECHNOLOGY INDUSTRY AT A GLANCE

Established in 1973, MEDEC is the national association representing Canada’s innovative medical technology (medtech) industry.

For more than 40 years, MEDEC has delivered essential programs and services to its member companies (members), including:

Representing approximately 100 medtech companies (ranging from Canadian-owned to multinationals), MEDEC works closely with the federal and provincial-territorial governments, health professionals, patients and other stakeholders to deliver a patient-centred, safe, accessible, innovative and sustainable, universal healthcare system supported by the use of medical technology.

• Serving as a trusted thought leader on current issues affecting the medtech industry, the healthcare system and international trade;

MEDEC is governed by a Board of Directors representing the diverse perspectives and experiences of its members from across the country.

OUR VISION Serving as an essential partner in providing better health and more sustainable healthcare for Canadians.

OUR MISSION

• Providing access and strategic opportunities for collaboration with government and other health partners; • Delivering timely communications and advocacy tools on key issues that matter to members; • Hosting timely educational sessions to keep members current on industry trends, legislative and policy initiatives at the federal and provincial-territorial level; • Hosting practical forums to accelerate knowledge transfer and the exchange of best practices; and • Promoting broad awareness about medical technology’s contributions to patient care, the healthcare system and to the broader economy.

MEDEC speaks with one voice for Canada’s medical technology companies in advocating for a responsive, safe and sustainable healthcare system that is enabled by the use of Medical Technology.

• • MEDEC represents over 100 member companies in Canada involved in the research, supply and manufacturing of medical technologies. • The size of the Canadian medical device market in 2012 was valued at approximately $6.8 billion, making it the 9th largest worldwide.1 • More than 1,500 medtech companies operate in Canada.2 • Medtech companies are located across Canada with the highest concentration in Ontario and Quebec.3 • Canada exports approximately $1.8 billion of medical technology and imports $7-billion.4 • The largest markets for export are the United States Europe, Middle East South America and China.5 • The Canadian medtech industry employs more than 35,000 Canadians with expertise across multiple disciplines, including but not limited to: life sciences, professional services, biomedical engineering, biological sciences, health economics, information technology, law, manufacturing, nursing, physical sciences, regulatory and quality, sales and marketing, and public affairs.

S Y M B O L A N D LO G OT Y P E _ M E D E C

Industry Canada. 2013. Medical Device Industry Profile 2013 – Canadian Life Sciences Industries. http://www.ic.gc.ca/eic/site/lsg-pdsv.nsf/eng/h_hn01736.html 2 Health Canada, 2013. http://webprod5.hc-sc.gc.ca/el-le/start-debuter.do?lang=eng 3 Industry Canada. 2013. Medical Device Industry Profile 2013 – Canadian Life Sciences Industries. http://www.ic.gc.ca/eic/site/lsg-pdsv.nsf/eng/h_hn01736.html 4 Industry Canada. 2011. Medical Device Industry Profile 2013 – Canadian Life Sciences Industries. http://www.ic.gc.ca/eic/site/lsg-pdsv.nsf/eng/h_hn01736.html 5 MEDEC Industry Market Data Survey, 2013. 1

C A N A DA’S ME DIC A L T E C HNOL O GY C OMPA NIE S LE S SOCIÉ TÉ S CANADIENNE S DE TECHNOLOGIE S MÉDICALE S

w: www.medec.org e: medec@medec.org

405 The West Mall, Suite 900 Toronto, Ontario, M9C 5J1

Your COA / Votre association

En prévision de la Réunion annuelle 2016

u nom du Comité organisateur, nous avons hâte de vous accueillir à la Réunion annuelle 2016 de l’ACO, à Québec, en juin. Le Comité responsable du programme a concocté cette année un programme de formation impressionnant qui offrira à nos membres une foule de possibilités d’apprentissage et de perfectionnement. Veuillez prendre connaissance de tout ce qui vous est proposé à la Réunion de cette année en jetant un coup d’œil au programme provisoire, sous « Participez », dans le menu en tête de notre page d’accueil, à www.coaannualmeeting.ca. La Réunion annuelle sera lancée le jeudi 16 juin, au Centre des congrès de Québec, avec les cérémonies d’ouverture, qui comportent entre autres une allocution du Dr Dave Williams, astronaute. Une intervention à ne pas manquer! Le Dr Robin Richards, président de l’ACO, donnera quant à lui son allocution sur l’état de la situation en plus de remettre les prix du mérite et d’excellence du président.

Nous espérons que vous amènerez votre famille à Québec et que vous profiterez des visites prévues dans le cadre 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, ce ne serait pas vraiment une réunion annuelle de l’ACO si les participants n’avaient pas l’occasion de se réunir entre collègues et amis. Nous vous invitons donc à assister à la Soirée à la marina de l’ACO, le samedi soir, dans le port de Québec. Voyez l’époustouflant panorama qu’offre le Saint-Laurent à cet endroit tout en profitant de la piste de danse et d’un bon repas. Achetez vos billets en vous inscrivant en ligne. Si vous n’êtes pas encore inscrit à la Réunion annuelle 2016, rendez-vous à www.coaannualmeeting.ca. Au plaisir de tous vous voir en juin!

Votre famille vous accompagne à Québec? Inscrivez-vous aux diverses visites et excursions proposées à l’occasion de la Réunion annuelle de l’ACO : • La visite historique • L’excursion culinaire • La chute Montmorency et l’île d’Orléans 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

Michèle Angers MD, FRCSC

Présidente du Comité organisateur 2016

Étienne Belzile MD, FRCSC

Président du Comité responsable du programme 2016

Photo: Luc-Antoine Couturier

COA Bulletin ACO - Spring / Printemps 2016

Your COA / Votre association

Getting Ready to Welcome You to the 2016 Annual Meeting

n behalf of the 2016 COA Annual Meeting planning committee, we look forward to welcoming you to Québec City this coming June. Our Program Committee has put together a very strong educational program this year providing our members with numerous learning and development opportunities. Please take a moment to see what is being offered at this year’s meeting by reviewing the Preliminary Program found in the Attend option in the top menu bar found at www.coaannualmeeting.ca. The Annual Meeting opens with the Opening Ceremonies on Thursday, June 16 at the Québec City Convention Centre. The ceremonies will feature a special address by astronaut Dr. Dave Williams that you don’t want to miss. COA President, Dr. Robin Richards, will deliver his state of the union address and will also present the COA’s distinguished awards of merit and excellence.

We hope that you will bring along your families to Québec City and enjoy the tours 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. Lastly, no COA Annual Meeting would be complete without the opportunity to gather with your colleagues and friends. Saturday evening we invite you all to join us at the port of Québec for the COA’s Night at the Marina. Experience the spectacular panoramic views of the St. Lawrence River while enjoying an evening of dinner and dancing. Purchase your tickets when you register online. If you have not yet registered for the 2016 Annual Meeting, please go ahead and do so by visiting www.coaannualmeeting.ca. We look forward to seeing you all this June.

Bringing Your Family to Québec City? Sign up for the various tours and excursions being offered at the COA Annual Meeting • The Grand Tour of Old Québec • Foodie Tour • Tour of Montmorency Falls & Isle d’Orléans 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

Michèle Angers MD, FRCSC

2016 Local Arrangements Committee Chair

Étienne Belzile MD, FRCSC 2016 Program Committee Chair

Photo: Jean-François Bergeron, Enviro Foto

COA Bulletin ACO - Spring / Printemps 2016

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 • Poster 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 Québec City.

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

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 Québec.

On Twitter @CdnOrthoAssoc

Sur Twitter, @CdnOrthoAssoc

Follow along using #COAQuebec2016

Suivez la Réunion en utilisant le mot-clic #COAQuebec2016

By visiting www.coaannualmeeting.ca

À www.coaannualmeeting.ca

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

COA Bulletin ACO - Spring / Printemps 2016

• 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

Your COA / Votre association

Free Pre-registration Deadline for Active & Associate Members Closes on April 29

ctive and Associate members of the COA are reminded to register for the upcoming COA, CORS and CORA Annual Meeting by April 29 in order to benefit from the waived registration fees. Reduced rates for our Senior, Overseas and Research Affiliate members are in effect until April 29 as well. Visit www.coaannualmeeting.ca to register today. Don’t forget to buy your Night at the Marina tickets before June 9. Tickets may not be available to purchase in Québec City. 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 the June 9 online registration cut-off date. See you in Québec City!

Les membres actifs et associés peuvent s’inscrire gratuitement jusqu’au 29 avril

n rappelle aux membres actifs et associés de l’ACO qu’ils doivent s’inscrire à la Réunion annuelle de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO) d’ici le 29 avril pour profiter de l’annulation de leurs droits d’inscription. Les réductions sur l’inscription offertes aux membres affiliés du milieu de la recherche, outre-mers et à la retraite sont également en vigueur jusqu’au 29 avril. Rendez-vous à www.coaannualmeeting.ca et inscrivez-vous dès aujourd’hui! N’oubliez pas d’acheter vos billets pour la Soirée à la marina avant le 9 juin. Il n’y aura pas nécessairement de billets disponibles à Québec. 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 en ligne avant le 9 juin. Au plaisir de vous voir à Québec!

Night at the Marina – COA Gala and Dinner at the Port of Québec Saturday, June 18

ocated inside Québec City’s Cruise Terminal, Espaces Dalhousie offers a breathtaking panoramic view of the St. Lawrence River where you can join your colleagues and friends for an evening of dinner, dancing and live entertainment. This casual evening is a great opportunity to catch up with colleagues from across the country. Purchase your tickets for Night at the Marina through the COA’s online meeting registration system at www.coaannualmeeting.ca.

Soirée à la marina – Souper-réception de l’ACO, dans le port de Québec Le samedi 18 juin

is à l’intérieur du Terminal de croisières de la ville de Québec, les Espaces Dalhousie offrent une magnifique vue panoramique sur le fleuve Saint-Laurent. Joignez-vous à vos amis et collègues pour une soirée avec souper, danse et divertissements. Cette soirée décontractée est une excellente occasion de renouer avec vos collègues de partout au pays. Procurezvous vos billets pour la Soirée à la marina par l’intermédiaire du système d’inscription à la Réunion annuelle de l’ACO, à www.coaannualmeeting.ca. COA Bulletin ACO - Spring / Printemps 2016

Your COA / Votre association

2016 Annual Business Meeting Notice

Avis de convocation à la séance de travail de la Réunion annuelle 2016

his year’s Annual Business Meeting will be held on Friday, June 17 at 11:00 in Room 2000A (level 2) of the Québec City Convention Centre.

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.

a séance de travail de la Réunion annuelle aura lieu le vendredi 17 juin, à 11 h, dans la salle 2000A (niveau 2) du Centre des congrès de Québec.

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

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 Friday, June 17 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 2016 at this special event.

COA Bulletin ACO - Spring / Printemps 2016

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 vendredi 17 juin, à 11 h, 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 2016 à cette occasion spéciale.

Your COA / Votre association

Residents! This is Your Meeting Too!

2016 CORA Annual Meeting focuses on leadership and Canadian research Simon Corriveau-Durand, M.D. Pierre-Luc Blouin, M.D. CORA Co-chairs Université Laval Québec City, QC

he Canadian Orthopaedic Residents’ Association (CORA) Annual Meeting will be held the day before the COA scientific programming begins on Thursday, June 16 at the Hilton Québec. All Canadian orthopaedic residents are invited to register for this exciting event. What’s on this year’s program? Resident research projects will be presented both at the podium during the morning’s paper session and through two CORA poster-viewing sessions adjudicated by Drs. Jean Lamontagne and Stéphane Pelet (Université Laval). Prizes will be awarded to the top three podium presentations as well as the top poster presented during the CORA meeting. The afternoon includes a symposium on Leadership in Orthopaedics featuring Drs. Robert Turcotte (McGill University), Neil White (University of Calgary), Stéphane Pelet (Université Laval) and Major Russell Eyestone as presenters. The meeting ends with a social night at Bistro L’Atelier where residents can network with their colleagues from across the country. 08:00-09:00 – Registration & Breakfast 09:00-11:45 – Residents’ Paper Session (includes coffee break with poster viewing) 11:45-12:50 – Lunch (and poster viewing) 13:00-15:00 – CORA Symposium: Leadership in Orthopaedics 20:00 – Residents’ Social Night (ticket required)

How to Register for the CORA Meeting The CORA meeting is FREE to attend, however pre-registration is required. 1. You can register for the CORA meeting through the online COA meeting registration system by visiting www.coaannualmeeting.ca. 2. When registering for your sessions, select the CORA Paper Session and CORA Symposium. 3. Select the Residents’ Social Night (Bistro l’Atelier) event from the ‘Registration Extras’ page. Tickets are $10 each. Free for COA Associate Members BEFORE APRIL 29! If you are a resident who is already an Associate member of the COA, there is no registration fee to attend the COA and CORA meetings if you pre-register by April 29. If you have any questions about the upcoming CORA meeting, please address them to coraweb@canorth.org and visit www.coraweb.org for meeting updates. We look forward to see our resident colleagues on June 16 at the Hilton Québec.

Oyez résidents! C’est aussi votre réunion!

La Réunion annuelle 2016 de l’ACRO met l’accent sur le leadership et la recherche au Canada Simon Corriveau-Durand, M.D. Pierre-Luc Blouin, M.D. Coprésidents de l’ACRO Université Laval Québec (Québec)

a Réunion annuelle de l’Association canadienne des résidents en orthopédie (ACRO) aura lieu le jeudi 16 juin, au Hilton Québec, la veille du volet scientifique de la Réunion de l’Association Canadienne d’Orthopédie (ACO). Tous les résidents canadiens sont invités à s’inscrire à cette manifestation fascinante.

À quoi doit-on s’attendre cette année? Dans le cadre de la séance de présentation de précis du matin, de même qu’à l’occasion de deux séances de présentation d’affiches de l’ACRO, des résidents communiqueront le fruit de leurs recherches; les Drs Jean Lamontagne et Stéphane Pelet (Université Laval) agiront à titre de juges. Trois exposés seront primés, tout comme la meilleure affiche présentée à la Réunion de l’ACRO. En après-midi, il y aura entre autres le symposium Le leadership en orthopédie, auquel participeront les Drs Robert Turcotte (Université McGill), Neil White (Université de Calgary), Stéphane Pelet (Université Laval) et Major Russell Eyestone. La Réunion se terminera par une soirée de réseautage entre résidents de partout au pays au Bistro L’Atelier.

COA Bulletin ACO - Spring / Printemps 2016

Your COA / Votre association

De 8 h à 9 h – Inscription et déjeuner De 9 h à 11 h 45 – Séance de présentation de précis des résidents (comprend la pause-café avec présentation d’affiches) De 11 h 45 à 12 h 50 – Dîner (et présentation d’affiches) De 13 h à 15 h – Symposium de l’ACRO : Leadership en orthopédie 20 h – Soirée des résidents de l’ACRO-ACO (billet exigé)

N’oubliez pas de sélectionner la séance de présentation de précis et le symposium de l’ACRO au moment de vous inscrire. Sélectionnez aussi la Soirée des résidents de dans la page « Suppléments à l’inscription ». Les billets coûtent 10 $.

Inscription à la Réunion annuelle de l’ACRO La participation à la Réunion annuelle de l’ACRO est GRATUITE, mais il faut tout de même s’y inscrire au préalable.

Si vous avez des questions sur la Réunion annuelle de l’ACRO, n’hésitez pas à écrire à coraweb@canorth.org. Et, pour obtenir toutes les mises à jour sur cette manifestation, consultez le site www.coraweb.org.

On peut s’inscrire à la Réunion annuelle de l’ACRO par l’intermédiaire du système d’inscription en ligne à la Réunion annuelle de l’ACO, à www.coaannualmeeting.ca.

Inscription gratuite pour les membres associés de l’ACO D’ICI LE 29 AVRIL! Si vous êtes membre associé de l’ACO et que vous vous inscrivez à la Réunion d’ici le 29 avril, vous n’avez pas de droits d’inscription à payer pour assister à la Réunion annuelle.

Au plaisir de vous voir le 16 juin, au Hilton Québec!

Canadian Research Featured Nationally and Internationally in 2016 Albert Yee, M.D., MSc, FRCSC 2015/16 Program Chair, Canadian Orthopaedic Research Society (CORS) Professor, Department of Surgery, Division of Orthopaedics, University of Toronto Holland MSK Program, Sunnybrook Health Sciences Centre Toronto, ON

During the CORS program, we also will celebrate our CORS 2015 Founders’ Medal Recipient, Dr. Simon Kelley (Toronto), for his research that advances our understanding of the importance of FGFR-3 in regulating fracture repair.

CORS Annual Meeting (Friday, June 17th, Québec City) We have an exciting program planned for this June’s Annual Meeting. Our afternoon symposium (15:30– 17:00) will focus on ‘Translating New Technology into the Clinic’ and will be of interest to COA and CORS members alike. Dr. Jacques de Guise from Montréal has accepted our invitation to provide the MacNab Lecture this year and we have invited respected surgeons and scientists to share their experiences in commercializing orthopaedic research discoveries:

International Combined Orthopaedic Research Society (ICORS) Meeting, Xi’an China, September 21-25, 2016 CORS has been participating in the ICORS Program Committee chaired by Professor Gang Li (Hong Kong) that is planning the fall meeting in Xi’an, China. This promises to be a fabulous academic and cultural experience! CORS has submitted two workshops as part of our involvement in ICORS, with Dr. Fackson Mwale (Montréal) and Dr. Stephen Waldman (Toronto) leading intervertebral disc and cartilage sessions, respectively. As special thanks to Drs. Mauro Alini, Rita Kandel, Rajiv Gandhi, and Jas Chalal for their participation in these workshops. Xi’an is also a key cultural antiquities destination, being home to the extensive Terracotta Warriors & Horses collection of the First Emperor of China. Canada will be hosting the next ICORS meeting in Montreal 2019 – so this year’s meeting in China will be a great opportunity for us to think about our planning for 2019!

- MacNab Lecturer: Dr. Jacques de Guise, QC - The Imaging and Orthopaedic Research Laboratory of Montréal (LIO), an Example of Health Care Technology Innovation Ecosystem - Dr. Daniel Boyd, NS - Lessons from the Trenches: Knowledge Translation and Commercialization of Biomaterials and Medical Devices - Dr. Victor Yang, ON - Taking Optical Imaging Navigation Research Work into the Commercial Arena - Dr. Thomas Steffen, QC - Idea to Market – Traps on the Way to Get There

As the Program Chair for CORS this year, it has been my pleasure to work with members of the 2015/16 CORS Executive (Drs. Fackson Mwale (Secretary - Montréal), Paul Beaulé (Member-at-Large - Ottawa), Janie Astephen-Wilson (President - Halifax), and Michael Dunbar (Past-President - Halifax). As always, special thanks to Meghan Corbeil and Cynthia Vezina at the COA Office for their expert help in facilitating program logistics. I very much look forward to our COA/CORS Annual Meeting in Québec City in June, as well as our ICORS meeting in China in the fall. Wishing all an enjoyable transition to spring!

n behalf of the Executive Committee of the Canadian Orthopaedic Research Society (CORS), we would like to highlight some of the recent CORS activities and upcoming events.

COA Bulletin ACO - Spring / Printemps 2016

Your COA / Votre association

Collaboration Makes all the Difference: CAMTA Celebrates 15 Years in Ecuador Barbara Moreau, CAMTA Head of Operations Marc Moreau, M.D., FRCSC Edmonton, AB

aining the trust and confidence and winning the hearts of local doctors, nurses and administrators in a low and middle income South American country like Ecuador requires long-term commitment and significant organizational skills. Canadian Association of Medical Teams Abroad (CAMTA) is embarking on its fifteenth year of partnership with la Fundación Tierra Nueva, to provide orthopaedic surgical care, support and teaching.

Barb and Marc Moreau applying a Ponseti cast on a 10-day-old baby while Matthew Moreau helps the little one stay calm during the procedure.

CAMTA provides mainly total hip replacements and paediatric orthopaedic surgery to the underprivileged people of Ecuador. The group started with a skeleton crew of nineteen people on a one-week mission in 2001, and has since proudly expanded to two teams of nearly 50 committed volunteers each, travelling to Ecuador for close to a total of three weeks annually. The mission now provides training experiences for students (medical, nursing and other) as well as residents (family, orthopaedic and anesthesia), planting the seed for their future interest in offering time and skills to underprivileged populations. Over the course of almost fifteen years, CAMTA has invited adult hip reconstruction surgeons and general orthopaedic surgeons to provide several hundred total hip replacements to a population in which hip dysplasia is rampant. Dr. Edward Masson, a reconstructive hip surgeon who is presently the Divisional Director of Orthopaedic Surgery at the University of Alberta, leads the team of adult hip reconstruction surgeons. He organizes the triage of X-rays sent in advance, earmarking equipment that is generously provided to CAMTA by Smith & Nephew. Dr. Masson was born and raised

in Kingston, Jamaica, a city where poverty struck a large portion of the population. From a young age, Dr. Masson had a desire to give back to the underprivileged. He began his first mission with CAMTA in 2007 and has been a pillar of our hip reconstruction work in Quito, Ecuador ever since. Dr. Masson coordinated the partnership between CAMTA and the Smith & Nephew Company that provided and continues to provide our implants free of charge. Residents and visiting orthopaedic surgeons from across Canada who have been involved in the care of our patients with severe hip dysplasia have commented that primary hip reconstructions in Ecuador are much more challenging than those seen in North America. At last year’s educational conference at Un Canto a la Vida Hospital, Dr. Masson coached his orthopaedic fellow from Columbia so that the teaching sessions could be given in Spanish, which was much appreciated by the local orthopaedic surgeons participating in the conference. Dr. Masson took part in his eighth CAMTA mission in February 2016. Paediatric orthopaedic surgeons join the team to care for children with clubfeet and early detected hip dysplasia and dislocation. The incidence of developmental dysplasia of the hip in Ecuador is much higher than in our North American population. Children with partially treated or untreated clubfeet appearing at our clinics come from underprivileged areas of the eastern jungle to the west coast. Drs. Marc Moreau and Jay Jarvis and their colleagues provide paediatric orthopaedic care and teaching. Dr. Jay Jarvis is the Chief of the Division of Orthopaedic Surgery at the Children’s Hospital of Eastern Ontario (CHEO). He has been practicing paediatric orthopaedic surgery there since 1985. Nine years ago Dr. Jarvis volunteered to be one of the two paediatric orthopaedic surgeons with the CAMTA mission at a time when CAMTA spent only ten days in Quito. Dr. Jarvis is an excellent teacher and his skills are put to good use with teaching local residents, staff and physiotherapists. He embarked on his tenth CAMTA mission in February Dr. Ed Masson bids farewell to one of his many happy patients following total hip sur2016. gery. Segunda, like most of CAMTA’s total hip patients, was discharged two days post-op.

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Your COA / Votre association

(continued from page 19)

The SIGN Nail program for CAMTA was initiated in Cuenca, Ecuador, under the supervision of Dr. Telmo Tapio. Dr. Tapio has inserted close to 200 nails since the inception of the program in Cuenca. He has also translated the Techniques Manual into Spanish and presented his research work on the SIGN Nail to the annual SIGN conference in Washington State on three occasions. A successful SIGN Nail program has been introduced in Babahoyo in southern Ecuador as well. A similar, but smaller parallel CAMTA program, run by Dr. Luis Piedrahita, has completed three successful one-week missions to Quito in the Tierra Nueva Fundación Hospital, Un Canto a la Vida. Dr. Piedrahita and his team of surgeons, nurses and physiotherapists from Tucson, Arizona, perform total knee replacements during their missions. CAMTA’s recently held Strategic Planning Meeting resulted in the establishment of a Board of Governors. CAMTA plans to expand the size of the mission, slowly, with a move to include other specialties and other sites. This fits well with the objectives of the Canadian Orthopaedic Association Global Surgery (COAGS) organization. A rapprochement between the two groups would assure a meaningful sharing of organizational information as well as better access to global projects for Canada’s orthopaedic surgeons. CAMTA is putting in place the steps to assure its own succession. There are many orthopaedic surgeons, anaesthetists, family practice doctors, nurses, physiotherapists, residents and students, lay people and translators eagerly awaiting their turn to help. Visit the CAMTA website (www.camta.com) to learn more about what CAMTA is doing in Ecuador and to meet some of our 2016 patients and team. Come join us for our 16th mission in Ecuador in February 2017! The COA Global Surgery (COAGS) Committee is pleased to feature Canadian global health organizations. If you are interested in profiling your organization, please contact Trinity Wittman at trinity@canorth.org. Drs. Jay Jarvis and Marc Moreau operate on a CAMTA paediatric patient during the 2016 mission.

Dr. Don Weber is a trauma surgeon at the University of Alberta Hospital where he was Site Chief from 2003 to 2013 and was the City Chief of Orthopaedics in 2013 and 2014. Dr. Weber participated in a SIGN Nail conference in Washington State and was able to perform SIGN Nail surgery in Cuenca, Ecuador on a tibial fracture, alongside a local orthopaedic surgeon. Dr. Weber recounts the mutually beneficial learning and teaching opportunities that he experienced, given the proficiency of the local orthopaedist with the SIGN IM Nail System combined with Dr. Weber’s own trauma expertise. CAMTA’s partnership with la Fundación Tierra Nueva is very valuable. Barbara Moreau, the manager of the project, has developed a successful and rewarding relationship with its Medical Director, Dra. Patricia Jarrin. Dra. Jarrin is pivotal in bringing such a big group with the inherent large quantities of equipment to Ecuador, assuring that patients who are in need are located and can make their way to the clinic, and helping to organize follow-up as required. Teaching sessions either at the bedside or for large groups of doctors, nurses and physiotherapists are planned well in advance.

COA Bulletin ACO - Spring / Printemps 2016

Kevin, two and a half, was born with a severe club foot. CAMTA doctors performed surgery and Kevin was discharged the next day. Kevin is shown here on the ward two hours post-op, enjoying one of the cobs of corn that his family brought to the hospital for the team’s lunch.

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

The COA Bulletin Welcomes New Scientific Editor, Dr. Femi Ayeni Marc Isler, M.D., FRCSC Editor-in-Chief, COA Bulletin

him an excellent addition to the Bulletin’s editorial team.

Dr. Ayeni will be charged with leading the scientific sections of the COA Bulletin including the point/counterpoint debates and clinical features. If you have any suggestions for topics that you would like to see covered in these sections of the journal, please contact Dr. Ayeni through Cynthia Vezina, Managing Editor: cynthia@canorth.org

lease join me in welcoming Dr. Olufemi (Femi) R. Ayeni as the COA Bulletin’s incoming Scientific Editor. Dr. Ayeni is Associate Professor and Fellowship Director of the Sports Medicine/Arthroscopy Fellowship at McMaster University in Hamilton. He completed his orthopaedic residency at McMaster University and pursued subspecialty training in sports medicine at the University of Ottawa/Carleton Sports Medicine Clinic and the Hospital for Special Surgery/Weill Cornell Medical Center (New York, USA). While in New York, he served as the Assistant Team Physician for the New Jersey Nets (NBA) and Iona College (NCAA). His clinical focus addresses non arthritic and athletic injuries of the hip, knee and shoulder. Dr. Ayeni also obtained his Master’s Degree in Health Research Methodology at the Department of Clinical Epidemiology and Biostatistics at McMaster University (2012) and has a research focus addressing hip preservation surgery and surgical outcomes in sports medicine. His extensive experience as a member of the editorial boards of various European and American sports medicine journals, as well as being an active reviewer for over 15 medical journals make

We would also like to extend our most sincere appreciation to Dr. Peter Lapner who aptly maintained the Scientific Editor position for the past two years and brought forward numerous intriguing debates and features that were of great interest to our readership. Thank you Dr. Lapner for your support and dedication. Keep reading!

Le Dr Femi Ayeni devient le nouveau rédacteur scientifique du Bulletin de l’ACO Marc Isler, MD, FRCSC Rédacteur en chef du Bulletin

ouhaitons la bienvenue au Dr Olufemi (Femi) R. Ayeni, nouveau rédacteur scientifique du Bulletin de l’ACO. Le Dr Ayeni est professeur agrégé et directeur de la formation supérieure en recherche en médecine sportive et arthroscopie à l’Université McMaster, à Hamilton. Il a fait sa résidence en orthopédie à l’Université McMaster, puis sa spécialisation en médecine sportive à la Clinique de médecine sportive de l’Université Carleton (Université d’Ottawa) et à l’Hospital for Special Surgery, affilié au Weill Cornell Medical College, à New York, aux États-Unis. Pendant son séjour à New York, il a été médecin adjoint des Nets du New Jersey (National Basketball Association) et de l’équipe de l’Iona College (National Collegiate Athletic Association). Ses activités cliniques sont axées sur les blessures non arthritiques et sportives à la hanche, au genou et à l’épaule. Le Dr Ayeni a aussi obtenu sa maîtrise en méthodologie de recherche en santé au département d’épidémiologie clinique et de biostatistique de l’Université McMaster (2012); ses

recherches portent sur les chirurgies permettant de conserver la hanche et les résultats chirurgicaux en médecine sportive. Sa vaste expérience au sein des comités de rédaction de diverses revues européennes et américaines en médecine sportive, de même qu’à titre de réviseur pour plus d’une quinzaine de revues médicales, en fait un atout important pour l’équipe de rédaction du Bulletin. Le Dr Ayeni se chargera du contenu scientifique du Bulletin de l’ACO, y compris les débats sur des questions cliniques et les articles cliniques. Si vous souhaitez suggérer des sujets à aborder dans ces sections, communiquez avec lui par l’entremise de Cynthia Vezina, adjointe au rédacteur en chef, à cynthia@canorth.org. Nous profitons également de l’occasion pour remercier sincèrement le Dr Peter Lapner qui a fait honneur au poste de rédacteur scientifique pendant deux ans et proposé divers débats et sujets intrigants qui ont suscité un grand intérêt chez nos lecteurs. Un grand merci, donc, au Dr Lapner pour son soutien et son dévouement. Bonne lecture! COA Bulletin ACO - Spring / Printemps 2016

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

An Introduction to This Edition’s Debate on the Management of Shoulder Instability with Replissage Femi Ayeni, M.D., MSc FRCSC, Dip Sport Med. Scientific Editor, COA Bulletin

houlder instability can be debilitating for the affected patient and family. Apart from the loss of function and pain, there is an associated loss of productivity for both patient and caregiver. The management of shoulder instability requires addressing the complex interplay of bony and soft

tissue structures. Recent advances in our understanding of shoulder instability surgery have yielded another tool in our surgical arsenal, the Remplissage procedure. In this debate, our expert panelists discuss both the pros and cons of the Remplissage procedure from two opposing perspectives. I would like to thank Drs. Pike and Goel from the University of British Columbia, and Drs. Pollock and MacEwan from the University of Ottawa for participating in this debate.

Remplissage is a Safe and Effective Technique in the Treatment of Recurrent Anteroinferior Shoulder Instability Jeffrey Pike, M.D., MPH, FRCSC Clinical Assistant Professor Danny Goel, M.D., MS, FRCSC Clinical Associate Professor University of British Columbia Vancouver, BC

he presentation of recurrent anterior shoulder instability is a common complaint to the orthopaedic surgeon’s office. Current surgical management in the absence of bone loss involves arthroscopic or open Bankart repair. This has been associated with excellent outcomes. If, however, a Bankart repair is performed in patients with glenoid bone loss approaching 20-25%, an unacceptably high failure rate may be anticipated. The literature has supported the use of a coracoid transfer (Latarjet) in this scenario1. In situations where glenoid bone loss is present, but does not approach 20-25%, the treatment algorithm becomes more complex. An understanding of the glenoid track phenomenon provides insight as to the possible treatment options. In 2007, Yamamoto and colleagues described the “glenoid track” to preoperatively identify a Hill Sachs lesion (HSL) that will course “off-track” and “engage” with the anterior glenoid2. The glenoid track method uses a formula to predict if a HSL will engage, which is the practical consideration rather than the extent and depth of the HSL in isolation. The utility of this concept permits the surgeon to preoperatively determine the likelihood of an engaging HSL following Bankart repair. The treatment of the “engaging” HSL with less than 25% anteroinferior glenoid bone loss therefore becomes controversial. One treatment strategy utilizes the Latarjet to convert the HSL into an “on-track” or non-engaging lesion. However, the complicaCOA Bulletin ACO - Spring / Printemps 2016

Figure 1 Preparing the Hill Sachs lesion.

tion rate associated with Latarjet approximates 30%, with a greater reoperation rate, loss of motion, arthritis, non-union, hardware failure and nerve injury3. With ongoing advances in arthroscopic techniques1, the Remplissage has emerged as an adjunct to Bankart repair to confer stability. First described by Wolf and Pollack in 2004, “Remplissage” is French for “to fill4,5”. It is an arthroscopic technique that involves myocapsulodesis of the infraspinatus, and a portion of the teres minor into the HSL (Figures 1 and 2)6. The indications for Remplissage continue to evolve as the contribution of the HSL in recurrent instability is understood using the concept of the “glenoid track.”

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 24)

Di Giacomo and colleagues recently described a treatment algorithm based on the glenoid track concept. They recommend a Bankart repair and Remplissage for “off-track” lesions with less than 25% glenoid bone loss7. Excluding the two subjects with glenoid bone loss greater than 25%, this study suggests that Bankart repair plus Remplissage is indicated in approximately 5% of cases per the algorithm7. Other indications for Remplissage include augmentation of a revision arthroscopic Bankart repair, and in cases where glenoid bone loss is encountered intraoperatively though not exceeding 20-25%. Other data supporting the Remplissage with Bankart include a reduced rate of recurrence when compared to Bankart repair8,9. A recent systematic review suggests a recurrent dislocation rate between 0 and 15% following Remplissage10. Given the arthroscopic approach to the Remplissage, it has been deemed a safe procedure with little to no post-surgical sequelae. In vitro concerns on potential shoulder stiffness, particularly loss of external rotation, have not translated into clinical relevance. The reported mean loss of external rotation ranges from 5-10 degrees, and is well tolerated in the majority of patients10. While safe, the Remplissage must be carefully considered in the throwing athlete. A recent series reporting that two-thirds of patients complained of decreased motion while throwing11. A single study reported that one-third of patients complained of posterosuperior shoulder pain with forceful movements12. Furthermore, when compared to Latarjet, the Bankart plus Remplissage was noted to have no difference in recurrent dislocation rates at two years. However, the complication rate in the Latarjet (14%) not observed in the Bankart plus Remplissage group (0%)13. In summary, Remplissage appears to be an effective and safe adjunct to primary Bankart repair for recurrent anteroinferior shoulder instability. The current indications for its use include “off-track” Hill Sachs lesions with <25% glenoid bone loss, augmentation of a revision arthroscopic Bankart repair, and in cases where unexpected bone loss is encountered and avoidance of bone graft procedures is preferred. Although the quality of available data examining Remplissage is improving, the precise indications, effectiveness over Bankart repair alone and safety profile remain under investigation. Long-term outcomes studies and more rigorous comparative studies will better define the role of Remplissage, and the risk of long-term complications, including degenerative arthrosis. References 1. Garcia G.H., Taylor S.A., Fabricant P.D., Dines J.S. Shoulder Instability Management: A Survey of the American Shoulder and Elbow Surgeons. Am J Orthop (Belle Mead NJ). 2016;45(3):E91-97.

Figure 2 After passage of the suture limbs.

2. Yamamoto N., Itoi E., Abe H., et al. Contact between the glenoid and the humeral head in abduction, external rotation, and horizontal extension: a new concept of glenoid track. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons ... [et al.]. 2007;16(5):649-656. 3. Griesser M.J., Harris J.D., McCoy B.W., et al. Complications and re-operations after Bristow-Latarjet shoulder stabilization: a systematic review. J Shoulder Elbow Surg. 2013;22(2):286292. 4. Purchase R.J., Wolf E.M., Hobgood E.R., Pollock M.E., Smalley C.C. Hill-sachs “remplissage”: an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy. 2008;24(6):723-726. 5. Wolf E.M., Pollack M.E. Hill Sachs remplissage: an arthroscopic solution for the engaging Hill-Sachs lesion. Arthrosc: J Arthros Relat Surg. 2004;20:e14-15. 6. Lädermann A., Arrigoni P., Barth J., et al. Is arthroscopic remplissage a tenodesis or capsulomyodesis? An anatomic study. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;24(2):573-577. 7. Di Giacomo G., Itoi E., Burkhart S.S. Evolving concept of bipolar bone loss and the Hill-Sachs lesion: from “engaging/nonengaging” lesion to “on-track/off-track” lesion. Arthroscopy : the journal of arthroscopic & related surgery : official publication of the Arthroscopy Association of North America and the International Arthroscopy Association. 2014;30(1):9098. 8. Cho N.S,. Yoo J.H., Juh H.S., Rhee Y.G. Anterior shoulder instability with engaging Hill-Sachs defects: a comparison of arthroscopic Bankart repair with and without posterior capsulodesis. Knee Surgery, Sports Traumatology, Arthroscopy. 2015.

COA Bulletin ACO - Spring / Printemps 2016

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

9. Garcia G.H., Park M.J., Zhang C., Kelly J.D., Huffman G.R. Large Hill-Sachs Lesion: a Comparative Study of Patients Treated with Arthroscopic Bankart Repair with or without Remplissage. HSS journal : the musculoskeletal journal of Hospital for Special Surgery. 2015;11(2):98-103.

12. Nourissat G., Kilinc A.S., Werther J.R., Doursounian L. A prospective, comparative, radiological, and clinical study of the influence of the “remplissage” procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair. Am J Sports Med. 2011;39(10):2147-2152.

10. Rashid M.S., Crichton J., Butt U., Akimau P.I., Charalambous C.P. Arthroscopic "Remplissage" for shoulder instability: a systematic review. Knee Surgery, Sports Traumatology, Arthroscopy. 2016;24(2):578-584.

13. Cho N.S., Yoo J.H., Rhee Y.G. Management of an engaging HillSachs lesion: arthroscopic remplissage with Bankart repair versus Latarjet procedure. Knee Surgery, Sports Traumatology, Arthroscopy. 2015.

11. Garcia G.H., Wu H.-H., Liu J.N., Huffman G.R., Kelly J.D. Outcomes of the Remplissage Procedure and Its Effects on Return to Sports: Average 5-Year Follow-up. The American Journal of Sports Medicine. 2016.

Avoid the Remplissage Matt MacEwan, M.D., MBA, FRCSC Fellow – Upper Extremity Surgery Division of Orthopedics J Whitcomb Pollock, M.D., MSc, FRCSC Division of Orthopedics, The Ottawa Hospital Assistant Professor University of Ottawa Ottawa, ON

he Remplissage procedure is not new. Connolly1 described it in 1972 as an open tenodesis of infraspinatus through a posterior approach. Wolf2 defined an arthroscopic variation in 2008. The Remplissage procedure is gaining momentum, as arthroscopic skills progress and shoulder subspecialists search for an all-arthroscopic alternative to the Latarjet procedure. However, there is minimal evidence supporting the increased use and reliance of this technique. To our knowledge, there is only one Level 2 study in the literature. All other Remplissage evidence is currently case series (Level 4) or biomechanical data. In our view, the Remplissage procedure should be avoided for the following reasons: Pain The best evidence to date supporting the use of the Remplissage is a Level 2 study from Nourissat in 20113. A prospective comparison was made between Bankart repair alone and Bankart repair combined with Remplissage (“the Remplissage group”). Outcomes at two years were similar between groups in terms of range of motion (no difference) and recurrence rates (6.25%). However, in the Remplissage group, 33% of patients (5 of 15 patients) noted postero-superior pain during forceful movements or when tired.

COA Bulletin ACO - Spring / Printemps 2016

Left shoulder arthroscopic anterior inferior labral repair and capsulorrhaphy.

Lost Range of Motion Elkinson & Athwal4 published important biomechanical data on the Remplissage procedure in 2012. Bankart lesions (15% surface area) and Hill Sachs lesions (30% articular surface) were created in eight cadaveric shoulders. Half of the specimens underwent an isolated Bankart repair, and half received a combined Remplissage and Bankart repair. When Remplissage was added, shoulder ROM was significantly decreased. External rotation was decreased by 15 degrees when the shoulder was in the adducted position and extension was reduced by 22 degrees; these results were not observed in the Bankart repaired shoulder without Remplissage. These findings have been correlated with similar and independent biomechanical research5. Furthermore, a loss of external rotation (8 deg) has also been reported clinically in a study by Boileau7. Stiffness Elkinson & Athwal4 also demonstrated that adding the Remplissage procedure increased the force required to move the glenohumeral joint to 4.7 N/mm, as compared to the isolated Bankart repair (4.0 N/mm). This difference was significant biomechanically. There is insufficient clinical evidence to deter-

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

mine whether increased stiffness leads to decreased efficiency of shoulder kinematics or affects performance in throwing or overhead striking athletes. Impingement Finally, Elkinson & Athwal4 found that 50% (4 of 8) of combined Remplissage/Bankart procedures created impingement on the posterior glenoid causing a pivoting/binding effect of the humeral and distraction of the glenohumeral joint. The clinical and functional consequences of these observations have not been determined. In our view, this alteration in shoulder kinematics could negatively affect the performance of the shoulder and potentially lead to increased stresses though the joint and eventual arthrosis. Publication Bias Most studies have poor patient selection and inadequately defined indications for the Remplissage procedure. For example, Garcia, et al.6, reported on a small number of arthroscopic Remplissage procedures. Most patients did well within the follow-up period. However, all patients in the series had a Hill-Sachs lesion which measured 10% or less. Elkinson’s4 biomechanical study has shown that a Hill Sachs lesion of 15% or less will not engage following an isolated Bankart repair. Therefore, the patients in Garcia’s series likely did not require the Remplissage (or any other adjunct procedure) in the first place, just a proper Bankart repair. (Lack of) Return to Sport Boileau7 published a series of 47 shoulders, treated with a Remplissage (all revisions), which showed less than 10% recurrence rates. However, 32% of patients were unable to return to the same level of sport. This is an important issue, as patients presenting with shoulder instability are often young and involved in competitive sports. In summary, while the Remplissage procedure is an all-arthroscopic option to augment a Bankart repair, most patients do not require it. In addition, it will restrict ROM, tighten the shoulder, and may permanently alter shoulder joint kinematics, all of which could lead to joint arthrosis and degeneration. Furthermore, evidence suggests that one-third of patients will experience shoulder pain with activity and one-third will unlikely be able to return to their preoperative level of sports. Based on the above, we do not recommend this non-anatomic

procedure for routine use. In our opinion, significant glenoid bone loss (>20%) should be addressed with a glenoid bone graft procedure. In patients with no glenoid bone loss and Hill Sachs lesions less then 15%, an isolated arthroscopic Bankart repair and capsulorrhaphy is effective at achieving stability. References 1. Connolly J.F. Humeral head defects associated with shoulder dislocation-Their diagnostic and surgical significance. Instr Course Lect. 1972; 21:42-54 2. Purchase R.J., Wolf E.M., Hobgood E.R., Pollock M.E., Smalley C.C. Hill-sachs “remplissage”: an arthroscopic solution for the engaging hill-sachs lesion. Arthroscopy 2008; 24(6):723-6 3. Nourissat G1., Kilinc A.S, Werther J.R., Doursounian L. A prospective, comparative, radiological, and clinical study of the influence of the “remplissage” procedure on shoulder range of motion after stabilization by arthroscopic Bankart repair. Am J Sports Med. 2011 Oct;39(10):2147-52. 4. Elkinson I., Giles J.W., Faber K.J., Boons H.W., Ferreira L.M, Johnson J.A., Athwal G.A. The Effect of the Remplissage Procedure on Shoulder Stability and Range of Motion. J Bone Joint Surg Am. 2012; 94:1003-12. 5. Omi R., Hooke A.W., Zhao K.D., Matsuhashi T., Goto A., Yamamoto N., Sperling J.W., Steinmann S.P., Itoi E., An K.-N. The Effect of the Remplissage Procedure on Shoulder Range of Motion: A Cadaveric Study. Arthroscopy. February 2014Volume 30, Issue 2, Pages 178–187 6. García-Germán-Vázquez D., Menéndez-Martínez P., Guijarro-Valtueña A., Viloria-Recio F., García-Rodríguez D., Canillas-del Rey F. Arthroscopic treatment of Hill-Sachs lesions in glenohumeral instability. “Remplissage” technique. Acta Ortop Mex. 2014 Nov-Dec;28(6):382-8. 7. Boileau P1, O’Shea K., Vargas P., Pinedo M., Old J., Zumstein M. Anatomical and functional results after arthroscopic Hill-Sachs remplissage. J Bone Joint Surg Am. 2012 Apr 4;94(7):618-26.

How to Get your Hip Fracture Patient “Ready for the OR” Leslie Zypchen, M.D., FRCPC (Hematology) Andrew Meikle, M.D, FRCPC (Anesthesiology) John Wade, M.D., FRCPC (Rheumatology) Pierre Guy, M.D., FRCSC Vancouver, BC

At the 2015 COA Annual Meeting held last June in Vancouver, Dr. Pierre Guy (University of British Columbia) moderated a casebased trauma symposium on preparing hip fracture patients for the OR which included presentations by specialists in anesthesiology, hematology, internal medicine and orthopaedics. We would like to thank each of the symposium’s participants for providing a

summary of their presentations in the article below. Please click through the supporting links that are hyperlinked throughout the text to access additional information. – Ed.

hip fracture is a life-changing, and often life-ending event, for older individuals. Preparing this population, with a mean age 80-85 years, to receive an anesthetic (general or spinal) and undergo surgery is no easy task. As medical care improves, hip fracture patients present with an ever-increasing list of acute and chronic medical conditions accompanying the fracture. A growing body of literature supports getting these elderly hip fracture patients medically stabilized and to the operating room promptly, to decrease morCOA Bulletin ACO - Spring / Printemps 2016

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

bidity, mortality and hospital length of stay1-3. This process puts additional pressure on an often already burdened health-care system, which, in and of itself, can prove to be “no easy task”.

Reason for delay at 48h 6% 4%

Over ten years ago, the Canadian ministers of health committed to improving access to care in critical areas including hip fractures. In some hospitals, this led to the practice of surgeons prioritizing the order of cases amongst themselves to ensure prompt surgery for hip fracture patients. At other sites, medical, surgical and anesthesia services joined together to streamline the assessment and stabilization process. More recently, under direction from their ministries of health (in some cases under the threat of financial penalty), health boards and health authorities have addressed this issue in a more systematic fashion. Barriers to timely surgery can be grouped into either “systemic” (e.g. patient transfer to an appropriate hospital, access to testing, access to the operating room) or “clinical” barriers (unstable acute medical conditions, severe chronic medical conditions such as valvular heart disease, anticoagulation). The frequency of each of these barriers has been poorly documented in published literature and administrative databases, making it difficult to determine strategies for improvement. Table 1

Reason for delay Administrative OR avaiIabiIity DxTests/Consults Transfers Bed avaiIabiIity Other I None identified Pt Readiness: Medical Instability Anticoagulation Delay in Dx Delay in consent Other

at 24h 42% 36% 2% 2% 0% 3% 10% 4% 4% 0% 0% 1%

at 48 6% 4% 1% 1% 0% 1% 4% 2% 1% 0% <0.1% 0%

Reason for delay to surgery by time from admission of hip fracture patients. Percentages represent the proportion of cases for n=5203 hip fracture cases. Results are rounded to the unit.

The British Columbia Hip Fracture Redesign project’s* prospective data collection (see inset text) has allowed us to clearly quantify the occurrence of each of these barriers and has helped us to appropriately focus administrative and clinical efforts to get these patients safely to the operating room in a prompt fashion. Table 1 lists the barriers to surgery at 24 and 48 hours for over 5000 hip fracture events collected to date. These barriers are grouped as “Administrative” (systemic) or “Patient Readiness” (clinical) and identify why overall 10% of patients cannot access the operating room (OR) within 48 hours of admission (Figure 1). Of the administrative reasons, “Access to the OR” (4%) remains the most common reason COA Bulletin ACO - Spring / Printemps 2016

Systemic Clinical No Delay

90% Figure 1

for delaying surgery. Of the clinical reasons, which can potentially be addressed by physicians, “Medical Instability” (2%) and “Anticoagulation” (1%) are the most frequent causes of delayed safe surgery. Medical Instability and Anticoagulation are the two areas we wish to address in this article. Additionally, as “taking a patient to the OR” involves both safely administering an anesthestic and performing surgery, we thought it pertinent to offer an anesthesiologist’s perspective as well. Medical Issues Medical co-management of hip fracture patients between orthopaedic surgeons and internists and geriatricians has been proven to reduce in-hospital and long-term mortality and length of stay4. The role of a perioperative medical provider prior to surgery is to both optimize a patient’s chronic medical conditions (known and previously unrecognized ones) and to diagnose and optimise new acute medical conditions. The overall goal is to stabilize the patient’s medical issues sufficiently to minimize the risk associated with anesthesia and surgery. The medical provider must therefore promptly and effectively work in collaboration with anesthesiologists and surgeons.

*The BC Hip Fracture Redesign project is a Provincial Quality Improvement initiative which aims to improve the care of hip fracture patients throughout the patient’s journey - from the initial fracture to returning to the community (Figure 2). This quality improvement effort is backed by a robust prospective data collection strategy to measure changes in predetermined indicators. The initiative is sponsored by the British Columbia Specialists Services Committee. The assessment of chronic medical conditions starts with a history, physical examination and a thorough medication reconciliation. Each condition, ranging from congestive heart failure to malignancy, can then be assessed individually and the need for further preoperative assessment (e.g. echocardiogram) and treatment determined. Common additional issues requiring

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

attention include delirium prophylaxis and pain control. The development of perioperative order sets and pathways developed by a multi-disciplinary team for the most common conditions and tests has proven useful in hastening the preoperative assessment and stabilisation phase. Only a few acute medical conditions require urgent preoperative medical correction and stabilization. Although not exhaustive, lists lend themselves well to identifying the common, reversible causes for surgical delay in elderly patients with a hip fracture5,6. The following table (Table 2) identifies some specific conditions and suggests parameters for intervention, acknowledging that treatment must be individualized and that risks and benefits of proceeding with surgery must be assessed on an Figure 2 individual basis5. Table 2

Medical condition Electrolyte imbalances

Intervention thresholds Na+ >150 or < 120

K+ > 6.0 or < 2.6

Anemia Coagulopathy

Hg < 80 g/L INR > 1.5, PLT < 50 000 (see also anticoagulation section)

Uncontrolled Diabetes Dehydration Cardiac Ischemia Cardiac Arrhythmia LV failure / Valve disease

no threshold identified no threshold identified no threshold identified Ventricular HR > 120 Order echocardiography only when it informs the care plan (see anesthesia section below)

1. Assess LV function in patient SOB at rest/mild exertion

2. Assess Aortic valve disease when Systolic Ejection Murmur identified in the setting of symptomatic Aortic Stenosis

Respiratory Failure Pneumonia / Sepsis

delay until medically stable delay until medically stable

In the postoperative phase, the medical specialist will also be involved in the monitoring and co-management of medical issues. The hip fracture admission offers the additional opportunity for a medication review (Beer’s criteria for potentially inappropriate medication) to assess the pertinence of some medications with a goal to reduce polypharmacy.

In summary, the medical specialist provides support for the management of chronic and acute medical conditions, aiming to have the patient undergo early anesthesia and surgery once the patient is stable, while encouraging collaboration and discussion among colleagues and the multidisciplinary team. Anticoagulation Issues It is not uncommon for hip fracture patients to be on anticoagulants for various reasons. These drugs include warfarin and the direct oral anticoagulants dabigatran, rivaroxaban and apixaban. The two questions which arise for such patients are 1) does the anticoagulant need reversal before surgery, and 2) is postoperative “bridging” with a heparin needed? Because anticoagulation is a somewhat common reason for a delay in hip fracture surgery, we have developed a local toolkit to pre-emptively deal with this issue and to stimulate discussion between local care team members. Warfarin has a long half-life and waiting five days for its effect to disappear is not practical or safe. Warfarin can be promptly reversed with intravenous vitamin K and a prothrombin complex concentrate (PCC). PCCs are blood products containing the vitamin K-dependent clotting factors. Their reversal effect is immediate but short-lived, which is why vitamin K must also be administered. Without vitamin K, the INR will prolong again over the course of a day. Plasma (aka FFP-Fresh Frozen Plasma) is a less preferred choice, mostly for practical reasons such as a larger volume and the risk of volume overload. Dosing recommendations for vitamin K and PCCs are easily found and many institutions have preprinted orders which make prescription easy. Lastly, it is easy to prove that warfarin’s effect has disappeared by checking an INR. The direct oral anticoagulants have the advantage of shorter half-lives but also carry the disadvantage of the lack of an antidote. However, antidotes are in development and seem to be effective in preliminary studies. In fact, the reversing agent for dabigatran, idarucizumab, has been approved by the COA Bulletin ACO - Spring / Printemps 2016

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 29)

FDA and has been submitted for approval to Health Canada. The ultimate role of these antidotes in hip fracture patients is unknown. A helpful principle to predict how long one must wait for the effect of a direct oral anticoagulant to disappear is that the effect will gradually decline and be completely gone five half-lives after the last dose was given. Dabigatran’s halflife is 12-18 hours and rivaroxaban and apixaban have half-lives of 7-13 hours. For example, rivaroxaban’s effect will disappear completely after 1.5 to 3 days after the patient’s most recent dose. It is important to remember though, that all of these drugs are at least partly dependent on renal excretion, so their half-lives will be prolonged with renal impairment. It is also important to note that there are no readily available laboratory tests that can prove that their effect has disappeared. The exception to this is a normal thrombin time in a patient on dabigatran.

An echocardiogram can be helpful in minimizing the perioperative risk of the hip fracture patient. It allows an accurate diagnosis of the type and severity of valvular heart disease, aids in the choice of anesthestic approach, and importantly, can guide decisions around the necessary level of perioperative monitoring (e.g., arterial pressure, pulmonary artery pressure, trans-esophageal echocardiography) and the need to manage the patient postoperatively in an ICU setting. Without an echocardiogram, the anesthesiologist can assume the worst (i.e. severe aortic stenosis) when a murmur is auscultated, but this will result in additional perioperative monitoring, the potential for iatrogenic line complications, and the requirement for a postoperative ICU bed. Thus, a normal preoperative echocardiogram can save on operating room and postoperative resources and is considered best practice when dealing with an undifferentiated murmur.

An additional special question for patients on a direct oral anticoagulant is when it might be safe to undergo neuraxial anesthesia, the concern being the risk of neuraxial hematoma. The American Society of Anesthesia’s recommendations on this matter are conservative, which are to wait five days after stopping dabigatran and three days after stopping rivaroxaban or apixaban. This is more conservative than the surgery guidelines, leading to an inherent conflict between orthopaedic surgeons and anesthesiologists. Discussions between clinical specialists regarding how long it is prudent to delay surgery in these patients is best done in advance, and ideally a consensus and a common hospital-wide approach could be reached. The BC Hip Redesign Toolkit can be used to help generate this discussion between the clinical departments.

Another important anesthestic consideration for the hip fracture patient is the method of anesthesia. In our institution, a neuraxial (or spinal) anesthestic is used for over 90% of the elective hip and knee arthroplasties, while it is used for 60% of the hip fracture patients. Although there are no cardioprotective effects of neuraxial anesthesia compared to general anesthesia, there are other advantages. For example, there is a reduction in PACU nursing interventions for pain and nausea. This saves the hospital money and improves early patient satisfaction. There appears to be a decrease in postoperative pneumonia rates, a possible reduction in the incidence of deep vein thrombosis, and a decrease in surgical blood loss and transfusions. Neuraxial anesthestics may also reduce the thirty day postoperative mortality rate. A neuraxial anesthestic is thus a commonly accepted anesthestic technique and offers patients some real benefits. However, these benefits are probably not sufficient to justify a delay in a potentially life-saving hip fracture surgery. If the surgeon is willing to accept the coagulation status for surgery, the anesthesiologist may choose to perform a general anesthestic or proceed with a neuraxial anesthestic and accept a slightly higher risk of neuraxial hematoma compared to the small baseline risk of 1/22 0008.

Lastly, there are some patients at high risk of thromboembolism for whom “bridging” back to warfarin with therapeutic doses of a heparin, usually low-molecular-weight heparin (LMWH), is recommended. These include patients with mechanical heart valves, high risk atrial fibrillation (e.g. prior stroke) or recent venous thromboembolism (e.g. within three months). A reasonable approach is to restart warfarin postoperatively, give prophylactic LMWH for a few days until you are comfortable with hemostasis, and then escalate the LMWH to a therapeutic dose until the INR is again therapeutic on warfarin. Because the direct oral anticoagulants have a fairly immediate onset of action, postoperative bridging is not necessary, and instead the therapeutic dose of the drug can be restarted after a few days of thromboprophylaxis. Anesthesia Issues Aortic stenosis has long been a concern for patients requiring anesthesia. The American Heart Association has recently published guidelines for the perioperative cardiovascular evaluation and management of patients undergoing elective non-cardiac surgery7. It is a class I recommendation “that patients with clinically suspected moderate or greater degrees of valvular stenosis or regurgitation undergo preoperative echocardiography if there has been no prior echocardiography within one year”. This recommendation is not meant to preclude surgery. In fact, even for elective orthopaedic surgery, there is a class IIa recommendation that “with appropriate intraoperative and postoperative hemodynamic monitoring (surgery) is reasonable to perform in patients with asymptomatic severe aortic stenosis7.”

COA Bulletin ACO - Spring / Printemps 2016

This debate about the relative merits of the two anesthestic options is controversial even within the anesthesia community. However, either option may be acceptable and it is probably not wise to delay surgery for the sole reason of allowing neuraxial anesthesia. For this issue, achieving a priori consensus about the appropriate delay from the last dose of anticoagulant to the use of neuraxial anesthesia is also helpful. We hope this brief article will encourage you to meet with colleagues around the care of hip fracture patients so that they can be safely and promptly taken to the operating room. Great benefit has come from the use of pre-printed order sets and protocols and from the co-management of hip fracture patients with medical specialists from internal medicine or geriatrics. Please take the opportunity to review the additional material we have made available through the Centre for Hip Health and Mobility’s web site: BC Hip Fracture Redesign, and the FReSH Start patient, family & caregiver information booklet

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

Acknowledgements BCHFR is sponsored by the British Columbia Specialist Services Committee, a joint committee of Doctors of BC and the BC Ministry of Health.

3. Ryan D.J., Yoshihara H., Yoneoka D., Egol K.A., Zuckerman J.D. Delay in Hip Fracture Surgery: An Analysis of PatientSpecific and Hospital-Specific Risk Factors. Journal of orthopaedic trauma. 2015;29(8):343-8.

The improved care of patients was only made possible by the commitment of members of the BCHFR Quality Improvement project at various sites who came together to develop the clinical guidance material essential to this work, and who continue to guide the initiative at their various sites.

4. Grigoryan K.V., Javedan H., Rudolph J.L. Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. Journal of orthopaedic trauma. 2014;28(3):e49-55.

References 1. Bohm E., Loucks L., Wittmeier K., Lix L.M., Oppenheimer L. Reduced time to surgery improves mortality and length of stay following hip fracture: results from an intervention study in a Canadian health authority. Canadian journal of surgery Journal canadien de chirurgie. 2015;58(4):257-63. 2. Nyholm A.M., Gromov K., Palm H., Brix M., Kallemose T., Troelsen A., et al. Time to Surgery Is Associated with Thirty-Day and Ninety-Day Mortality After Proximal Femoral Fracture: A Retrospective Observational Study on Prospectively Collected Data from the Danish Fracture Database Collaborators. The Journal of bone and joint surgery American volume. 2015;97(16):1333-9.

5. Association of Anaesthetists of Great B, Ireland, Griffiths R, Alper J, Beckingsale A, Goldhill D, et al. Management of proximal femoral fractures 2011: Association of Anaesthetists of Great Britain and Ireland. Anaesthesia. 2012;67(1):85-98. 6. Hung W.W., Egol K.A., Zuckerman J.D., Siu A.L. Hip fracture management: tailoring care for the older patient. Jama. 2012;307(20):2185-94. 7. Fleisher L.A., Fleischmann K.E., Auerbach A.D., Barnason S.A., Beckman J.A., Bozkurt B., et al. 2014 ACC/AHA guideline on perioperative cardiovascular evaluation and management of patients undergoing noncardiac surgery: a report of the American College of Cardiology/American Heart Association Task Force on practice guidelines. Journal of the American College of Cardiology. 2014;64(22):e77-137. 8. Moen V., Dahlgren N., Irestedt L. Severe neurological complications after central neuraxial blockades in Sweden 19901999. Anesthesiology. 2004;101(4):950-9.

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 COA Bulletin ACO - Spring / Printemps 2016

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

Making sense of too much data - a better way to view evidence. The Issue with Evidence-Based Medicine (EBM) EBM has grown rapidly across the medical profession, becoming a central focus in the training of new health care practitioners. The number of RCTs published in a top orthopaedic journal, The Journal of Bone and Joint Surgery, increased by more than 150% between 2001-2013.1 40

Introducing CoreView – A new way to view the evidence CoreView is a new tool that has been developed to assist in the practice of EBM. It highlights and graphically summarizes the ﬁndings from clinical practice guidelines, meta-analyses, and RCTs on one topic, providing a Curated, Objective, Relevant Evidence Viewpoint, giving users the ability to sift through high-quality evidence based on patient and treatment characteristics of interest to determine potential efﬁcacy. CoreView enables practitioners to get a full understanding of the evidence base at a glance.

1 CoreView = 10 Guidelines + 15 Meta-analyses + 150 RCTs 20

2013

2012

2011

2010

2009

2008

2007

2006

2005

2004

2003

2002

2001

YEAR OF PUBLICATION

Figure 1: Publica on of RCTs by year from 2001-2013.

The sheer volume of research available and inconsistency within the methodology and ﬁndings can make synthesizing accurate conclusions for application in practice an almost insurmountable task. An example of both this volume and inconsistency can be seen in the recent debate surrounding the efﬁcacy of intra-articular hyaluronic acid (IAHA) for the management of knee osteoarthritis. Clinical practice guidelines that have evaluated the use of IAHA highlight an inability to determine a consistent recommendation, with some guidelines recommending IAHA (EULAR 2003),2 with others indicating that the available evidence 3 does not support its use (AAOS 2013).

OrthoEvidence's ﬁrst CoreView topic is the use of IAHA in the treatment of osteoarthritis. This topic comprises more than 180 high-quality publications, with 10 clinical practice guidelines, 15+ meta-analyses, and 150+ RCTs. Key insights from this CoreView enable practitioners to evaluate the effectiveness of IAHA in different patient populations and to see how efﬁcacy differs based on treatment characteristics. Practitioners can be sure they are getting the whole picture because OrthoEvidence updates CoreView whenever new evidence is found. CoreView pages on other topics will follow regularly. Upcoming topics include bone stimulation for fracture healing, and the use of platelet-rich plasma in multiple patient populations. Access to CoreView and OrthoEvidence has been made available to all members of the Canadian Orthopaedic Association and can be accessed by following the instruction provided below.

RCTs Efﬁcacy of IAHA vs. Placebo/Control for Knee OA

Overall

Pain

Func on

S ﬀness

IAHA Recommendations for knee OA

AAOS 2013

Weeks Post Injec on

Guidelines

Figure 2: Guideline recommenda ons for IAHA.

If clinical practice guidelines, designed to synthesize all available high-quality evidence, are unable to come to an agreement on treatment recommendations, how are those treating patients supposed to do this?

Number of Comparisons Favours IAHA

No Diﬀerence

Favours Placebo/Control

Figure 3: Graphical representa on of comparisons between IAHA and Placebo/Control from iden ﬁed RCTs by me point.

1. An Assessment of Randomised Controlled Trial Quality in the Journal of Bone and Joint Surgery – Update from 2001-2013 - Unpublished 2. The European League Against Rheuma sm. (2003) h p://www.eular.org 3. American Academy of Orthopaedic Surgeons. Treatment for Osteoarthri s of the Knee (2013) h p://www.aaos.org/research/guidelines/GuidelineOAKnee.asp

OrthoEvidence (OE) is a provider of the highest-quality clinical evidence in Orthopaedics. Our goal is to improve decision making by increasing the collec ve baseline of knowledge from which decisions are made by prac oners, and our focus is the mely discovery, dis lla on, grading and repurposing of the 500+ randomized clinical trials, meta-analyses and systema c reviews published each year across 13 orthopaedic sub-special es from 300+ journals.

All COA Ac ve and Associate members have access to OE. To receive your custom content please follow this link: www.myorthoevidence.com/signupassociation/3c1o7A1a4 COA Bulletin ACO - Spring / Printemps 2016

Patients prefer our knee while going down stairs. How do your patients feel? A staged bilateral TKA study using different designs showed that patients were more satisfied with the ACL-PCL Substituting Knee design: 76% preferred it over PS and CR designs, and 61% preferred it over mobile-bearing designs. Fast Forward™ to patient satisfaction.

For more information about our patient satisfaction studies, visit ortho.microport.com/clinical_marketing. ™

The ACL-PCL Substituting Knee ™

Every patient is different, and individual results will vary. There are risks associated with surgery. Pritchett JW. Patients prefer a bi-cruciate-retaining or the medial-pivot total knee prosthesis. J Arthroplasty. 2011;26(2):224-8. Trademarks and Registered marks of MicroPort Orthopedics. ©2015 MicroPort Orthopedics Inc. All rights reserved. 010687

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

Wait Time Alliance 2015 Report Card: Another Year of Slow Progress Trinity Wittman Manager, Development and Advocacy Canadian Orthopaedic Association

ach year, the Wait Time Alliance (WTA) releases a report card evaluating provincial performance in reducing health-care wait times across a range of procedures, and offering some recommendations on addressing problem areas. Based on self-reported data from provincial wait-time web sites (which are themselves evaluated for quality in the report), the 2015 national snapshot highlights the lack of progress being made around timely access to care. The provinces that scored well in 2014 continue to have the highest grades for hip and knee arthroplasty wait times, which are the only two orthopaedic procedures included in the report. Saskatchewan and PEI each garnered a double A+ (Table 1), meaning that 90-100% of patients are treated within the national benchmark of 26 weeks for T2 developed by the COA Standards Committee. The study highlights Saskatchewan’s success in cutting surgical wait times with a system-wide effort including financial resources and innovative practices such as pooled referrals and increased use of nurses and other allied health-care professionals. Newfoundland, Québec and Ontario were runners up with a grade of A for both hip and knee replacement, indicating that 80-89% of treatments meet the

T2 benchmark. Orthopaedic surgeries continue to have the longest wait times of all the specialties reported. To view the full 2015 WTA Report or Technical Backgrounder, please visit http://www.waittimealliance.ca/wta-reports/. Though there have been some reductions in wait times for arthroplasty and the other four areas identified in the 2004 Health Accord, the report card fails to adequately capture the gravity of current access to orthopaedic care, reporting only on the time from specialist consultation to surgery (T2), without addressing substantial delays to access referral or consult. Variability in data collection across provincial health ministries and hospitals is also problematic. The COA supports a national standard for measuring wait times for not only the five WTA procedures, but for a larger inventory of orthopaedic surgeries. See the full WTA recommendations on the role of the federal government in providing timely access to care for all Canadians, which include health human resource planning. Despite data collection concerns, the message remains clear, that provincial ministries still have a long road ahead to achieving optimal orthopaedic surgical wait times for Canadians. System-wide changes are needed, including innovative models of care to ease the current bottleneck of patients and address demographic changes. The COA is entering a new phase of its advocacy strategy, and will continue to keep the membership abreast of developments. We welcome feedback from members at policy@canorth.org.

Bulletin de l’Alliance sur les temps d’attente de 2015 : La lente progression se poursuit Trinity Wittman Directrice du développement et des activités de défense des droits et intérêts Association Canadienne d’Orthopédie

haque année, l’Alliance sur les temps d’attente (ATA) diffuse un bulletin d’évaluation de la réduction des temps d’attente dans divers domaines dans les provinces, qui comporte également des recommandations applicables aux domaines problématiques. D’après les données autodéclarées sur les sites Web provinciaux sur les temps d’attente (dont la qualité est aussi évaluée dans le Bulletin), 2015 est caractérisée par l’absence de progrès. Les provinces qui ont obtenu de bons résultats en 2014 ont maintenu le cap et obtenu les meilleures notes en ce qui a trait aux temps d’attente pour les arthroplasties de la hanche et du genou – les deux seules interventions orthopédiques évaluées. La Saskatchewan et l’Île-du-Prince-Édouard ont obtenu un A+ (Table 1) pour les 2 interventions, ce qui signifie que de 90 à 100 % des patients ont été traités conformément au point de repère national, soit 26 semaines pour la période T2, tel qu’établi par le Comité sur les normes de l’ACO. L’évaluation met en outre en évidence la réduction des temps d’attente pour une chirurgie en Saskatchewan, tout le système étant mis à contribution, que ce soit par l’utilisation des ressources financières ou par l’application de pratiques novatrices, comme le regroupement des renvois aux soins de spécialistes et le recours accru aux infirmières et autres professionnels des soins de santé connexes. Terre-Neuveet-Labrador, le Québec et l’Ontario ont toutes obtenu un A pour les arthroplasties de la hanche et du genou, ce qui signifie que de 80 à 89 % des patients ont été traités conformément au point de repère national pour la période T2. Les chirurgies orthopédiques continuent COA Bulletin ACO - Spring / Printemps 2016

d’être associées aux temps d’attente les plus longs parmi toutes les spécialités évaluées. Pour lire le Bulletin de l’Alliance sur les temps d’attente de 2015 ou le Document d’information technique, consultez le site www.waittimealliance.ca/rapports-de-lata/bulletin-2015-de-lata/?lang=fr. Bien qu’il y ait eu réduction des temps d’attente pour les arthroplasties et les quatre autres domaines établis dans l’Accord de 2004 des premiers ministres sur le renouvellement des soins de santé, le Bulletin ne montre pas à quel point l’accès aux soins orthopédiques est problématique, précisant seulement le temps d’attente entre la consultation d’un spécialiste et la chirurgie (période T2), omettant les délais importants associés au renvoi vers un spécialiste et à l’obtention d’une consultation. La collecte des données varie d’un ministère de la Santé et d’un hôpital à l’autre, ce qui pose aussi problème. L’ACO est en faveur d’une norme nationale d’évaluation des temps d’attente ne se limitant pas aux cinq domaines établis par l’ATA, mais englobant un grand nombre de chirurgies orthopédiques. Consultez toutes les recommandations de l’ATA quant au rôle du gouvernement fédéral dans la prestation des soins en temps opportun à tous les Canadiens, ce qui comprend la planification des ressources humaines en santé. Malgré les préoccupations entourant la collecte des données, il ressort clairement de leur analyse que les ministères provinciaux ont encore beaucoup de travail à faire pour que les Canadiens bénéficient de temps d’attente optimaux pour les chirurgies orthopédiques. Des changements profonds sont nécessaires, y compris la mise en œuvre de modèles de soin remédiant à l’engorgement actuel et tenant compte des changements démographiques. L’ACO entame une nouvelle étape de sa stratégie de défense des droits et intérêts et continuera de vous informer de la progression de ce dossier. Vous pouvez envoyer vos commentaires sur la question à policy@canorth.org.

Advocacy & Health Policy / DĂŠfense des intĂŠrĂŞts et politiques en santĂŠ

TABLE 1. Wait time grades for WTA selected procedures tablE 1. Wait time grades for Wta selected procedures based on Wta benchmarks 2015 based on WTA benchmarks 2015

Treatment/service/procedure

Cancer Care (radiation therapy, curative care)â˜˘ Referral to consult wait time (all body sites combined) Decision to treat to start of treatment (All body sites combined) Breast

14 days

A+

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

14 days

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

14 days

Lung

14 days

? ? ?

D F D

? ? ?

A+ A A+

D F B

? ? ?

â˜ź

? ? ?

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ?

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ? A+

? ? ?

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ? A

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ? ?

Prostate

Cardiac Care (Scheduled cases)â™Ľ

14 days

â˜ź

Electrophysiology catheter ablation

90 days

Echocardiography

30 days

Cardiac rehabilitation CABG

Chronic Pain (Anesthesiology)

Nerve damage after surgery or trauma

6 weeks

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ? /

30 days

? ? ? ?

? ?

F A

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ?

B A+

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ?

F B

? ?

â˜ź

? ? ? â˜ź

? ? ?

30 days

Pain related to disc problems

3 months

Exacerbations or flare ups of chronic pain

3 months

Cancer pain

Diagnostic Imaging (non-urgent)

MRI CT

Emergency Departmentâ€

2 weeks

60 days 60 days

Family Medicine (Same day access)

Gastroenterology (Endoscopy)

Cancer

Inflammatory bowel disease (IBD) Fecal occult blood test positive

General Surgery Nuclear Medicine (scheduled cases)

â˜ź 2 weeks

? ?

? ? ?

â˜ź

? ? ? ?

30 days

2 weeks

2 months

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ? â˜ź â˜ź ? C

â˜ź ? ? ? â˜ź

? ? ? â˜ź

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ?

? ? ? ? â˜ź ? ?

Bone scan - whole body

30 days

Cardiac nuclear imaging

14 days

? ? ?

â˜ź

Abnormal premenopausal uterine bleeding

12 weeks

Pelvic prolapse

12 weeks

â˜ź

FDG-PET

Obstetrics and Gynaecology (scheduled cases)

Urinary incontinence

Orthopaedics (Joint Replacement)

Total hip arthroplasty

12 weeks

26 weeks

A+

26 weeks

A+

Advanced Dental Caries: carious lesions/ pain

90 days

Strabismus: 2-6 years old

90 days

? ? ?

4 months

? ? ?

Major depression

4 weeks

Mania (urgent)

1 week

6 wks (4 wks consult; 2 wks start of therapy)

6 weeks

Total knee arthroplasty

Pediatric Surgery* Cleft Lip/Palate

Plastic Surgery

Breast reconstruction Carpal tunnel release

Skin cancer treatment

Psychiatry (scheduled)

First episode, psychosis

Rheumatology

Rheumatoid Arthritis (RA) Spondyloarthritis (SpA)

Psoriatic Arthritis (PsA)

Sight restoration

Cataract surgery

21 days

4 weeks

2 months

2 weeks

3 months

16 weeks

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

A+

â˜ź

? ? ?

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

F F

? ? ?

D A ?

? D â˜ź ? F ?

â˜ź ? ? ? â˜ź ? ? ? â˜ź

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

? ? ?

â˜ź F ? ?

? ? ? â˜ź

? ? ?

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

â˜ź ? ? ? â˜ź F

B ?

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

â˜ź

A+

â˜ź

đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“ đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“

â˜ź

A+

Methodology Based on provincial websites from July/August 2015: A+: 90-100% of population treated within benchmark A: 80-89% of population treated within benchmark B: 70-79% of population treated within benchmark C: 60-69% of population treated within benchmark D: 50-59% of population treated within benchmark F: Less than 50% of population treated within benchmark na: no data are provided or data do not lend themselves to estimates of performance. The diagonal line " â „" in white squares indicates that the service is not provided i.e., CABGs in PEI. â™Ľ Please refer to the Canadian Cardiovascular Society website at www.ccs.ca for a full range of benchmarks for cardiovascular services and procedures. All of these benchmarks need to be adopted to meaningfully address wait times. â˜˘ Cancer radiotherapy. Wait times currently reflect only waits for external beam radiotherapy, while waits for brachytherapy (implanted radiation treatment, e.g., for prostate and cervical cancers) go unreported â€ The Canadian Association of Emergency Physicians (CAEP) introduced revised ED wait-time targets in 2013 (see the WTA website for more information). ? Symbol is assigned if the province does not report wait times for the treatment. đ&#x;‘“đ&#x;‘“đ&#x;‘“đ&#x;‘“ The province reports wait times for this specific procedure but not in a manner that would permit it to be graded by WTA measures. â˜ź The province reports wait times for this specialty. * These benchmarks enable pediatric institutions to compare with peers and share learning Colour Grading Methodology This table identifies the change in wait times using the most recent publicly available data for each of the 5 priorities by province as follows: decrease in wait times over the previous year increase in wait times over the previous year no significant change (i.e., less than 5% increase or less than 10% decrease) over the previous year insufficient data to make determination

Source: Eliminating Code Gridlock in Canadaâ€™s Health Care System - 2015 Wait Time Alliance Report Card COA Bulletin ACO - Spring / Printemps 2016

INTRODUCING

TRIATHLON TRITANIUM ®

Orthopaedics

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

FONT: Helvetica with bell curve

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

The Canadian Orthopaedic Foundation is pleased to have awarded the following research grants for 2015:

La Fondation Canadienne d’Orthopédie est heureuse d’accorder les prix et bourse de recherche suivants pour 2015 :

J. EDOUARD SAMSON AWARD

PRIX J.-ÉDOUARD-SAMSON

Dr. Pascal-André Vendittoli

Dr Pascal-André Vendittoli

(Montreal, QC)

(Montréal, Qc)

“Optimization of management and treatment of subjects with knee and hip joint degeneration”

« Optimization of management and treatment of subjects with knee and hip joint degeneration »

Spring 2016 bulletin 112

The Spring 2016. #112 edition of the COA Bulletin

Spring 2016 bulletin 112

Published on Apr 21, 2016

The Spring 2016. #112 edition of the COA Bulletin

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