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

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




Value for Your Commitment New membership dues structure takes effect in 2016............... p. 9 Votre engagement rapporte Entrée en vigueur de la nouvelle structure tarifaire en 2016....... p.10

Seeking Adventure and Giving Back - Getting to Know your COA Global Surgery Committee � � � � � � � � � � � � � � � � � � � � � � � � � � � � 12 Use of Bone Graft and Substitutes in Orthopaedics – clinical feature� � � � � � � � � � � � � � 25 A Political Call to Arms (and Hips, Knees, and Ankles) � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 37 Nouveau look moderne à l’image des programmes dynamiques de la Fondation Canadienne d’Orthopédie� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 39

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

Form e know rly n as JBJS ( Br)

Editor-in-Chief Mr Ben Ollivere

Editor-in-Chief Prof Fares Haddad

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

To activate your subscription go to If you do not know your login details to activate your subscription please email

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

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

Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 109 Summer / Été 2015 COA / ACO Dr. Robin R. Richards President / Président Dr. John Antoniou Secretary / Secrétaire Mr. Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4150 Ouest, rue Sainte-Catherine West Suite 450, Westmount, QC H3Z 2Y5 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: Web site/Site internet: COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Dr. Marc Isler Editor-in-Chief / Rédacteur en chef Dr. Peter Lapner Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (, the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www., une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.


A Year of Change Bas Masri, M.D., FRCSC Immediate Past President, Canadian Orthopaedic Association


s president, I have had the opportunity to witness, first hand, some of the concerns and successes of orthopaedic surgeons in Canada. In my President-Elect Address delivered in Montreal last June, I emphasized the need for change and the importance of our resilience, as a profession, to adapt to this change. It is therefore fitting to highlight some of the changes within the COA that have taken place this year. In an effort to match our sister international orthopaedic organizations, and in an effort to encourage our members to attend the Annual Meeting, our premier educational event, the Board has approved a change in our current membership dues structure. Beginning in 2016, COA annual membership dues will allow Active members to attend the Annual Meeting at no charge. We expect that this will improve attendance, without reducing revenue for the organization. At the time of writing, the COA has just over 920 active members practicing in Canada. The Membership Committee would like to celebrate reaching our 1000th Active member milestone with a special incentive program. The orthopaedic surgeon who is the 1000th Active member will have his or her membership dues waived for three full years. Please take this opportunity to encourage your colleagues, who are not yet members, to join and make the COA their organization as well. This brings me to the changes that the COA has made to add value for its members. • OrthoEvidence. Based on feedback from the COA’s Education Pillar, we have agreed to extend this added benefit for another year. Active members of the COA can access full content on at no charge. Visit page 42 of this edition to learn more about this membership benefit. • New this year, COA Active members (practicing in Canada) and Associate members now have access to the electronic versions of the Bone and Joint Journal, formerly Journal of Bone and Joint Surgery (British Volume) as well as the review journal, Bone & Joint 360. These journals can be accessed electronically at and In addition, the Bone and Joint Journal App can be downloaded to your smart phone or tablet for easy reference. This should prove to be a valuable resource for our members. Login information was sent via e-mail earlier this spring. If you have any questions about accessing these journals, please contact the COA office. The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450, Westmount, Quebec, H3Z 2Y5. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450 Westmount, Quebec, H3Z 2Y5

Le Bulletin de l’Association Canadienne d’Orthopédie est publié au printemps, été, automne, hiver par l’Association Canadienne d’Orthopédie, 4150, rue Ste-Catherine Ouest, Suite 450, Westmount, Québec H3Z 2Y5. Le Bulletin est distribué aux memb­res de l’ACO, aux gouvernements, aux hôpitaux, aux professionnels de la santé et à l’industrie orthopédique. Veuillez faire parvenir tout changement d’adresse à : l’Association Canadienne d’Orthopédie, 4150, rue Ste-Catherine Ouest, Bureau 450, Westmount, Québec H3Z 2Y5

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

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

COA Bulletin ACO - Summer / Été 2015

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• The COA Bulletin has now moved to an online format. Paper issues will no longer be mailed. The online version allows us to provide more timely and interactive access to members while dramatically reducing our production costs and impact on the environment. The COA Bulletin can be accessed on our web site at Please book mark this link and add it to the homescreen of your tablets for quick reference. The Bulletin is also available through the COA mobile App. You can download the COA App from the App Store or Google Play. As my year as president draws to a close, I would like to take this opportunity to address some primary concerns for the COA. The unemployment and under employment of orthopaedic surgeons continues to be the top priority for the leadership of the COA. Data collected from every hospital in Canada on anticipated hiring needs was presented in June by our Professional Practice Committee as were the results from the latest survey, issued by the Orthopaedic Human Resources Committee, of R3-R5 residents and recent graduates. Our position statement on the issue continues to guide our advocacy efforts in this critical area. The COA Board has been tasked to update a COA response plan. In the meantime, l would like to personally thank program directors across the country for reducing the number of orthopedic residency slots, but I would encourage them to reduce even further. While there is a growing need for orthopaedic services, the reality of funding across the country is such that lobby efforts for additional hospital resources will not bear fruit. Reducing the number of residency positions is of great importance to help address the issue of unemployment and underemployment. I would also like to touch on the current usage of orthopaedic locums. Locums were initially intended to replace orthopaedic surgeons for brief absences due to illness, leave or extended vacations. Surgeons of all ages in established practices seem to have more than welcomed the opportunity to give away what is probably the least attractive aspect of their practices to the more eager, enthusiastic and certainly motivated new graduates. While I understand that some of our members would like to give up their trauma responsibilities, they should do so in such a way that a full-time position, perhaps for trauma coverage, is created as opposed to relying on locums. This brings me to another double-edged sword, namely the issue of subspecialization. While increasing specialization and narrowing the focus of practice may potentially lead to better patient outcomes, it may also lead to potential overutilization of resources, and difficulties in providing comprehensive care, especially in smaller communities. It may create difficulties for young surgeons to find employment, particularly if their chosen subspecialty is not in demand when they are looking for a job. This is an area for future discussion and consideration. Perhaps the area of community or comprehensive orthopaedics should receive increased focus, and orthopaedic fellowship programs in that area need to be established. Although I realize that these are contentious topics which will require significant discussion and careful review, I challenge the profession to start thinking about the issue of super-speCOA Bulletin ACO - Summer / Été 2015

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 17 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 37 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 41 cialization and its positive and negative consequences. I would also like to remind our members that the issue of unemployment/underemployment does not only affect our younger colleagues. It affects our entire profession. The basic laws of supply and demand will, in time, reduce the value of our work because of the oversupply of surgeons. Changing models of practice may allow us to open positions for our younger colleagues. As a profession, we need to resist the phenomenon of outsourcing our work to other professionals to screen surgical cases from non-operative cases. To borrow from the American Orthopaedic Association, we should “own the bone” and offer a comprehensive service of musculoskeletal care to our patients. We should encourage all referrals and we should encourage non-operative care, when appropriate. It is unreasonable to expect that most of our referrals will be surgical. By limiting our referrals, we will, in effect, reduce the number of surgeons required in Canada. If we encourage all referrals, and we see them in a timely manner, there will be a need for more surgeons to manage the additional demand and will open positions for new graduates. With time, as we work to reduce T1, T2 may increase. Consequently, if we already have surgeons working to see patients in a timelier manner, hospitals will be pressured to respond with additional resources. Some provinces are looking at wait-time guarantees. In BC, for example, hospitals will be penalized for having patients on a waiting list for over a year, and this may go down to six months in the long-term. By addressing the unmet need in the community ourselves, we will be able to lobby for additional resources because the relevance of our work will become obvious to hospitals. The Practice Management Committee will begin work on a pan-Canadian database that aims to catalogue projects related to improving access to care. All provincial associations will be invited to submit a brief description of relevant projects for inclusion on the COA web site, with a link to further information, to allow for sharing of best practices. Also on the advocacy front, the COA, in partnership with the Canadian Orthopaedic Foot & Ankle Society (COFAS) and the Ontario Orthopaedic Association, has completed a submission to the Ontario Ministry of Health in respect to the Ontario government’s consideration of a dramatic increase in the scope of practice for podiatrists in Ontario. This increase in scope of practice, if it stands unchanged, would allow podiatrists to perform foot and ankle surgery in the absence of educational program

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standards, identified professional competencies and the means to meet and maintain those competencies. We felt strongly that the podiatrist’s proposal failed to provide evidence of optimal patient outcomes, patient safety and cost-effectiveness. Following a 2014 survey of COA and Canadian Arthroplasty Society (CAS) members regarding the American Academy of Orthopaedic Surgeons (AAOS) – American Dental Association (ADA) Clinical Practice Guidelines for antibiotic prophylaxis in THA/TKA patients prior to dental procedures, the COA Standards Committee continues to collaborate with the Canadian Dental Association (CDA) and the Canadian Infectious Disease and Medical Microbiology experts related to best practices. The COA and the CDA ultimately hope to issue a combined position statement regarding clinical guidelines/recommendations for the use of antibiotic prophylaxis in patients with lower extremity arthroplasties undergoing a variety of dental procedures. This is a complicated and often controversial topic, often causing confusion and anxiety for both the patients and their care-givers. A consistent, unified, evidence-based approach to the issue will benefit all.

These are some of the projects and issues facing the COA that we have been addressing in the past year. It has been a privilege serving as your president and I would like to thank our membership for entrusting me with this position. As this is my last presidential message in the COA Bulletin, I would like to thank the Executive for their tireless work over the past year, and the Board for maintaining oversight and vigilance over the activities of the organization. Our CEO, Doug Thomson, and our staff, Cynthia Vezina, Trinity Wittman and Meghan Corbeil have also provided excellent support, and without them, my job would be impossible. I would like to take this opportunity to personally thank them for their excellent work and their commitment to the COA. Dennis Jeanes has retired from his position as Manager, Communications and Advocacy this year, and I would like to wish him all the happiness in his retirement and thank him for his years of support. In closing, I would like to welcome our new president, Dr. Robin Richards, whom I would like to thank in advance for his commitment to the COA.

Une année de changement Bas A. Masri, MD, FRCSC Président sortant de l’Association Canadienne d’Orthopédie


n tant que président, j’ai eu l’occasion de constater de visu certaines des préoccupations et des réussites des orthopédistes au pays. Dans mon allocution à titre de président élu, prononcée en juin dernier, à Montréal, j’insistais sur le besoin de changement et l’importance de notre résilience, en tant que professionnels, afin de nous y adapter. Il convient donc de souligner certains des changements survenus au sein de l’ACO au cours de la dernière année. Dans la foulée des initiatives en ce sens de nos associations sœurs dans le monde, et dans le but d’inciter nos membres à assister à la Réunion annuelle, notre principale activité de formation, le conseil d’administration a approuvé la modification de notre structure tarifaire. Ainsi, à compter de 2016, la cotisation annuelle à l’ACO permettra aux membres actifs d’assister à la Réunion annuelle gratuitement. Nous croyons que cette mesure améliorera la participation sans réduire les revenus de l’ACO. Au moment de rédiger cet article, l’ACO comptait un peu plus de 920 membres actifs au Canada. Le Comité d’admission souhaite souligner l’adhésion du millième membre actif de façon spéciale. En effet, l’orthopédiste qui sera notre millième membre actif sera exempté de cotisation annuelle pendant trois ans. Voilà donc une belle occasion d’inciter vos collègues non membres à joindre les rangs de l’ACO.

J’en profite d’ailleurs pour vous parler des changements apportés par l’ACO pour mieux servir ses membres : • OrthoEvidence. D’après les commentaires recueillis sur la formation, un des volets de la mission de l’ACO, nous avons convenu d’offrir cet avantage encore cette année. Les membres actifs de l’ACO ont donc accès gratuitement à l’ensemble du contenu publié à Consultez la page 42 du présent numéro pour obtenir des détails sur cet avantage pour les membres. • Cette année, les membres actifs de l’ACO qui exercent au Canada et les membres associés ont droit à une nouveauté : l’accès à la version électronique du Bone and Joint Journal (anciennement le British Journal of Bone and Joint Surgery) et de la revue Bone & Joint 360. Ces revues sont accessibles à et à De plus, les membres peuvent télécharger l’application du Bone and Joint Journal sur leur téléphone intelligent ou tablette pour plus de commodité. L’accès à cette ressource devrait s’avérer fort utile. Les membres ont reçu leurs coordonnées de connexion par courriel plus tôt ce printemps. Si vous avez des questions quant à l’accès à ces publications, n’hésitez pas à communiquer avec les bureaux de l’ACO. • Le Bulletin de l’ACO est maintenant publié en ligne. Il n’y aura donc plus d’envois postaux. La version en ligne du Bulletin nous permet d’offrir un accès plus rapide et interactif aux membres tout en réduisant de façon marquée les coûts de production et les répercussions sur l’environnement. Pour le consulter, rendez-vous sur notre site Web, à

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Vous pouvez ajouter ce lien à vos signets et à vos icônes sur votre tablette pour y accéder rapidement. Le Bulletin est aussi accessible grâce à l’application mobile de l’ACO. Téléchargez-la à partir de l’App Store d’iTunes ou de Mes applis Android de Google Play. Alors que mon mandat de président se termine, je profite de l’occasion pour souligner quelques-unes des grandes préoccupations de l’ACO : Le chômage et le sous-emploi chez les orthopédistes continue d’être la priorité de la direction de l’ACO. Les données recueillies auprès de l’ensemble des hôpitaux canadiens sur l’embauche prévue au cours des prochaines années ont été présentées en juin par le Comité exécutif sur l’exercice orthopédique, tout comme les résultats du dernier sondage mené par le Comité sur les ressources humaines en orthopédie auprès des résidents de troisième, quatrième et cinquième années et des jeunes diplômés. Notre énoncé de position sur la question demeure au cœur de nos efforts de défense des droits et intérêts dans ce dossier névralgique. Le conseil d’administration de l’ACO s’est vu confier le mandat de mettre à jour sa stratégie d’intervention. Pour le moment, je me permets de remercier les directeurs de programme partout au pays d’avoir réduit le nombre de postes de résidence en orthopédie, et je les invite à continuer cet effort. Bien que les besoins en orthopédie soient croissants, le financement disponible au pays est si limité que les pressions en vue d’obtenir davantage de ressources en milieu hospitalier seraient futiles. Ainsi, réduire le nombre de postes de résidence est très important si l’on veut arriver à remédier au chômage et au sous-emploi. J’aimerais aussi aborder la question des suppléances en orthopédie. À l’origine, elles visaient le remplacement d’orthopédistes pendant de courtes périodes en cas de maladie, de départ ou de congé prolongé. Des orthopédistes de tous âges et bien établis semblent vraiment apprécier cette possibilité de déléguer ce qui constitue probablement l’aspect le moins intéressant de leur pratique à des jeunes orthopédistes plus enthousiastes et très motivés. Il est certes compréhensible que certains membres veuillent renoncer aux soins en traumatologie, mais ils devraient le faire de sorte qu’un poste à temps plein, peut-être assigné aux soins en traumatologie, soit créé plutôt que de recourir à des suppléances. Ce qui m’amène à vous parler de la sous-spécialisation, une autre arme à double tranchant. Bien que la spécialisation et la réduction de son champ d’exercice puissent mener à de meilleurs résultats pour les patients, cela peut aussi causer la surexploitation des ressources, et donc rendre la prestation de soins globaux plus ardue, surtout dans les collectivités plus petites. Les jeunes orthopédistes peuvent avoir de la difficulté à trouver un emploi, surtout si leur sous-spécialité n’est pas recherchée. Cette question demande des discussions et réflexions plus poussées. On devrait peut-être s’intéresser davantage à l’orthopédie en milieu communautaire ou générale et créer des programmes de formation supérieure en orthopédie dans ce secteur. Je suis conscient qu’il s’agit de questions controversées qui doivent être discutées à fond et étudiées avec soin, mais je demande à notre communauté professionnelle d’entamer une réflexion sur la surspécialisation et ses conséquences positives et négatives. J’aimerais aussi rappeler aux membres que la COA Bulletin ACO - Summer / Été 2015

question du chômage et du sous-emploi n’affecte pas seulement nos jeunes collègues, mais bien la profession dans son ensemble. Les lois fondamentales de l’offre et de la demande vont éventuellement réduire la valeur de notre travail en raison du surplus d’orthopédistes. Changer nos modèles d’exercice pourrait créer des ouvertures pour nos jeunes collègues. En tant que communauté, nous devons résister au phénomène de la sous-traitance du tri des cas chirurgicaux ou non à d’autres professionnels. L’American Orthopaedic Association utilise l’expression to own the bone : nous devrions nous approprier les soins de l’appareil locomoteur de sorte à offrir des soins globaux à nos patients. Nous devrions favoriser toutes les références et les soins non chirurgicaux quand il convient de le faire. Il n’est pas raisonnable de s’attendre à ce que la majorité des cas qui nous sont référés nécessitent une chirurgie. Dans les faits, en limitant le nombre de cas référés, nous réduisons le nombre d’orthopédistes nécessaires au pays. Si nous favorisons toutes les références et que nous recevons les patients rapidement, davantage d’orthopédistes seront nécessaires pour gérer la demande accrue, ce qui se traduira par la création de postes pour les nouveaux diplômés. En travaillant à réduire le temps d’attente pour la période T1, celui pour la période T2 pourrait augmenter. Donc, si des orthopédistes cherchent déjà à rencontrer les patients plus rapidement, les hôpitaux seront amenés à allouer des ressources supplémentaires. Dans certaines provinces, on envisage des garanties de temps d’attente. En Colombie-Britannique, par exemple, les hôpitaux seront pénalisés si leurs patients sont inscrits à une liste d’attente pendant plus d’un an, un délai qui pourrait passer à six mois à long terme. En répondant nous-mêmes aux besoins négligés dans la collectivité, nous pourrons faire pression pour obtenir des ressources supplémentaires, car la pertinence de notre travail deviendra évidente pour les hôpitaux. Le Comité sur la gestion de l’exercice se penchera sur une banque de données pancanadienne qui a pour but de répertorier les projets d’amélioration de l’accès aux soins. Toutes les associations provinciales seront invitées à soumettre une brève description des projets pertinents en vue d’une publication sur le site Web de l’ACO, où un lien permettra d’obtenir de plus amples renseignements, de sorte à favoriser le partage des pratiques exemplaires. Aussi, sur le plan de la défense des droits et intérêts, l’ACO, en collaboration avec la Société Orthopédique Canadienne pour le Pied et la Cheville (SOCPC) et l’Ontario Orthopaedic Association (OOA), vient de soumettre un avis au ministère de la Santé ontarien relativement à l’élargissement spectaculaire du champ d’activité des podiatres et podologues qui est envisagé. S’il est adopté tel quel, cet élargissement permettra aux podiatres et podologues d’effectuer des chirurgies au pied et à la cheville sans normes pour les programmes de formation, compétences établies ni moyens de confirmer et de maintenir de telles compétences. Nous sommes convaincus que la proposition des podiatres et podologues ne fournit pas la preuve de résultats optimaux pour les patients, de sécurité pour les patients et d’économies. Dans la foulée du sondage de 2014 auprès des membres de l’ACO et de la Société canadienne d’arthroplastie (CAS) sur les lignes directrices cliniques de l’American Association of Orthopaedic Surgeons (AAOS) et de l’American Dental Association (ADA) en matière d’antibioprophylaxie chez les

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patients ayant une prothèse totale de la hanche ou du genou qui subissent une procédure dentaire, le Comité sur les normes de l’ACO poursuit sa collaboration sur les pratiques exemplaires avec l’Association dentaire canadienne (ADC) et des spécialistes canadiens en infectiologie et microbiologie médicale. Au bout du compte, l’ACO et l’ADC espèrent pondre un énoncé de position conjoint sur les lignes directrices et recommandations cliniques en matière d’antibioprophylaxie chez les patients qui ont une prothèse articulaire à un membre inférieur et doivent subir diverses procédures dentaires. Il s’agit d’un sujet complexe et controversé, qui provoque souvent de la confusion et de l’anxiété tant chez les patients que les soignants. Une approche commune, uniforme et fondée sur des données probantes ne peut qu’être bénéfique pour tous.

Dennis Jeanes, notre directeur des communications et des activités de défense des droits et intérêts, a pris sa retraite cette année, et je lui souhaite tout le bonheur possible et le remercie pour ses années de soutien à notre organisation.

Il s’agit là de quelques-uns des projets et dossiers traités par l’ACO au cours de la dernière année. Vous servir à titre de président a été un privilège, et je souhaite remercier les membres de leur confiance à mon égard. Comme il s’agit de mon dernier message comme président dans le Bulletin de l’ACO, j’en profite pour remercier la direction pour son travail incessant au cours de l’année, ainsi que le conseil d’administration, pour la surveillance qu’il exerce sur les activités de l’organisation et sa vigilance à cet égard. Doug Thomson, notre directeur général, de même que notre équipe, soit Cynthia Vezina, Trinity Wittman et Meghan Corbeil, m’ont aussi été d’un grand soutien. Sans eux, je n’aurais pas pu faire mon travail. Je profite également de l’occasion pour les remercier personnellement pour leur excellent travail et leur engagement envers l’ACO.

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

Enfin, je souhaite la bienvenue à notre nouveau président, le Dr Robin Richards, que je remercie à l’avance pour son engagement envers l’ACO.

Article submissions to the COA Bulletin are always welcome!

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

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Prochain arrêt : Québec!

Next Stop – Québec City!



ous souhaitons d’abord remercier tous les membres qui se sont inscrits à la Réunion annuelle 2015 de l’ACO, à Vancouver. Votre soutien et votre participation sont grandement appréciés. La Réunion annuelle 2016 de l’ACO aura lieu dans la magnifique ville de Québec; le Comité responsable du programme est coprésidé par les Drs Etienne Belzile et Mélissa Laflamme, le Comité organisateur étant quant à lui dirigé par la Dre Michèle Angers. Attention : la soumission des précis pour les affiches et les exposés commence en septembre. Nous souhaitons enfin remercier l’Université Laval pour sa collaboration. Au plaisir de vous voir à Québec l’an prochain! Soyez des nôtres au Centre des congrès de Québec, du 16 au 19 juin 2016. • Le jeudi 16 juin : Réunion annuelle de l’Association canadienne des résidents en orthopédie (ACRO), séances de travail du conseil d’administration et des comités de l’ACO, et cérémonies d’ouverture • Les vendredi et samedi 17 et 18  juin  : Séances scientifiques toute la journée. Soirée le samedi 18 juin • Le dimanche 19  juin  : Séances scientifiques jusqu’en mi-journée

e would like to thank all members who registered for the 2015 COA Annual Meeting in Vancouver. Your support and participation are much appreciated.

Next year’s Annual Meeting will be held in beautiful Québec City hosted by Program Co-Chairs, Drs. Etienne Belzile and Mélissa Laflamme, as well as Local Arrangements Chair, Dr. Michèle Angers. Stay tuned for the call for abstracts for podium and poster presentations in September. We thank Université Laval for their collaboration and look forward to seeing you all next June. Make your plans to join us at the Québec City Convention Centre from June 16-19, 2016. • Thursday, June 16: CORA Annual Meeting, COA Board and Committee meetings and Opening Ceremonies • Friday, June 17 & Saturday, June 18: Scientific sessions all day. Social night Saturday, June 18. • Sunday, June 19: Scientific sessions ending midday Sunday, June 19 Housing now open.

Il est maintenant possible de réserver une chambre. COA Bulletin ACO - Summer / Été 2015

Your COA / Votre association


Value for Your Commitment

New membership dues structure takes effect in 2016 Cynthia Vezina Manager, Membership Services & Communications Canadian Orthopaedic Association


here are some exciting changes coming into effect next year, including a new membership dues amount for Active members which will also include Annual Meeting registration fees. Learn more about the changes that apply to your respective membership category and the various membership benefits available to you through this new structure. Although the upcoming changes primarily affect members in the Active category, we encourage all members to review the benefits below to have a better understanding of the advantages that come with your COA membership. Active Members When and how much? - Membership dues invoicing will take place in January next year instead of March. Your 2016 renewal notification and invoice will be sent by e-mail in January with followup reminders by both e-mail and post if payment is not received. - The new membership dues amount for all Active members will be $985 CAD annually. What about Annual Meeting registration fees? - The new dues amount will also include your registration fees for the 2016 COA and CORS Annual Meeting being held in Québec City. - Upon receipt of your dues payment, your registration fees for the 2016 Annual Meeting will be automatically waived. - Free registration applies to registrations that are completed and processed prior to the pre-registration cut-off date. Fees for onsite registration for all membership categories still apply. - Your 2016 dues invoice must first be paid in order to obtain the free pre-registration rates. - Tickets for ICLs, workshops, social events and guest program activities can be purchased per their rates indicated on the registration form. What are my other membership benefits aside from the Annual Meeting? • Communications & Access to Education - Subscription and publishing opportunities in the COA Bulletin, the online quarterly journal of the COA featuring the most current clinical resources, articles on best practices, advocacy and practice management.

- Weekly enewsletter, the COA Dispatch where you can keep your finger on the pulse of the latest updates and headlines. Through the COA Dispatch, members can promote courses and events in your centre, request participation in a research survey or share news of interest with your colleagues. - Free subscriptions to both the Bone & Joint Journal (formerly JBJS Br) AND Bone & Joint 360. The BJJ covers the most clinically challenging areas in orthopaedics, and their team of specialty editors means that the journal maintains equity across the complete field and provides the very best information required for each orthopaedic subspecialty. Bone & Joint 360 is a digest journal designed to keep you up-to-date across all areas of orthopaedics. 360’s editorial board scan the major journals and expertly digest their findings into concise summaries, pulling out the bottom line clinical message in a quick and easy read. Discounted offers for print access to these journals is also offered to COA members. - Access to OrthoEvidence is an online provider of the highest quality orthopaedic evidence with over 13,000 orthopaedic professionals using the product around the globe. OrthoEvidence provides instant access to summaries and appraisals of the best available research, leaving more time for what matters most, your patients. - COA Annual Meeting webcasts – recapture educational content from the meeting accessible to COA members only. - Member access to job listings in the COA Community Portal: Advertise an available position in your centre at no charge or log in to build your profile and be notified when a new position is posted online. • Membership in Affiliated Societies - COA membership is a prerequisite in order to join the Canadian Orthopaedic Foot and Ankle Society (COFAS), the American Orthopaedic Foot and Ankle Society (AOFAS) and the Canadian Arthroplasty Society (CAS). By joining the COA, you are eligible for membership within these additional subspecialty societies. • Networking Opportunities - Certain travelling fellowship opportunities through the Association are available to COA members exclusively. - By participating in COA educational and social events, joining a committee and through our communications, COA members gain valuable networking opportunities with their colleagues from across the country. • Advocacy, Media and Government Relations - The COA represents the viewpoints and best interests of the orthopaedic community with provincial and federal Health Ministries, the Royal College, the Canadian Medical Association and other key stakeholders.

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- Strength in numbers to address major concerns in the profession, such as the current underemployment of surgeons across Canada. - Members are encouraged to take a leadership role in local advocacy efforts, using tools at your disposal through the COA web site. - Opportunity to contribute to the national health care conversation through traditional and social media. Associate Members When and how much? - There are no annual membership dues for Associate members. You will not receive an invoice for any membership dues while you remain in this category. - In addition, you will not be charged annual dues after completion of your residency and fellowship training if you are solely doing locums/clinical assists and not yet in a full time position. Once you are working full time and transferred to the Active membership category, your annual dues will be reduced by 50% during your first year of practice. You are supported by the COA throughout your training and career. What about Annual Meeting registration fees? - Associate members do not pay any Annual Meeting registration fees either. - Free registration applies to registrations that are completed and processed prior to the pre-registration cut-off date. Fees for onsite registration for all membership categories still apply. - Tickets for ICLs, workshops, social events and guest program activities can be purchased per their rates indicated on the registration form.

What are my other membership benefits? • Communications & Access to Education - Associate members have all of the same access to the COA Bulletin, Dispatch, BJJ, Bone & Joint 360,, webcasts and Community Portal as Active members. Read more about these benefits by referring to the listing above. • Resident-specific Courses & Events - Being a COA member allows you access to the Calgary Orthopaedic Review Forum (CORF) – the annual exam preparation and review course offered to R5 residents. - The Canadian Orthopaedic Residents Association (CORA) Annual Meeting is conveniently held one day prior to the COA Annual Meeting allowing residents the opportunity to attend two premiere educational events at no charge. • Leadership opportunities - An increasing number of COA committees include positions for resident members. Overseas Members Overseas Membership dues will slightly increase to $350 CAD per year for orthopaedic surgeons practicing abroad. Annual Meeting registration fees are still required from Overseas members and will be similar to those of past meetings. Senior or Research Affiliate Members Fees and services for these two categories of membership remain unchanged. There are no annual membership dues associated with either of these categories; however a registration fee to attend the COA Annual Meeting will still apply. Registration fees will be similar to past events. If you have any questions about the new Active member dues structure or would like to know more about your COA membership benefits, please contact Doug Thomson: We hope to continue to add value to your membership commitment.

Votre engagement rapporte

Entrée en vigueur de la nouvelle structure tarifaire en 2016 Cynthia Vezina Gestionnaire, Communications et services aux membres Association Canadienne d’Orthopédie


es changements fort réjouissants entreront en vigueur l’année prochaine, y compris une nouvelle cotisation annuelle pour les membres actifs qui inclura les droits d’inscription à la Réunion annuelle. Voici quelques détails sur les changements applicables à votre catégorie d’adhésion et les différents avantages qui l’accompagnent. Bien que les changements à venir touchent surtout les membres actifs, nous incitons tous les membres à consulter les avantages ci-dessous pour mieux comprendre en quoi l’adhésion à l’ACO est profitable.

COA Bulletin ACO - Summer / Été 2015

Membres actifs Quand la cotisation doit-elle être versée? À combien s’élève-t-elle? - Le processus de facturation de la cotisation annuelle aura lieu en janvier 2016 plutôt qu’en mars. Vous recevrez votre avis de renouvellement et la facture correspondante par courriel en janvier, puis nous enverrons une série de rappels par courriel et par la poste si vous ne payez pas votre cotisation. - La nouvelle cotisation annuelle pour les membres actifs sera de 985 $CAN.

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Qu’en est-il des droits d’inscription à la Réunion annuelle? - La nouvelle cotisation annuelle comprendra vos droits d’inscription à la Réunion annuelle 2016 de l’ACO et de la Société de recherche orthopédique du Canada (SROC), qui aura lieu à Québec. - Sur réception de votre paiement, vos droits d’inscription à la Réunion annuelle 2016 seront automatiquement considérés comme réglés. - L’inscription sera donc gratuite si elle est faite avant la date limite prescrite pour la préinscription. Les droits d’inscription sur place resteront toutefois en vigueur pour toutes les catégories d’adhésion. - Votre facture pour 2016 devra ainsi être réglée si vous souhaitez bénéficier d’une inscription gratuite. - Vous pourrez vous procurer des billets pour les conférences d’enseignement, les ateliers, les activités sociales et les activités du programme des invités au prix indiqué dans la demande d’inscription. En plus de l’inscription gratuite à la Réunion annuelle, quels sont les autres avantages de l’adhésion? • Communications et accès aux formations - Un abonnement au Bulletin, la revue trimestrielle en ligne de l’ACO, où on trouve les dernières ressources cliniques et des articles sur les pratiques exemplaires, la défense des droits et des intérêts et la gestion de l’exercice, ainsi que la possibilité de contribuer au contenu. - Un cyberbulletin hebdomadaire, la Dépêche, qui vous tient au fait des derniers développements dans le milieu. La Dépêche permet aux membres de promouvoir les cours et activités offerts dans leur centre, de solliciter la participation de leurs pairs à des recherches et enquêtes ou de leur transmettre des nouvelles. - Un abonnement gratuit au Bone & Joint Journal (anciennement le British Journal of Bone and Joint Surgery) ET à Bone & Joint 360. The Bone & Joint Journal (BJJ) aborde les questions cliniques les plus épineuses en orthopédie; son équipe de rédacteurs spécialisés lui permet d’assurer l’équilibre entre les diverses sous-spécialités, en plus de donner accès aux meilleurs renseignements qui soient pour chacune. Bone & Joint 360 est un recueil qui permet de rester au courant de ce qui se passe dans tous les secteurs de l’orthopédie. L’équipe de rédaction parcourt les principales publications et en résume avec talent les conclusions sous forme de comptes rendus courts et simples qui transmettent l’essentiel des constatations cliniques. Les  membres de l’ACO bénéficient également d’une réduction sur la version imprimée de ces revues. - L’accès à OrthoEvidence est un fournisseur en ligne de connaissances en orthopédie de la plus grande qualité, qui peut compter sur un bassin d’utilisateurs de plus de 13 000 professionnels de la communauté orthopédique. Il permet d’accéder instantanément aux sommaires et évaluations des meilleures recherches disponibles, ce qui vous permet de consacrer plus de temps à ce qui importe vraiment, vos patients. - Les webdiffusions de la Réunion annuelle de l’ACO. Revoyez le contenu éducatif de la Réunion, un privilège réservé aux membres.

- L’accès aux possibilités d’emploi dans le Portail communautaire de l’ACO, à Faites connaître toute possibilité d’emploi à votre centre sans frais ou ouvrez une session pour mettre votre profil à jour de sorte à être avisé de toute nouvelle offre. • Adhésion aux sociétés affiliées - L’adhésion à l’ACO est exigée par la Société Orthopédique Canadienne pour le Pied et la Cheville (SOCPC), l’American Orthopaedic Foot & Ankle Society (AOFAS) et la Société canadienne d’arthroplastie (CAS). En devenant membre de l’ACO, vous pouvez donc devenir membre de chacune de ces sociétés spécialisées. • Possibilités de réseautage - Certaines bourses de voyage sont offertes en exclusivité aux membres de l’ACO. - En participant aux activités sociales et de formation de l’ACO, en devenant membres d’un de ses comités et en consultant ses communications, les membres de l’ACO bénéficient d’excellentes possibilités de réseautage auprès de leurs collègues de tout le pays. • Défense des droits et des intérêts et relations gouvernementales et avec les médias - L’ACO fait valoir les points de vue et les intérêts de la communauté orthopédique auprès des ministres provinciaux et fédéral de la Santé, de même que du Collège royal des médecins et chirurgiens du Canada, de l’Association médicale canadienne et d’autres intervenants clés. - La force du nombre quand il faut aborder les préoccupations de premier plan en orthopédie, comme le sous-emploi qui touche les orthopédistes partout au pays. - Nous invitons les membres à assumer un rôle de leadership dans les efforts locaux de défense des droits et des intérêts à l’aide des outils mis à leur disposition sur le site Web de l’ACO. - L’occasion de participer aux discussions nationales sur la santé par l’intermédiaire des médias sociaux et traditionnels. Membres associés Quand la cotisation doit-elle être versée? À combien s’élève-t-elle? - Il n’y a aucune cotisation annuelle pour la catégorie « Membres associés ». Vous ne recevrez donc pas de facture tant que vous appartiendrez à cette catégorie d’adhésion. - De plus, vous n’aurez pas de cotisation annuelle à payer après votre résidence et formation supérieure si vous ne faites que de la suppléance ou de l’assistance clinique et que vous n’occupez pas encore de poste à temps plein. Une fois employé à temps plein et membre actif de l’ACO, vous bénéficierez d’une réduction de 50  % sur votre cotisation durant votre première année d’exercice. L’ACO vous soutient pendant votre formation, mais aussi pendant votre carrière.

COA Bulletin ACO - Summer / Été 2015

Your COA / Votre association


(suite de la page 11)

Qu’en est-il des droits d’inscription à la Réunion annuelle? - Les membres associés ne payent aucuns droits d’inscription à la Réunion annuelle. - L’inscription sera donc gratuite si elle est faite avant la date limite prescrite pour la préinscription. Les droits d’inscription sur place resteront toutefois en vigueur pour toutes les catégories d’adhésion. - Vous pourrez vous procurer des billets pour les conférences d’enseignement, les ateliers, les activités sociales et les activités du programme des invités au prix indiqué dans la demande d’inscription. Quels sont les autres avantages de mon adhésion? • Communications et accès aux formations - Les membres associés bénéficient du plein accès au Bulletin et à la Dépêche de l’ACO, au Bone & Joint Journal, à Bone & Joint 360, à, aux webdiffusions et au Portail communautaire, au  même titre que les membres actifs. Ces avantages sont détaillés précédemment. • Formations et activités à l’intention des résidents - Être membre de l’ACO vous donne accès au Calgary Orthopaedic Review Forum (CORF), le cours de préparation et de révision offert aux résidents de cinquième année en vue de l’examen annuel. - La Réunion annuelle de l’Association canadienne des résidents en orthopédie (ACRO) a commodément lieu un jour avant celle de l’ACO, de sorte que les résidents peuvent assister à ces deux manifestations éducatives de premier plan gratuitement.

• Possibilités de leadership - Un nombre croissant de comités de l’ACO réservent des places aux résidents. Membres outre-mer La cotisation annuelle des membres outre-mer augmentera légèrement; elle sera en effet de 350 $CAN pour les orthopédistes qui exercent à l’étranger. Ils doivent aussi payer les droits d’inscription à la Réunion annuelle, qui demeureront sensiblement les mêmes. Membres à la retraite et affiliés du milieu de la recherche Les droits et avantages liés à ces deux catégories d’adhésion sont inchangés. Aucune cotisation annuelle n’est exigée pour ces catégories de membres, qui doivent néanmoins continuer de payer les droits d’inscription à la Réunion annuelle de l’ACO. Les droits d’inscription demeureront sensiblement les mêmes. Si vous avez des questions sur la nouvelle structure tarifaire applicable aux membres actifs ou souhaitez en savoir davantage sur vos avantages en tant que membre de l’ACO, veuillez communiquer avec Doug Thomson, à Sachez que nous espérons continuer d’ajouter de la valeur à votre engagement envers l’ACO.

Seeking Adventure and Giving Back

Getting to Know your COA Global Surgery Committee


he COA Global Surgery (COAGS) initiative brings Canadian orthopaedic surgeons together to share ideas and promote opportunities for providing humanitarian care to vulnerable populations. COAGS invites you to get to know the committee and some of the projects they are proud to support. The spotlight in this issue is on two COAGS Executive members, Dr. Peter O’Brien and Dr. Paul Moroz. Dr. Peter O’Brien is an orthopaedic trauma surgeon and Head of the Division of Orthopaedic Trauma at the Vancouver General and University of British Columbia (UBC) Hospitals. He is an Associate Professor at UBC and serves as Deputy Head of the Department of Orthopaedics. He has served on the Board and multiple committees for both the COA and the Orthopaedic Trauma Association (OTA), as well as being a Past President of the COA. Peter’s research includes a number of projects at the Centre for Hip Health and Mobility studying orthopaedic care in low and middle income countries (LMIC), including the sterile drill cover project. Dr. O’Brien has been involved with the Canadian Orthopaedic Trauma Society in adult orthopaedic trauma multi-centre clinical trials and is curCOA Bulletin ACO - Summer / Été 2015

rently Co-Principal Investigator for the Canadian Far Cortical Locking Multi-centre Prospective Randomized Trial. The Uganda Sustainable Trauma Orthopaedic Program (USTOP) emerged in 2006 when Dr. O’Brien joined forces with Dr. Piotr Blachut, recognizing that Uganda suffers one of the highest rates of traumatic injury in the world (largely due to motor vehicle collisions), coupled with very limited human health resources and supplies to manage the overwhelming burden of injury. Given that most injuries occur in young men and women, short-term and permanent disabilities have a ripple effect on families’ wellbeing, often forcing young children to work instead of attending school. The partnership between UBC Faculty of Medicine and Makerere University in Kampala aims to collaboratively and sustainably improve fracture care education for local surgical residents and allied health care workers through workshops, seminars and clinical teaching. The multidisciplinary USTOP team, including Peter, travels to Kampala twice annually since its inception. He describes each trip as challenging and dynamic, offering

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USTOP 2013 team of attending surgeons, residents, nurses and physiotherapists with Ugandan colleagues.

new skills and friendships along the way: “If you like adventure and something that is entirely different, you cannot help but enjoy this type of experience. I have met wonderful people in Uganda, both health-care workers and patients. It is truly a privilege to be associated with the fine group of individuals that make up the team of Canadians travelling to Africa.” When asked what advice he would offer to a colleague just beginning their foray into international outreach, Dr. O’Brien says the key is to avoid imposing first world standards in the developing world, and instead to develop a relationship with local health care providers, offering help in the context of available resources. Staff on the ground require sustained training in Advanced Trauma Life Support protocols for assessment and treatment of polytrauma, therefore commitment to working with a group over a number of years is more effective than a single visit. If you’re wondering whether USTOP is a good fit for your interests, Dr. O’Brien advises that any orthopaedic surgeon, throughout their career trajectory who does trauma or emergency call, will be able to contribute to this project. For more information about USTOP, please visit or contact Nathan O’Hara at or 604-875-4111 x 66270. Sister Mary Margaret Ajiko, a general surgeon from Soroti Regional Referral Hospital in northeastern Uganda, participates in a biannual USTOP bioskills course.

Dr. Paul Moroz is a paediatric orthopaedic surgeon at the Children’s Hospital of Eastern Ontario (CHEO) and Assistant Professor of Surgery at the University of Ottawa. Paul took an interest in global health from the start of his career, working with Canadian Crossroads International during his undergrad, studying breathing problems in Western Arctic children during his Masters in Epidemiology, and spending six months in Nepal during medical school (instead of the forecasted four weeks long story!). During residency he again worked in Nepal and India, and after his first fellowship, took his entire young family to Bhutan for three months with Orthopedics Overseas, while working in a community hospital in Owen Sound, Ontario. After a second fellowship in paediatric orthopaedics, Paul and his family moved to Ottawa, where he developed global surgery into one of his major academic interests. He serves on the University of Ottawa Faculty of Medicine’s Global Health Advisory Council and is Co-Chair of Global Health at CHEO. He published in the Canadian Journal of Surgery the findings of a 2011 cross-Canada survey identifying barriers to surgical residents participating in international electives. Orthopaedic and general surgery resident respondents were keen to participate in global surgery projects, but perceived barriers included lack of financial support, lack of available organized activities, and fear of using up precious elective time. A full 50% of respondents stated that a residency program promoting international electives would be a positive factor in selecting a program. Dr. Moroz has spent more than 15 years working periodically overseas with the Canadian Network for International Surgery (CNIS), which is especially active in East Africa, teaching surgical skills to African clinical officers, medical students, and residents. This work has been very fulfilling and Paul believes the CNIS is a great way for Canadian orthopaedic surgeons to get involved in global surgery, especially related to education. For more information about CNIS, please visit For more hands-on operative experience, Dr. Moroz volunteers with Health Volunteer Overseas (HVO - the updated name for COA Bulletin ACO - Summer / Été 2015

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Orthopedics Overseas) in Bhutan in South Asia. HVO partners with a number of countries all over the world (see their excellent web site at He also works as an expert consultant with the World Health Organization Global Initiative for Emergency and Essential Surgical Care (WHO-GIEESC), where he is Vice-Chair of the Committee for Training and Education. This committee is currently working to revise one of the primary basic surgical manuals used in rural developing countries, “Surgical Care at the District Hospital – The WHO Manual”. With respect to research in global surgery, Paul is very involved with Dr. Mohit Bhandari’s world-wide research initiative, the International Orthopaedic Multi-centre Study of Fracture Care, (“INORMUS”), a landmark observational cohort study of more than 50,000 patients in low and middle income countries who have sustained fractures and/or dislocations. The goal is to better understand the burden of orthopaedic trauma in the developing world where the impact of orthopaedic injuries on hospital systems have become more recognized, mostly on account of motor vehicle collisions. Paul is the Principal Investigator for the African continent arm of INORMUS where he uses his many contacts in Africa to recruit centers for INORMUS. The practice of dung-wrapped fractures still exists in rural Bhutan, Nepal and Northern India among traditional bone-setters.

Dr. Moroz is interested in expanding opportunities to his orthopaedic colleagues during his work as the Chair of the newly-formed COAGS Committee. COAGS aims to provide a “virtual place” where COA members can learn more about opportunities to get involved in global health, whether it is working in Canada to support global health, with high-level organizations such as the WHO or UN, or at surgical sites in developing countries or disaster zones. COAGS will be a hub for information-sharing, networking and connecting people to the many excellent programs, organizations, and NGO’s around the world where surgeons can serve. COAGS is in its early stages and the Executive welcomes membership feedback regarding the initiative’s development. For more information or to reach a COAGS Committee member, please contact Trinity Wittman at or 514-874-9003 x 2.

Dr. Paul Moroz treating one of the Holy Reincarnates of the Shabdrun (the child in the baseball cap) from Bhutan for a repeat fracture of his forearm from rough playing, and taking on the unwanted job of explaining to the family that the child needs to settle down.

COA Bulletin ACO - Summer / Été 2015

Your COA / Votre association


Reply to debate: What is the best way to achieve needed reform in the health care? Dear Editor,


t was of great interest to read the timely debate on needed health care reform in the Spring Bulletin.

At Manitoba Bone and Joint Health (MBJH), our core belief is that the best way to achieve needed reform in our health care system is to move the discussion upstream to the debate between public and private care. It was therefore fitting that the debate was preceded by a tribute to Dr. Cy Frank and a discussion of the development and current state of Alberta Bone and Joint Health Institute (ABJHI). Dr. Don Dick, who reviewed both his work with Dr. Frank and the development of ABJHI, was our inspiration to establish our not for profit MBJH corporation. We remain a small organization ( We are stepping up our activity this year with the confluence of increasing debt in Manitoba, the provincial debt downgrade by Moody’s and the debilitating effect this has on the continued provision of health-care services, as well as a provincial election next year which will include a vigorous, but increasingly misguided, debate on health care. Our core MBJH belief is that modern health must be organized first by systems of the human body through which we educate, research, evaluate, provide, and pay for health care.

For musculoskeletal (MSK) care, we present MBJH as a template for orthopaedics including other MSK-related disciplines. We agree with Dr. Danielle Martin and colleagues, arguing for system changes within our publicly-funded system, and with Dr. Day, advocating for Canadian’s right to pay directly for health care. We believe Dr. Day’s suit should and will be successful, and we also believe in the goal of our national system enshrined in the Canada Health Act (CHA) for care that is comprehensive, accessible, universal, portable and publicly administered. At MBJH our approach to MSK care is to provide a template for the Ministry of Health, which maintains an overall responsibility to the public to carry out the CHA effectively. With an umbrella template in place, we believe the best ideals of the public system and the reinvigoration and expansion enabled by the freedom of Canadians to purchase health care (directly or indirectly) will be combined in a synergistic way to preserve and foster MSK care in Canada. At the time of submitting this letter to the Editor, we are working on presenting a conference on this subject from November 20-21, 2015 preceding Grey Cup Week in Winnipeg. We hope to be able to present further details to the COA membership in the upcoming months Doug Kayler, M.D., FRCSC President, Manitoba Bone and Joint Health

Gordon Andrew Hunter, MB, FRCS, FRCSC May 25, 1937 – June 11, 2015


t is with deep sadness that we announce the passing of Gordon Andrew Hunter at Sunnybrook Health Sciences Centre (SBHSC) on Thursday, June 11 at the age of 78. He had fought a courageous and lengthy battle against multiple health issues with stoicism and fortitude. Gordon had a distinguished career as a Senior Orthopaedic Surgeon at SBHSC, spanning a period of 30 plus years. He became a Professor in the Department of Surgery, University of Toronto in 1986, gaining Professor Emeritus status in 2002. Gordon leaves his beloved wife of 50 years, Virginia (Gini) and his adored daughter Carolyn (Nigel Kirkwood) and son Jonathan (Nita). He was a much loved Grandfather (Papa) to Thomas and Emma Kirkwood in Vancouver and (Ampa) to Alexandra, Campbell and Sophie Hunter in Toronto. In Australia and New Zealand, Gordon will be sadly missed by his nephews, niece and sisters-in-law: Andrew, David, Robert (Fred), Sally, Sue and Jean.

Born in London, England, he was the second son of Dr. John William Hunter and Antoinette Smyth. Gordon is predeceased by his parents and his brother, Dr. Ian Anthony Hunter. Gordon was educated at Epsom College, Surrey, England and began his medical career at the age of 17 at the University College of London, graduating in 1960. He received several prestigious awards, notably the Gold Medal in Medicine (University College Hospital, London) and the Begley Prize in Surgery (Royal College of Surgeons of England) in 1960, the Otto Aufranc Award (the Hip Society of North America) in 1976, and the Bruce Tovee Award in Surgical Education (University of Toronto) in 1986. Postgraduate trainCOA Bulletin ACO - Summer / Été 2015

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ing included appointments at the Birmingham Accident Hospital and the University College Hospital in England, and at the University of the West Indies in Jamaica. He and his family emigrated to Toronto in 1969. Gordon joined the staff of Sunnybrook as a Consultant Orthopaedic Surgeon in 1970, retiring from surgical practice in 2002. Thereafter he worked part time as a medicolegal consultant at Canadian Trauma Consultants until 2013. Gordon will be remembered as a renowned educator, travelling widely to lecture on various orthopaedic topics, principally trauma, hip and knee replacements, and foot and ankle problems. He was a doctor in the true sense of the word – devoted to the care of each and every one of his patients. Friends and colleagues knew him as a quiet man with a dry sense of humour and a keen interest in world events. In earlier years he enjoyed tennis, sailing and swimming, and he was an avid gardener at his cherished home of 44 years in Lawrence Park. As time began to slow him down, he took pleasure in reading,

jigsaw puzzles and watching cricket and rugby. He loved a good conversation, and to the end he was both curious and well informed. Above all, Gordon relished spending time with his family and his treasured dog Benji. He was very much at home in the countryside, and he spent many happy times in the outdoors with his children and grandchildren on both sides of the Atlantic and, more recently, on both sides of this country. Despite a full and rewarding life in Canada, Gordon ever remained an Englishman, with fond memories of his frequently visited home county of Suffolk. In lieu of flowers, we would ask that donations may be made in Gordon’s memory to the Sunnybrook Foundation, (www., Prostate Cancer Research, Princess Margaret Hospital ( or the Heart and Stroke Foundation ( Provided by: Humphrey Funeral Home A.W.Miles-Newbigging Chapel Limited.

Carroll A. Laurin, O.C., M.D.C.M., FRCSC, F.A.C.S. August 13, 1928- July 24, 2015


on of Alice Lapointe and Carroll E. Laurin, born in Hull on August 13, 1928, passed away peacefully on July 24, 2015 at the Montreal General Hospital. He leaves his beloved wife and best friend Madeleine Loranger, his daughter Manon, his sons Carroll (Alison Smith), Pierre (Gisèle Molgat), Benoit (Marie-Pascale Lalonde), his eleven grandchildren, Andrée, Julie, Jean-Carroll, Marc-Henri, Claire, Frédéric, Simon, Antoine, Madeleine, Étienne and Marianne and his four great-grandchildren Alexis, Margot, Aurélie and Hugo. He will join his daughter Julie, who died in 1976. Dr. Laurin was director of the orthopaedic programs at the University of Montreal and at McGill University. Part of his legacy will ensure that research is a living part of the training of future orthopaedic surgeons in both Universities. He was responsible for the medical aspect of the Montreal Olympic Games in 1976 and was a member of the Medical Section of the Central Committee of the Olympic Games. He was President of the Canadian Orthopedic Association. He was invested as an Officer of the Order of Canada by the Governor General in 1996.

COA Bulletin ACO - Summer / Été 2015

The family wishes to express its deepest gratitude to Dr. Bill Fisher and staff at the Montreal General Hospital for their exceptional care for all these years. In lieu of flowers, memorial contributions to the Julie-Laurin Award would be greatly appreciated. This is awarded annually to the most deserving orthopaedic resident at each of the universities of Montreal and McGill. The residents are judged by their peers both for their professional and humanitarian attributes and the winner is also chosen by his or her peers. The postal address for the Julie-Laurin Award is as follows: Notary PierreLavoie-In-Trust: 1545 Boulevard Curé Labelle, Laval, Qc, H7V 2W4 Published in The Gazette from July 28 to July 29, 2015

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

Prevention and Management of OA in Canada Rhona McGlasson PT, MBA Executive Director Bone and Joint Canada

needs to be provided in such a way as to be transferrable into an individual’s personal life and daily activity, including a community facility or gym where relevant.

Aileen Davis, PhD Senior Scientist, Division of Health Care and Outcomes Toronto Western Research Institute and Professor, University of Toronto

There is emerging research that is finding that an evidencebased education and exercise program that addresses the muscular functioning from a neuro-muscular perspective is effective in the reduction of symptoms and disease progression for individuals presenting with early to late hip and knee OA. In fact, it can decrease symptoms to the point of patients choosing not to proceed with joint replacement surgery. Improvements have been identified to last for over two years with individuals controlling their symptoms through their daily routines and movement patterns. The program is standardized across Denmark and is provided by health-care professionals who are certified through attending a training program. Data on participation in the program and patient outcomes is tracked through a web-based portal which allows for the health-care system and patients to have confidence in the validity of the programs at a local and a national level. Such an approach across Canada could lead to an increase in the options for access to Canadians to evidence-based care for individuals presenting with signs of OA.



steoarthritis (OA) and the resulting pain and disability are a significant and pressing problem across the world as identified in a number of international reports. According to the World Health Organization, 9.6% of men and 18.0% of women older than 60 years of age worldwide have symptomatic OA making it one of the most prevalent chronic diseases. However, OA is not only a disease of older age as two of three people with arthritis are under 65 years old1 and 10% report symptomatic knee OA by age 602. In Canada there are currently more than 4.6 million people living with OA and this will rise, within a generation (in 30 years) to more than 10 million (or one in four). OA is also a major source of pain, severely impacting the health-related quality of life (HRQOL) and productivity of affected individuals. It leads to reduction in ability to work, therefore negatively affecting work place productivity and the Canadian economy3.

Although there are guidelines with respect to pharmacological and non-pharmacological strategies, there is poor adherence and little information on the model of care that needs to be in place at a system level to successfully implement the treatments and optimize care for people with the earliest symptoms to those with end stage disease in Canada. As such, Bone and Joint Canada (BJC) undertook a project to identify the current status of OA management in Canada and to make recommendations on what was required to improve OA care nationally. From this work, it was recommended that there be a focus on expansion of evidence-based strategies to improve the prevention and management of OA, including self-management and medical management, from local level to regional or provincial programs. One of the main issues in the management of OA is early detection and disease self-management, including exercise. Early detection and management is critical and should take place within a primary care environment. However, many patients who are experiencing signs and symptoms of early OA often do not receive a diagnosis and there is little information and educational opportunities available for people at this stage in the disease process. Throughout the course of their disease, people with OA may receive interventions through a large range of health-care providers but this often occurs within a private pay model with limited publicly-funded health care available and, as such, care is not standardized. OA is a chronic disease that requires self-management strategies within a person’s everyday life to manage the symptoms and prevent the progression of the disease. As such, any education or exercise

However, OA is a complex disease and one strategy will not solve all the issues experienced by patients through their disease process. Through the planning work undertaken by BJC over the last year, a number of additional strategies were discussed including4: 1) Conduct the research to evaluate any implementation and/ or program transfer/expansion opportunities identified and/or develop an evaluation framework at a local and population-based level. 2) Development of a repository of existing programs for sharing information and leveraging knowledge. 3) Engage with the other sectors, such as health and wellness, to more formally partner in developing programs and exchanging knowledge. 4) Target educators/providers with a consistent message related to prevention of primary and secondary OA and its management. The management of OA requires a comprehensive approach to care that includes early diagnosis, evidence-based education and exercise that provides the individual with the ability to manage their symptoms on a day-by-day basis. As such, over the next few years we need to work together to identify the best practices across the country in addressing the care needs of individuals presenting with early OA and using a systems approach to linking them with the appropriate self-management opportunities.

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 17)

References 1. Centre for Disease Control. Prevalence of Doctor-Diagnosed Arthritis and Arthritis-Attributable Activity LimitationUnited States, 2010–2012. Morbidity and Mortality Weekly Report (MMWR) 2013; 62: 869-873. 2. Losina E., Weinstein A.M., Reichmann W.M., Burbine S.A., Solomon D.H., Daigle M.E. et al. Lifetime risk and age at diagnosis of symptomatic knee osteoarthritis in the US. Arthritis Care Res 2013; 65: 703-711.

3. Arthritis isn’t a big deal... ...until you get it. Ask 4 million Canadians. Report from the Summit on Standards for Arthritis Prevention and Care, November 1 – 2, 2005”. Arthritis Alliance of Canada activities/index.php 4. Reducing the impact of OA: A report on the prevention and effective management in Canada, Bone and Joint Canada accessed July 8, 2015

Critical Appraisal of the Literature: Studies on Prognosis Duong Nguyen, M.D., FRCSC, MSc(ClinEpi), DipABOS, FAAOS, CIME, DipSportsMed (ABOS/CASEM) Toronto, ON


atient E.B.M. is a 24 year-old female varsity athlete diagnosed with an ACL tear on MRI after a soccer injury. She asks her orthopaedic surgeon: ‘Doc…what would happen if I don’t have surgery?’ The surgeon replies: ‘patients reduce their activity of daily living levels on average by 21% with only 49 % of athletes returning to sports. There is also an increased risk of cartilage degradation at five to seven years following injury’1-3. Prognosis, or the forecast of the likely course of a disease, is the foundation of medical decision-making. To best inform patients about treatment options, one must be knowledgeable about the outcomes of these treatments, the natural history of the disease, and the probability with which the outcome is expected to occur.  Prognostic information can be derived from prospective cohorts (best and most common source), randomized controlled trials (may not be representative of the population with the disease), or case-control studies (for rarer diseases or long follow-up periods but they are susceptible to bias). The reference checklist below was compiled from various sources to help surgeons navigate the literature4-8. A. Is the research valid (Internal Validity)? 1. Was a defined, representative sample of patients assembled at a common (usually early) point in the course of their disease? This is typically called the ‘inception cohort’. Look in the ‘Methods’ section for the stage at which patients entered the study (e.g. newly diagnosed osteosarcoma, 1st time shoulder dislocation). Were patients from primary (more likely to represent the full spectrum of illness without ‘referral bias’) or tertiary referral centres (more advanced disease & poorer prognoses)? 2. Was patient follow-up sufficiently long and complete? This is important to detect the outcome of interest (e.g. arthritis, remission, death). Numbers, reasons and demographics of the COA Bulletin ACO - Summer / Été 2015

lost patients should be provided in the ‘Results’ section. Was a ‘worst-case scenario/sensitivity analysis’ performed? Find the median (middle number) or mean (average) length of follow-up. 3. Were objective outcome criteria applied in a ‘blind’ fashion? A clear definition of the outcome should be provided in ‘Methods’. To minimize bias, the assessor should not know whether the patient has a potential prognostic factor, especially if a great deal of judgment is required to measure the outcome (e.g. pivot shift test of the knee). 4. If subgroups with different prognoses are identified, was there adjustment for important prognostic factors (variables that predict which patients do better or worse e.g. age, sex)? Typically described in ‘Results’ in the form of tables or figures (e.g. different survival curves for age), these predictor variables (not necessarily causal, just strongly associated) should be adjusted in the analysis (Cox proportional hazards regression) because they influence the likelihood of having the outcome (e.g. re-injury more common in younger patients). Subgroups can also be separated into different cohorts based on suspected prognostic factors and comparing the effect on the outcome. 5. Was there validation of the prognostic factors in an independent group (‘test-set’) of patients? Typically called ‘Clinical Prediction Guide’, this is to confirm the importance/ predictive power of a prognostic variable that was identified for the first time in a given study, and to ensure it did not emerge on the basis of chance alone. This is important if the adjustment performed above for subgroups with different prognoses is not explanatory. The authors would perform a separate, pilot study in a smaller set of patients showing for example, an increased failure rate after ACL reconstruction on the non-dominant knee of female athletes, which was an unknown prognostic factor prior to the start of the bigger study. B. Is the research important? Prognosis studies aim to predict which individual will have an outcome of interest using regression techniques. The outcome can be in the form of a functional outcome scale (e.g. linear regression – IKDC score), a dichotomous variable (e.g. logistic regression - alive/dead), or a dichotomous variable and how it occurs over time (e.g. survival analysis – failure/no failure).

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 18)

1. What was the outcome or endpoint (typically dichotomous i.e. failure/no failure)? How large is the likelihood of the outcome event in a specified period of time (e.g. five-year survival is 60% for males)? In ‘Results’, look for the survival rate (proportion of patients experiencing an event for a given period of time after diagnosis/start of treatment). The rate can be reported as either the ‘median survival’ (length of time from diagnosis or start of treatment, that half of the study population do not have the outcome of interest – e.g. revision surgery after ACL reconstruction) or as the ‘mean survival’ (average length of time from diagnosis/start of treatment, that patients do not have the outcome of interest (revision surgery). This concept of survival rate is simple, easy to understand and share with colleagues but may not convey all the information. For example, two groups with the same five-year survival rate of 60% may have different prognosis curve shapes. Group A may have a steeper curve with patients failing early in the study and then plateauing over the remainder of the study. Hence survival curves (e.g. graph of the chance of being free from a revision after ACL reconstruction over time between males and females) are more commonly used to show the whole picture by depicting, at each point in time, the proportion (expressed as a percentage) of the original study sample who have not yet had the specified outcome. These curves can estimate the survival of a cohort and can estimate the likelihood of the outcome changing over time. The Kaplan-Meier curve is a commonly used, more specific type of survival graph which can take into account ‘censored’ data (patients lost to follow-up, who drop out, or who did not have the outcome at the end of follow-up period). What was the probability of the outcome occurring? Results typically written as a hazard ratio (similar to odds ratios e.g. hazard for females is 1.46 times the hazard of males) or a rate (hazard rate is 46% higher in females than males) with a probability value/significance level from a hypothesis test (e.g. p = 0.006), where “p” is the probability of the data arising by chance when the null hypothesis is true. 2. How precise are the prognostic estimates? Described in ‘Results’, find the 95% confidence interval (CI) around the estimate – a range of values, calculated from the sample of observations that are believed, with particular probability to contain the parameter value (e.g. hazard ratio 1.46, p = 0.02, lower 1.23, upper 2.45 95% CI). This means that if we used the same sampling method to select different samples and computed an interval estimate for each sample, we would expect the true population parameter to fall within the interval estimates 95% of the time). The narrower the 95% confidence interval around the estimate, the more useful the estimate will be, which is typically observed at the beginning of the survival curve (because there are a greater number of observations on which the estimate is based – i.e. more patients are alive, less dropouts, less late entrants in the study). C. Can I apply it to my patient? 1. Were the study patients similar to my own? Typically found in Table 1 of the ‘Results’ section with a description of the patient demographics along with mean and standard deviations. Look at the inclusion and exclusion criteria in ‘Methods’.

Figure 1 Example of a survival curve (Y axis - cumulative survival probability (proportion of survivors) is 0.6 = 60%, X axis - length of follow-up in days). Females are shown here to have a higher failure rate which should not be taken at face value until analyzed quantitatively for statistical significance with regression calculations (hazard/odds ratio with 95% confidence intervals and p values).

2. Will this evidence make a clinically important impact on my conclusions about what to offer or tell my patient? Will the results lead directly to selecting or avoiding therapy (knowing the expected clinical course of your patient’s condition can help you judge whether treatment should be offered at all)? Are the results useful for reassuring or counselling patients? In conclusion, prognostic studies investigate the influence of predictive variables or risk factors on the outcome of a disease from either a prospective (Level I) or retrospective (Level II) perspective. Using the checklist above, surgeons can sift through the prognostic literature and extract median survival rates, hazard ratios along with their 95% confidence intervals and the p-values for each individual prognostic variable to make an informed treatment plan for patient E.B.M. References 1. Muaidi Q.I, Nicholson L.L., Refshauge K.M., Herbert R.D., Maher C.G. Prognosis of conservatively managed anterior cruciate ligament injury: a systematic review. Sports medicine. 2007;37(8):703-716. 2. Potter H.G., Jain S.K., Ma Y., Black B.R., Fung S., Lyman S. Cartilage injury after acute, isolated anterior cruciate ligament tear: immediate and longitudinal effect with clinical/ MRI follow-up. The American journal of sports medicine. Feb 2012;40(2):276-285. 3. Bonamo J.J., Fay C., Firestone T. The conservative treatment of the anterior cruciate deficient knee. The American journal of sports medicine. Nov-Dec 1990;18(6):618-623.

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

4. Carneiro A.V. Critical appraisal of prognostic evidence: practical rules. Revista portuguesa de cardiologia : orgao oficial da Sociedade Portuguesa de Cardiologia = Portuguese journal of cardiology : an official journal of the Portuguese Society of Cardiology. Jul-Aug 2002;21(7-8):891-900. 5. Dahm P., Gilbert S.M., Zlotecki R.A., Guyatt G.H. How to use an article about prognosis. The Journal of urology. Apr 2010;183(4):1303-1308.

6. Laupacis A., Wells G., Richardson W.S., Tugwell P. Users’ guides to the medical literature. V. How to use an article about prognosis. Evidence-Based Medicine Working Group. Jama. Jul 20 1994;272(3):234-237. 7. Sackett D.L. S.S., Richardson W.S., Rosenberg W., Haynes R.B. . Evidence-based Medicine: How to Practice and Teach EBM. 2000. 8. Guyatt G. R.D., eds. . User’s guides to the medical literature: a manual for evidence-based clinical practice. . AMA press. Chicago. 2002;706.

Ankle Syndesmotic Disruption – an introduction to this edition’s debate


any ankle fractures appear innocuous and are readily treated by the general orthopaedic surgeon. However, new information has led to a greater understanding of associated syndesmotic injuries and has brought to light the high incidence of syndesmotic malreduction and the associated deleterious effect on functional outcomes.  Successful management of these injuries requires a methodical approach to both diagnosis and surgical treatment.  Although the focus

of this debate is on the type of implant used, it is important to consider the principles highlighted both in terms of imaging and surgical approach, as well as postoperative management in order to achieve optimal results. I would like to thank Drs. Laflamme and Apostle for their contributions to this feature.  Peter Lapner, M.D., FRCSC

Acute Ankle Syndesmosis Rupture Fixation : Consider the Dynamic Device Mélissa Laflamme, M.D., FRCSC, MSc Clinical Professor, Laval University Orthopaedic Surgeon, CHU de Québec, CHUL Ville-de-Québec, QC


any controversies surround the clinical and radiological diagnosis of syndesmotic injuries, mainly due to anatomic variations of the syndesmosis and to rotational malalignment of traditional X-rays. Once the diagnosis is confirmed, surgical fixation is necessary. It is crucial to regain rotation and length of the fibula and to reduce the fibula anatomically in the tibial incisura to adequately stabilize the talus in the mortise and therefore allow a normal load distribution and biomechanics of the ankle joint. This will lower the risk of early degenerative osteoarthritis and will improve the functional results1-5. Physiologic micromotion at the distal tibio-fibular joint has been studied in detail. During normal ankle range of motion, the fibula can migrate up to 2.4mm distally and rotate externally up to two degrees. The distal tibio-fibular joint can also widen to up to 1.2mm6-7. To allow this micromotion, a dynamic fixation device, also called suture-button, has been used for several years by the orthopaedic community. The optimal number of dynamic devices to use is unclear, but two devices COA Bulletin ACO - Summer / Été 2015

are probably better for true Maisonneuve fractures where rotatory instability is high. The malreduction rate of the distal tibio-fibular joint following a syndesmotic injury is surprisingly high, varying from 16 to 52%8-12. Syndesmosis malreduction can be caused by a malreduced fibular fracture, a malposition of the fibula in the tibial incisura or secondary to the screw fixation effect. To illustrate this latter issue, a recent prospective study of 15 patients treated with screw fixation for a syndesmosis rupture showed a malreduction rate of 40% on the initial postoperative CT scan, but only 6.7% of malreduction one month after syndesmotic screw removal suggesting that screw removal might be beneficial to obtain an anatomic reduction of the syndesmosis13. It remains to be seen if the flexibility of the suture-button system might enable better reduction of the syndesmosis14. Since this system allows some micromotion, it might possibly help the positioning of the fibula more anatomically in the tibial incisura if the fibular fracture is well reduced. This implant might be more forgiving to surgeons than when the distal tibio-fibular joint is not perfectly reduced and held by a rigid fixation device like a screw. The functional results of suture-buttons are promising. A systematic review15 published in 2012 demonstrated better AOFAS scores with the suture-button compared to screw (89.1 vs 86.3

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 20)

al ressources and exposes patients to potential complications such as infection and late diastasis if the screw is removed too early. Suture-button related complications are mainly related to knot prominence and / or infection and can be avoided with some simple technical tips or with the use of knotless devices. In conclusion, published results on the suture-button appear promising in terms of functional outcomes. The feared issue of loss of reduction of the syndesmosis has not been described, but the long-term results are not known. There is certainly a need for studies on cost-effectiveness of this device. Nevertheless, regardless of the fixation device used, the most important thing to consider in acute syndesmosis rupture is to perform an open anatomic reduction of the distal tibio-fibular joint. A


Figure 1 AP and lateral X-rays of a Weber C ankle fracture with syndesmotic injury.

respectively). Two studies also reported an earlier return to work with the suture-button. Implant removal was performed in 10% of patients in the suture-button group compared to an average of 51.9% in the screw group. Moreover, two randomized controlled trials compared the screw to the dynamic device in acute syndesmosis rupture. Coetzee14 included 24 patients with a mean follow-up of 2.3 years. AOFAS scores were similar between groups, but range of motion was significantly better in the suture-button group, suggesting more normal motion at the distal tibio-fibular joint. In Laflamme’s study16 of 70 patients, those in the dynamic fixation group achieved better Olerud-Molander and AOFAS scores. Implant failure was significantly higher in the screw group (36.1% vs 0%) and loss of reduction was also higher in this group (11.1% vs 0%).

References 1. Pettrone F., Gail M., Pee D., Fitzpatrick T., Van Herpe L. Quantitative criteria for prediction of the results after displaced fracture of the ankle. JBJS Am. 1983Jun.30;65-A(5):667–77. 2. Leeds H., Ehrlich M. Instability of the distal tibiofibular syndesmosis after bimalleolar and trimalleolar ankle fractures. JBJS Am. 1984Apr.7;66-A(4):490–503. 3. Mont M., Sedlin E., Weiner L., Miller A. Postoperative radiographs as predictors of clinical outcome in unstable ankle fractures. J Orthop Trauma; 1992 Mar. p. 352–7. 4. Chissell H., Jones J. The influence of a diastasis screw on the outcome of Weber type-C ankle fractures. JBJS Br. 1995May28;77-B(3):435–8. 5. Kennedy J., Soffe K., Dalla Vedova P., Stephens M., O’Brien T., Walsh M., et al. Evaluation of the syndesmotic screw in low Weber C ankle fractures. J Orthop Trauma; 2000 Jun. p. 359–66. 6. Peter R., Harrington R., Henley M., Tencer A. Biomechanical effects of internal fixation of the distal tibiofibualr syndesmotic joint: comparison of two fixation techniques. J Orthop Trauma; 1994 Dec. p. 215–9. 7. Pereira D., Koval K., Resnick R., Sheskier S., Kummer F., Zuckerman J. Tibiotalar contact area and pressure distribution: The effect of mortise widening and syndesmosis fixation. Foot Ankle Int. 1996May9;17(5):269–74.



Figure 2 Postoperative AP and lateral X-rays of the ankle. Note the fixation of the syndesmotic injury with a dynamic device after ORIF of the fibular fracture.

Finally, an interesting advantage of the suture-button is that routine removal is not required. According to the literature, screw fixation without loosening or breakage should be removed17-19. Removal of syndesmotic screws requires additon-

8. Weening B., Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J Orthop Trauma. 2005Feb.28;19(2):102–8. 9. Gardner M., Demetrakopoulos D., Briggs S, Helfet D., Lorich D. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006Oct.28;27(10):788–92. 10. Vasarhelyi A., Lubitz J., Gierer P., Gradl G., Rosler K., Hopfenmueller W., et al. Detection of fibular torsional deformities after surgery for ankle fractures with a novel CT method. Foot Ankle Int. 2006Dec.30;27(12):1115–21.

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

11. Schwarz N. Postoperative computed tomography-based control of syndesmotic screws. European Journal of Trauma; 2005 Dec. p. 266–70. 12. Mukhopadhyay S., Metcalfe A., Guha A.R., Mohanty K., Hemmadi S., Lyons K., et al. Malreduction of syndesmosis—Are we considering the anatomical variation? Injury. 2011Oct.;42(10):1073–6. 13. Song, D.J., Lanzi, J., Groth, A., Drake, M.L., Orchowski, J.R. & Lindell, K.K. The effect of syndesmosis screw removal on the reduction of the distal tibiofibular joint: A prospective radiographic study. Presented at the 2012 AAOS meeting, 2012. 14. Coetzee, J. & Ebeling, P. Treatment of syndesmoses disruptions : A prospective, randomized study comparing conventional screw fixation vs Tightrope fiber wire fixation - medium term results. SA Orthopaedic Journal 32–37 (2009).

16. Laflamme M., Belzile E.L., Bédard L., van den Bekerom M.P., Glazebrook M., Pelet S. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma. 2014 Sep 25. 17. Schepers T. To retain or remove the syndesmotic screw: a review of literature. Arch Orthop Trauma Surg. 2010Dec.16;131(7):879–83. 18. Manjoo A., Sanders D., Tieszer C., MacLeod M. Functional and radiographic results of patients with syndesmotic screw fixation: Implications for screw removal. J Orthop Trauma. 2010Jan.30;24(1):2–6. 19. Heim D., Schmidlin V., Ziviello O. Do type B malleolar fractures need a positioning screw? Injury; 2002 Oct. p. 729–34.

15. Schepers T. Acute distal tibiofibular syndesmosis injury: a systematic review of suture-button versus syndesmotic screw repair. Int Orthop. 2012 Jun;36(6):1199-206.

Syndesmotic Disruption: The Argument for Screw Fixation Kelly Apostle, M.D., FRCSC Clinical Assistant Professor University of British Columbia New Westminster, BC


yndesmotic injuries are believed to most commonly occur via pronation external rotation or pronation abduction forces across the ankle joint. It has also been shown that up to 39% of supination external rotation injury patterns have syndesmotic involvement as seen on intra-operative stress testing after malleolar fixation1,2. Ankle fractures that require syndesmotic stabilization have more pain and worse functional outcomes than patients with malleolar fractures alone3. Malreduction of the syndesmosis has been shown by multiple previous authors to be an independent predictor of poorer outcomes and presence of post-traumatic ankle arthritis3,4,5. Historically, evaluation of syndesmotic malreduction has been evaluated on plain films (Figure 1). Based on these parameters, malreduction rates were reported to be between 0-16%4,6. More recent evidence has suggested that these parameters are inadequate and that mlareduction is more effectively evaluated by CT scan7,8. Using CT criteria, it has been suggested that syndesmotic malreduction rates may be as high as 52%7. In order to improve patient outcomes and minimize the incidence of post-traumatic arthritis, improvements need to be made in achieving and maintaining syndesmotic reduction.

COA Bulletin ACO - Summer / Été 2015

Figure 1 Radiographic criteria for syndesmotic reduction. On the AP film (left) the tibiofibular overlap (red line A) should be > 6mm and the tibiofibular clear space (yellow line B) should be < 6mm. On the Mortise film (right) the tibiofibular overlap (red line C) should be > 1mm and the tibiofibular clear space should be < 6mm (yellow line D.) All measurements are made 1 cm proximal to the joint line.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 22)

The historical gold standard for syndesmotic fixation has been with rigid screws from the fibula into the tibia. Flexible fixation has recently gained much attention with the theoretical benefits of allowing for continued physiologic motion across the syndesmotic articulation without the need for implant removal, which may lower the risk of recurrent syndesmotic diastasis and obviate the need for a second procedure to remove hardware. However, evidence supporting these claims is lacking. Early reports included small cohort studies with short follow-up that were underpowered, lacked control groups, were confounded by industry bias and judged loss of reduction based on conventional radiography alone. Figure 2

Flexible fixation is also not without compli- CT criteria for syndesmotic reduction using contralateral extremity as a control. [Anterior cations. Previous small studies have shown width injured ankle (C) – anterior width normal ankle (A)] + [posterior width injured ankle (D) – additional issues including; implant irritation posterior width normal ankle (B)] / 2. Value should be < 2mm. necessitating device removal (this may be reduced by using a knotless device), osteolysis up (minimum two years). It was seen that intra-operative CT and subsidence of the device, widening of the drill hole and identified one malreduction (5%) in the rigid fixation group pathologic fracture, superficial and deep infection and osteoand seven (33%) in the flexible fixation group. Open reducmyelitis9. Despite the lack of evidence for use of flexible fixation was performed for all seven in the flexible group; it was tion, popularity of this device among orthopaedic surgeons has seen that the syndesmosis reduced with the ankle placed at increased rapidly10. 90 degrees of dorsiflexion and no re-fixation was needed. All patients were treated in a below knee cast at 90 degrees for six There have been two recent randomized control trials comweeks. At final follow-up 3/19 (16%) of the rigid fixation group paring the use of flexible versus rigid fixation. In the study by had a malreduction, compared with 1/21 (5%) in the flexible Laflamme et al11 34 patients with flexible fixation using one fixation group. This is lower than recently reported based on TightRope®(Arthrex, Naples, FL, USA) were compared with 36 CT parameters for both groups. Although they were underpatients with a single 3.5mm screw across four cortices with a powered to detect a difference in outcome scores or rates of primary outcome of Olerud-Molander scores at three, six and arthritis, they found no difference in outcome scores between 12 months. The authors showed improved outcome scores at the two groups at one and two-year time points. All outcome all time points with statistical significance at 12 months with scores were worse in the four patients with a malreduced flexible fixation. All syndesmotic reductions were carried out syndesmosis suggesting that CT is better at determining malusing “closed” technique, internal fixation was not routinely reduction and predicting outcome scores. There was no differused on posterior malleolar fractures, and the quality of the ence in rates of post-traumatic ankle arthritis between the two reduction was judged based on fluoroscopy and plain films of groups. A possible explanation for the finding of intra-operathe injured extremity without the use of 3-dimensional imagtive malreduction in the flexible fixation group is that flexible ing. Given the various limitations in the approach used in the fixation does not control rotational or translational reduction evaluation of the reduction, it is not truly known from this adequately without the use of prolonged (six weeks) external study what percentage were malreduced. No correlation was immobilization at 90 degrees. Prolonged immobilization after identified between clinical outcome and malreduction based ankle fracture may be considered less than ideal in restoring on tibiofibular clear space on plain films, which may suggest range of motion in a joint at high risk of stiffness. that this parameter alone may not be an adequate measure of syndesmotic reduction. Ultimately, it is not known from this In summary, although flexible fixation is increasing in popularstudy whether functional outcomes are associated with the ity, evidence for its superiority over screw fixation is lacking. quality of the reduction, as measured by CT parameters. The only factor that has continuously shown to influence outcome after syndesmotic injury is syndesmotic reduction. There In the study by Kortekangas et al.12, 22 patients with a sinis currently no evidence that flexible fixation is superior to rigid gle 3.5mm screw across three cortices were compared to 21 fixation in achieving or maintaining reduction using CT criteria. patients treated with a single TightRope. The primary outcome It has been shown that formal open reduction of the syndeswas accuracy and maintenance of syndesmosis reduction. This mosis has lower malreduction rates than percutaneous reducwas evaluated using CT of bilateral ankles in the neutral position with a clamp13. If present, fixation of a posterior malleolus tion both intra-operatively and at two years postoperatively. fracture has the lowest rates of syndesmotic malreduction Reductions were carried out by closed technique using fluscosby anatomically restoring the posterior tibiofibular ligament copy. Intra-operative CT was utilized to assess the syndesmotic anatomy and has at least equivocal, if not improved stability reductions. Malreductions were opened and reduced under to syndesmotic screws14,15. A well-done anatomic reduction of direct visualization, refixed and rescanned. Follow-up standing the syndesmosis or stable fixation of the posterior malleolus cone-beam CT of bilateral ankles was performed at final followshould not be trumped by the use of a new device that has not COA Bulletin ACO - Summer / Été 2015



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

been shown to reduce malreduction rates or improve patient outcomes. To date, studies would suggest that once syndesmotic reduction has been achieved, the device used for fixation is possibly of little significance. References 1. Stark E., Tornetta P. 3rd, Creevy W.R. Syndesmotic instability in Weber B ankle fractures: a clinical evaluation. J Orthop Trauma. 2007 21(9):643-6. 2. Pakarinen H.J., Flinkkilä T.E., Ohtonen P.P., Hyvönen P.H., Lakovaara M.T., Leppilahti J.I., Ristiniemi J.Y. Syndesmotic fixation in supination-external rotation ankle fractures: a prospective randomized study. Foot Ankle Int. 2011 Dec;32(12):1103-9 3. Egol K.A., Pahk B., Walsh M., Tejwani N.C., Davidovitch R.I., Koval K.J., Outcome after Unstable Ankle Fracture: Effect of Syndesmotic Stabilization. J Orthop Trauma. 2010 24(1): 7-11

12. Kortekangas T., Savola O., Flinkkilä T., Lepojärvi S., Nortunen S., Ohtonen P., Katisko J., Pakarinen H. A prospective randomised study comparing TightRope and syndesmotic screw fixation for accuracy and maintenance of syndesmotic reduction assessed with bilateral computed tomography. Injury. 2015 21 13. Miller A.N., Caroll E.A., Parker J.R., Boraiah S., Helfet D.L., Lorich D.G. Direct visualization for syndesmotic stabilization of ankle fractures. Foot Ankle Int 2009 30(5):419-26 14. Gardner M.J., Brodsky A., Briggs S.M., Nielson J.H., Lorich D.G. Fixation of posterior malleolar fractures provides greater syndesmotic stability. Clin Orthop Relat Res 2006 447:165-71 15. Miller A.N., Carroll E.A., Parker R.J., Helfet D.L., Lorich D.G. Posterior Malleolar stabilization of syndesmotic injuries is equivalent to screw fixation. Clin Orthop Relat Res 2010 468(4): 1129-35

4. Weening B.; Bhandari M. Predictors of functional outcome following transsyndesmotic screw fixation of ankle fractures. J. Orthop Trauma 2005 19:102–108 5. Sagi H.C., Shah A.R., Sanders R.W. The Functional Consequence of Syndesmotic Joint Malreduction at a Minimum 2-Year Follow-Up. J Orthop Trauma 2012 26(7);439-443 6. Yamaguchi K., Martin C.H., Boden S.D., Labropoulos P.A. Operative treatment of syndesmotic disruptions without use of a syndesmotic screw: a prospective clinical study. Foot Ankle Int. 1994 15:407 – 414 7. Marmor M., Hansen E., Han H.K., Buckley J., Matityahu A. Limitations of standard fluoroscopy in detecting rotational malreduction of the syndesmosis in an ankle fracture model. Foot Ankle Int. 2011 32(6):616-22 8. Gardner M.J., Demetrakopoulos D., Briggs S.M., Helfet D.L., Lorich D.G. Malreduction of the tibiofibular syndesmosis in ankle fractures. Foot Ankle Int. 2006 27(10):788-92 9. DeGroot H., Al-Omari A.A., El Ghazaly S.A., Outcomes of Suture Button Repair of the Distal Tibiofibular Syndesmosis. Foot Ankle Int. 2011 39(5): 250-256 10. Bava E., Charlton T., Thordarson D. Ankle fracture syndesmosis fixation and management: the current practice of orthopedic surgeons Am J Orthop 2010 39(5):242-6 11. Laflamme M., Belzile E.L., Bédard L., van den Bekerom M.P., Glazebrook M., Pelet S. A prospective randomized multicenter trial comparing clinical outcomes of patients treated surgically with a static or dynamic implant for acute ankle syndesmosis rupture. J Orthop Trauma. 2015 29(5):216-2

COA Bulletin ACO - Summer / Été 2015

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

Use of Bone Graft and Substitutes in Orthopaedics


istorically, autogenous bone has been used in most orthopaedic applications that require graft. Autograft bone is readily available and has many advantages; it provides the ideal scaffold for bony ingrowth, provides osteoprogenitor cells, growth factors, and bone morphogenic protein that contribute to bone healing, and it offers the option of cortical bone for structural support if needed. Potential negative aspects of this approach include donor site morbidity. Allograft bone has become more readily available through the practice of bone donation and allograft banks. However, processing results in a reduction in its structural properties. In addition, the potential for disease transmission exists despite extensive screening.

state of the science and clinical utilization of these products. It should be underlined that any listing of brand name products is neither complete nor does it constitute an endorsement of that product. The orthopaedic surgeon must choose a strategy that respects both justification of cost and a reasonable understanding of the science of bone healing and expected clinical outcomes. We hope you find this section of the Bulletin useful and welcome any comments.

For these reasons, the bone substitute fillers have been used with increasing frequency as they seek to address the limitations outlined above. Bone substitutes are difficult to compare considering their many different properties. We are faced with intense marketing and much industry-sponsored literature. This section endeavors to bring some light to the current

Marc Isler, M.D., FRCSC Editor, COA Bulletin

We would like to thank Dr. Tice and his team, Dr. Kuzyk, Drs. Ghert and Poon as well as Dr. Monument for their contributions to this section.

Peter Lapner, M.D., FRCSC Scientific Editor, COA Bulletin

Bone Substitutes: Basic Science, Options, Benefits/Risks and Relative Cost Andrew Tice, M.D.;2,3Darren M. Roffey, Ph.D.; Stephen P. Kingwell, M.D., FRCSC; 1,2,3Philippe Phan, M.D., PhD, FRCSC; 1,2,3 Eugene K. Wai, M.D., MSC, FRCSC 1


Division of Orthopaedic Surgery, Faculty of Medicine, University of Ottawa, The Ottawa Hospital, Ottawa, ON 2 Ottawa Combined Adult Spinal Surgery Program (OCASSP), The Ottawa Hospital, Ottawa, ON 3 Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON 1

Introduction any orthopaedic interventions rely on fusion for a successful outcome. Procedures including joint arthrodesis, fracture non-union, filling of bony defects after tumour resection and spinal fusions have been performed by orthopaedic surgeons for decades. As surgical techniques evolve, combined with a drive to improve patient outcomes and reduce morbidity, increased attention has been paid to the type of bone graft used.


Autograft has long been considered the standard of care; specifically, iliac crest bone graft is the “gold standard”. However, autograft is associated with significant graft site morbidity and limited volume1,2. Allograft is another viable option, although sterilization, cost, delayed incorporation, disease transmission, and long-term durability need to be considered2. Due to these concerns, rates of allograft use have remained constant, while the use of bone substitutes has increased dramatically3. Bostrom and Seigerman3 showed that spine surgery utilizes

more bone substitutes in comparison to arthroplasty, foot/ hand and trauma surgery. In this article, we hope to provide a greater understanding of osteoconductive synthetic bone substitutes to assist with decision-making about their use in clinical practice. Basic Science The influential work of Frost4 first described the biology of fracture healing. Boden et al.5 went on to describe the phases of fusion formation, specifically in posterolateral spine fusion. The three phases include: 1. Inflammatory 2. Reparative 3. Remodelling The inflammatory phase lasts approximately three weeks and involves haematoma formation, recruitment of pro-inflammatory cytokines, vascular ingrowth, and formation of a collagen and cartilage scaffold. The reparative phase, which occurs during the next three weeks, is characterized by differentiation of mesenchymal cells to chondroblasts and osteoblasts, further vascularization and local debridement. Cartilaginous tissue begins to ossify. The remodelling phase lasts from six weeks to 6-18 months. The remaining ossification occurs and the immature woven bone is remodelled to mature lamellar bone under the influence of external stresses5.

COA Bulletin ACO - Summer / Été 2015



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

Other definitions important to this discussion involve the mechanisms of bone formation which include osteogenesis, osteinduction, and osteoconduction. Osteogenesis refers to the direct ability of a substance to create bone. Osteoinduction defines the ability of a substance to attract necessary precursors for bone formation. Osteoconduction relates to whether the substance provides the necessary framework or scaffolding for the creation of bone1,6. A fourth mechanism named osteopromotion is currently generating interest. An osteopromotor is seen to act as an adjunct to enhance bone formation7. To date, each of these mechanisms has been targeted with different types of bone substitutes. In this article, we will focus on osteoconductive synthetic bone substitutes. Options The osteoconductive class of bone substitutes incorporates agents such as synthetic mineralized and ceramic matrices as well as less commonly used agents including collagenbased matrices, biocompatible osteoconductive polymers, bioactive glass and metal augments. It should be noted that these agents are frequently available as composite materials (Table 1)8. Ceramics are available in a multitude of different ratios of calcium sulfate, calcium phosphate, beta tricalcium phosphate, and hydroxyapatite. The collagen-based matrices are xenografts, most often bovine collagen combined with hydroxyapatite9. Biocompatible osteoconductive polymer examples include polymethylmethacrylate and vinylpyrrolidone. Bioactive glass has also been used, and new materials, such as tantalum metal, are in the experimentation phase. Osteoconductive options require an osteoinductive component, such as bone marrow aspirate, local autograft, or possibly silicone-substitution10. A recent systematic review suggests that fusion success rate may depend on the type of ceramic used11. Results indicate that the composite of beta-tricalcium phosphate, hydroxyapatite and local autograft may have fusion rates similar to iliac crest autograft in posterolateral lumbar fusion surgery. However, the review notes that further high quality studies are required11. Benefits/Risks The advantages of ceramics include a virtually limitless supply, lack of potential for disease transmission, low immunogenicity and toxicity, stability at physiologic pH, maintained structural integrity despite the sterilization process, as well as customization of porosity12,13. Among the known disadvantages, some ceramics may resorb too fast, are brittle, have low tensile strength, and can increase the risk of seroma and subsequent infection6,14. Calcium sulfate resorbs within weeks, beta-tricalcium phosphate resorbs over several months, while hydroxyapatite rebsorbs over the course of years7. Collagen-based matrices, though beneficial in that they can be combined with an osteoinductive agent, lack structural strength. At the same time, they possess risks of disease transmission as well as hypersensitivity reaction15. Biocompatible osteoconductive polymers showed early promise with regards to safety, osteoconductivity, and biocompatibility. However, they have recently fallen out of favour due COA Bulletin ACO - Summer / Été 2015

to lack of biodegradation and poor incorporation resulting in high rates of displacement and non-union12. Bioactive glass possesses both osteoconductive and osteoinductive properties. There is a great deal of variability dependent on composition. An advantage of bioactive glass is the lack of connective tissue interface between bone and the agent, allowing for strong apposition. The efficacy of bioactive glass relies on its composition to dictate solubility, porosity and resorption16. Table 1. Examples of commercially available osteoconductive synthetic bone substitutes Company Biomet Osteobiologics Depuy Spine Exactech

Product ProOsteon® 500R HEALOS® Bone Graft Replacement OpteMxTM

Composition Available forms Coralline-derived HA/CC Granules or block composite Mineralized collagen matrix Strip

HA/TCP biphasic combination Integra Integra 80% highly purified β-TCP/ Orthobiologics MozaikTM 20% highly purified Type-1 collagen Medtronic MasterGraft® Biphasic calcium phosphate Granules (15% HA/85% β-TCP) MasterGraft® Biphasic calcium phosphate Putty and collagen (15% HA/85% β-TCP) NovaBone/MTF NovaBone® Bioactive silicate Stryker





Dicalcium phosphate dihydrate, tetracalcium phosphate and tri-sodium citrate 100% β-TCP and 80% β-TCP/20% collagen and 70% β-TCP/20% collagen/ 10% bioactive glass β-TCP

Granules, sticks, wedges, cylinders Strip, putty, moldable morsels Granules Moldable putty Particulate, putty and morsels Injectable cement

Putty, strip, flow, morsels and shapes

Granules, blocks and wedges Norian® SRS® Calcium phosphate Moldable putty Wright Medical CELLPLEX® β-TCP Granules Technology MIIG® X3 High strength surgical grade Injectable graft calcium sulfate Zimmer CopiOs® BVF Dibasic calcium phosphate Sponge and paste and Type-1 collagen BVF: bone void filler; CC: calcium carbonate; HA: hydroxapatitie; TCP: tricalcium phosphate

Relative Cost Cost must be factored in when choosing a suitable bone substitute. Osteoconductive bone substitutes are less expensive than bone morphogenic proteins, although their raw material cost remains higher than allograft bone1,3. Roberts and Rosenbaum1 indicated the average selling price for synthetic bone substitutes is: calcium sulfate=$655/10 mL, tricalcium

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

phosphate=$875/10 mL and calcium phosphate=$1,520/10 mL. Importantly, Leung et al.17 demonstrated that the total cost of femoral head allograft use (USD $978/each), including screening and manpower costs, was less economical compared to bone substitute (USD $9-$26/gram). True cost-effectiveness analysis must include patient outcomes – which to our knowledge has not been performed. When considering the health economic perspective, the addition of more expensive bone substitutes may be cost-effective in certain patient populations when considering the cost of revision surgery for non-union18. Further analysis is required to take into account overall expenses. Conclusion In conclusion, there are many bone substitutes available, although there is a lack of high-level evidence to support the use of any single combination of products. Cost, safety, efficacy as well as knowledge of the mechanisms of bone formation and specific product properties should be considered when selecting the appropriate osteoconductive synthetic bone substitute. References 1. Roberts T., Rosenbaum A. Bone grafts, bone substitutes and orthobiologics. The bridge between basic science and clinical advancements in fracture healing. Organogenesis 2012;8(4):114-124. 2. Mobbs R., Chung M., Rao P. Bone graft substitutes for anterior lumber interbody fusion. Orthopaedic Surgery 2013;5:77-85. 3. Bostrom M., Seigerman D. The clinical use of allografts, demineralized bone matrices, synthetic bone graft substitutes and osteoinductive growth factors: A survey study. HSSJ 2005;1:918. 4. Frost H. The biology of fracture healing. An overview for clinicians. Part I and II. Clin Orthop Relat Res 1989;248:283-309. 5. Boden S., Schimandle J., Hutton W., Chen M. 1995 Volvo Award in basic sciences: The use of an osteoinductive growth factor for lumbar spinal fusion. Part I: Biology of spinal fusion. Spine (Phila Pa 1976) 1995;20(24):2626-2632.

7. Grabowski G., Cornett C. Bone graft and bone graft substitutes in spine surgery: Current concepts and controversies. J Am Acad Orthop Surg 2013;21:51-60. 8. Oryan A., Alidadi S., Moshiri A., Maffulli N. Bone regenerative medicine: classic options, novel strategies, and future directions. JORS 2014;9:18. 9. Hak D. The use of osteoconductive bone graft substitutes in orthopaedic trauma. J Am Acad Orthop Surg 2007;15:525.536. 10. Brandoff J., Silber J., Vaccaro A. Contemporary alternatives to synthetic bone grafts for spine surgery. Am J Orthop 2008;37(8):410-414. 11. Alsaleh K., Tougas C., Roffey D., Wai E. Osteoconductive bone graft extenders in posterolateral thoracolumbar spinal fusion: A systematic review. Spine (Phila Pa 1976) 2012;37(16):E993-E1000. 12. Chau A., Mobbs R. Bone graft substitutes in anterior cervical discectomy and fusion. Eur Spine J 2009;18:449-464. 13. Panchbhavi V. Synthetic bone grafting in foot and ankle surgery. Foot Ankle Clin N Am 2010;15:559-576. 14. Arner J., Santrock R. A historical review of common bone graft materials in foot and ankle surgery. Foot & Ankle Spec 2014;7(2):143-151. 15. Park J., Hershman S., Kim Y. Updates in the use of bone grafts in the lumbar spine. Bull Hosp Jt Dis 2013;71(1):39-48. 16. Kurien T., Pearson R., Scammell B. Bone graft substitutes currently available in orthopaedic practice. The evidence for their use. Bone Joint J 2013;95-B:583-597. 17. Leung H., Fok M., Chow L., Yen C. Cost comparison of femoral head banking versus bone substitutes. Journal of Orthopaedic Surgery 2010;18(1):50-54. 18. Beswick A., Blom A. Bone graft substitutes in hip revision surgery: A comprehensive overview. Injury 2011;42:S40-S46.

6. Berven S., Tay B, Kleinstueck F., Bradford D. Clinical applications of bone graft substitutes in spine surgery: consideration of mineralized and demineralized preparations and growth factor supplementation. Eur Spine J 2001;10:S169-S177.

COA Bulletin ACO - Summer / Été 2015


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

Bone Allograft: Processing, Options, Risks/Benefits and [Relative] Cost Paul Kuzyk, M.D., MASc, FRCSC Assistant Professor, University of Toronto Division of Orthopaedic Surgery, Mount Sinai Hospital Toronto, ON


arge bone defects are frequently encountered by orthopaedic surgeons specializing in hip and knee arthroplasty, tumour, trauma and spine surgery. Despite recent advances in implant materials (such as highly porous metal implants), allograft bone remains a common option for dealing with large bone defects. Over 150,000 allograft bone procedures are performed in the US every year1. Allograft bone may be harvested from living donors (femoral heads from hip arthroplasty) or from deceased donors. Allograft bone is available in multiple forms for different purposes. Whole bones are used for structural allografts in revision joint replacement surgery and tumour surgery. Allograft-prosthetic composites (APCs) may be useful for joint arthroplasty in the setting of massive bone loss (Figure 1). The implant is cemented into the allograft bone and the allograft is then fit into the host bone. Healing occurs between the host bone and allograft junction. Soft tissue attachments (such as hip abductors) may be sutured onto the APC. Cortical strut allografts may be produced from sectioning long bones (such as a femur or tibia) or smaller bones (such as a fibula or radius) may be used whole. Strut allo- Figure 1 grafts are commonly used An allograft-prosthetic composite used to reinforce weak or thin for total hip arthroplasty with extensive host cortical bone around proximal femoral bone loss. Radiograph an implant (Figure 2). done at 18 years follow-up shows These are very useful for incorporation of the proximal femoral the treatment of femoral allograft. periprosthetic fractures. Cancellous bone is ground into different particle sizes to be used to fill bone defects within metaphyseal bone. Cortical bone chips may be added to the ground cortical bone to enhance its’ mechanical support as a void filler. This cortico-cancellous bone is also useful for impaction bone grafting for proximal femoral and acetabular revision surgery.

Figure 2 A fibular strut allograft used in conjunction with a plate for fixation of a Vancouver B1 periprosthetic femur fracture.

Although allograft bone today is very safe, there remains the risk of viral and bacterial transmission from donor to recipient. Tissue banks rely on donor screening for medical history and behavioural risk assessment as well as a physical examination of the donor for any evidence of infectious disease. Donor serum screening includes tests for HIV, Hepatitis B and C, West Nile virus, T-cell lymphotropic virus (HTLV) antibodies, and Syphilis. Blood is also sent for aerobic and anaerobic culture and testing for fungi. The estimated risk of HIV transmission from screened donors is one in 1.6 million procedures, the risk is one in 60,000 procedures for Hepatitis C, and the risk is one in 100,000 procedures for Hepatitis B2. Bacterial transmission may also occur during harvesting and processing of the bone. Aseptic recovery and processing techniques are essential. To minimize the risk of bacterial contamination allograft bone is recovered using aseptic technique, often in an operating room setting, by technicians with surgical training. Specimen swabs from the allograft bone are sent for culture prior to and after processing. The allograft bone may be discarded if certain types of bacteria are grown on the swab (e.g., Streptococcus Group A, Clostridium). Up to 22% of allograft bone may be discarded due to the possibility of donor infection or post-harvest contamination3.

COA Bulletin ACO - Summer / Été 2015



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

Allograft bone processing begins with the removal of soft tissues, blood and bone marrow from the bone to reduce the possibility of disease transmission and reduce the immunogenicity of the allograft. This is accomplished with the help of fluid washes with antibiotics, detergents, alcohols/ethers and/or hydrogen peroxide. The allograft bone is cut into the appropriate size and shape. Donor age, sex and bone quality are used to determine if the bone will be used for structural purposes or ground in to cortico-cancellous graft. Sterilization of the allograft may be performed using low-dose gamma irradiation ranging from 10 to 25kGy. However, gamma irradiation has been shown to weaken the bone by damaging the collagen through the generation of free radicals. One study showed a 64% reduction in energy to failure with 28kGy of gamma irradiation4. Furthermore, a dose of at least 50kGy is required to eradicate HIV and such a dose would significantly weaken the graft4. As a result, not all tissue banks use gamma irradiation and some only use it on select specimens. If irradiation is not used, than bacterial contamination is prevented primarily through processing under sterile conditions. Allograft bone may be preserved by freezing or freeze-drying. Deep freezing allograft bone is used primarily as a means of preserving the tissue; however, it also decreases the possibility of host immune response3. Bone may be kept frozen at temperatures below -40oC for up to five years. Freezing does not change the mechanical properties of the bone or the ability for the surgeon to shape the bone intra-operatively and therefore is the most common method for preservation of allograft bone for orthopaedic procedures. Freeze-drying, or lyophilisation, of the bone removes greater than 95% of the water content. This allows the allograft bone to be stored at room temperature, but alters the mechanical properties of the bone. Freeze-dried bone is brittle and likely should not be used for structural applications.

Allograft bone is generally more economical than commercial synthetic bone substitutes or implants. For example, APCs offer significant cost savings as compared to knee revision megaprosthesis for distal femoral periprosthetic fractures5. However, risks of disease transmission, failure of host bone ingrowth into the allograft, and possible fracture of structural allografts have limited the use of bone allograft and spurred the development of synthetic materials. Nonetheless, allograft bone remains an excellent option for the treatment of bone defects. References 1. Costain D.J., Crawford R.W. Fresh-frozen vs. irradiated allograft bone in orthopaedic reconstructive surgery. Injury. 2009 Dec; 40(12):1260-4. 2. Laurencin C.T., Khan Y., El-Amin S.F. Bone graft substitutes. Expert Review Medical Devices 2006; 01: 49-57. 3. Delloye C., Cornu O., Druez V., Barbier O. Bone allografts: What they can offer and what they cannot. J Bone Joint Surg Br. 2007 May; 89(5): 574-9. 4. Costain D.J., Crawford R.W. Fresh-frozen vs. irradiated allograft bone in orthopaedic reconstructive surgery. Injury. 2009 Dec; 40(12): 1260-4. 5. Saidi K., Ben-Lulu O., Tsuji M, Safir O., Gross A.E., Backstein D. Supracondylar periprosthetic fractures of the knee in the elderly patients: a comparison of treatment using allograftimplant composites, standard revision components, distal femoral replacement prosthesis. J Arthroplasty. 2014 Jan; 29(1): 110-4.

Bone Allograft: Basic Science Jeffrey Poon, MB BCh BAO Resident, Division of Orthopaedic Surgery, Department of Surgery, McMaster University Hamilton, ON Michelle Ghert M.D., FRCSC Associate Professor, Division of Orthopaedic Surgery, Department of Surgery, McMaster University Hamilton, ON

1. What is bone allograft and what types are available? llograft bone is that which is transferred between two genetically dissimilar individuals of the same species1. Allograft bone serves a similar function to that of autologous bone graft in that they support mechanical loads and resist failure by supplementing a bone deficit in a patient1.


COA Bulletin ACO - Summer / Ă&#x2030;tĂŠ 2015

Allograft may be prepared in a number of different ways; structural versus morselized; mineralized or demineralized; fresh, fresh-frozen or freeze-dried; by site (femoral head, fibula etc.); and by source (cadaveric or living). At a basic science level however, allograft may be considered in two main types: cortical and cancellous. 2. Cortical allograft and cancellous graft incorporation The ideal bone graft should have the following characteristics: osteogenesis, osteoinductivity, osteoconductivity, and osseointegration. Osteogenesis implies that active osteoblasts from the host or donor produce new bone2. Osteoinduction refers to the induction of multipotent mesenchymal stem cells to differentiate into osteoblasts and other bone forming cells to ultimately form new bone2. Osteoconduction is a process in which graft acts as a template by providing structural support for new vessel formation and bone synthesis2. Osseointegration is the final step of incorporation of the bone graft via the binding of graft and host bone via fibrous tissue formation between the two2.

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

Allogenic bone graft is processed to remove antigenic cells and proteins to reduce the possibility of rejection. It is also sterilized to reduce the transmission of pathogens. However, in processing and sterilizing allograft, the intrinsic capacity to produce new bone by the osteoblasts differentiating from osteoprogenitor cells (ie. osteogenesis) is lost2,3. This leaves processed allograft with only the characteristics of osteoinductivity, osteoconductivity, and osseointegration. How an allograft performs these functions is reflected in its incorporation. Incorporation of graft may be defined as the biologic interactions between graft material and host site that result in bone formation leading to adequate mechanical properties4. Regardless of source, all bone grafts undergo five stages of incorporation: inflammation, revascularization, osteoinduction, osteoconduction, and finally remodelling2. A failure in any one of these steps may lead to failure of the allograft implant.   Inflammation: Unlike autologous bone graft, allograft, even with processing, is at risk of evoking an extensive immune response and ultimately lead to rejection1,4,2. During the first two weeks, the inflammation is in an acute phase and modulated mainly by lymphocytes and macrophages.  Th1 lymphocytes produce pro-inflammatory cytokines (Interleukin-2, Interferon gamma and tumour necrosis factor beta) which leads to macrophage activation and possible graft rejection and failure2. On the contrary, Th2 lymphocytes produce cytokines (Interleukin 4, 5, 6 and 10) that do not activate macrophages and are hypothesized to be associated with graft incorporation2. By eight weeks inflammation moves to a more chronic nature. The bone graft may begin to be encapsulated by fibrous tissue and will continue to evoke an immune response up to eight months or more depending on the histocompatibility of the graft1. If an allograft is inadequately processed resulting in a great degree of immuno-histo incompatibility, the graft may be rejected during this stage and fail possibly due to poor revascularization. Revascularization: Rapid incorporation of bone graft is achieved with adequate independent vascular supply to the defect site2,3. If an immune response is rampant, neoangiogenesis is delayed due to the new vessels being surrounded by inflammatory cells leading to occlusion and necrosis1. Slow revascularization due to physiologic differences may also lead to failure. Cancellous bone graft is revascularized via a rapid creeping substitution method while cortical bone graft is slowly revascularized along the Haversian canals2. This may be why cancellous bone chips are popular and the most commonly used type of bone graft1. Osteoinduction: Revascularization brings in growth factors such as bone morphogenetic proteins, transforming growth factor, fibroblast growth factor, insulin like growth factor and platelet derived growth factor to aid vessel infiltration. Failed revascularization may result in failed osteoinduction.    Osteoconduction: Cortical bone has a higher density than cancellous bone and allows for greater mechanical support. Although cortical bone allows for additional stability and for the filling in of bone defects, cortical bone may be slow to form new bone. Cortical

bone requires resorption by osteoclasts prior to new bone formation. Cancellous bone may form new bone simultaneously as it is being resorbed because newly formed osteoblasts line cancellous trabeculae easily2. The inability of newly formed osteoblasts to infiltrate a bone graft may lead to failure of incorporation.    Remodelling/ Osseointegration: Once osteoconduction is well underway, remodelling and osseointegration begins and is the final goal of using allograft. Clinical Implications of Allograft Incorporation Fresh autologous graft is superior to allograft with respect to incorporation. Autologous graft does not inherit the burden of possible disease transmission, immune rejection and is readily vascularized. However, not all patients are amenable to the harvesting of autologous graft. Indications for the use of allograft over autologous graft include limited quantities of autologous graft, donor site morbidity and occasionally unsatisfactory biologic activity1. The use of cortical versus cancellous allograft varies depending upon the desired results. Given that cortical bone may provide greater structural support at the cost of slower incorporation, both types of bone may be used together to complement each other when faced with a challenging clinical problem. The reported failure rate in limb reconstruction with structural allograft is 20-30%5. In order of decreasing incidence, failures are most often due to fracture, nonunion and infection5. These failures typically occur within the first three years of implantation5. Factors associated with nonunion of the allograft-host have been studied in the clinical orthopaedic oncology setting6. Variables associated with poorer outcomes included an increased number of surgical procedures6, and the use of chemotherapy. Indications for allograft use associated with nonunion include alloarthrodesis, intercalary and osteoarticular reconstruction, and alloprosthesis composites6. Rigorous evidence-based recommendations for bone graft use are limited. Drosos et al. recently published a large meta analysis regarding the use of bone allograft (specifically demineralized bone matrix) in fractures, non-unions, bone cysts and tumours surgery and was unable to provide definitive recommendations7. Additional research on the clinical outcomes of bone grafts is necessary especially given its continually rising popularity for the filling of bone defects. References 1. Khan S.N. et al. The Biology of Bone Grafting. J Am Acad Orthop Surg 13:77-86 (2005) 2. Oryan et al. Bone regenerative medicine: classic options,novel strategies, and future directions. J Orthop Surg and Research 9:18 (2014) 3. Karachalios T. et al. Bone-Graft and Implant-Graft Interface in Total Hip Arthroplasty. Bone-Implant Interface in Orthopedic Surgery. Springer-Verlag, London. (2014).

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

4. Bauer et al. Bone Graft Materials: An Overview of the Basic Science. Clinical orthopaedics and related research 371:1027 (2000) 5. Mankin H.J. et al. Current status of allografting for bone tumors. Orthopedics. 15 (10): 1147-54. (1992)

6. Hornicek F.J. et al. Factors affecting nonunion of the allografthost junction. Clin Orthop Relat Res. (382): 87-98. (2001) 7. Drosos G.I. et al. Use of demineralized bone matrix in the extremities. World J of Orthopedics. March. 6(2): 269-277 (2015)

Bone Morphogenetic Proteins: Basic Science, Benefits, Risks and Relative Cost Michael J. Monument, M.D., MSc, FRCSC Assistant Professor Department of Surgery, Section of Orthopaedic Surgery University of Calgary Calgary, AB

Introduction one healing is essential for the success of many orthopaedic surgeries. Unfortunately, for a variety of anatomic, patient and surgical factors, bone healing is not always predictable or reliable. Delayed or unsuccessful bone healing contributes to inferior outcomes, prolonged disability and often, revision surgeries.


Autogenous iliac crest bone graft (AICBG) is considered the gold standard bone graft for bone induction. It is osteogenic (live mesenchymal progenitor cells), osteoconductive (permissive bone forming scaffolding) and osteoinductive (bone stimulating growth factors). It is also histocompatible, nonimmunogenic and is not associated with disease transmission. However, significant disadvantages include limited host availability, additional surgical sites, increased blood loss and reports of persistent donor site morbidity. Synthetic bone morphogenetic proteins (BMPs) have been introduced into multiple facets of orthopaedic care in hopes of augmenting the biology driving bone healing. Results have been promising and the indications for BMPs in orthopaedic surgery appear to be increasing. In an era of increasing cost containment and fiscal accountability however, usage of BMPs must be carefully weighed against the significant cost, and specific complications of these products. Basic Science Bone Morphogenetic Proteins (BMPs) are a group of phylogenetically conserved growth factors, which constitute the largest subgroup of the Transforming Growth Factor Beta (TGFβ) superfamily1. These growth factors are not bone-specific and collectively support a diverse array of biologic processes including limb development, skeletal repair and regeneration, ligament and tendon development, cartilage formation, spermatogenesis, neurogenesis and kidney development1, 2. On a cellular level, BMP proteins bind to, and activate cell surface receptors, which in turn activate numerous downstream signalling pathways. This intracellular signalling is largely mediated via activation of the Smad family of transcription factors1, 3. COA Bulletin ACO - Summer / Été 2015

Numerous BMPs are involved in skeletal growth and repair; however BMP-2 and BMP-7 appear to possess the greatest potential for bone induction4, 5. BMP-2 and -7 induce bone formation via three principle osteoinductive mechanisms: 1) Recruitment and proliferation of mesenchymal progenitor cells from surrounding muscle, bone marrow or blood vessels; 2) Differentiation of these progenitor cells into bone and cartilage forming chondroblasts and osteoblasts; 3) Augmenting bone matrix production and tissue neo-vascularization3, 6-8. The bone forming osteoinductive properties of BMP-2 and BMP-7 has been documented in numerous preclinical models including, rodents, sheep and non-human primates9-12. Clinical Applications Recombinant versions of these proteins (rhBMP-2, InfuseTM, Medtronic Sofamor Danek. Inc, Minneapolis, MN; and rhBMP-7, OP-1TM, Stryker Biotech, Hopkinton, MA) have been developed and approved by the FDA and Health Canada for select clinical applications such as open tibial shaft fractures, recalcitrant long bone non-unions and lumbar spine fusions. Spine The role of rhBMP-2 and rhBMP-7 in spinal fusion procedures has been evaluated in numerous clinical studies, including randomized controlled trials and systematic reviews13, 14. These studies assessed the efficacy of rhBMP-2 and rhBMP-7 for spinal fusion associated with lumbar procedures [posterolateral fusion (PLF), anterolateral interbody fusion (ALIF) and posterolateral interbody fusion (PLIF)] across a spectrum of spine conditions (single level degenerative disc disease, adult idiopathic scoliosis, adult spinal deformity, lumbar spondylosis and lumbar spondylolisthesis). Compared to autogenous iliac crest bone graft (AICBG), these studies consistently demonstrated improved early radiographic fusion rates in rhBMP-2 study arms. This advantage however, was not consistently observed at 12 and 24 months follow-up. Radiographic fusion was equivocal comparing rhBMP-7 with AIBG. Other advantages of rhBMP-2 were decreased operative time, decreased blood loss, decreased hospital stay and no donor site pain. Functional outcome measures such as the Owestry Disability Index (ODI) and SF-36 were not significantly different between the BMP and AICBG groups13-17. Trauma BMPs have theoretical potential to improve surgical management of acute fractures, delayed unions and non-unions. Two

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

systematic reviews by Garrison et al.,18 and Wei et al.19 compared rhBMP-2 to standard of care for acute tibial fractures. Both studies suggested a decreased time to union, increased union rates and fewer secondary operations in open tibial shaft fractures treated with rhBMP-2. The BESST trial had a significant influence on the results of these systematic reviews, given that it included over 400 patients with an open tibial shaft fracture. In this RCT, 1.50mg/ml of rhBMP-2 was compared to standard of care. RhBMP-2 was associated with less time to union, fewer secondary procedures and a lower rate of infection20. The methodology of this study, however did introduce potential sources of bias given that surgeons were not blinded and there were significantly more reamed intramedullary nails used in the rhBMP-2 group compared to control. In a later publication, which added more patient numbers to the BESTT dataset using an identical protocol, it was later deemed that rhBMP-2 was equivocal to control for open fractures amenable to intramedullary nail fixation (Gustilo-Anderson grades I and II)21. For reconstruction of segmental tibial defects (mean 4cm), Jones et al.22 compared rhBMP-2 to AICBG and demonstrated no significant difference in union rate, infection or functional outcome. Based on two smaller randomized controlled trials, rhBMP-7 is equivalent to autogenous bone graft for the treatment of established non-unions of the tibia when combined with intramedullary nail fixation18, 23. Adverse Events A variety of adverse events have been attributed to BMP use. Most of these events have been reported in the spine literature. Best evidence calculations of BMP-associated complications in cervical spine surgery as follows: ectopic (extradiscal) ossification (3%), dysphagia following ventral procedures (5%), graft subsidence (43%) and graft migration (2%)24; for lumbar procedures, cage migration (27%), elevated BMP-antibody response (rhBMP-2 1%, rhBMP-7 26%) and surgical site haematoma (4%)24. Lower quality retrospective studies have also reported convincing rates of retrograde ejaculation (7.2%) and radiculitis (14%) associated with rhBMP-225, 26. Despite these numbers, secondary surgeries for these complications are rare. Not surprisingly, BMP-associated adverse events are much more likely to be reported in studies that are not industry sponsored25, 27, 28. Although these complications are not unique to the use of rhBMP-2, their prevalence seems to be elevated with the use of rhBMP-2 compared with AICBG. In the trauma literature, there is no high quality evidence to suggest that BMPs are associated with increased adverse events and in the context of open tibia fractures, may actually be protective of complications such as infection and hardware failure18. Cost Analysis The approximate cost for each dose (unit) of BMP is $5000$6000 U.S. dollars. With increasing awareness and pressure for cost containment, judicious use of BMP products is essential. Despite improved radiographic fusion rates, rhBMP-2 is not associated with significant functional improvements for routine spinal fusion procedures. According to the results of an economic evaluation by Garrison et al. in 200716, the use of BMP for single-level spine fusions was not deemed cost-effective. A second cost analysis in 2009 by Carreon et al.15 however,

did demonstrate a cost benefit in spinal fusion procedures in patients 60 years of age and older. This analysis included single and multilevel posterolateral fusions and excluded interbody fusion procedures. Furthermore, the study population was also much smaller than the Garrison et al. analysis (n= 106 vs. n=631, respectively). Ackerman et al.17 also found BMPs to be cost neutral for single level anterior lumbar interbody fusions. For fracture healing, rhBMP-2 appears most cost effective when used for severe (Gustilo-Anderson grade III) acute open tibial fractures16, 18. There is no evidence to suggest BMPs are costeffective for the treatment of nonunions. Conclusion Best evidence would suggest that BMPs are safe and effective adjuncts to promote bone healing for select orthopaedic procedures. The indications for this technology remain narrow and given the increasing need for cost containment in the Canadian health-care system, stringent selection of patients most likely to benefit from BMP adjuncts is essential. References 1. Bragdon B., Moseychuk O., Saldanha S., King D., Julian J., Nohe A. Bone morphogenetic proteins: a critical review. Cell Signal. 2011;23(4):609-20. 2. Axelrad T.W., Einhorn T.A. Bone morphogenetic proteins in orthopaedic surgery. Cytokine Growth Factor Rev. 2009;20(5-6):481-8. 3. Yamamoto N., Akiyama S., Katagiri T., Namiki M., Kurokawa T., Suda T. Smad1 and smad5 act downstream of intracellular signalings of BMP-2 that inhibits myogenic differentiation and induces osteoblast differentiation in C2C12 myoblasts. Biochem Biophys Res Commun. 1997;238(2):574-80. 4. Axelrad T.W., Kakar S., Einhorn T.A. New technologies for the enhancement of skeletal repair. Injury. 2007;38 Suppl 1:S4962. 5. Blokhuis T.J., Lindner T. Allograft and bone morphogenetic proteins: an overview. Injury. 2008;39 Suppl 2:S33-6. 6. Sampath T.K., Maliakal J.C., Hauschka P.V., Jones W.K., Sasak H., Tucker R.F., et al. Recombinant human osteogenic protein-1 (hOP-1) induces new bone formation in vivo with a specific activity comparable with natural bovine osteogenic protein and stimulates osteoblast proliferation and differentiation in vitro. J Biol Chem. 1992;267(28):20352-62. 7. Sakano S., Murata Y., Miura T., Iwata H., Sato K., Matsui N., et al. Collagen and alkaline phosphatase gene expression during bone morphogenetic protein (BMP)-induced cartilage and bone differentiation. Clin Orthop Relat Res. 1993(292):33744. 8. Kawasaki K., Aihara M., Honmo J., Sakurai S., Fujimaki Y., Sakamoto K., et al. Effects of recombinant human bone morphogenetic protein-2 on differentiation of cells isolated from human bone, muscle, and skin. Bone. 1998;23(3):223-31.

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

9. Termaat M.F., Den Boer F.C., Bakker F.C., Patka P., Haarman H.J. Bone morphogenetic proteins. Development and clinical efficacy in the treatment of fractures and bone defects. J Bone Joint Surg Am. 2005;87(6):1367-78. 10. Noshi T., Yoshikawa T., Ikeuchi M., Dohi Y., Ohgushi H., Horiuchi K., et al. Enhancement of the in vivo osteogenic potential of marrow/hydroxyapatite composites by bovine bone morphogenetic protein. Journal of biomedical materials research. 2000;52(4):621-30. 11. Virk M.S., Conduah A., Park S.H., Liu N., Sugiyama O., Cuomo A., et al. Influence of short-term adenoviral vector and prolonged lentiviral vector mediated bone morphogenetic protein-2 expression on the quality of bone repair in a rat femoral defect model. Bone. 2008;42(5):921-31. 12. Gerhart T.N., Kirker-Head C.A., Kriz M.J., Holtrop M.E., Hennig G.E., Hipp J., et al. Healing segmental femoral defects in sheep using recombinant human bone morphogenetic protein. Clin Orthop Relat Res. 1993(293):317-26. 13. Papakostidis C., Kontakis G., Bhandari M., Giannoudis P.V. Efficacy of autologous iliac crest bone graft and bone morphogenetic proteins for posterolateral fusion of lumbar spine: a meta-analysis of the results. Spine (Phila Pa 1976). 2008;33(19):E680-92.

19. Wei S., Cai X., Huang J., Xu F., Liu X., Wang Q. Recombinant human BMP-2 for the treatment of open tibial fractures. Orthopedics. 2012;35(6):e847-54. 20. Govender S., Csimma C., Genant H.K., Valentin-Opran A., Amit Y., Arbel R., et al. Recombinant human bone morphogenetic protein-2 for treatment of open tibial fractures: a prospective, controlled, randomized study of four hundred and fifty patients. J Bone Joint Surg Am. 2002;84-A(12):2123-34. 21. Swiontkowski M.F., Aro H.T., Donell S., Esterhai J.L., Goulet J., Jones A., et al. Recombinant human bone morphogenetic protein-2 in open tibial fractures. A subgroup analysis of data combined from two prospective randomized studies. J Bone Joint Surg Am. 2006;88(6):1258-65. 22. Jones A.L., Bucholz R.W., Bosse M.J., Mirza S.K., Lyon T.R., Webb L.X., et al. Recombinant human BMP-2 and allograft compared with autogenous bone graft for reconstruction of diaphyseal tibial fractures with cortical defects. A randomized, controlled trial. J Bone Joint Surg Am. 2006;88(7):1431-41. 23. Friedlaender G.E. Regarding the article “Overexpression of noggin inhibits BMP-mediated growth of osteolytic prostate cancer lesions”, by Feeley et al. Bone. 2006;39(3):666; author reply 7.

14. Agarwal R., Williams K., Umscheid C.A., Welch W.C. Osteoinductive bone graft substitutes for lumbar fusion: a systematic review. J Neurosurg Spine. 2009;11(6):729-40.

24. Mroz T.E., Wang J.C., Hashimoto R., Norvell D.C. Complications related to osteobiologics use in spine surgery: a systematic review. Spine (Phila Pa 1976). 2010;35(9 Suppl):S86-104.

15. Carreon L.Y., Glassman S.D., Djurasovic M., Campbell M.J., Puno R.M., Johnson J.R., et al. RhBMP-2 versus iliac crest bone graft for lumbar spine fusion in patients over 60 years of age: a cost-utility study. Spine (Phila Pa 1976). 2009;34(3):238-43.

25. Carragee E.J., Mitsunaga K.A., Hurwitz E.L., Scuderi G.J. Retrograde ejaculation after anterior lumbar interbody fusion using rhBMP-2: a cohort controlled study. Spine J. 2011;11(6):511-6.

16. Garrison K.R., Donell S., Ryder J., Shemilt I., Mugford M., Harvey I., et al. Clinical effectiveness and cost-effectiveness of bone morphogenetic proteins in the non-healing of fractures and spinal fusion: a systematic review. Health Technol Assess. 2007;11(30):1-150, iii-iv.

26. Rihn J.A., Patel R., Makda J., Hong J., Anderson D.G., Vaccaro A.R., et al. Complications associated with single-level transforaminal lumbar interbody fusion. Spine J. 2009;9(8):623-9.

17. Ackerman S.J., Mafilios M.S., Polly D.W., Jr. Economic evaluation of bone morphogenetic protein versus autogenous iliac crest bone graft in single-level anterior lumbar fusion: an evidence-based modeling approach. Spine (Phila Pa 1976). 2002;27(16 Suppl 1):S94-9. 18. Garrison K.R., Shemilt I., Donell S., Ryder J.J., Mugford M., Harvey I., et al. Bone morphogenetic protein (BMP) for fracture healing in adults. Cochrane Database Syst Rev. 2010(6):CD006950.

COA Bulletin ACO - Summer / Été 2015

27. Williams B.J., Smith J.S., Fu K.M., Hamilton D.K., Polly D.W., Jr., Ames C.P., et al. Does bone morphogenetic protein increase the incidence of perioperative complications in spinal fusion? A comparison of 55,862 cases of spinal fusion with and without bone morphogenetic protein. Spine (Phila Pa 1976). 2011;36(20):1685-91. 28. Even J., Eskander M., Kang J. Bone morphogenetic protein in spine surgery: current and future uses. J Am Acad Orthop Surg. 2012;20(9):547-52.

Pelvis & Acetabulum


PRO System Pelvis Reduction & Osteosynthesis

Lighting Up Pelvis Surgery

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 oerings. 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. MT-BA-1 Rev. 1 Copyright 速 2015 Stryker

Right from the Start. Stem and baseplate loosening should be your last concern—which is why we made it our first. In a multicenter clinical study, the Equinoxe® prosthesis showed no aseptic loosening.1 In other in vitro studies, the Equinoxe demonstrated superior initial glenoid fixation 2, least bone removed 3, and largest contact area for the baseplates.3,4

©2015 Exactech, Inc.

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

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


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Go to to view the research. 1. Flurin PH. et al. Comparison of Outcomes Using Anatomic and Reverse Total Shoulder Arthroplasty. Bulletin of the Hospital for Joint Diseases. 71(2):S101-107. 2013. 2. Stroud N. et al. Reverse Shoulder Glenoid Loosening: An Evaluation of the Initial Fixation Associated with Six Different Reverse Shoulder Designs. Bulletin for the Hospital for Joint Diseases. 71(2):S12-17. 2013. 3. Roche C. et al. Comparison of Bone Removed with Reverse Total Shoulder Arthroplasty. Bulletin for the Hospital for Joint Diseases. 71(2):S36-40. 2013. 4. Nigro PT. et al. Improving Glenoid-side Load Sharing in a Virtual Reverse Shoulder Arthroplasty Model. J Shoulder Elbow Surg. Vol.22(7):954-62. 2013. 905-765-1117

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

A Political Call to Arms (and Hips, Knees, and Ankles) Dafna Strauss Special to the COA Bulletin


o you envy the fervor of American voters? Wish Canadians were Harperventilating at the polls, or feeling the Mulcamania? That’s because we’ve been too Canadian to demand good service from our politicians. As the federal election approaches, it’s on us to let our elected employees know what we want. Here, courtesy of the COA, are some pointers to take you from kvetching among colleagues to informing the political discussion. How political engagement works As an orthopaedic surgeon, most of your interaction with people occurs when they’re in need of your help, are unconscious, or healing from what you’ve done for them. Speaking with political candidates is a bit different – you can’t approach them with a 2 lb. mallet – but there is a parallel here. Just as you welcome information from patients so that can you use your expertise to help them, similarly, candidates want to know what ails us and how they can help, so that they can use that information to make better health policy…or at least better campaign promises. It’s a bit like public relations for orthopaedic surgeons: the more candidates hear our well-targeted messages while on the campaign trail, the more prominence our issues will have on their agendas. At the very least we hope to ignite some conversation. Like many things in representative democracy, it may feel like you’re playing a tiny part, but it’s effective in aggregate. After the election in November, one MP will become Minister at Health Canada and one will be the Parliamentary Secretary, some will sit on the Standing Committee on Health, another two will be the opposition Health Critics, and about a dozen more will be other Ministers who, as part of the cabinet, will have some influence on health policy. These people together will guide the direction of health policy in Canada. If any of the candidates you speak with during campaign season is elected, we may have a champion for orthopaedics in government! Whatever we whisper to them during the campaign may stay with them when they’re all sitting around coming up with ideas to make Canadians happy (aka setting the agenda). Odds are good that someone will bring forward an idea on orthopaedics and if it seems accessible to the other decision makers present, it may slowly plod its way into their policies. What Candidates Can and Can’t Do What can’t they do for us? A candidate can’t make promises on behalf of the future government or even themselves, since they don’t know what hand they’ll be dealt after the election. And, MPs can only affect the federal government’s role in health, so, they have no say in Provincial responsibilities like hospitals, community care, billing, and other details you encounter day to day.

What they can do is encourage initiatives at Health Canada (national strategies and informational campaigns, research grant subjects, prevention through the Public Health Agency of Canada, among other things) and the Standing Committee on Health, which studies best practices and standards, health issues, and has input on bills. And the health critics can put pressure on the ruling government on all of these points. Read Health Canada’s web site to get your creative juices flowing. Four Things Political Engagement Can Accomplish for Us Speaking with candidates makes orthopaedic surgeons more visible as voting stakeholders – this has always worked in favour of seniors, those notorious voters. An additional bonus for you is that there is an obvious and strong alignment between orthopaedics and seniors. Our ideas gain airtime with politicians-to-be and other citizens who may be listening. Remember: when “wait times” became a hot topic, they began to be addressed. If we do a good job of advocacy, they’ll consider us reasonable and trustworthy partners for a common goal, and seek out our opinion. We may learn more about our own situation from the feedback they give us – more clarity on what the barriers to change are, which other stakeholders may be allies, other creative solutions, policy changes being considered, etc. Now is the Time – Here’s Why “Now” as in the entire election season. Campaigning’s already started unofficially and most ridings have their candidates in place. There’s a benefit to being the one to start a conversation – your perspective is the one that informs the candidate (who’s probably not a health policy expert) and any subsequent opposing ideas will need to nudge them from that position. It’s also a good election cycle to bring our issues forward since there hasn’t been a dominant issue taking up all the airtime yet – the floor’s open for a health care conversation. And it’s a good time to ride coattails (aka “synergize”) with other groups and their messages. The CMA has put together a Senior’s Strategy to help governments contend with “the grey tsunami”. Other health professionals, patient advocates, medical companies, or institutions may also be putting out messages ahead of the election. We need to be part of the conversation. And remember, the nearer we get to the election, the busier the candidates will be. Are you feeling politically pumped? Our next edition will provide some practical suggestions for where/when/how to engage with political candidates.

COA Bulletin ACO - Summer / Été 2015


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Foundation / Fondation


Modern New Look Reflects Dynamic Programs of the Canadian Orthopaedic Foundation Isla Horvath, Executive Director Canadian Orthopaedic Foundation


s we celebrate our 50th anniversary this year, the Canadian Orthopaedic Foundation has a renewed focus on supporting surgeons. Partially in response to the COA’s expressed need for more funds invested in research, and partially in response to shrinking orthopaedic research funds from governments, we adopted a plan for an even larger research program. COF President Geoff Johnson explains: “Orthopaedics has to take advantage of the rapidly evolving technology and health-care environments, which drive innovation. Innovation only comes from bright ideas which can translate to the bedside. We need to expand our grants to surgeons to kindle the research and innovation ideas that our surgeons propose, to improve the way surgeons practice, to improve our patients’ surgical outcomes, and to make the difference we all want for Canadians suffering from bone, joint and muscular disorders.” With our renewed focus the Foundation worked on a re-brand: a look which depicts who we are. Part of that brand is our new logo. It vividly reflects the vibrancy and the ultimate purpose of the COF: helping

people to return to full mobility. The logo depicts one individual, as our ultimate focus is each individual patient, moving forward. As a result of the research, education and patient services provided by the COF, the patient is again mobile. The ball is reminiscent of a medicine or exercise ball, and is also a portal through which people can learn about Canadian orthopaedic research. The COF’s blue colour is used, and red is incorporated, succinctly and proudly showing that we are a Canadian Foundation. Our new web site,, is designed to be simple, dynamic and bright, encouraging visitors to recognize that this is a modern, vibrant place to find the latest information. It is quickly and easily changeable, so that content is always current. As we begin our next 50 years, committed to re-invigorating Canadian orthopaedic research, we invite all surgeons to re-connect and reengage with us. Visit Share our educational materials with your patients. Apply for COF research funding awards for your research proposals and innovation ideas. Most importantly, we urge you to make a donation to your Foundation to ensure the livelihood and legacy of Canadian orthopaedic research programming.

Nouveau look moderne à l’image des programmes dynamiques de la Fondation Canadienne d’Orthopédie Isla Horvath, directrice générale Fondation Canadienne d’Orthopédie


l’occasion de son cinquantième anniversaire, la Fondation Canadienne d’Orthopédie renouvelle son engagement envers les orthopédistes. En raison des besoins exprimés par l’ACO quant au financement de la recherche et de la réduction de l’enveloppe gouvernementale allouée à la recherche en orthopédie, la Fondation a adopté un plan visant l’élargissement de son soutien à la recherche. Geoff Johnson, président de la Fondation, explique cette décision : « Le milieu de l’orthopédie doit profiter de l’évolution rapide de la technologie et des milieux de soins, qui est au cœur de l’innovation. Et cette innovation n’est possible que lorsque de bonnes idées sont transposées au chevet des patients. Nous devons donc élargir l’offre de financement aux orthopédistes pour stimuler leurs idées de recherche et d’innovation, pour améliorer l’exercice de la profession et les résultats pour nos patients et pour opérer le changement que nous souhaitons tous dans la vie des personnes atteintes d’un trouble osseux, articulaire ou musculaire au pays. » Forte de la réaffirmation de son engagement, la Fondation a travaillé au renouvellement de son image pour qu’elle lui ressemble. Son nouveau logo fait partie de cette démarche. Il illustre admirablement

le dynamisme et le but ultime de la Fondation, soit aider les gens à retrouver leur pleine mobilité. On peut y voir une personne s’élancer, reflétant l’objectif ultime de la Fondation, qui est d’aider chaque patient. Grâce au soutien à la recherche, à la formation, à la sensibilisation et aux patients offert par la Fondation, la personne a retrouvé sa mobilité. La balle rappelle un ballon d’exercice ou médicinal, mais c’est aussi un portail grâce auquel on peut se renseigner sur la recherche en orthopédie au Canada. Le bleu, couleur de la Fondation, est accompagné de rouge, une façon simple de souligner avec fierté que nous sommes un organisme canadien. Notre nouveau site Web,, est convivial, dynamique et minimaliste, ce qui donne l’image d’un site moderne et vivant où l’on peut trouver les derniers renseignements disponibles. Sa modification est rapide et facile, de sorte que le contenu y est toujours à jour. Alors que la Fondation entame les cinquante prochaines années fermement engagée à énergiser la recherche en orthopédie au Canada, elle invite tous les orthopédistes à renouer avec elle, à se réengager. Consultez Remettez notre matériel de sensibilisation à vos patients. Proposez vos projets de recherche et vos idées novatrices dans le cadre des appels de candidatures pour les divers prix et bourses de la Fondation. Mais, surtout, nous vous prions de faire un don à votre fondation afin que perdure le legs de la recherche en orthopédie au Canada et que son financement demeure viable. COA Bulletin ACO - Summer / Été 2015

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

South African Orthopaedic Association (SAOA) 61st Annual Congress August 31 août-September 3 septembre Drakensberg, South Africa Web Site/Site Int. :

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

European Orthopaedic Research Society (EORS) 23rd Annual Meeting September 2-4 septembre Bristol, UK Web Site/Site Int. :

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

British Orthopaedic Association (BOA) Annual Scientific Congress September 15-18 septembre Liverpool, UK Web Site/Site Int. : 36th SICOT Orthopaedic World Congress September 17-19 septembre Guangzhou, China E-mail/Courriel : Web Site/Site Int. : The 32nd Annual Western Homecoming Sport Medicine Symposium Presented by The Fowler Kennedy Sport Medicine Clinic Sport Medicine 2K15 – Highlighting Current Concepts in the Diagnosis & Treatment of Ankle Injury September 25 septembre 7:30 – 15:15 The Best Western Lamplighter Inn & Conference Centre London, ON Guest Speaker: Mark Glazebrook, MSc, PhD, MD, FRCSC, Dalhousie University Web Site/Site Int. : - Click on the Symposium Banner or select Events on the home page menu. E-mail/Courriel : Anna Hales Australian Orthopaedic Association (AUST.OA) 75th Annual Scientific Meeting October 11-15 octobre Brisbane, Australia Web Site/Site Int. :

CAS 4th Annual Meeting November 26-27 novembre Ottawa, ON E-mail/Courriel : Web Site/Site Int. :

2016 Canadian Shoulder and Elbow Society (CSES) Shoulder Course (formerly JOINTS) January 28-29 janvier Ottawa, ON E-mail/Courriel : 13th Meeting of the Combined Orthoaedic Associations April 11-15 avril Cape Town, South Africa 12th Biennial Canadian Orthopaedic Foot & Ankle (COFAS) Symposium April 14-16 avril Wet lab on April 14 Eaton Centre Marriott Toronto, ON E-mail/Courriel : Web Site/Site :

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

2016 June 16-19 juin Québec City, QC

2017 June 16-18 juin Ottawa, ON

2018 June 21-23 juin Victoria, BC

COA Bulletin ACO - Summer / Été 2015



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

Can Reading Evidence Improve Your Practice? Reviewing Evidence Improves Resident Preparedness. The continually evolving orthopaedic landscape presents a challenge for surgeons and residency programs to provide and maintain an appropriate level of surgical knowledge. While many orthopaedic programs are attempting to identify the best method for continued knowledge acquisition, there remains a lack of consensus. It is apparent, however, that a weekly literature review program is a key component for providing a strong platform for attaining core knowledge. A US-based orthopaedic training hospital’s implementation of a weekly literature review program using JBJS and AAOS reviews demonstrated superior acquisition of core knowledge by residents over a one year period. The program led to a significant improvement in exam performance on the Orthopaedic In-Training Examination, with a percentile increase of 11 (P=0.007)1. While evidence demonstrates the benefits of a regular literature review program, the question of how best to identify and implement relevant resources to ensure acquisition of practice-changing research still remains, and a better understanding of research consumption habits is needed2,3. Identifying Best Evidence for Review is a Limiting Factor. In orthopaedics alone, approximately 30 research papers are published daily. Of these 30 papers, there may be one or two that have the potential to change orthopaedic practice. The volume of literature and small ratio of potentially practicechanging evidence Top journals' share of high-quality research presents a (2010-2014) challenge for the Top 5 journals' % of highSub Specialty clinician attempting quality research* to identify relevant Sports Med 60% trials. This issue is Spine 55% exacerbated by a Arthroplasty 51% lack of time to Shoulder & Elbow 43% critically appraise Foot & Ankle 38% and read full text Hand & Wrist 35% articles and the Physical Therapy & Rehab 34% potential inability Trauma 28% to access a full Pediatric Orthopaedics 19% article. While most General Ortho 13% surgeons have Overall value 43% access to some *RCTs, meta-analyses and systematic reviews journals, there is Source: OrthoEvidence still the chance that relevant evidence is being missed. Analysis of the OrthoEvidence (OE) database indicates that the top five journals for a given orthopaedic specialty account for 13%-60% of these potentially practice-changing studies, highlighting the possibility for specialists to miss valuable research.

COA Members Read More than Just the Top Journals. From an analysis of COA members who use OrthoEvidence (OE) it is clear that their consumption of orthopaedic-related content extends far beyond the top journals by area of specialty. Among COA members who were subscribers to OE during March, 57% of all articles reviewed came from 10 individual journals (43% came from journals outside of the top 10). These numbers reversed in April, with 43% of the articles reviewed coming from 10 individual journals (57% from journals outside of the top 10). The list of journals comprising the top 10 changed significantly from March to April, with only three of the top 10 journals from March carrying over into April. OE articles reviewed by COA members (by underlying journal) Bolded Journals appear in Top 10 for both April and March % of month's content reviewed 7%

Top 10 Journals for April 2015 Arthroscopy

Journal of Arthroplasty


Clinical Orthopaedics and Related Research


European Journal of Orthopaedic Surgery & Traumatology


The Bone & Joint Journal PLoS One

4% 4%

Journal of Bone and Joint Surgery


Journal of Hand Surgery (American Volume) Journal of Surgical Research Disability and Rehabilitation

3% 3% 2%

All Other Sources


Top 10 Journals for March 2015 Journal of Arthroplasty


Orthopaedics Orthopaedics & Traumatology: Surgery & Research Knee Surgery, Sports Traumatology, Arthroscopy

European Journal of Orthopaedic Surgery & Traumatology

Journal of Orthopedic Trauma

9% 7% 5%

5% 5%

Journal of Bone and Joint Surgery


International Orthopaedics


The American Journal of Sports Medicine PM&R

3% 2%

All Other Sources

43% Sources: COA and Orthoevidence

Read Content Selected by Your Most-Similar COA Peers. OE is working with the COA to develop a common language of evidence among clinicians. We believe this is an effective way for clinicians to identify and access relevant, practice-changing research. A growing number of COA members already use OE to access topics that reflect their areas of specialty. This month, COA is launching a new program with OE that will better identify relevant research for individual practitioners based on specialty and areas of interest. Called “Fast Track,” it enables new OE subscribers to discover evidence most-relevant to them based on area of interest and the reading habits of their mostsimilar peers. If you are an Active or Associate member of the COA who has not yet accessed OE, we encourage you to click here to get on the “Fast Track” to high-quality research.

1. Weglein DG, Gugala Z, Simpson S, Lindsey R. Impact of a Weekly Reading Program on Orthopedic Surgery Residents’ In-Training Examination. Orthopedics May 2015 - Volume 38 · Issue 5: e387-e393 2. Hurwitz SR, Slaawson D, Slaughnessy A. Orthopaedic information mastery: applying evidence-based information tools to improve patient outcomes while saving orthopaedists' time. J Bone Joint Surg Am 2000;82:888-94. 3. Alper BS, Hand JA, Elliott SG, et al. How much effort is needed to keep up with the literature relevant to primary care? J Med Libr Assoc 2004;92:429-37. OrthoEvidence (OE) is a provider of the highest-quality clinical evidence in Orthopaedics. Our goal is to improve decision making by increasing the collective baseline of knowledge from which decisions are made by practitioners, and our focus is the timely discovery, distillation, grading and repurposing of the 500+ randomized clinical trials, meta-analyses and systematic reviews published each year across 13 orthopaedic sub-specialties from 300+ journals.

All COA Active and Associate members have access to OE. To receive your custom content please follow this link. COA Bulletin ACO - Summer / Été 2015

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




STAY MOTIVATED YEAR-ROUND WITH ENGAGING SPEAKER SESSIONS THAT WILL HELP YOU ELEVATE YOUR CAREER THROUGH THE COA LIVE LEARNING CENTRE Whether you missed a specific session or were unable to attend the conference altogether, COA’s Live Learning Centre lets you access the education you need. Re-experience your favourite sessions, share our most informative presentations with your colleagues and continue your professional development between COA meetings.



COA Bulletin ACO - Summer / Été 2015



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

COA Bulletin ACO - Summer / Été 2015

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

Welcome Message Welcome to Guangzhou(Canton),China, the venue of 2015 SICOT Orthopaedic World Congress. On behalf of the Committees of the SICOT China branch,I will sincerely invite you to join this grand meeting in September 2015.This is the first time that SICOT Orthopaedic World Congress come to China Mainland. The meetings will lay out new blueprints for important issues of orthopedics development today and address our role in resurveying the current controversy of orthopaedic. We also expect to have in-depth discussions on all orthopeadic subspecialties to enhance the international academy exchange. Young generations are the hope of globe orthopaedic development.Various instructional courses will also be held for the young surgeons and trainees from China and abroad during this grand meeting. Guangzhou,the forerunner of China's reform and opening up endeavor,is endowed with a profound history of two thousand years and boasts a unique and splendid South China Culture. Hence, Guangzhou will not only make a perfect venue for the meetings,but also offers a chance for participants to explore the Chinese culture, traditions , as well as China's unique way of development. We promise Guangzhou will definitely leave you an unforgettable memory. You will be delighted by discovering the charms behind the Ancient East. We sincerely look forward to meeting you in Guangzhou in 2015! Guixing Qiu Congress President

Programme Thursday, 17 September 5th SICOT Educational Day Scientific Sessions Exhibition Opening Ceremony Friday, 18 September Scientific Sessions Exhibition Congress Party

Venue: Baiyun International Convention Centre

Saturday, 19 September Scientific Sessions Exhibition Closing Ceremony


Early (until 15 June 2015)

Normal (16 June - 15 August 2015)

SICOT Active Member

EUR 170

EUR 260

On-Site (16 August - 19 September 2015) EUR 360

SICOT Associate Member

EUR 85

EUR 150

EUR 200


EUR 370

EUR 460

EUR 600

Non-Member Trainee

EUR 170

EUR 260

EUR 360

Registration fees in EUR

COA Bulletin ACO - Summer / Été 2015


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Summer 2015 COA Bulletin #109  
Summer 2015 COA Bulletin #109  

The Summer 2015 edition of the COA Bulletin, the official publication of the Canadian Orthopaedic Association