Canadian Orthopaedic Association Association Canadienne d’Orthopédie
Summer / Été 2017 Publication Mail Envoi Poste-publication Convention #40026541 4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3
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Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 117 - Summer / Été 2017 COA / ACO Peter B. MacDonald President / Président Kishore Mulpuri Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: email@example.com Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Femi Ayeni Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: firstname.lastname@example.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.
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We Live in Changing Times Peter B. MacDonald, M.D., FRCSC President, Canadian Orthopaedic Association
s practicing physicians, particularly in orthopaedic surgery, we are reminded that there are changing times in health care, as well as in the world in general. With health care consuming up to 45% of the provincial budgets and trending upward each year, we are reminded that first and foremost, we must do whatever we can to make our system as efficient as possible. A report released by the Canadian Institute for Health Information (CIHI) and Choosing Wisely Canada on The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4060 St. Catherine Street West, Suite 620, Westmount, Quebec, H3Z 2Z3. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: email@example.com
Le Bulletin de l’Association Canadienne d’Orthopédie est publié au printemps, été, automne, hiver par l’Association Canadienne d’Orthopédie, 4060, rue Ste-Catherine Ouest, Suite 620, Westmount, Québec H3Z 2Z3. Le Bulletin est distribué aux membres de l’ACO, aux gouvernements, aux hôpitaux, aux professionnels de la santé et à l’industrie orthopédique. Veuillez faire parvenir tout changement d’adresse à : firstname.lastname@example.org
Unless specifically stated otherwise, the opinions expressed and statements made in this publication reflect the author’s personal observations and do not imply endorsement by, nor official policy of the Canadian Orthopaedic Association. Legal deposition: National Library of Canada ISSN 0832-0128
À moins que le contraire ne soit spécifié, les opinions exprimées dans cette revue sont celles de leur auteur et ne reflètent aucunement un endossement ni une position de l’Association Canadienne d’Orthopédie. Dépot légal : Bibliothèque nationale du Canada ISSN 0832-0128
COA Bulletin ACO - Summer / Été 2017
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April 6th, 2017 looked at selected medical tests, treatments and procedures across Canada and found that up to 30% of them were potentially unnecessary. These included CT scanning in a minor head trauma, the use of benzodiazepines in the Canadian senior population, unnecessary sleep medication in children, and MRI in low back pain, and other cases such as osteoarthritic knees. We are reminded through Choosing Wisely that guidelines can be followed that are evidence-based and eliminate trends that tend to be historical and ingrained in our health-care system that have no benefit to our population. Recent media attention has highlighted the BMJ recommendations with regard to arthroscopy in the arthritic knee. This is not really anything new from a scientific point of view as it began with the late Dr. Sandy Kirkley and the Western University group with their randomized clinical trial published in the NEJM in 2008. However, although the trend is away from this procedure, there are still likely too many of them being done. We also need to steward our imaging resources better. Use of unnecessary MRI’s such as in knee osteoarthritis are partly our responsibility in terms of educating primary care physicians as to the poor use of this precious resource. We all need to be more evidence-based in our practice and I look forward to our upcoming Annual Meeting’s Presidential Guest Speaker, Dr. James Wright, who questions our ability to be evidencebased in our practices on a daily basis. It is important to be reminded of our social responsibility in orthopaedics. There are things that come through our practices that we either choose to ignore or fail to recognize including
Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 14 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 33 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 38 intimate partner violence (IPV) and the opioid crisis. We recommend that all orthopaedic surgeons refresh their IPV knowledge by reviewing the COA’s 2017 IPV Position Statement and Best Practice Recommendations. Our Standards Committee, chaired by Dr. Jeff Gollish, is taking a detailed look at the opioid issue and will report back to the membership shortly. We are in final preparations for our Annual Meeting being held in Ottawa from June 15-18. Ottawa is a wonderful city to visit, especially during the nation’s 150th celebration activities, and our educational program offers quality content that is relevant to our entire orthopaedic community. This should be one of the best meetings in recent memory. Sherry and I look forward to seeing you all there!
Une époque de bouleversements Peter B. MacDonald, MD, FRCSC Président de l’Association Canadienne d’Orthopédie
douleurs au bas du dos et dans d’autres circonstances, comme des douleurs au genou dues à l’arthrose.
Choisir avec soin nous rappelle que des lignes directrices fondées sur des données probantes permettent d’endiguer ces tendances bien ancrées dans notre système de santé et, pourtant, sans avantage pour la population. Les médias ont récemment traité des recommandations du British Medical Journal (BMJ) en matière d’arthroscopie du genou en cas d’arthrite. Ces recommandations ne comportent rien de vraiment nouveau du point de vue scientifique depuis l’essai clinique aléatoire de feu Sandy Kirkley et du groupe de l’Université Western, dont les résultats ont été publiés dans le New England Journal of Medicine (NEJM) en 2008. Cela dit, même si on tend à s’éloigner de cette intervention, il est possible qu’on y ait encore recours trop souvent.
n tant que praticiens, et plus particulièrement en tant qu’orthopédistes, nous sommes confrontés aux changements qui bouleversent actuellement le milieu de la santé, voire le monde en général. Les soins de santé représentent jusqu’à 45 % des budgets provinciaux, une proportion qui tend à croître chaque année; cette réalité nous rappelle que, avant tout, nous devons faire tout en notre pouvoir pour rendre le système le plus efficace possible. Le 6 avril 2017, l’Institut canadien d’information sur la santé (ICIS) et la campagne nationale Choisir avec soin ont publié un rapport selon lequel jusqu’à 30 % des examens, interventions et traitements médicaux effectués au Canada sont potentiellement non nécessaires. Parmi ceux-ci, mentionnons le recours à la tomodensitométrie (TDM) en cas de traumatisme crânien mineur, l’administration de benzodiazépine chez les personnes âgées, la prescription non nécessaire de médicaments pour traiter l’insomnie chez les enfants, et le recours à un examen d’imagerie par résonance magnétique (IRM) pour des COA Bulletin ACO - Summer / Été 2017
Nous devons aussi gérer plus efficacement notre utilisation de l’imagerie. C’est en partie à nous qu’il revient de sensibiliser les médecins de première ligne au recours judicieux à l’IRM, une ressource précieuse, pour éviter les examens non nécessaires, entre autres dans les cas d’arthrose au genou. Nous devons tous nous fonder davantage sur les données probantes; j’ai
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d’ailleurs hâte d’entendre le Dr James Wright, conférencier invité par le président à la Réunion annuelle d’Ottawa, qui met en doute notre capacité à le faire au quotidien dans notre exercice. Dans un autre ordre d’idées, il est bon qu’on nous rappelle notre responsabilité sociale à titre d’orthopédistes. Au fil des dossiers, nous croisons des situations dont nous faisons fi ou que nous ne décodons pas, y compris les cas de violence conjugale et de dépendance aux opioïdes. Nous recommandons à tous les orthopédistes de rafraîchir leurs connaissances au sujet de la violence conjugale en lisant les Énoncé de position sur la violence conjugale et pratiques exemplaires recommandées de 2017.
Le Comité sur les normes, présidé par le Dr Jeff Gollish, étudie quant à lui le dossier de la crise des opioïdes et devrait informer les membres de ses constatations sous peu. C’est le dernier droit avant la Réunion annuelle d’Ottawa, qui a lieu du 15 au 18 juin 2017. Ville magnifique, Ottawa est particulièrement attrayante cette année à l’occasion des célébrations du 150e anniversaire de la Confédération, sans compter que notre programme de formation vous propose du contenu de qualité et pertinent pour l’ensemble du milieu orthopédique. Ce devrait être l’une des réunions les plus réussies des dernières années. Sherry et moi avons hâte de vous y voir!
Getting Ready to Le 72e président Welcome the 72nd President de l’ACO prendra bientôt of the COA le relais
r. Kevin Orrell will deliver his President Elect Address titled, We Are Our Own Best Friends, at the upcoming Annual Meeting on Saturday, June 17 during the Transfer of Office ceremony in the plenary hall at 11:30.
l’occasion de la cérémonie de transfert des charges, à la Réunion annuelle, le Dr Kevin Orrell donnera son allocution à titre de président élu de l’ACO, intitulée Nous sommes nos meilleurs alliés, à 11 h 30 le samedi 17 juin, dans la salle plénière.
Meet both Dr. Kevin Orrell and his wife, Anne, during the Transfer of Office ceremony and learn more about Dr. Orrell’s priorities and focus during his upcoming term as President of the COA.
Venez rencontrer le Dr Orrell et Anne, son épouse, et en apprendre davantage sur les priorités du nouveau président de l’ACO pendant son mandat.
“I am hoping to give the membership a better understanding of where the COA fits into your life and orthopaedic practice. There are valuable opportunities available through the COA that could benefit so many aspects of your career. I hope to assist members in learning how to take better advantage of all that the Association has to offer.” – Dr. Kevin Orrell
« J’espère permettre aux membres de mieux comprendre la place qu’occupe l’ACO dans leur vie et leur exercice. L’ACO offre des occasions intéressantes qui pourraient être bénéfiques pour leur carrière à bien des égards. J’espère aider les membres à mieux tirer profit de tous les avantages de leur adhésion à l’ACO. » – Dr Kevin Orrell
Article submissions to the COA Bulletin are always welcome!
Les contributions au Bulletin de l’ACO sont toujours les bienvenues!
Contact: Cynthia Vezina Tel: (514) 874-9003 ext. 3 E-mail: email@example.com
Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : firstname.lastname@example.org COA Bulletin ACO - Summer / Été 2017
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Suivez l’ACO sur Twitter pour être au courant de tout ce qui concerne la Réunion annuelle :
Tweet using hashtag #COAOttawa2017 to be part of the conversations going on about the 2017 COA, CORS and CORA Annual Meeting.
Utilisez le mot-clic #COAOttawa2017 dans vos gazouillis à la Réunion annuelle 2017 de l’ACO, de la SROC et de l’ACRO.
at the COA, CORS and CORA Annual Meeting in Ottawa
à la Réunion annuelle de l’ACO, de la SROC et de l’ACRO à Ottawa
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The Lancet Commission on Global Surgery: What it is, Why it’s a Big Deal, and How Canada’s INORMUS Study Results Influenced its Recommendations Clary Foote, M.D., MSc, FRCSC Hamilton, ON Paul J. Moroz, M.D., MSc, FRCSC Honolulu, Hawaii Mohit Bhandari, M.D., PhD, FRCSC Hamilton, ON
any Canadian orthopaedic surgeons are likely unaware of the true burden of musculoskeletal (MSK) disease that is carried by our colleagues in much of the world outside North America and Europe. Indeed, the need for surgical and anaesthetic services throughout the low- and middle- income countries (LMIC) is profound. In an evidence-based world, it is the duty of high-income countries (HIC) and medical associations like the COA to disseminate knowledge to our colleagues of the immense efforts being made to improve availability of surgical care throughout the world. Moreover, a key Canadian research project, McMaster’s INternational ORthopaedic MUlticentre Study in Fracture Care (INORMUS) has played an important role in establishing that orthopaedic injury care, specifically open fracture care, is an important surgical procedure which should be available at every district hospital in the developing world, but unfortunately is not. The Lancet Commission on Global Surgery was formed to address crucial gaps in knowledge, policy, and action, and was launched in January, 2014. The Commission brought together an international, multidisciplinary team of 25 commissioners, supported by advisors and collaborators in more than 110 countries and six continents and supported by the United Nations, World Bank, the World Health Organization and other international institutions. This article is a brief introduction to the Lancet Commission and the challenges it will face to improve surgical care to underserviced and marginalized populations in LMIC. Harrowing Statistics It has been estimated that 67% of the world’s population (about five billion people) cannot access safe, affordable surgical and anaesthesia care in a timely fashion1. Modest estimates calculate that 143 million additional surgical procedures are needed to address the burden of surgical care worldwide each year2. Moreover, 33 million individuals are thought to face catastrophic health expenditures every year due to payments for surgical and anaesthesia services3, largely because payment for these services are mainly out-of-pocket4. Finally, lack of access to surgery causes losses in economic productivity to LMIC, estimated cumulatively at USD $12.3 trillion5.
The epidemiology of musculoskeletal trauma in LMICs, where most of the burden resides, is poorly understood6. There is a growing body of evidence of an emerging road traffic epidemic suggesting an immediate need for high-quality large scale studies investigating MSK trauma in these nations. The World Health Organization (WHO) conducted preliminary analysis looking at road traffic accidents (RTA) in 2010, and reported staggering numbers of RTAs with associated mortality and morbidity in LMICs. Specifically, there were 1.3 million reported deaths annually just due to RTAs and at least 90% of these were in LMICs. The United Nations (UN) reported that by 2020, trauma is projected to be the third most common cause of death and the most common cause of the death among young adults and children. In 2011, the WHO responded by deeming 20112021 the road traffic safety decade. The two central goals of this initiative are to reduce road traffic accident-related deaths by 50% and morbidity by up to 90%. An updated report from the WHO in 2013 suggested that as many as 50 million people incur non-fatal injuries annually. This number was larger than previously predicted and underscored a major shortcoming in trauma research and the need for further intensive research7. Evolution of INORMUS In 2010, our McMaster trauma group visited several Level I trauma centres in India and found the burden of MSK injury to be shocking. Several emergency areas were devoted solely to MSK trauma, which was often severe. Some of the hospitals served ten million or more citizens, some of whom had to travel great lengths to receive primary or definitive orthopaedic care. The demand for essential trauma care clearly outweighed the supply. Initially, we attempted to do a systematic review of MSK injuries in large population-based studies that involved RTAs. We found that, over time, there had been an increase in the frequency in documenting ‘musculoskeletal’, ‘orthopaedic’, and ‘open’ injuries, but descriptions remained brief and relatively uninformative, and failed to apprise us of a potential growing orthopaedic epidemic. There was a clear need for large studies evaluating injury mechanism, types and treatments, in order to better understand the problem. In 2011, we launched the INORMUS pilot study. This was a prospective cohort study that was conducted in 14 Level I trauma facilities throughout India, over several years, recruiting adult patients who had sustained a fracture, dislocation, or disc herniation within an eight-week recruitment period. We recruited 4612 patients, which exceeded the sample size needed for regression analyses to look at predictors of death, infection, and reoperation6-8. Key findings from the study are shown in Table 17. The study demonstrated that trauma primarily affects citizens in the first four decades of life, presumably prior to or during their peak COA Bulletin ACO - Summer / Été 2017
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bread-earning years. RTAs account for more than half of all trauma, with motorcycles implicated in the majority of injuries. Consequently, there are high rates of open fractures and patients with multiple injuries. Fifteen percent of all patients had open fractures and more than half were Gustilo Grade III fractures. Only a third of patients arrive to hospital via emergency medical services (EMS), regardless of socioeconomic status. Less than a fifth of those patients arrive to hospital within an hour. Currently, a third of patients with open fractures are not receiving irrigation and debridement within 12 hours of the injury. There are significant delays in surgical care for many other types of closed injuries as well. The severity of the MSK injuries was significantly associated with all adverse outcomes, including mortality. Timing to orthopaedic care was associated with all adverse outcomes. Open fractures were five times more likely to become infected after a delay in treatment of more than 24 hours. This is likely related to lack of any open fracture care prior to arrival as well as to the severity of the injury. Table 1: Key points from INORMUS Pilot Study
Key Points Musculoskeletal trauma primarily affects citizens in their first four decades of life. Road traffic accidents are implicated in more than half of injuries, motorcycles primarily. A third of patients arrive to hospital via EMS systems, only a fifth of patients arrive within an hour. One in five patients had multiple fractures and 15% had open fractures. More than half of open fractures were Gustilo III. One in five patients had irrigation and debridement delayed more than 12 hours. Timing to definitive care was a predictor of all adverse outcomes (mortality, reoperation, and infection), suggesting that early intervention may reduce preventable death and morbidity. We submitted our results to the Lancet’s Global Commission for Global Surgery in 2014 and later presented the results at their conference in 2015. In April 2015, they rendered a report called ‘Global surgery 2030: evidence and solutions for achieving health, welfare, and economic development’, outlining global priorities for surgical care (Table 2)9. These cited that the demand for surgical care in LMICs far outweighs the supply (Figure 1). They identified three key surgical procedures with the greatest effect on patients and society. These were named the Bellwether Procedures and included open fracture management, cesarean section, and laparotomy. They concluded that orthopaedic surgical procedures likely have a greater impact on daily-adjusted life years than most vaccines, and a similar effect as human immunodeficiency virus therapy and maternal health procedures. The summary of the report can be found at http://www.globalsurgery.info/wp-content/ uploads/2015/01/Overview_GS2030.pdf and the full report can be found at http://www.thelancet.com/pdfs/journals/lancet/PIIS01406736(15)60160-X.pdf. The Canadian Orthopaedic Association has been provided with a copy for distribution upon request9. COA Bulletin ACO - Summer / Été 2017
Figure 1 Proportion of population without access to surgery (courtesy of the Lancet Commission for Global Surgery Report, 2015)9. Table 2: Key messages from Global Commission for COA Members
Key Messages Five billion people lack access to safe, affordable surgical and anaesthesia care when needed. 143 million additional surgical procedures are needed each year to save lives and prevent disability. 33 million individuals face catastrophic health expenditure due to payment for surgery and anaesthesia each year. Investment in surgical and anaesthesia services is affordable, saves lives, and promotes economic growth. Surgery is an indivisible, indispensable part of health care. The Lancet Commission on Global Surgery and The WHO Decade of Road Safety are just the beginning of a bigger movement in the recognition of impact of acute and delayed trauma on patients and society, especially in LMICs. With further large-scale research and outreach efforts, we can continue to narrow the information and personnel gap and come up with innovative solutions to prevent injury and reduce mortality and morbidity among those victimized. What COA Members Can Do With This Information Canadian surgeons can become involved in efforts to address the worldwide burden of musculoskeletal problems in a number of ways: • Keep in touch with the COA Global Surgery (COAGS) Committee – Read our quarterly article in the COA Bulletin, and don’t forget to attend COAGS symposia at the COA Annual Meetings. • Volunteer! Our new web page features a growing list of opportunities for Canadian orthopaedic surgeons to work in developing countries or in disaster response.
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• Join the Canadian Network for International Surgery (www.cnis.ca). This organization is always looking for orthopaedic surgeons to help teach surgical skills, predominantly in East Africa. • Attend the Bethune Surgical Roundtable annual meeting held in Canada in May or June of each year (sponsored in part by CNIS). The COA Global Surgery (COAGS) Committee is pleased to share Canadian global health initiatives. If you are interested in COAGS featuring your organization in the Bulletin, or if you are a resident and you would like to share an essay about your global surgery experience, please contact email@example.com for details.
3. Shrime M.G., Dare A.J., Alkire B.C., et al. Catastrophic expenditure to pay for surgery worldwide: a modelling study. Lancet Glob Health 2015: 3(Suppl. 2): S38–S44 4. Lin B.M., White M., Glover A., et al. Barriers to surgical care and health outcomes: a prospective study on the relation between wealth, sex, and post-operative complications in the Republic of Congo. World J Surg. 2016: 41(1):14-23. doi:10.1007/s00268-016-3676-x. 5. Alkire B.C., Shrime M.G., Dare A.J., et al. Global economic consequences of selected surgical diseases: a modelling study. Lancet Glob Health 2016: 3(Suppl. 2):S21–S27. 6. Meara J.G., et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Int J Obstet Anesth 2016: 25: 75-78.
References 1. Alkire B.C., Raykar N.P., Shrime M.G., Weiser T.G., Bickler S.W., Rose J.A., … Farmer P.E. Global access to surgical care: a modelling study. The Lancet. Global Health 2015: 3(6), e316– e323. doi:10.1016/S2214-109X(15)70115-4. 2. Rose J., Weiser T.G., Hider P., et al. Estimated need for surgery worldwide based on prevalence of diseases: a modeling strategy for the WHO Global Health Estimate. Lancet Global Health 2015: 3:S13–S20.
7. Meara J.G., Greenberg S.L. The Lancet Commission on Global Surgery Global surgery 2030: Evidence and solutions for achieving health, welfare and economic development. Surgery 2015: 157(5): 834-835. 8. Foote C.J. et al. Musculoskeletal trauma and all-cause mortality in India: a multicentre prospective cohort study. Lancet 2015: 385 Suppl 2: S30. 9. Meara J.G. et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet 2015: 386(9993): 569-624.
UBC Well-represented on 2016 CFBS Fellowship Tour The 2016 COA CFBS Fellows: Danny Goel, M.D., MSc, FRCSC Clinical Associate Professor, Faculty of Medicine Department of Orthopaedic Surgery, University of British Columbia (UBC) Burnaby, BC Andrea Veljkovic, M.D., MPH(Harvard), BComm, FRCSC Clinical Associate Professor, Department of Orthopaedic Surgery, St. Paul’s Hospital, University of British Columbia (UBC) Vancouver, BC
e arrived in Paris on October 16, 2016 on a warm fall evening. Having checked into our hotel, we walked along to the Louvre along the Champs-Élysées to stretch our legs and get a taste of the Parisian atmosphere. Having some early computer issues, we took a trip to the Apple store for a crash course on using the French QWERTY keyboard (they are not the same as back home). Feeling jetlagged, we headed home early but not before a sampling of steak tartare with crispy fries and mustard.
On our first full day in Paris, Andrea (Andie) went to the clinique chirurgicale Victor Hugo and assisted Dr. Christophe Piat in the OR on eight foot procedures. Danny went to the famous Hôpital Ambroise Paré and observed a reverse shoulder arthroplasty performed through a lateral approach by Professor Philippe Hardy’s group. More impressive was the extent of hypotensive anaesthesia in the beach chair position for an arthroscopic Dr. Danny Goel with Dr. Hermes Miozzari rotator cuff repair. and members of the biomechanics lab in Subsequently, we Geneva COA Bulletin ACO - Summer / Été 2017
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hopped on a tour bus and saw Paris from above, stopping to enjoy a phenomenal view of the Eiffel Tower. A lovely glass of local wine and sparkling water rounded out the day. The remainder of the week was spent in Paris observing minimally invasive techniques and learning from our new European colleagues. Andie and Danny were especially impressed by the level of Parisian productivity, witnessing over 20 cases completed by one surgeon in a single day. During the second leg of our trip, we transferred to Brussels where we met our host, Professor Olivier Cornu. He was a tireless and passionate guide to the ornate city, introduced us to Kriek, a cherry brew, Belgian chocolate and the famous Magritte whose painting well-known to most is that of a man in the hat with an apple in front of his face. Our stop in Brussels included a day at the Hôpital Erasme. A rigorous academic schedule was prepared for us that day include a scientific symposium, observation of OR cases, tour of the gait lab, bone bank and physical therapy area. That evening Andie enjoyed a dish of wild game that Danny was gracious enough to pay for, having only tasted one gamey bite. We then carried on to the Cliniques universitaires Saint-Luc, where our host, Professor Cornu, is the Chief of Orthopaedics. Andie was impressed with Dr. Dan Putinaneu’s passion for diabetic foot and ankle reconstruction while Danny spent some clinic and OR time with the upper extremity group. Later that evening we went to a beautiful faculty dinner.
Dr. Danny Goel, Prof. Emanuel Gautier, Dr. Andie Veljkovic, Dr. Marc Lottenbach at HFR Fribourg - Hôpital Contoal
On the evening of October 26, Prof. Cornu personally drove us to Liège. While in Liège, we visited two community-oriented hospitals: Sart-Tilman and Hôpital La Citadelle under Professor Philippe Gilet and Dr. Nanni Allington. We saw an interesting arthroscopic Latarjet the first day and Andie was able to help out with a midfoot fusion on the subsequent day. On our last evening in Belgium, we stayed in a hotel at the high security Brussels airport. It was here that we had a small taste of home comforts for an evening, which was a welcome after two weeks of rigorous academic travel.
COA Bulletin ACO - Summer / Été 2017
Dr. Hermes Miozzari and Dr. Andie Veljkovic in Geneva
The following morning, we flew to Geneva after successfully passing multiple airport security checkpoints. We were greeted warmly in Geneva by Dr. Hermes Miozzari. A refreshing walk on our own around the beautiful lakeside city was rejuvenating. In the evening, we met up with the staff for a cultural dinner at a local restaurant. The next day, we enjoyed taking a jog by the water to the United Nations buildings followed by a beautiful dinner at the Brasserie Lipp restaurant with Dr. Miozzari. The subsequent two days were spent in the department of Professor Didier Hannouche at the prestigious University of Geneva, observing eloquently performed operations and assessing relevant pathology in clinic. While at the University, we toured the research facilities, presented at a stimulating educational symposium, and had a lovely dinner in beautiful old town Geneva. On our last day, we observed additional interesting procedures and engaged in stimulating dialogue around cases. That afternoon we explored the remarkable Red Cross Museum, reflecting on the past history of medicine and its future directions. This is a must see for anyone travelling through Geneva. Later that night we travelled by train to Fribourg and met up with the dynamic team of HFR Fribourg. The following morning, we presented at an educational symposium and took part in a fabulous international exchange of ideas during clinic with Dr. Lottenbach. This visit remains fondly in our memory as one of our most engaging exchanges. On the afternoon of November 2, we left for Lausanne where we met up with Dr. Frédéric Vauclair. The following day we took part in an educational symposium at the Centre hospitalier universitaire vaudois (CHUV), followed by septic ward rounds and discussion around the management of orthopaedic infections by the well-known Professor Olivier Borens. In the evening, we exchanged ideas on health-care management in Europe as compared to Canada over a wonderful fondue dinner with the faculty. That weekend we were free to explore Lausanne and its many beautiful sites. We were particularly impressed by the Olympic Museum. Of our own volition, we exchanged our airline tickets for train tickets to Paris so that we could better appreciate the picturesque landscape between Switzerland and France.
Your COA / Votre association
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On November 6, we returned to Paris where Danny spent an exciting day with the famous Professor Philippe Valenti who is renowned for his work in complex shoulder tendon transfers. This was followed by the final week at the SOFCOT Annual Meeting. Here, Andie presented her research and took part in the full breadth of educational seminars. We left France for home at the end of the conference week, feeling enriched by our recent experiences. We had been exposed to numerous new viewpoints on how to tackle foot and ankle and shoulder pathology, which will embellish our future practices. In addition, we learned about the different ways health care is delivered in the European countries we visited and gained insights into effective practices that may help us improve health-care delivery in Canada. We would like to extend an extra special thanks to the COA’s Exchange Fellowships Committee for selecting us as the 2016 CFBS fellows, and especially to Cynthia Vezina in the COA office for this incredible opportunity.
Dr. Andie Veljkovic , Prof. Olivier Cornu , Dr. Danny Goel in Brussels
COA Bulletin ACO - Summer / Été 2017
Your COA / Votre association
THOMAS W. BARRINGTON, M.D., FRCSC, FACS August 27, 1932 - February 22, 2017
ith heavy hearts we announce the death of Dr. Thomas Barrington on February 22, 2017. Tom died in Caledon, his family by his side, after a struggle with lymphoma. He will be missed by his wife Patricia of 58 years, his sons Timothy and Edward and his daughters Sarah (Richard Bateman) and Stephanie. He is also survived by his six grandchildren Matthew, Zoe, Daisy, Thomas, Graydon and Lucas and predeceased by his sister Ida Campbell. Tom was born in Gore Bay (while summering) and was raised in Toronto. He graduated from Oakwood Collegiate and University of Toronto Medical School in 1956 and specialized in Orthopaedic Surgery. He was at one time Head of Orthopaedic Surgery at Sunnybrook Health Sciences Centre and Head of Orthopaedic Surgery at Toronto East General Hospital (TEGH). More recently he was Surgeon- In-Chief at TEGH and Assistant Professor of Surgery at University of Toronto. He introduced the fixation of joint replacement and bone cement to Canada in 1965. He enjoyed the physical aspects of his specialty. Tom was a sports and car enthusiast as well as a war history buff. He was on both his school swim and hurdling teams (Ontario champ) and was passionate about tennis and skiing, building a rich social
life around these sports at Donalda and Caledon Ski Clubs. His love of fine cars was unparalleled, owning almost 100 different models over his lifetime with the favorite being his current Jaguar F-Type. Manitoulin Island was his summer oasis and he will be remembered in the glorious sunsets when we all gather with family and friends. “If you will, remember me occasionally - I would like that; but no mourning, please, death in old age is a solution, not a tragedy.” Published in the Toronto Star from Feb. 26 to Feb. 27, 2017
DAVID HARDER, M.D., FRCSC January 17, 1933 – May 4, 2017
urrounded by loved ones, on the fourth of May, David passed peacefully, at the end of the day. He was born in Yarrow, near Chilliwack, BC, On a cold winter day, in nineteen thirty-three. Along with five siblings, raised on a farm, Got into some mischief, but no serious harm. At MEI high school, he attended class, Knocked the establishment flat on its a**. But the religious lore, he did not jettison, Just changed his focus, UBC’s School of Medicine. Became a doctor, a talented GP, After five years, he chose a specialty. The field of orthopaedics, was calling his name, His ticket to happiness, fortune and fame. Respected surgeon, the best one around, Patients loved him, their accolades abound. Of knowledge and wisdom, he was eager to share, With new younger doctors, he taught them to care. For family at home, he strived to make time, Weekend activities, were always sublime. His interests were varied, but usually outside, Ski, golf, hike, tennis, and a bicycle to ride. He bought Klub Kal, a campground to stay, A safe place, for young families to play. On the shores of Kal Lake, summers were spent, While at Klub Kal, RVs replaced tents. Retired to Oyama, in ninety-eight, COA Bulletin ACO - Summer / Été 2017
A beautiful dream home, on the shore of the lake. Where outdoor activities, always abound, Fun and frolic, all year round. He’s survived by wife Sandra, his true soul mate, And five grown children, who inherited his best traits. Also four grandchildren, and as of today, Nine great-grandkids, and more on the way. We miss David dearly, so caring and kind, A finer human being, you will never find. We’ll celebrate his life, and properly remember, Stay tuned for details, it’ll be in September. The Harder family sincerely thank the staff on 4West, the Medical staff and the Oncology team at KGH for the wonderful care they provided over the last few years. In lieu of flowers a donation to the Okanagan Rail Trail would be greatly appreciated (for David Harder, in memoriam) - www.okanaganrailtrail.ca.
Published in Vancouver Sun and/or The Province from May 9 to May 13, 2017
TRIATHLON TRITANIUM ®
Cementless. Redefined. Single radius and delta keel Triathlon design elements provide initial stability for biologic fixation.1,2 Defined porous and solid zones Tritanium 3D printing enables complex designs to improve tibial fixation3 and patella strength.4 SOMA-designed Size-specific peg design secures into denser regions of bone.5
FONT: Helvetica with bell curve
1. Bhimji S, Alipit V. The effect of fixation design on micromotion of cementless tibial baseplates. Orthopaedic Research Society Annual Meeting. 2012; Poster #1977. 2. Harwin S, et al. Excellent fixation achieved with cementless posteriorly stabilized total knee arthroplasty. J Arthroplasty. 2013;28(1):7–13. 3. Alipit V, Bhimji S, Meneghini M. A flexible baseplate with a partially porous keel can withstand clinically relevant loading. Orthopaedic Research Society Annual Meeting. 2013; Poster #0939. 4. Stryker Test Report RD-12-044. 5. Stryker Test Protocol 92911; D02521-1 v1. © 2014 Stryker Corporation. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: SOMA, Stryker, Triathlon, Tritanium. All other trademarks are trademarks of their respective owners or holders. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any Stryker product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. TRITAN-AD-1
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COA Bulletin ACO - Summer / Été 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques
Periprosthetic Infection Rates - Acknowledging the Incidence is the First Step in Prevention Gavin C.A. Wood, MB ChB, FRCS Edin, FRCSC Assistant Professor, Department of Surgery Queen’s University Kingston, ON
nfection control monitoring is an essential and reportable statistic for every hospital. An infected arthroplasty is a devastating and costly complication to both individual and health-care provider, associated with numerous clinic visits, readmissions and repeated surgeries. The most common cause for hospital readmission after a hip or knee replacement is surgical site infection (SSI)1. The most concerning outcome for the patient can be loss of limb or life. Mortality from infected arthroplasty has been shown to range from 3-8% in the first year, greater than or equivalent to some cancers2-4. The cost implications are immense and the United States (US) alone can account for $1 billion per year5, with estimates from $150,000 to $500,000 per case5-7. Infection is the third most common reason for revision total hip arthroplasty (THA) and one of the most frequent reasons for revision total knee replacement (TKR), at 14.8% and 25.2% respectively6. Prevention is better than cure, and there are numerous established guidelines for best practice in achieving this end8,9. The most recent and concise guidelines were published in the proceedings of the International Consensus Meeting on Periprosthetic Joint Infection led by J. Parvizi10. A multi-national
group of experts in this field met and collated their experience with the published literature into detailed recommendations based on current evidence and best practice. In Canada, the Canadian Institute for Health Information (CIHI) stipulates that all hospitals must publish their infection rates, but the reality is that most institutional web sites only publish their hand washing compliance rates. Perhaps making public knowledge of infection rates is embarrassing? Or maybe it should be something to be proud of? Do our hospitals truly know their infection rates? Many highly respected international institutions such as National Institute for Health and Care Excellence (NICE), Scottish Arthroplasty Project (SAP) and Centres for Disease Control and Protection (CDC) provide data for periprosthetic joint infection for primary arthroplasty. Annual reports are produced with current and accepted rates and identify outliers that may require further investigation. For example, in the United Kingdom, national rates for primary joint infection in THA and TKR are approximately 0.67-1.1% with the upper range of normal being 1.5% (Table 1). The SAP has a national standard of 1-1.2%. Any hospital with a rate above 2% is deemed an outlier and is a cause for concern. These hospitals are notified and asked to change their practice as well as to document measures taken, and resulting changes.
Table 1 Number of Operations, SSIs and rate of SSI, by category in all 5 years (April 2004-March 2009)
COA Bulletin ACO - Summer / Été 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques
(continued from page 15)
A recent analysis of my institution’s rate of periprosthetic joint infection from 2013 to 2016 demonstrated an acceptable infection rate of 1% for TKR, but an alarming increase in deep infection of primary THA of 4.2%, which increased annually over the last three years (Table 2). I believe that this rate was too high and did not compare favourably with the best practice standards or published acceptable deep infection rates. On review of these figures and closer examination of these infected hip cases, it became evident that some were in fact hip fracture cases that had hemiarthroplasties. We expect the incidence of infection in that patient cohort to be higher, so once excluded from the data, our results revealed a more respectable deep infection rate of 1.5%. The exercise exposed a number of points. Firstly, no one had previously identified the possibility of a potential deep infection problem occurring, as the infected cases were not being reported as a percentage of the total cases performed. The institution had been reporting the monthly cases to individual surgeons without an overall view of the collective cases and data. Next, many of those collecting and processing the data did not have the needed knowledge to appropriately group or classify cases, hence why hip fractures were included with the arthroplasty figures. Table 2 Ontario Teaching Hospital Deep Infection Rates for Total Hip and Total Knee Arthroplasty
2013/14 2.1% 1.1%
2014/15 3.4% 0.8%
2015/16 4.2% 1%
2016 Q2 1.2% 0%
Total Combined 3% 1.9% 1%
Our patients deserve excellent care and I believe that we should adopt recognized standards as targets by which to measure our performance at the institutional level, as well as provincially and nationally. The reporting of mortality rates, dislocation, DVT, PE, readmission, and revision surgery rates should be available to the public and should be mandatory instead of voluntary. The reporting of such outcomes, as with reporting of infection, first establishes awareness of a problem, which can subsequently be addressed. Ignorance is bliss, but knowledge is power. Establishing acceptable rates and national standards by which to measure ourselves shines the light on outliers. Once an outlier is identified, an investigation can ensue and measures can be taken to reduce complication rates. This has been shown in the SAP, which publishes its annual rates for all complications of joint replacement. Since reporting began, complications such as infection, as well as health-care costs, have been reduced significantly, while quality of service to the patient has improved11. Similar publications are carried out in England and New York State, with more care providers across the US following suit (Table 3). Introducing reportable complications such as infection should begin with the surgical Quality Based Procedures (QBP’s), where a dollar value is attached to each patient’s care. Given that infection is a devastating and costly complication in arthroplasty5,12, hospitals should have their infection rates assessed in addition to accepted “standards of excellence”, and results outside of the target range should trigger an investigation for each individual surgical procedure being monitored. Other regulated health-care bodies around the world publish their actual infection rates in the accepted standardized fashion recognized by surgeons. Canada, as a leading health nation with a universal health-care system, should follow suit. Individual hospitals should be held accountable and their annual rates made public. COA Bulletin ACO - Summer / Été 2017
Table 3 Published Deep Infection Rates
NICE UK SAP CDC AAOS AAOS Acta Orthop JBJS NewYork State Hosp HPA UK 5yrs
1% standard set 1% THA 1.5% TKR actual 1.9% actual 0.7% 1.7% THA 2.5% TKR 1-2% 0.72% TKR 1% 1.01% THA 0.67% TKR
www.nice.org.uk www.arthro.scot.nhs.uk www.cdc.gov JAAOS April 20156 JAAOS June 20158 Acta Orthop 200614 JBJS AM May201315 www.ny.gov www.hpa.org.uk
One proposal for infection surveillance would be to establish an accepted standard for arthroplasty infection. Rates at 1.5% or more could trigger an ‘Orange Alert’, and at 2% or more a ‘Red Alert’. An ‘Orange Alert” trigger requires investigation by the institution to confirm deep infection, to identify the organism and to look at trends in data e.g. variations among calendar months, surgeons, operating rooms, patient demographics, etc. A ‘Red Alert’ trigger should instigate further investigation or intervention such as checking the laminar flow system, HVAC filters, deep cleaning the OR, reviewing central processing equipment and procedures, and reviewing antibiotic prophylaxis and best practice guidelines with all staff. The Hospital Infection Committees should provide quarterly reports for each surgical QBP procedure to the surgeons and publically-declared annual reports. Monitoring and reporting outcomes that reflect the quality of patient care have been shown to improve cost efficiencies, which are very important in a public health-care system, and focus on the outcomes important to individual patients. Resistance to such proposals has come from surgeons and hospital administrators fearful of loss of reputation, withdrawal of services or funding. This was the case in the countries that now have such public reporting. Individual surgeons or doctors are de-identified and institutions are instead held accountable which quickly improved their performance and rewarded them with additional funding. The cost of collecting such data is minimal as most hospitals already currently collect this information, certainly those who submit to joint registries do. There is minimal cost in the data processing offset against the money that can be saved from reduced infection rates. The word ‘institution’ implies an old establishment that provides a service for the good of the people, without care of cost. This attitude needs to change. Like it or not, health care is a business and the patients are purchasers who want quality and value. We, as providers, need to publish and advertise the quality of our product. In Canada, where the payer is the government, they want value. The recent report by the Commonwealth Fund revealed that Canada has fallen to second last overall among 11 industrialized countries on measures of health-system quality, access to care, efficiency, equity and healthy lives (Table 4). This is not the kind of advertisement we want for our healthcare system13.
Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 17)
References 1. Ramkumar P.N., Chu C.T., Harris J.D., Athiviraham A., Harrington M.A., White D.L., et al. Causes and Rates of Unplanned Readmissions After Elective Primary Total Joint Arthroplasty: A Systematic Review and Meta-Analysis. Am J Orthop (Belle Mead NJ). 2015;44(9):397-405. 2. Awad S.S. Adherence to surgical care improvement project measures and post-operative surgical site infections. Surgical infections. 2012;13(4):234-7.
9. Kucukdurmaz F., Parvizi J. The Prevention of Periprosthetic Joint Infections. The open orthopaedics journal. 2016;10:58999. 10. Parvizi J. International Consensus Group on Periprosthetic Joint Infection. 2014. 11. Project S.A. Biennial Report 2014. 2014.
3. Gundtoft P.H., Pedersen A.B., Varnum C., Overgaard S. Increased Mortality After Prosthetic Joint Infection in Primary THA. Clin Orthop Relat Res. 2017.
12. Gow N., McGuinness C., Morris A.J., McLellan A., Morris J.T., Roberts S.A. Excess cost associated with primary hip and knee joint arthroplasty surgical site infections: a driver to support investment in quality improvement strategies to reduce infection rates. The New Zealand medical journal. 2016;129(1432):51-8.
4. Rezapoor M., Parvizi J. Prevention of Periprosthetic Joint Infection. J Arthroplasty. 2015;30(6):902-7.
13. Davis K., Schoen C., Stremekis K.. Mirror Mirror on the wall. June 2014.
5. Kurtz S.M., Lau E., Watson H., Schmier J.K., Parvizi J. Economic burden of periprosthetic joint infection in the United States. J Arthroplasty. 2012;27(8 Suppl):61-5 e1.
14. Anagnostakos K., Furst O., Kelm J. Antibiotic-impregnated PMMA hip spacers: Current status. Acta Orthop. 2006;77(4):628-37.
6. Hackett D.J. The Economic Significance of Orthopaedic Infections. Journal American Academy Orthopaedic Surgeons. 2015;23(supplement 1):S1-7.
15. Namba R.S., Inacio M.C.S., Paxton E.W. Risk Factors Associated with Deep Surgical Site Infections After Primary Total Knee Arthroplasty: An Analysis of 56,216 Knees. JBJS. 2013;95(9):775-82.
7. Kapadia B.H., McElroy M.J., Issa K., Johnson A.J., Bozic K.J., Mont M.A. The economic impact of periprosthetic infections following total knee arthroplasty at a specialized tertiary-care center. J Arthroplasty. 2014;29(5):929-32. 8. Daines B.K. Infection Prevention in Total Knee Arthroplasty. Journal American Academy Orthopaedic Surgeons. 2015;23(6):356-64.
Additional Resources www.hpa.org.uk www.ny.gov. www.cdc.gov www.nice.org.uk www.arthro.scot.nhs.uk
COA Bulletin ACO - Summer / Été 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques
Lisfranc Injuries: Fix or Fuse?
An introduction to this edition’s debate
njuries of the Lisfranc (tarsometatarsal joints) of the foot remain a disabling condition. For such an innocuous and often missed injury, it can be a career-ending event. This is one of several injuries in the foot that can cause long-term disability in a younger patient demographic. Traditional surgical treatment such as reduction and cross joint screw fixation has resulted in outcomes that are better than non-operative treatment but the outcome is still less than ideal. However, modern surgical techniques have the potential to improve the
outcomes of this injury that causes grief for both the patient and the surgeon. I would like to thank our debate authors for their excellent contributions to this edition of the COA Bulletin. We hope that the next time you see this injury, you will be better informed and more comfortable with the treatment options available to you. – Ed.
Lisfranc Injuries: Why ORIF Remains Treatment of Choice David Walton, M.D. University of Michigan Ann Arbor, Michigan Joel Morash, M.D., FRCSC Dalhousie University Halifax, NS
rauma to the tarsometatarsal (TMT) joints is a life-altering event for which treatment is controversial. Much of the controversy is due to the wide variety of injuries that are collectively known as “Lisfranc injuries”. The TMT joint complex is thought to contain three columns, which constitute a longitudinal and transverse arch. This complicated structure is responsible for maintaining the stability of the midfoot, the keystone of which is the base of the second metatarsal base10. Lisfranc injuries have multiple complex classification schemes based on displacement morphology but can also be categorized either by low energy and high energy or ligamentous and osseous. These latter groupings often have much more impact on treatment and potentially on long-term outcomes. Historically, open reduction and internal fixation has been the gold standard for treating Lisfranc injuries, regardless of their composition, unless severe comminution of the articular surface made this unreasonable. In 2006, a prospective randomized clinical trial by Coetzee et al. challenged this notion. This study reported significant and superior outcomes with primary arthrodesis in primarily ligamentous Lisfranc injuries11. This study cited an increase in secondary surgery for removal of painful hardware and subsequent TMT arthrodesis. Given the lower satisfaction rates and increased reoperation rate, interest in primary arthrodesis has increased over the last decade. Part of the controversy in treatment of Lisfranc injuries can be attributed to nomenclature. Osseous injuries of the Lisfranc continue to be treated by ORIF when the articular surface is salvageable2. Primarily ligamentous injuries remain the object in question. These injuries can be further subclassified through directional and morphological classification modified COA Bulletin ACO - Summer / Été 2017
by Hardcastle et al. and by the classification by Nunley et al. which distinguishes lower energy midfoot sprains by severity7,13. The former portends a higher energy injury with a more complex injury pattern which categorizes injuries into partially incongruent, totally incongruent and divergently incongruent patterns. Whereas the midfoot sprain classification is specific to lower energy injuries with no displacement between the medial cuneiform and the base of the second metatarsal, displacement of 1-5mm and displacement with collapse of the longitudinal arch. The conclusions from Coetzee et al. must be applied in the proper context. The inclusion criteria were primarily ligamentous injuries without regard to classification or grade of injury and they were treated with positional screws violating the TMT joints (Figure 1). With advances in implant technology and surgical techniques, many Figure 1 surgeons have adapt- Primarily ligamentous injury treated with ed to dorsal plating positional screws violating the TMT joints. techniques that spare the articular surfaces4,9,15. Additionally, these plates are used as internal splints and not permanent implants and therefore their removal is an anticipated event, not a complication. In a prospective comparison between screw fixation and dorsal plate fixation for ORIF of Lisfranc injuries, Hu et al. reported statistically significant superior outcomes and trended toward better anatomic alignment with dorsal plating9 (Figure 2). In a biomechanical study by Marks et al., plating was shown to be stiffer and have less displacement with initial and cyclic loading compared to screw fixation12. Inherently, ORIF of Lisfranc
Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 18)
injuries would tend to do better when properly reduced. Abid et al. noted 80% occurrence of posttraumatic osteoarthritis in non-anatomically reduced patients compared to 35% in appropriately reduced patients1. Several other studies have noted similar results3,5,6. Figure 2
Treatment of a osseous Lisfranc injury with
Low energy Lisfranc ORIF of a 2nd MT intra-articular fragment and injuries should be ORIF of the TMT joints using joint sparing approached in a dif- bridge plating. ferent manner from high-energy injuries. Nunley et al. reported on 15 injuries to the Lisfranc complex in athletes. Eight of these patients were classified as type 2, meaning 1-5mm displacement of the base of the second metatarsal from the medial cuneiform with displacement medially or laterally driven without evidence of arch collapse. These patients were treated with ORIF and all returned to previous level of sport at mean 15.3 weeks with seven excellent results and one good13. In low energy injuries, the soft tissues are less traumatized and fewer articulations are generally disturbed. In these patients, return to higher activity level is anticipated. For these reasons, joint-sparing procedures are often preferable (Figure 3).
gold standard for complex ligamentous injuries. In cases with extensive comminution, where anatomic reduction cannot be achieved with ORIF, primary arthrodesis would be the treatment of choice. References 1. Adib F., Medadi F., Guidi E., Harandi A.A., Reddy C. Osteoarthritis Following Open Reduction and Internal Fixation of the Lisfranc Injury. Orthopaedic Proceedings. 2012;94-B(SUPP XXXVII):20-20. 2. Arntz C.T., Veith R.G., Hansen S.T. Fractures and FractureDislocations of the Tarsometatarsal Joint. J Bone Joint …; 1988. 3. Blanco R.P., Merchán C.R., Sevillano R.C. Tarsometatarsal fractures and dislocations. … of orthopaedic trauma. 1988. doi:10.1016/s0304-4181(06)00003-0. 4. Lau S., Howells N., Millar M., De Villiers D., Joseph S., Oppy A. Plates, Screws, or Combination? Radiologic Outcomes After Lisfranc Fracture Dislocation. The Journal of Foot and Ankle Surgery. 2016;55(4):799-802. doi:10.1053/j.jfas.2016.03.002. 5. Buzzard B.M., Briggs P.J. Surgical Management of Acute Tarsometatarsal Fracture Dislocation in the Adult. Clin Orthop Relat Res. 2005;353:1-9. doi:10.1097/00003086-19980800000014. 6. Goossens M., De Stoop N. Lisfranc’s Fracture-Dislocations: Etiology, Radiology, and Results of Treatment. Clinical orthopaedics and related …. 1983. doi:10.1037/05232212. 7. Hardcastle P.H., Reschauer R., Kutscha-Lissberg E., Schoffmann W. Injuries to the tarsometatarsal joint. Incidence, classification and treatment. J Bone Joint Surg Br. 1982;64(3):349-356.
Figure 3 Ligamentous Lisfranc injury treated with ORIF joint-sparing bridge plating.
There continues to be controversy surrounding the treatment of Lisfranc injuries but this remains only in a subset; the high-energy complex ligamentous injuries. Osseous and low energy simple morphology injuries are still optimally treated with ORIF. A recent systematic review and meta-analysis has demonstrated no difference in patient-reported outcomes, risk for non-hardware removal revision surgeries or postoperative alignment14. Another recent prospective randomized trial noted equivalent patient outcomes with either primary arthrodesis or ORIF and only increase reoperation rates if hardware removal was routinely performed8. Given this information, an anatomically reduced ORIF for Lisfranc injuries continues to be the treatment of choice for osseous and simple ligamentous Lisfranc injuries and has not been clearly supplanted as the
8. Henning J.A., Jones C.B., Sietsema D.L., Bohay D.R., Anderson J.G. Open Reduction Internal Fixation versus Primary Arthrodesis for Lisfranc Injuries: A Prospective Randomized Study. Foot & Ankle International. 2009;30(10):913-922. doi:10.3113/FAI.2009.0913. 9. Hu S.-J., Chang S.-M., Li X.-H., Yu G.-R. Outcome comparison of Lisfranc injuries treated through dorsal plate fixation versus screw fixation. Acta ortop bras. 2014;22(6):315-320. doi:10.1590/1413-78522014220600576. 10. Kelikian A.S., Sarrafian S.K. Sarrafian’s Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional. Wolters Kluwer Health/Lippincott Williams \& Wilkins; 2011. 11. Ly T.V., Coetzee J.C. Treatment of primarily ligamentous Lisfranc joint injuries: primary arthrodesis compared with open reduction and internal fixation. A prospective, randomized study. J Bone Joint Surg Am. 2006;88(3):514-520. doi:10.2106/JBJS.E.00228.
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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 19)
12. Marks R.M., Parks B.G., Schon L.C. Midfoot fusion technique for neuroarthropathic feet: biomechanical analysis and rationale. Foot & Ankle International. 1998;19(8):507-510. doi:10.1177/107110079801900801. 13. Nunley J.A., Vertullo C.J. Classification, investigation, and management of midfoot sprains: Lisfranc injuries in the athlete. Am J Sports Med. 2002;30(6):871-878.
14. Smith N., Stone C., Furey A. Does Open Reduction and Internal Fixation versus Primary Arthrodesis Improve Patient Outcomes for Lisfranc Trauma? A Systematic Review and Meta-analysis. Clin Orthop Relat Res. 2015;474(6):1445-1452. doi:10.1007/ s11999-015-4366-y. 15. van Koperen P.J., de Jong V.M., Luitse J.S.K, Schepers T. Functional Outcomes After Temporary Bridging With Locking Plates in Lisfranc Injuries. The Journal of Foot and Ankle Surgery. 2016;55(5):922-926. doi:10.1053/j.jfas.2016.04.005.
Lisfranc Injuries: Fix or Fuse? The Argument for Primary Fusion Kelly Apostle, M.D., FRCSC Clinical Associate Professor, Department of Orthopaedic Surgery, University of British Columbia Royal Columbian and Eagle Ridge hospitals New Westminster, BC
tis (PTA) with this treatment ranging from 25-72% and symptomatic arthritis in up to 51%2,3. Midfoot pain, PTA, hardware failure, loss of reduction and foot deformity have all been identified as contributing factures for failure to return to pre-injury function and activity level (Figure 1)2,3,4,5,6. Figure 1 Six weeks (A) and four months (B) post-ORIF ligamentous Lisfranc injury with loss of reduction, hardware failure and post-traumatic arthritis.
anagement of acute injuries to the tarsometatarsal (TMT) joint complex (Lisfranc articulation) remains controversial. Primary fusion (PF) historically was considered a salvage procedure for missed injuries, delayed presentation, failed fixation and progression of post-traumatic TMT joint arthritis with or without midfoot deformity. More recently, PF has gained popularity as a viable alternative to open reduction internal fixation (ORIF) as a primary procedure with some evidence that outcomes may be superior to ORIF. Anatomy and Biomechanics The medial (medial navicular-medial cuneiform- 1st metatarsal) and middle (lateral navicular – middle and lateral cuneiform – 2nd and 3rd metatarsals) columns of the foot are biomechanically considered stability joints of the medial longitudinal arch and have very little inherent motion. Hypermobility at these locations can lead to collapse of the medial longitudinal arch and loss of biomechanical function of the foot throughout gait. Despite the necessary rigidity of the medial column, the anatomy of midfoot provides very little inherent stability. The ligamentous structures provide the majority of the support to the medial midfoot. The plantar interosseous ligaments are the strongest and although anatomy may vary, they comprise ligamentous attachments that extend plantarly from the medial, middle and lateral cuneiforms to the plantar bases of the 1st, 2nd, 3rd and 4th metatarsals1. The short thick obliquely-oriented fibres between the plantar medial cuneiform and bases of the second and third metatarsals are very strong and more specifically referred to as the Lisfranc ligament1. Treatment Challenges; the Argument for Primary Fusion Obtaining successful outcomes for patients with displaced midfoot injuries is challenging. Treatment with open anatomic reduction and fixation with transarticular screws for the medial and middle column and smooth k-wires for the lateral column has been the mainstay of operative management. Previous studies have found rates of radiographic post-traumatic arthriCOA Bulletin ACO - Summer / Été 2017
The role of transarticular fixation is to hold the reduction until solid scar tissue forms to reconstitute stability of the midfoot. It has been suggested that three months is required for sufficient stability to be obtained from soft tissue scarring. This is a significant amount of time to keep patients non-weight-bearing, although this period of immobilization has been associated with lower rates of hardware failure, loss of reduction and PTA for isolated ligamentous injuries4. Furthermore, the amount of scarring that is required to maintain stability of the midfoot decreases the range of motion of an articulation in which the initial range of motion is already negligible. PF offers the benefit of allowing for restoration of the functional anatomy of the midfoot with solid bony healing which does not take as long as soft tissue healing with stable scar tissue. The time spent non-weight-bearing is therefore shorter and functional rehabilitation can begin sooner. As long as union is achieved, PA eliminates the risk of PTA and has lower rates of hardware failure, loss of reduction and subsequent progression of deformity (Figure 2).
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Relevant Literature Retrospective studies of patients undergoing ORIF for ligamentous, bony and combined Lisfranc injuries have shown that PTA is evident radiographically in 25-72%, while clinically symptomatic arthritis is present in 12-51%2,3. Both studies found the best predictor of progression of arthritis was malreduction. Kuo et al. found that the incidence of PTA was higher in isolated ligamentous injuries then in bony injuries (40 vs. 18%) despite quality of reduction2. Abbasian et al. conducted a retrospective review of primary ligamentous Lisfranc injuries and found a lower 27% incidence of PTA with a more conservative protocol of three months in a non-weight-bearing cast followed by hardware removal. Patients then wore an arch support for four to six months4. It was suggested that PF may be of benefit in patients with primary ligamentous injuries given the higher incidence of PTA in this subgroup. Ly and Coetzee performed a prospective randomized clinical trial of 41 patients undergoing PF (n = 21) or ORIF (n = 20) at two-year follow-up5. In the ORIF group, they found a 75% radiographic incidence of loss of reduction, deformity and PTA and 35% of patients were symptomatic enough at two years to proceed with conversion to arthrodesis5. In the PF group, all reductions were maintained; there was one delayed union and one non-union. Patients undergoing PF were found to be more satisfied overall with improved AOFAS midfoot and lower VAS pain scores at all study time points5. Henning et al. found no significant difference between SF-36 and SMFA outcome scores in patients randomized to either PF or ORIF for both ligamentous and combined Lisfranc injuries6. This study did not specifically discuss the incidence of radiographic or clinically symptomatic PTA and enrollment was stopped prior to reaching a large enough sample size based on power analysis. They were also only able to enroll 22% of eligible patients which may affect study results6. Dorsal spanning plate fixation has also gained recent popularity over transarticular screws with the theoretical advantage of not violating the articular surface, therefore, possibly reducing rates of PTA. Although a biomechanical cadaveric study found that dorsal plating is equivocal to transarticular screws in maintaining reduction7, Lau et al. found no difference in rates of PTA in patients treated with transarticular screws (71%) compared with dorsal plates (76%)8. To date there is no current evidence comparing delayed conversion to fusion against PF, however Rammelt et al. performed a retrospective comparative cohort study of 20 patients who underwent ORIF and 20 patients who had residual deformity after non-operative management who underwent a secondary corrective arthrodesis at an average of 22 months post injury9. Patients who were managed acutely had improved AOFAS midfoot and Maryland foot scores at all follow-up intervals. The authors found that delayed fusion for midfoot deformities are more difficult to correct and achieve high patient satisfaction9. This reasoning may also apply to the correction of deformity and arthritis post failed ORIF. Complications specifically related to PF are largely related to non-union and have been reported to be between 0-16%5,6,10. Appropriate debridement of all articular cartilage and use of two lag screws for each joint being fused can minimize non-
union rates. Malunion and associated foot deformity can occur however Qiao et al. has shown the incidence of this to be lower than for ORIF (12.5% PF vs. 41.2% ORIF)11. In order to limit foot deformity related to midfoot malunion, it is imperative that the midfoot be anatomically reduced prior to fusion. Figure 2 Preoperative X-ray (A) and CT (B) of a patient with a ligamentous Lisfranc confirmed with intra-operative stress view (C) and treated with a primary fusion of the 1st and 2nd tarsometatarsal joint.
Conclusion Treatment for injuries to the medial midfoot remains controversial. Currently there are few high level studies to guide management. However, ORIF has been shown to be associated with high rates of PTA of the midfoot which leads to worse patient outcome scores and higher rates of secondary surgery. Ensuring an anatomic reduction of the midfoot has been shown to reduce rates of PTA, however even when an anatomic reduction is achieved, a significant percentage of patients will still develop PTA. PF has the advantage of eliminating the need for a secondary surgery as long as union is achieved with the index procedure. Current studies have found the non-union rates to be 0-16%5,6,10. Randomized control trials for isolated ligamentous injuries have also found self-reported outcomes for PF to be better than ORIF5,6. Secondary arthrodesis for delayed deformity and arthritis has also been shown to have worse outcomes than acute surgery which would favour early PF versus reserving this as a procedure for those who fail ORIF9. It is important to ensure an anatomic reduction of the midfoot with PF so as not to alter foot position and biomechanics. It COA Bulletin ACO - Summer / Ă&#x2030;tĂŠ 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 21)
should also be stressed that a percentage of patients with midfoot injuries do not return to their preinjury level of activity or work despite achieving an anatomic reduction and union. Patients presenting with these injuries should also be counselled accordingly10.
6. Henning J.A. et al., Open reduction internal fixation versus primary arthrodesis for Lisfranc injuries: A prospective randomized study. Foot Ankle Int. 2009;30(10):914-22
7. Alberta F.G. et al., Ligamentous Lisfranc joint injuries: A biomechanical comparison of dorsal plate and trasarticular screw fixation. Foot Ankle Int. 2005;26(6):462-73
1. Kelikian A.S. 2011. Anatomy of the foot and ankle 3rd ed. Philadelphia (PA): Lippincott Williams & Wilkins. Chapter 4, Syndesmology; p. 209-211
8. Lau S. et al., Plates, screws or combination? Radiologic outcomes after Lisfranc fracture dislocation. J Foot Ankle Surg. 2016;55:799-902
2. Kuo R.S. et al. Outcome after open reduction and internal fixation of Lisfranc joint injuries. J Bone Joint Surg (Am). 2000;82a (11):1609-18
9. Rammelt S. et al., Primary open reduction and fixation compared with delayed corrective arthrodesis in the treatment of tarsometatarsal (Lisfranc) fracture dislocation. J Bone Joint Surg (Br). 2008;90-B(11):1499-1506
3. Dubois-Ferriere V. et al. Clinical outcomes and development of symptomatic osteoarthritis 2 to 24 years after surgical treatment of tarsometatarsal joint complex injuries. J Bone Joint Surg (Am). 2016;98:713-20 4. Abbasian M.R. et al., Temporary internal fixation for ligamentous and osseous Lisfranc injuries: outcome and technical tip. Foot Ankle Int. 2015;36(8):976-83
10. MacMahon A. et al., Return to sports and physical activities after primary partial arthrodesis for Lisfranc injuries in young patients. Foot Ankle Int. 2016;37(4):355-362 11. Qiao Y et al., Comparison of arthrodesis and non-fusion to treat Lisfranc injuries. Ortho Surg. 2017;9:62-8
5. Ly T.V. and Coetzee J.C. Ligamentous Lisfranc joint injuries: Primary arthrodesis compared with open reduction and internal fixation; A prospective, randomized study. J Bone Joint Surg (Am). 2006;88-a(3): 514-20
Denosumab as a Treatment for Giant Cell Tumour of Bone Manuel de Elias, M.D. Hospital Universitario Austral, Derqui, Buenos Aires, Argentina Michelle Ghert, M.D., FRCSC McMaster University, Hamilton Health Sciences Hamilton, ON
enosumab (Amgen) is a human monoclonal antibody which represents an exciting new targeted therapy option for patients with giant cell tumour of bone (GCTB). Nevertheless, current indications for its use are still not clear. Ongoing multi-centre phase II trials are currently assessing the safety and efficacy of denosumab therapy for GCTB. The main goal of this review is to summarize the current knowledge about this novel drug and its indications and contraindications when considered for GCTB treatment. Giant Cell Tumor of Bone General Aspects GCTB is a typically benign, locally aggressive, and osteolytic primary bone tumour1,2 which usually affects young adults3. This COA Bulletin ACO - Summer / Été 2017
lesion represents one of the many locally aggressive benign neoplasms characterized by the presence of numerous multinucleated osteoclast-type giant cells. Nevertheless, what really defines this bone lesion is the presence of mesenchymal spindle-like stromal cells, which represent the neoplastic element of the tumour4. The osteoclast-like giant cells express RANK (receptor activator of nuclear factor-kB), while the mesenchymal spindle-like stromal cells express RANKL (RANK ligand), and the functional interaction between the stromal-cell-derived RANKL and the osteoclast receptor RANK results in a steady production of osteoclast-like cells in the tumour, leading to bone resorption4. Although it has been found that the stromal cells in culture produce osteocalcin precursors indicating osteoblastic lineage, they also produce active matrix-degrading proteases therefore playing a central role in bone destruction4. Epidemiology GCTB often develops in the weight-bearing areas of the knee, and tends to be more common in women than men1,5-7. Moreover, it accounts for 3% to 8% of all bone tumours, with recurrence rates of 15% and lung metastases development in as many as 5% of patients5,6,8-11. Most GCTBs present as solitary lesions, the majority located in the distal femur, proximal tibia or distal radius, and the patients usually present with pain and swelling at the affected site.
Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 22)
Treatment Even though classified as a benign tumour, GCTB has an unpredictable clinical course mostly due to its locally aggressive features and its epiphyseal location12,13,14. Two traditional forms of treatment are surgical in nature: 1) en bloc resection, and 2) intralesional curettage with or without adjuvants such as phenol or liquid nitrogen, both with advantages and disadvantages. En bloc resection achieves the best local control (close to 100%)15, but often results in functional disabilities due to the epiphyseal location and its proximity to the joints16. Intralesional curettage appears as a less aggressive type of surgery but with a higher rate of recurrence (13% - 49%)15,17-20. A meta-analysis showed Figures 1 and 2 that meticulous surgical technique includ- 24-year-old woman who presented with mild to moderate pain when ambulating. AP pelvis X-ray ing high-speed burring is the most impor- and coronal MRI showed a predominantly lytic lesion located in the right acetabulum, affecting the tant step in reducing recurrence rates in weight-bear surface. the intralesional treatment of GCTB, and Traub et al. reported a study in which 20 patients with resectthe claim that adjuvants such as phenol and/or polymethylmethable GCTB received denosumab 6-11 months preoperatively. acrylate (PMMA) or liquid nitrogen are necessary to reduce recurIn all cases, new bone formation was radiologically evident. Six 22 rence rates, is not supported in the literature . patients had complete healing of pathological fractures. Joint preservation was possible in 18 of the 20 patients. Nevertheless, Recently, a new systemic therapy for GCTB has been develthe recurrence rate was similar to that reported in other studies oped. The targeted therapy, denosumab (Amgen), has shown in which the drug was not used (15%)32. 23,24 anti-resorption effects in GCTB , and will be described below in detail. Denosumab Definition and Mechanism of Action Denosumab is a human monoclonal antibody with demonstrated anti-resorption effects23,24. It acts by binding to RANKL inhibiting the RANKL pathway7,23,27,28, and by doing so, it inhibits osteoclast activation and moderates bone resorption25. Drug History Initially denosumab was produced to treat osteoporosis, and in fact, a phase III randomized trial called FREEDOM (Fracture Reduction Evaluation of Denosumab in Osteoporosis Every Six Months) demonstrated a significant decrease in osteoporotic fractures among women treated with denosumab when compared with placebo23,29. Subsequently, a randomized controlled trial showed a reduction in the incidence of new vertebral fractures among men with non-metastatic prostate cancer undergoing androgen-deprivation treatment that had been treated with denosumab, when compared to placebo23,30. Evidence in the Treatment of GCTB A study performed in 37 patients, published by Thomas et al., showed a 90% or greater elimination of giant cells relative to baseline, and ten out of fifteen patients with GCTB treated with denosumab experienced radiologic response. Nevertheless 33 of 37 patients reported adverse events of diverse types: extremity pain, back pain and headache, and one patient had a serious possibly treatment-related event: a grade 3 increase in human chorionic gonadotropin concentration, not related to pregnancy31.
Figure 3 AP pelvis X-ray after intermittent treatment with denosumab for two years, with complete resolution of symptoms.
The largest study of denosumab in patients with GCTB included 222 patients with preoperative substantial functional compromise and morbidity. In this study, 48% of patients did not require surgery, and 38% underwent a less morbid procedure than originally planned. However, the local recurrence rate remained at 15%33. Indications, Contraindications and Side Effects Standard dosing of denosumab consists of 120mg subcutaneously every four weeks with additional doses on days eight and 15 during the first cycle.
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The main indication for denosumab in the treatment of GCTB is primary unresectable GCTB2,28,31,33. Some examples may include: • • • •
GCTB located in the spine or sacrum Metastatic pulmonary nodules GCTB of the pelvis GCTB of the patella
In some cases, the objective is to use the drug as a preoperative neoadjuvant to slow the progression of GCTB and create bone formation around the lesion, which leads to a safer resection. In others, where resection is not an option because of the location of the GCTB, the drug is used to control symptoms and expansion of the lesion.
5. Szendroi M. Giant-cell tumour of bone. J Bone Joint Surg Br. 2004;86:5–12. 6. Zheng M.H., Robbins P., Xu J, Huang L., Wood D.J., Papadimitriou J.M. The histogenesis of giant cell tumour of bone: a model of interaction between neoplastic cells and osteoclasts. Histol Histopathol.2001;16:297–307. 7. Brodowicz, T., Hemetsberger, M., & Windhager, R. (2015). Denosumab for the treatment of giant cell tumor of the bone. Future Oncology, 11(13), 1881-1894. doi:10.2217/fon.15.94. 8. Bertoni F., Present D., Enneking W.F. Giant-cell tumor of bone with pulmonary metastases. J Bone Joint Surg Am. 1985;67:890–900.
Pregnancy represents an absolute contraindication for the use of denosumab.
9. Bertoni F., Present D., Sudanese A., Baldini N., Bacchini P., Campanacci M. Giant-cell tumor of bone with pulmonary metastases: six case reports and a review of the literature. Clin Orthop Relat Res. 1988;237:275–285.
Long term serious side effects include osteonecrosis of the jaw and atypical femur fractures. The possibility of malignant transformation to sarcoma has also been reported25,26.
10. Cheng J.C., Johnston J.O. Giant cell tumor of bone: prognosis and treatment of pulmonary metastases. Clin Orthop Relat Res. 1997; 338:205–214.
Unresolved Issues There are still no consensus regarding the dosing of denosumab and despite numerous trials, the long-term effects are unknown. The effects of RANKL blockade in a young population are also unclear and the effects on the potential for childbearing in patients treated with denosumab is also still unknown. Finally, there is still insufficient data regarding dosing, efficacy and toxicity in the skeletal immature paediatric population.
11. Faisham W.I., Zulmi W., Saim A.H., Biswal B.M. Pulmonary metastases of giant cell tumour of the bone. Med J Malaysia. 2004;59(Suppl F):78–81.
Denosumab may be a therapeutic option in patients suffering from unresectable or metastatic GCTB. Nevertheless, it should not be considered as a first line treatment in other cases since there is still lack of evidence regarding its long-term effects and optimal length and dosing of treatment. The potential rates of rapid recurrence post-treatment or malignant transformation after treatment cessation are still unclear. Moreover, even though denosumab inhibits the RANKL pathway and by doing so moderates bone resorption, it certainly has not demonstrated effect on the neoplastic cells of the tumour (the mesenchymal spindle-like stromal cells). All of these issues should be carefully discussed with the patient when considering this drug as part of a treatment regimen.
12. Campanacci M., Baldini N., Boriani S, Sudanese A. Giant-cell tumor of bone. Journal of Bone and Joint Surgery. American, vol. 69, no. 1, pp. 106–114, 1987. 13. Balke M., Schremper L., Gebert C. et al. Giant cell tumor of bone: treatment and outcome of 214 cases. Journal of Cancer Research and Clinical Oncology, vol. 134, no. 9, pp. 969–978, 2008. 14. Rock M. Curettage of giant cell tumor of bone. Factors influencing local recurrences and metastasis. La Chirurgia Degli Organi di Movimento, vol. 75, no. 1, pp. 204–205, 1990. 15. Su Y.-P., Chen W.-M., Chen T.-H. Giant-cell tumors of bone: an analysis of 87 cases. International Orthopaedics, vol. 28, no. 4, pp. 239–243, 2004. 16. Gitelis S., Mallin B. A., Piasecki P., Turner F. Intralesional excision compared with en bloc resection for giant-cell tumors of bone. Journal of Bone and Joint Surgery. American, vol. 75,no. 11, pp. 1648–1655, 1993.
17. Turcotte R. E., Wunder J. S., Isler M.H et al. Giant cell tumor of long bone: a Canadian Sarcoma Group study. Clinical Orthopaedics and Related Research, no. 397, pp. 248–258, 2002.
1. Lopez-Pousa, A., Martin-Broto, J., Garrido, T., & Vazquez, J. (2015). Giant cell tumor of bone: new treatments in development. Clinical and Translational Oncology, 17(6), 419-430. doi: 10.1007/s12094-014-1268-5.
18. Blackley H. R., Wunder J. S., Davis A. M., White L. M., Kandel R., Bell R. S. Treatment of giant-cell tumors of long bones with curettage and bone- grafting. Journal of Bone and Joint Surgery. American, vol. 81, no. 6, pp. 811–820, 1999.
2. Ueda, T., Morioka, H., Nishida, Y., Kakunaga, S., Tsuchiya, H., Matsumoto, Y., Asami, Y. (2015). Objective tumor response to denosumab in patients with giant cell tumor of bone: a multicenter phase II trial. Annals of Oncology, 26(10), 2149-2154. doi: 10.1093/annonc/mdv307. 3. Turcotte R.E. Giant cell tumor of bone. Orthop Clin North Am. 2006 Jan;37(1):35-51. 4. Ghert M., Simunovic N., Cowan R.W., Colterjohn N., Singh G. Properties of the stromal cell in giant cell tumor of bone. Clin Orthop Relat Res. 2007 Jun;459: 8-13. COA Bulletin ACO - Summer / Été 2017
19. Ghert M. A., Rizzo M., Harrelson J. M., Scully S. P. Giant-cell tumor of the appendicular skeleton. Clinical Orthopaedics and Related Research, no. 400, pp. 201–210, 2002. 20. O’Donnell R. J., Springfield D. S., Motwani H. K., Ready J. E., Gebhardt M. C., Mankin H. J. Recurrence of giant-cell tumors of the long bones after curettage and packing with cement. Journal of Bone and Joint Surgery. American, vol. 76, no. 12, pp. 1827–1833, 1994.
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21. Pazionis T.J.C., Alradwan H., Deheshi B.M., Turcotte R.E., Farrokhyar F., Ghert M. A Systematic Review and MetaAnalysis of En-Bloc vs Intralesional Resection for Giant Cell Tumor of Bone of the Distal Radius. The Open Orthopaedics Journal, no.7, pp. 103-108, 2013.
28. Martin-Broto, J., Cleeland, C., Glare, A., Engellau, J., Skubitz, M., Blum, R., et al. (2014). Effects of denosumab on pain and analgesic use in giant cell tumor of bone: Interim results from a phase II study. Acta Oncologica, 53(9), 1173-1179. doi: 242 10.3109/0284186X.2014.910313.
22. Algawahmed H., Turcotte R.E., Farrokhyar F., and Ghert M. High-Speed Burring with and without the Use of Surgical Adjuvants in the Intralesional Management of Giant Cell Tumor of Bone: A Systematic Review and Meta-Analysis. Hindawi Publishing Corporation Sarcoma Volume 2010.
29. Cummings, S., San Martin, J., McClung , M., Siris, E., Eastell, R., Reid, I., et al. (2009). Denosumab for prevention of fractures in postmenopausal women with osteoporosis. New England Journal of Medicine, 361(8), 756–765. doi: 250 10.1056/ NEJMoa0809493.
23. Dufresne, A., Derbel, O., Cassier, P., Vaz, G., Decouvelaere, A., & Blay, J. (2012). Giant-cell tumor of bone, anti-RANKL therapy. BoneKEy Reports, 1,149. doi: 10.1038/bonekey.2012.149.
30. Smith, M., Egerdie, B., Hernandez Toriz, N., Feldman, R., Tammela, T., Saad F., et al. (2009). Denosumab in men receiving androgen-deprivation therapy for prostate cancer. New England Journal of Medicine, 361(8), 745-755. doi: 1056/ NEJMoa0809003.
24. Bekker, P., Holloway, D., Rasmussen, A., Murphy, R., Martin, S., Leese, P., et al. (2004). A single-dose placebo-controlled study of AMG 162, a fully human monoclonal antibody to RANKL, in postmenopausal women. Journal of Bone and Mineral Research, 19, 246 1059-1066. doi: 10.1359/ jbmr.2005.20.12.2274. 25. Aponte-Tinao, L., Piuzzi, N., Roitman, P., & Farfalli, G. (2015). A high-grade sarcoma arising in a patient with recurrent benign giant cell tumor of the proximal tibia while receiving treatment with denosumab. Clinical Orthopaedics and Related Research, 473(9), 3050-3055. doi: 10.1007/s11999-015-4249-2. 26. Broehm, C., Garbrecht, E., Wood, J., & Bocklage, T. (2015). Two cases of sarcoma arising in giant cell tumor of bone treated with denosumab. Case Reports in Medicine. doi: 10.1155/2015/767198. 27. Watanabe, N., Matsumoto, S., Shimoji, T., Ae, K., Tanizawa, T., Gokita, T., et al. (2014). Early evaluation of the therapeutic effect of denosumab on tartrate-resistant acid phosphatase 5b expression in a giant cell tumor of bone: a case report. BMC Research Notes, 7, 608. doi: 10.1093/annonc/mdv307.
Reminder: Survey on Post-surgical Discharge and Follow-up Pain Management Practices
iven the national epidemic of opioid abuse and overdoses, the COA Standards Committee is looking to provide members with a position statement on the use of narcotics in pain management in orthopaedics. We would like to hear from our members about their clinical practices. If you have not done so already, please take a moment to respond to this survey (no more than 3 minutes to complete). Survey: https://www.surveymonkey.com/r/PainManagementOpioids
31. Thomas, D., Henshaw, R., Skubitz, K., Chawla, S., Staddon, A., Blay, J.Y., Roudier, M., Smith, J., Ye, Z., Sohn, W., Dansey, R., Jun, S. (2010) Denosumab in patients with giant cell tumour of bone: an open-label, phase 2 study. Lancet Oncol. 11(3), 275-80. doi: 262 10.1016/S1470-2045(10)7001032. Traub, F., Singh, J., Dickson, B., Leung, S., Mohankumar, R., Blackstein, M. E., et al. (2016). Efficacy of denosumab in joint preservation for patients with giant cell tumour of 269 the bone. European Journal of Cancer, 59, 1–12. doi: 10.1016/j. ejca.2016.01.006. 33. Rutkowski, P., Ferrari, S., Grimer, R., Stalley, P., Dijkstra, S., Pienkowski, A., et al. (2015). Surgical downstaging in an open-label phase II trial of denosumab in patients with giant cell tumor of 272 bone. Annals of Surgical Oncology, 22(9), 2860-2868. doi:10.1245/s10434-015-4634-9.
Rappel : Sondage sur les pratiques de gestion de la douleur postopératoire après l’obtention du congé et au suivi
ans la foulée de la crise nationale de consommation d’opioïdes et de surdoses attribuées à ceux-ci, le Comité sur les normes de l’ACO souhaite rédiger un énoncé de position sur l’utilisation des narcotiques pour la gestion de la douleur en orthopédie. Nous souhaitons donc connaître les pratiques cliniques des membres. Si vous n’avez pas encore répondu à ce sondage, merci de prendre quelques minutes (3 minutes maximum) pour le faire. Sondage : https://www.surveymonkey. com/r/PainManagementOpioids COA Bulletin ACO - Summer / Été 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques
Navigating Orthopaedic Spine Surgery Kyle Stampe1, M.D. Daipayan Guha2,3, M.D. Victor X.D. Yang2,3,4, MD, PhD, P Eng, FRCSC Albert Yee1, M.D., MSc, FRCSC 1. Holland MSK Program, Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre and Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, ON 2. Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, ON 3. Biophotonics and Bioengineering Laboratory, Sunnybrook Health Sciences Centre, Toronto, ON 4. Department of Electrical and Computer Engineering, Ryerson University, Toronto, ON
urgical navigation falls under the broader umbrella of “computer-assisted surgery” (CAS), which is defined as a suite of devices, methodologies, and technologies for assisting surgical planning, intra-operative guidance, and actuation (i.e. robotics) in surgery. The current utilization of surgical navigation in orthopaedic surgery varies tremendously amongst our subspecialties for a variety of reasons1.
The concept of navigation for spine surgery requires matching of a computer-generated spine imaging reconstruction (i.e. XR/ CT/MRI) with bony anatomy intra-operatively. It requires the use of modern intra-operative camera technologies in order to track the movement of ‘tagged’ surgical instruments to the reference points attached to the patient. This is required in order The practice of orthopaedic surgery continues to evolve. We to align the patient with imaging are faced with an explosion of information stemming from and to validate related patient published cutting-edge research (bench and clinical). Likewise, radiographic images. An interacan increasingly informed public has rapid access to information tive computer display monitor about novel therapies and surgical techniques. Oftentimes the then visualizes the tracked surgibest way to integrate evidence-based practice and innovative cal tools relative to the patienttreatments is unknown or challenging. To add some perspective specific imaging. Where indion how to approach emerging and/or controversial topics, we vidual commercially available systems differ is in how the spine have developed this Horizons feature in the COA Bulletin. imaging is acquired (e.g. imagIn the Horizons articles, thought leaders from various ing time, resolution) and how subspecialties will provide insights based on their extensive the patient-to-image registraclinical experience and ongoing research. The goal of this feature tion is performed/validated (i.e. ease of the surgical workflow). is to “shed some light” on the best way forward.
Spine surgery is one area where navigation and robotics have Femi Ayeni, M.D., FRCSC complemented well with cliniScientific Editor, COA Bulletin cal needs, becoming more commonplace. This is largely motivated by the need for accuracy and precision when placing implants in and around critical neurologic structures. The ‘safe’ placement of pedicle screws in the spine is a current ‘standard of care’, whether this placement is guided by non-navigated or navigated surgical techniques. Pedicle screw/rod constructs are helpful in the spine to restore vertebral mechanical stability. Biomechanically sound orthopaedic constructs may be necessary for longer-term osseous fusion and procedural success. Several stereotactic navigation techniques are now available, which facilitate the insertion of pedicle screws with real-time 3D image guidance in order to improve accuracy as may be beneficial to both short- and longer-term patient outcomes. The most common use of surgical navigation in the spine is to guide pedicle screw placement. Pedicle screws are most commonly inserted in the thoracic and lumbar spine, although there is some experience on its select application in the cervical spine. Options available to Canadian spinal surgeons currently include a ‘free-hand’ pedicle screw insertion technique, 2D fluoroscopy guided insertion, or CAS-navigated. A free-hand pedicle screw insertion technique is performed using open/ surgically exposed bony landmarks. Surgical experience of anatomy is necessary to identify the correct starting location COA Bulletin ACO - Summer / Été 2017
and trajectory for the pedicle screw. The success of this technique depends largely on surgical experience and comes with a steep learning curve, with the reported accuracy between 75–98%3. The lowest accuracy rates for free-hand techniques have been associated with the mid thoracic area and in patients with spinal deformities. For lower thoracic and lumbar pedicles and in patients with no pre-existing deformity, the accuracy rating of free-hand placed screws is 92%4.
Presently, the two most common spine surgical navigation techniques (Figure 1) are to either:
Figure 1 Comparison of current surgical navigation techniques registering to preop CT (left), intra-op 3D fluoroscopy (middle) and intra-op cone beam CT (right). Pros and cons (italics) of each technique are highlighted.
Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 26)
1) Register to a preoperative supine CT scan, or 2) Register to an intra-operative 3D fluoroscopic or CT imaging system (e.g. Iso-C or Orbic 3D, Medtronic® O-arm, Ziehm Vario3D).
screw insertion as well as the ability to check screw placement with an intra-operative scan prior to closure. However, these imaging techniques require increased radiation exposure to the patient to generate CT-like images.
Registering to a Preoperative CT Scan The surgeon typically matches several points of bony anatomy off the CT to the actual bony spine intra-operatively, or alternatively perform ‘surface-matching’ of surgically exposed bony anatomy to the 3D-reconstructed surface on the preop CT. Because matching to the bony vertebral spine is required, this technique is largely confined to open surgery where the posterior spine elements are exposed. Several initial set points of the posterior elements (e.g. the superior tip of a spinous process) are selected for initial setpoint matching, followed by surface-matching of multiple points on the bony lamina and posterior elements in the region of interest are required to refine accuracy to acceptable error margins. Validating the intra-operative registration to the preoperative CT is necessary for subsequent navigation of surgical tools.
Intra-operative imaging may be acquired in the form of 3D fluoroscopy systems (e.g. Iso-C, Orbic 3D, Ziehm Vario3D), which have the form factor of a standard C-arm but are able to perform 190° isocentric rotations with subsequent computerized 3D reconstruction. Imaging may also be acquired by cone-beam CT systems (e.g. O-Arm, BodyTom, Airo), which are circumferential around the operating table and obtain a full 360° acquisition with, therefore, higher resolution than 3D fluoro systems but at significantly greater radiation exposure to the patient.
Approval of a new navigation system for spine surgery by the Food and Drug Administration as well as Health Canada resulted in the 7D navigation system. This unit utilizes optical topographic imaging for patient-to-image registration. The unit consists of a surgical light head, into which are integrated grayscale machinevision stereo cameras, a digital pico-projector and infra-red cameras for tracking of tools with passive-reflective spheres. Following exposure of the posterior elements, a digital reference frame is clamped to the spinous process of the vertebrae to be instrumented. The machine-vision cameras are then aligned along the axis of the spine using a laser guidance system. The pico-projector illuminates the exposed anatomy with a structured light pattern, the reflected deformation of which is recorded by the machinevision cameras and used to generate a 3D surface reconstruction of the exposed anatomy. This is subsequently aligned to the preoperative CT using a registration algorithm. The system does not require the point matching workflow unlike other preop CT registration systems, and the entire registration and verification process typically takes less than 30 seconds.
In both preoperative and intra-operative-based navigation techniques, working further from the reference marker results in a less accurate system. In addition, any movement of the reference marker will decrease the accuracy. Re-registering and/ or re-imaging intra-operatively is an added step that may be necessary when instrumenting multiple spinal levels. The benefit of utilizing navigation technology in pedicle screw insertion is increased accuracy, particularly in cases with narrow pedicles, complex deformity corrections, and minimallyinvasive cases where anatomic landmarks are distorted or not readily visible. Reported ranges of screw accuracy varies from 91–98%3. The mid thoracic spine is the area that sees the largest improvement in accuracy compared to free-hand screw insertion techniques. Different surgical tools can be navigated including pedicle probes, drill-bits and taps. Surgical curettes are an example of other tools that can be navigated for other portions of the spinal procedure as in decompression surgery. In summary, continued improvements in technology are helping to improve the application of surgical navigation in the spine. This technique in the surgical “tool box” can be helpful in the care of appropriate patient populations. References 1. Schep N.W., Broeders I.A., van der Werken C. Computer assisted orthopaedic and trauma surgery. State of the art and future perspectives. Injury 2003;34(4):299-306. 2. Jakubovic R., Guha D., Lu M., et al. A. 709: Design and development of a novel, fast, extensive intraoperative registration technique of optical machine vision to pre-operative imaging for cranial and spinal neurosurgical procedures: clinical feasibility and comparison with existing neuronavigation. J Neurosurg. 2016;124(4):A1146-209. doi:10.3171/2016.4.JNS. AANS2016abstracts.
Figure 2 7D Surgical Navigation System with representative intra-operative images.
3. Puvanesarajah V., Liauw J.A., Lo S., Lina I.A., Witham T.F. Techniques and accuracy of thoracolumbar pedicle screw placement. World Journal of Orthopedics. 2014;5(2):112123. doi:10.5312/wjo.v5.i2.112.
Registering to Intra-operative Radiologic Imaging This technique adjusts for any positional changes to the spine that may occur in the patient during surgical positioning and eliminates having to match points for registration. Other advantages include the capability for percutaneous pedicle
4. Gautschi O.P., Schatlo B., Schaller K., Tessitore E. Clinically relevant complications related to pedicle screw placement in thoracolumbar surgery and their management: a literature review of 35,630 pedicle screws. Neurosurgery Focus. 2011;31:E8 COA Bulletin ACO - Summer / Été 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 27)
5. Vaccaro A.R., Rizzolo S.J., Balderston R.A., Allardyce T.J., Garfin S.R., Dolinskas C., An H.S. Placement of pedicle screws in the thoracic spine. Part II: An anatomical and radiographic assessment. J Bone Joint Surg Am. 1995;77:1200–1206
6. Modi H.N., Suh S.W., Hong J.Y, Yang J.H. Accuracy of thoracic pedicle screw using ideal pedicle entry point in severe scoliosis. Clin Orthop Relat Res. 2010;468:1830–1837
7. Modi H.N., Suh S.W., Hong J.Y., Yang J.H. Accuracy of thoracic pedicle screw using ideal pedicle entry point in severe scoliosis. Clin Orthop Relat Res. 2010;468:1830–1837
8. Vaccaro AR et al. An evaluation of image-guided technologies in the placement of anterior thoracic vertebral body screws in spinal trauma: a cadaver study. J Spinal Cord Med 2005; 28(4):308-13.
Tranexamic Acid use in Hip and Knee Arthroplasty In a meta-analysis comparing IV to topical TXA in patients undergoing primary TKAs and THAs, Xie et al. reported no significant difference in transfusion requirements, but a smaller maximal drop in hemoglobin in the IV group compared to the topical group5. In a randomized controlled trial involving TKAs without the use of tourniquets and drains, Nielsen et al. reported a 37% decrease in blood loss at 24 and 48 hours, when comparing patients receiving IV TXA prior to incision combined with intraranexamic acid (TXA) is a articular TXA upon capsular closynthetic amino acid that sure, to those who only received decreases blood loss by the pre-incision IV TXA dose6. decreasing clot degradation. TXA In a meta-analysis of 15 studies In this edition, we introduce the first of a series of articles led involving 1495 patients underdecreases fibrinolysis by reversiby experts and thought leaders who advise on how to manage going TKAs, Lin et al. reported bly binding to plasminogen, thus clinical controversies or address emerging treatment trends lower total blood loss in patients making the binding site unavailwhile applying evidence-based principles. With these vignettes, receiving combined IV and topiable for fibrin attachment1,2. we aim to help provide the best evidence-based strategies to cal TXA compared to those who Maximal plasma levels of TXA are enable clinicians to incorporate new treatment and diagnostic received no TXA, only IV TXA, or noted in 5-15 minutes after IV, 30 minutes after intra-muscular, strategies into current practice. Although no patient or condition only topical TXA4. The benefit of and two hours after oral adminisfits into the proverbial “box,” we often need to solve problems in combined dosing is likely due to tration3. In most studies pertain“real time” and these comprehensive opinions will, hopefully, the provision of a second dose, ing to intravenous TXA use in and not necessarily due to the provide some useful and applicable insights. hip (THA) and knee arthroplasty route of administration of TXA, (TKA), a weight-based dose of as a similar effect (lower total Dr. Femi Ayeni, Scientific Editor, COA Bulletin 10-20mg/kg, or a standardized blood loss – 528mL vs. 776mL) dose of 1g or 2g has been used. was reported by Tanaka et al., When administered topically, higher doses of TXA, up to 3g, when a second dose of IV TXA was administered prior to tournihave been reported. Oral TXA is usually administered as 2g. quet deflation3. In a study comparing patients receiving either IV or oral TXA in primary TKA and THAs, Irwin et al. reported a There is significant heterogeneity, in terms of study methodolstatistically significant decrease in transfusions in the oral TXA ogy, dosing, timing, and route of administration, in the pubgroup (4.6% vs 7.9%) when compared to the IV group, with a lished data on TXA use in hip and knee arthroplasty. However, similar safety profile7. from the various meta-analyses, it is evident that intra-operaWith the exception of a true allergy to TXA, active thromboemtive, postoperative, total blood loss (peri-operative blood loss), bolic disease, or seizure disorder, there are currently no other and need for allogeneic blood transfusions are all decreased clear contraindications to TXA use in TKAs and THAs. Impaired in patients who received TXA, irrespective of the dose, timing, colour vision can be worsened with TXA, and is thus considered and route of administration, compared to those who did not a relative contraindication1. Because TXA is renally cleared, receive TXA2,4. doses must be adjusted for patients with impaired renal funcTaranjit S Tung, M.D., FRCSC1 Eric R. Bohm, BEng, M.D., MSc, FRCSC1,2 1 Section of Orthopaedics, 2 George and Fay Yee Centre for Health-care Innovation, University of Manitoba Winnipeg, MB
COA Bulletin ACO - Summer / Été 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 28)
tion. Although most studies show no increase in symptomatic deep vein thrombosis (DVT) and pulmonary emboli (PE) following TXA use when compared to healthy controls, it must be noted that high-risk patients have routinely been excluded from these studies. However, in a retrospective review of highrisk patients with ASA III or IV, Whiting et al. reported no statistically significant increase in 30-day symptomatic DVT or PE (6.7% vs. 4.3% without TXA; p=0.27). Patients were considered high risk if they had more than one risk factor for clotting (prior DVT, PE, myocardial infarction, cerebrovascular accident, coronary artery stent placement, coronary artery bypass graft, or prothrombotic conditions such as Factor V Leiden deficiency, protein C deficiency and antiphospholipid syndrome)8. Multiple studies have shown significant cost savings associated with use of TXA in TJA patients. These costs are primarily from decreased need of allogeneic blood transfusions, and shorter hospital stays5. In their study, Gilbody et al. reported an increase in pharmacy costs by a mean of US$140 per patient administered IV TXA, but this was offset by a reduction in transfusion rates from 21.6% to 8.9%, resulting in roughly $879 in hospital cost savings9. Use of standardized dosing as opposed to weight-based in the majority of patients could potentially decrease the need for pharmacy preparation costs even further. Oral TXA is cheaper than IV or topical TXA, and has a similar safety profile7. Implementation of standardized protocols in arthroplasty centres appears to have significantly increased the utilization of TXA. Demos et al. reported an increase in TXA administration by anaesthesia for their TJA patients from 3.57% to 86.01%10. Similarly, Baker et al. reported an increase in TXA administration from 45.8% to 95.3% in their patients11.
In Summary: • Routine use of TXA should be considered in most patients undergoing total hip and knee arthroplasty. • Typical dose of 1-2g per dose of TXA suffice for most patients irrespective of route of administration. • For maximal benefit, oral TXA is best given about two hours prior to incision, while IV TXA is given about 15 minutes prior to incision. • Use of a second dose of TXA at time of closure appears to be beneficial in patients receiving IV TXA, especially in TKA patients. • Most high-risk patients without active thromboembolic events, seizure disorders or a known TXA allergy, are candidates for TXA use. Topical TXA is a good option for this latter group of patients. • Consideration should be given to introducing standardized protocols for increasing TXA utilization. • Consideration should be given to oral TXA as it offers a less expensive alternative to IV and topical TXA.
References 1. Melvin J.S., Stryker L.S., Sierra R.J. Tranexamic Acid in Hip and Knee Arthroplasty. The Journal of the American Academy of Orthopaedic Surgeons. 2015 Dec;23(12):732-40. PubMed PMID: 26493971. 2. Moskal J.T., Capps S.G. Meta-analysis of Intravenous Tranexamic Acid in Primary Total Hip Arthroplasty. Orthopedics. 2016 Sep 01;39(5):e883-92. PubMed PMID: 27248332. 3. Tanaka N., Sakahashi H., Sato E., Hirose K., Ishima T., Ishii S. Timing of the administration of tranexamic acid for maximum reduction in blood loss in arthroplasty of the knee. The Journal of Bone and Joint Surgery British Volume. 2001 Jul;83(5):702-5. PubMed PMID: 11476309. 4. Lin Z.X., Woolf S.K. Safety, Efficacy, and Cost-effectiveness of Tranexamic Acid in Orthopedic Surgery. Orthopedics. 2016 Mar-Apr;39(2):119-30. PubMed PMID: 26942474. 5. Xie J., Hu Q., Huang Q., Ma J., Lei Y., Pei F. Comparison of intravenous versus topical tranexamic acid in primary total hip and knee arthroplasty: An updated meta-analysis. Thrombosis research. 2017 May;153:28-36. PubMed PMID: 28319822. 6. Nielsen C.S., Jans O., Orsnes T., Foss N.B., Troelsen A., Husted H. Combined Intra-Articular and Intravenous Tranexamic Acid Reduces Blood Loss in Total Knee Arthroplasty: A Randomized, Double-Blind, Placebo-Controlled Trial. The Journal of bone and joint surgery American volume. 2016 May 18;98(10):83541. PubMed PMID: 27194493. 7. Irwin A., Khan S.K., Jameson S.S., Tate R.C., Copeland C., Reed M.R. Oral versus intravenous tranexamic acid in enhanced-recovery primary total hip and knee replacement: results of 3000 procedures. The Bone & Joint Journal. 2013 Nov;95-B(11):1556-61. PubMed PMID: 24151279. 8. Whiting D.R., Gillette B.P., Duncan C., Smith H., Pagnano M.W., Sierra R.J. Preliminary results suggest tranexamic acid is safe and effective in arthroplasty patients with severe comorbidities. Clinical Orthopaedics and Related Research. 2014 Jan;472(1):66-72. PubMed PMID: 23817754. Pubmed Central PMCID: 3889421. 9. Gilbody J, Dhotar HS, Perruccio AV, Davey JR. Topical tranexamic acid reduces transfusion rates in total hip and knee arthroplasty. The Journal of arthroplasty. 2014 Apr;29(4):681-4. PubMed PMID: 24095586. 10. Demos H.A., Lin Z.X., Barfield W.R., Wilson S.H., Robertson D.C., Pellegrini V.D., Jr. Process Improvement Project Using Tranexamic Acid Is Cost-Effective in Reducing Blood Loss and Transfusions After Total Hip and Total Knee Arthroplasty. The Journal of Arthroplasty. 2017 Mar 02. PubMed PMID: 28343823. 11. Baker J.E., Pavenski K., Pirani R.A., White A., Kataoka M., Waddell J.P., et al. Universal tranexamic acid therapy to minimize transfusion for major joint arthroplasty: a retrospective analysis of protocol implementation. Canadian Journal of Anaesthesia = Journal Canadien d’anesthesie. 2015 Nov;62(11):1179-87. PubMed PMID: 26335903.
COA Bulletin ACO - Summer / Été 2017
Clinical Features, Debates & Research / Débats, recherche et articles cliniques
CIHI’s Patient-Reported Outcome Measures (PROMs) Program and Survey to CAS Members Patient-Reported Outcome Measures (PROMs) Team, Canadian Institute for Health Information (CIHI)
here is increasing interest both in Canada and internationally in using patient-reported outcome measures (PROMs) — measurement instruments that are completed by patients to obtain information on their health — to support value-based health-care delivery. In response to stakeholder desire for Canadian Institute for Health Information (CIHI) to provide leadership and guide a panCanadian approach to PROMs, CIHI is developing data collection and reporting standards for use across the country. Hip and knee arthroplasty and chronic renal care were selected as initial areas of focus for PROM as they are high-volume, high-cost procedures which have a significant impact on patient quality of life.
COA Bulletin ACO - Summer / Été 2017
To better understand the PROMs landscape in Canada, CIHI and the Canadian Arthroplasty Society (CAS) Research Committee asked CAS members to complete a brief survey on current practices related to the collection and use of PROMs for hip and knee arthroplasty. Results from the survey will be shared in the Fall edition of the COA Bulletin. CIHI would like to thank survey participants for their time and the opportunity to learn from the orthopaedic community. If you have any questions about this survey, please contact CIHI’s PROMs team at firstname.lastname@example.org. Additional information on CIHI’s PROMs program is available at www.cihi.ca/proms
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Advocacy & Health Policy / Défense des intérêts et politiques en santé
Mythology Doug Thomson CEO, Canadian Orthopaedic Association
r. Chris Simpson (Past President of the Canadian Medical Association (CMA), currently practising cardiology in Kingston, ON) recently wrote an insightful blogpost where he paraphrased Dr. Jack Kitts, the CEO of the Ottawa Hospital: “One of the biggest challenges is persuading Canadians that our health-care system is not the best in the world.” The CMA has a considerable history in attempting to generate public interest and a sense of urgency to move our political leaders forward and institute much needed change in health care in this country. The late great comedian, George Carlin, observed that “the status quo sucks.” And it really is the status quo that is our enemy here. Unfortunately, too many Canadians feel that to reject the status quo in our health-care system is to embrace the dreaded “American-style” system. A 2015 Ipsos poll of Canadians, as reported in a recent report issued by the Canadian Institute for Health Information (CIHI), demonstrated the challenge – 3 out of 4 Canadians believe we have the best health-care system in the world. This warm embrace of a system that has become a source of national pride may not stand the test of comparative data from other countries. In a nutshell, here is what CIHI found: • Canada spends considerably more on health care per person ($5,543) than the Organization for Economic Co-operation and Development (OECD) average ($4,463). • Provincial governments pay 70% of health costs in Canada. In most OECD countries, the government pays a higher percentage of health costs. Only the USA and Australia had a lower percentage of costs paid by the government. • Canada has one of the lowest percentages of public coverage for drug costs. • Potential years of life lost (PYLL) is considered a major population-level outcome indicator that estimates the additional years a person would have lived had he or she not died prematurely (before age 70, as defined by OECD). Canada is a mid-pack performer overall compared to OECD averages and performs behind the international median for deaths from ischemic heart disease, cancer and external causes (e.g., traffic crashes, falls). • Canada is again a mid-pack performer on five dimensions of care: health status, non-medical determinants of health, quality of care, patient safety and access to care. Canada does well, comparatively, in the areas of stroke mortality, perceived health status and avoidable admissions. We do less well than average in the areas of obesity, patient safety and access to care. • Canada has one of the highest prevalence rates of diabetes among peer OECD countries • Canada has the highest wait times, in adults over 55 years, for primary and specialist care (to the surprise of no one).
As Dr. Simpson says, “not only are we not serving …seniors well, we are creating intolerable hospital congestion that creates incredible economic inefficiencies, poor quality care, long waits, and siloed patient experiences.” Yet 75% of Canadians see little need for change. Is it any wonder then that our federal government was able to present a take-it-or-leave-it health-care funding offer to the provinces and everyone simply rolls over and says “OK”? Several years ago, the provinces were able to extract a generous health transfer from Prime Minister Paul Martin that finally expired and was replaced by Steven Harper’s 2014 offer to extend the six per cent annual increases, gradually narrowing to a formula based on economic growth, but guaranteed not to drop below three per cent. To this offer, the provinces huffed and puffed to Finance Minister Jim Flaherty about the cruel reduction that would leave Canadians suffering.
Canada spends considerably more on health care per person ($5,543) than the Organization for Economic Co-operation and Development (OECD) average ($4,463).
Cut to March of this year where Liberal Health Minister Jane Philpott proclaimed “Today is a fantastic day for us,” after Ontario, Quebec and Alberta all accepted the same terms that Harper offered three years ago. Ontario, who had made the argument in 2014 that the Harper formula would shave off $36 billion from health-care support, was now suggesting that the Liberal repackaging was just what they needed. Even Quebec, which raged against the Harper formula, now says the deal is a “welcome reflection of Quebec’s special place in Confederation.” So here we are. A health-care system that is begging for system-wide solutions to its challenges, a population that subscribes to mythology as it pertains to Canadian health care and the related absence of political will to tackle the difficult discussions that are desperately needed. Oh, and the recently released 2016 Census results reported, as expected, that there are now more seniors than children for the first time in this country. As many of our American friends were asking the morning of last November 9, what do we do now? Perhaps the best thing is to take a page from the Toronto Blue Jays handbook. After a disastrous start to the season, Blue Jays skipper John Gibbons says the team will keep on hitting for base and try to manufacture runs the hard way. Sounds like a plan to me. COA Bulletin ACO - Summer / Été 2017
Advocacy & Health Policy / Défense des intérêts et politiques en santé
Mythes et croyances Doug Thomson Directeur général, Association Canadienne d’Orthopédie
e Dr Chris Simpson, ancien président de l’Association médicale canadienne (AMC) et cardiologue à Kingston, en Ontario, publiait récemment une entrée très perspicace sur son blogue, où il paraphrase le Dr Jack Kitts, président-directeur général de l’Hôpital d’Ottawa : « Un de nos grands défis est de convaincre les Canadiens que notre système de santé n’est pas le meilleur au monde. »
• Le Canada affiche l’un des taux de prévalence du diabète les plus élevés parmi les pays de l’OCDE. • Le Canada affiche les temps d’attente les plus longs pour des soins primaires et spécialisés chez les adultes de plus de 55 ans, ce qui ne surprendra personne. Comme l’affirme le Dr Simpson, en plus de ne pas bien servir les personnes âgées, nous créons un engorgement intolérable en milieu hospitalier qui se traduit par des inefficiences ahurissantes, une piètre qualité des soins, de longs temps d’attente et une compartimentation des soins.
Comme en témoigne un pan non négligeable de son histoire, l’AMC essaie de susciter l’intérêt de la population et un certain sentiment d’urgence pour amener nos dirigeants à agir afin de répondre aux besoins criants de changement dans les soins de santé au pays. Comme le disait le grand humoriste George Carlin : « Le statu quo, c’est nul! » Et c’est vraiment notre ennemi aujourd’hui. Malheureusement, trop de Canadiens croient que rejeter le statu quo en santé revient à adopter le terrifiant système « à l’américaine ». Comme on peut le lire dans un rapport diffusé récemment par l’Institut canadien d’information sur la santé (ICIS), un sondage Ipsos mené en 2015 auprès des Canadiens illustre bien ce défi : trois personnes sur quatre croient que nous avons le meilleur système de santé au monde. Cette sanction enthousiaste d’un système devenu une fierté nationale pourrait toutefois être ébranlée si on le comparait à celui d’autres pays.
Pourtant, 75 % des Canadiens sont plutôt satisfaits de l’état des choses. Il n’est donc pas surprenant que le gouvernement fédéral ait pu faire une offre péremptoire aux provinces pour le financement de la santé, à laquelle tout le monde s’est soumis sans broncher.
En somme, l’ICIS a constaté ce qui suit : • Le Canada dépense 5 543 $ par habitant pour des soins de santé, un montant bien au-dessus de la moyenne de 4 463 $ de l’Organisation de coopération et de développement économiques (OCDE). • Les gouvernements provinciaux assument 70 % des dépenses en santé au Canada. Dans la plupart des pays de l’OCDE, le gouvernement paye une plus grande partie des coûts des soins de santé. Seuls les gouvernements des États-Unis et de l’Australie assumaient un plus faible pourcentage des coûts. • Au Canada, la part des dépenses en produits pharmaceutiques financée par le secteur public est parmi les plus faibles. • Les années potentielles de vie perdues (APVP) sont considérées comme un important indicateur des résultats pour la santé de la population. Elles permettent d’estimer le nombre d’années additionnelles qu’une personne aurait vécues si elle n’était pas décédée prématurément (soit avant l’âge de 70 ans, selon la définition de l’OCDE). Le Canada a maintenu une performance générale dans la moyenne, mais il s’est classé sous la médiane internationale au chapitre des décès dus à une cardiopathie ischémique, à un cancer et à une cause externe (p. ex. accidents de la route, chutes). • La performance du Canada dans cinq dimensions des soins – état de santé, déterminants non médicaux de la santé, qualité des soins, sécurité des patients et accès aux soins – se situe là encore dans la moyenne. Le Canada fait bonne figure en comparaison des autres pays du point de vue de la mortalité due à un AVC, de l’état de santé perçu et des admissions évitables. Il se situe sous la moyenne en ce qui concerne l’obésité, la sécurité des patients et l’accès aux soins.
Malgré cela, en mars dernier, dans la foulée de l’accord avec l’Ontario, le Québec et l’Alberta sur le maintien des conditions établies par le gouvernement Harper trois ans plus tôt, la ministre libérale de la Santé Jane Philpott claironnait qu’il s’agissait d’une journée fantastique. L’Ontario, qui arguait en 2014 que la formule du gouvernement Harper réduirait de 36 milliards de dollars le soutien aux soins de santé, laisse désormais entendre que la proposition libérale, qui n’est essentiellement que la reformulation de l’offre conservatrice, est exactement ce dont elle a besoin. Même le Québec, vivement opposé à cette formule, affirme maintenant que l’accord reflète la place spéciale que la province occupe dans la Confédération.
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Il y a plusieurs années, les gouvernements provinciaux avaient obtenu de généreux transferts en santé du premier ministre Paul Martin, mais cet accord est échu et a été remplacé par l’offre de Stephen Harper en 2014, soit le maintien de la hausse annuelle de 6 %, graduellement remplacée par un calcul fondé sur la croissance économique avec un minimum garanti de 3 %. En réaction à cette proposition, les gouvernements provinciaux ont tonné au ministre des Finances Jim Flaherty qu’il s’agissait là d’une coupe cruelle qui ferait souffrir les Canadiens.
Voilà où nous en sommes : un système de santé qui a désespérément besoin de solutions en profondeur pour remédier à ses difficultés, une population qui adhère aux mythes et croyances sur le système de santé canadien, et l’absence de volonté politique qui en résulte face aux discussions épineuses qui sont manifestement nécessaires. Ah, j’oubliais! Les résultats du Recensement de 2016, publiés cette semaine, indiquent que, comme on s’y attendait, il y a maintenant plus de personnes âgées que d’enfants au pays pour la première fois de son histoire. Pour reprendre ce qu’ont dit nombre de nos voisins américains le matin du 9 novembre dernier : et maintenant, qu’est-ce qu’on fait? La meilleure chose serait peut-être de nous inspirer des Blue Jays de Toronto : après un début de saison désastreux, le gérant des Blue Jays, John Gibbons, a déclaré que l’équipe allait continuer de frapper des coups sûrs et d’essayer de provoquer des courses. Ça me paraît une bonne idée.
Community Innovation Award – Request for Proposals The Canadian Orthopaedic Foundation is pleased to announce that proposals are now being accepted for a new awards program. The Community Innovation Awards program will celebrate community-based surgeons and research studies dedicated to improving patient care or musculoskeletal health in their community. There are two awards of $15,000 each available for research projects led by orthopaedic surgeons who do not hold academic appointments. Are you a community orthopaedic surgeon with a research idea that will enhance MSK health? Apply today. Details and application information are available at www.whenithurtstomove.org.
Prix d’innovation communautaire – Appel de candidatures La Fondation Canadienne d’Orthopédie est heureuse d’annoncer qu’il est maintenant possible de soumettre sa candidature à un nouveau prix. Le Prix d’innovation communautaire récompensera les orthopédistes en milieu communautaire et les projets de recherche visant à améliorer les soins ou la santé de l’appareil locomoteur dans leur collectivité. En tout, 2 prix de 15 000 $ seront remis pour des travaux de recherche dirigés par des orthopédistes qui n’occupent pas un poste universitaire. Vous êtes un orthopédiste en milieu communautaire qui a une idée de recherche qui contribuerait à la santé de l’appareil locomoteur? Posez votre candidature dès aujourd’hui. Pour les détails sur la soumission de votre candidature, consultez http://whenithurtstomove.org/fr/.
Foundation / Fondation
Sunnybrook Orthopaedic Associates Challenge Surgeon Groups to Support the COF
ncouraged by the progress of the Canadian Orthopaedic Foundation in its efforts to meet its mandate to advance orthopaedic research, education and care, a group of surgeons has pledged its support to the COF, with a commitment of $10,000 per year for the next five years. Dr. Albert J.M. Yee, Holland MSK Program Chief, and Marvin Tile Chair, Division of Orthopaedic Surgery in the Department of Surgery at Sunnybrook Health Sciences Centre, says, “Numerous Canadian orthopaedic surgeons over the years, myself included, have benefited from academic research and education funding support from the Canadian Orthopaedic Foundation. The COF remains integral to current Canadian Orthopaedic Association (COA) activities. Both organizations remain keen in supporting ‘cutting-edge’ Canadian innovation in orthopaedic patient care, research, and related education.” The COF announced earlier this year that it has expanded its research program significantly, thanks in large part to a transformational donation from Zimmer Biomet, a large gift from DePuy Synthes Canada, and a generous bequest from an orthopaedic patient. The surgeons at Sunnybrook wanted to add their support, pledged their five year donation. Now, they have issued a friendly challenge to their colleague orthopaedic surgeons Dr. Albert J.M. Yee, Holland in both academic health sciences cen- MSK Program Chief
tres (AHSCs) and in the community across Canada to match their support. “Just think of what we can help the COF to achieve in terms of expanding the research agenda, and supporting the educational and care needs of our patients, if surgeons across the country rise to Marvin Tile Chair, Division our challenge,” says Dr. Hans Kreder, of Orthopaedic Surgery a team member of the Sunnybrook Orthopaedic Associates and Director of the COF. “We have seen how the transformational support of industry partners has enabled tremendous growth in the research program alone in this past year. Now, we surgeons need to step up and show our support, too.” Dr. Kreder says, “So far Sunnybrook, Toronto gets all the bragging rights. Who is going to take up the Sunnybrook Challenge? If you can raise the Sunnybrook pledge by at least $5,000, you will take the spotlight and the challenge will be named after your centre. Let’s do this! Together we can do great things.” For more information, contact Isla Horvath, COF Executive Director and CEO, at firstname.lastname@example.org.
Les Sunnybrook Orthopaedic Associates mettent au défi leurs homologues au profit de la Fondation
nspirés par le travail fructueux de la Fondation Canadienne d’Orthopédie pour l’avancement de la recherche, de la sensibilisation et des soins en orthopédie, une équipe d’orthopédistes s’est engagée à soutenir sa mission à hauteur de 10 000 $ par an pendant les 5 prochaines années. « Tout comme moi, un grand nombre d’orthopédistes canadiens ont profité du soutien financier à la recherche et à la formation de la Fondation au fil des ans, souligne le Dr Albert J.M. Yee, chef du programme de soins musculosquelettiques du Holland Centre et titulaire de la chaire Marvin Tile de la division de la chirurgie orthopédique du service de chirurgie du Sunnybrook Health Sciences Centre. La Fondation demeure un élément central des activités de l’ACO. Les deux entités souhaitent
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ardemment soutenir l’innovation de pointe au pays dans les domaines des soins, de la recherche, de la formation et de la sensibilisation en orthopédie. » Plus tôt cette année, la Fondation a annoncé une expansion marquée de son programme de financement de la recherche, en grande partie grâce au don porteur de changement de Zimmer Biomet, au don généreux de DePuy Synthes Canada et au legs important d’un patient. Les orthopédistes du Sunnybrook souhaitaient faire leur part, et se sont donc engagés à faire un don pendant cinq ans. Ils lancent maintenant un défi amical à leurs homologues canadiens, autant dans les centres universitaires des sciences de la santé que dans le milieu communautaire : égaler leur don.
Foundation / Fondation
« Imaginez à quel point la Fondation pourrait étendre la portée de ses programmes de recherche et répondre aux besoins des patients en matière de sensibilisation et de soins si les orthopédistes partout au pays relevaient notre défi, ajoute le Dr Hans Kreder, membre des Sunnybrook Orthopaedic Associates et du conseil d’administration de la Fondation. Nous avons pu constater à quel point les dons porteurs de changement des partenaires de l’industrie ont contribué à l’incroyable expansion des programmes de financement de la recherche au cours de la dernière année. C’est maintenant au tour des orthopédistes de faire leur part et de manifester leur soutien. »
« Pour le moment, l’équipe du Sunnybrook Health Sciences Centre de Toronto est la seule à pouvoir se vanter d’un tel engagement, indique le Dr Kreder. Qui va relever le défi? Si vous arrivez à dépasser l’engagement du Sunnybrook d’au moins 5 000 $, vous nous volerez la vedette, et le défi sera renommé en l’honneur de votre centre. Ensemble, nous pouvons réaliser de grandes choses. »
COF awards Bones and Phones Scholarship to Ahmed Aoude
La Fondation Canadienne d’Orthopédie remet la Bourse d’études Bones and Phones au Dr Ahmed Aoude
he Canadian Orthopaedic Foundation is pleased to announce the recipient of the 2017 Bones and Phones Scholarship. Dr. Ahmed Aoude from McGill University receives the award for a project which allows residents and staff at McGill University to give back to the global community through volunteer orthopaedic missions which help improve orthopaedic care around the world. “The International Orthopaedic Surgery Committee”, created by Dr. Aoude and Dr. Eric Lenczner, works to send groups of health-care professionals from McGill University, including physicians, nurses, physiotherapists and respiratory technicians, to countries in need to provide orthopaedic care and education.
Pour de plus amples renseignements, communiquez avec Isla Horvath, directrice générale et présidente de la Fondation, à email@example.com.
a Fondation Canadienne d’Orthopédie est heureuse d’annoncer le lauréat 2017 de la Bourse d’études Bones and Phones, le Dr Ahmed Aoude, de l’Université McGill. Il reçoit la Bourse pour un projet permettant aux résidents et au personnel de l’Université de redonner à la collectivité grâce à des missions bénévoles qui contribuent à améliorer les soins orthopédiques partout dans le monde. « Le comité international de chirurgie orthopédique créé par le Dr Aoude et le Dr Eric Lenczner permet l’envoi d’équipes de professionnels de la santé de l’Université McGill, dont des médecins, infirmières, physiothérapeutes et techniciens en inhalothérapie, dans des pays défavorisés afin d’offrir des soins orthopédiques et de la formation.
Founded by Dr. Veronica Wadey and Mr. Henry Chow, the Bones and Phones Legacy Scholarship Fund recognizes orthopaedic residents who have demonstrated commitment and contribution to enhancing musculoskeletal health beyond that which would be expected during their residency training period.
Créé par la Dre Veronica Wadey et M. Henry Chow, le Fonds de la Bourse d’études Bones and Phones vise à reconnaître des résidents en orthopédie dont la contribution et l’engagement exceptionnels pendant leur résidence ont permis d’améliorer la santé de l’appareil locomoteur.
To read more about the McGill International Orthopaedic Surgery Committee click here.
Pour en savoir davantage sur le comité international de chirurgie orthopédique de l’Université McGill, cliquez ici.
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Training & Practice Management / Formation et gestion d’une pratique
Calendar of Events / Calendrier des événements 12th Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip June 15-17 juin Westin Ottawa Held in conjunction with the COA Annual Meeting Web Site/Site Int. : www.coaannualmeeting.ca 2017 CORA Annual Meeting June 15 juin Ottawa, ON E-mail/Courriel : firstname.lastname@example.org Web Site/Site Int. : www.coraweb.org South African Orthopaedic Association (SAOA) 63rd Annual Congress September 4-7 septembre Port Elizabeth, South Africa Web Site/Site Int. : http://www.saoa.org.za/ 38th SICOT Orthopaedic World Congress November 30 novembre – December 2 décembre Cape Town, South Africa E-mail/Courriel : email@example.com Web Site/Site Int. : http://www.sicot.org/cape-town British Orthopaedic Association (BOA) Annual Scientific Congress Quality and Innovation September 19-22 septembre Liverpool, UK Web Site/Site Int. : http://congress.boa.ac.uk/
European Orthopaedic Research Society (EORS) 25th Annual Meeting September 13-15 septembre Munich, Germany Web Site/Site Int. : http://eors2017.org/ Australian Orthopaedic Association (AUST.OA) & New Zealand Orthopaedic Association (NZOA) Combined Scientific Meeting Meeting October 8-12 octobre Adelaide, Australia Web Site/Site Int. : http://asm.aoa.org.au/ New Zealand Orthopaedic Association (NZOA) Annual Congress October 15-18 octobre Auckland, New Zealand Web Site/Site Int. : http://nzoa.org.nz Le 92ème Congrès de la SOFCOT November 6-9 novembre Paris, France Web Site/Site Int. : www.sofcot-congres.fr CAS 6th Annual Meeting November 23-24 novembre Vancouver, BC E-mail/Courriel : firstname.lastname@example.org Web Site/Site Int. : http://www.coa-aco.org
Upcoming COA/CORS/CORA Annual Meeting Dates Dates de la prochaine Réunion annuelle de l’ACO, de la SROC et de l’ACRO
June 15-18 juin CORA Meeting/Réunion de l’ACRO June 15 juin 12th Symposium on Joint Preserving and Minimally Invasive Surgery of the Hip Held in conjunction with the COA Annual Meeting June 15-17 Web Site/Site Int. : http://www.ottawa2017.ca/
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June 20-23 juin CORA Meeting/Réunion de l’ACRO June 20 juin Victoria, BC
Combined with the 2nd ICORS Meeting June 19-22 juin CORA Meeting/Réunion de l’ACRO June 19 juin Montréal, QC www.2019icors.org
Training & Practice Management / Formation et gestion d’une pratique
Using the CanMEDS Roles in Your Practice
COA Bulletin series focuses on effective use of the CanMEDS framework
he CanMEDS framework is a tool used for teaching and for our continuing medical education. It is well established, benefits our profession and has been integrated into the Royal College’s programs including Maintenance of Certification. The seven roles of the CanMEDS are: • • • • • • •
Medical Expert (the integrating role) Communicator Collaborator Leader Health Advocate Scholar Professional
Over the next few editions of the COA Bulletin, I will be asking various members of the COA to define each of the roles and how they can be used in day to day practice and education. This series will provide guidelines on how to use the CanMEDS roles to their full advantage in your orthopaedic practice. Drs. Glen Richardson and Trenholm have kindly agreed to examine the role of Communicator in this edition’s feature. Enjoy! – Ed.
Communicator C. Glen Richardson, M.D., MSc, FRCSC Associate Professor of Surgery Program Director Division of Orthopaedic Surgery Dalhousie University Halifax, NS J. Andrew I. Trenholm M.D., MSc, FRCSC Associate Professor of Surgery Co-director Surgical Foundations Program Unit Head MSK/Derm Section Dalhousie University Halifax, NS
he CanMEDS framework includes the role of Communicator in its list of competencies and has been used to guide the education and maintenance of certification for physicians. Frank et al. and the Royal College of Physicians and Surgeons of Canada have outlined the key competencies for an effective communicator including ability to establish professional and therapeutic relationships with patients and families, the ability to elicit and synthesize accurate information that incorporates the perspectives of patients and finally, the ability to share healthcare information and care plans with patients1. The challenge for orthopaedic educators of residents and practicing surgeons is defining ways to evaluate competence in communication as it is such an integral part of everything we do. It is generally accepted that good communication between patients and physicians can result in improved patient satisfaction, fewer
medical errors and avoidance of medical legal action2-6. In the realm of patient safety, orthopaedic surgeons clearly agree with the importance of communication7. Furthermore, the Canadian Medical Protection Agency distinguishes communication in its good practices guide. Unfortunately, as orthopaedic surgeons, we may not be as good at communicating as we think we are, since patients feel we focus on the technical part of our profession2. Moreover, we are not as likely to identify ourselves as poor communicators but interestingly, are able to see poor communication in colleagues and trainees2,8. This is because effective communication is broadly defined and rarely discreetly evaluated as good or bad. Good communication is described as both appropriate and effective, which is affected by different parameters8. These factors can include the perspective and biases of the participants, the environment and context of the communication. This becomes important when trying to design teaching and evaluation strategies for communicator roles in the CanMEDS framework. There has been considerable recognition of the importance of communication training in medical schools and there have been efforts to incorporate this into the medical curriculum. The use of didactic lectures and simulated patients has been shown to improve communication skills9. Some authors have recognized that communication skills training is not something that medical students can perfect during medical school. The knowledge that they accrue with training is an important part of effective communication10.
Copyright © 2015 The Royal College of Physicians and Surgeons of Canada. http://rcpsc.medical.org/canmeds Reproduced with permission
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Training & Practice Management / Formation et gestion d’une pratique (continued from page 39)
As a result of the need to demonstrate competency in communication for the CanMEDS communicator role, post-graduate medical education programs such as Dalhousie University have incorporated a simulated patient exams. Difficult topics physicians face when communicating with patients are presented. The residents receive important feedback about their performance and this has been shown to improve communication skills11. Objective Structured Clinical Exams (OSCE’s) have been successfully used to evaluate and provide feedback to residents on many of the CanMEDS roles, including communicator12. Supervising surgeons teaching surgical skills have incorporated communication training along with other roles such as collaborator and manager into courses for surgical residents. They recognize the overlap between the different CanMEDS roles13. The deficit in communication skills training is evident only once residents are being taught and evaluated in the actual clinical environment. The teaching of clinical and technical skills is ubiquitous in most programs but most supervisors will resort to role modeling for CanMEDS roles such as the communicator14. Typically, observation of resident communication skills is indirect, focusing on information obtained from patients and the questions asked as opposed to the actual way the information was gathered from patients15. Watching residents take a history or gain consent from a patient is an important evaluation but likely does not happen frequently or is only part of a final exam15. Improving communication skills is not just an issue for residents, but for orthopaedic surgeons as well. Clinical practice is changing with multidisciplinary teams, elderly patients with complex medical comorbidities and increased handover of patient care. This provides increased opportunity for miscommunication and the inevitable medical errors that can occur2. Practicing physicians currently have few options for accessing continuing professional development (CPD) on communication skills. In contrast there is a large amount of technical skills training available from professional associations. There is a real opportunity for professional societies to incorporate communication skills training into their CPD offerings, by bundling it with other skills training. Ultimately, orthopaedic surgeons that take the time and expense of working on communication skills may have a greater positive impact on their practices and careers than acquiring new technical skills. This education can be through reading, active practice and attending CPD courses at local Medical Schools. References 1. Frank J.R., Langer B. Collaboration, communication, management, and advocacy: teaching surgeons new skills through the CanMEDS Project. World journal of surgery. 2003;27(8):9728; discussion 8. 2. Frymoyer J.W., Frymoyer N.P. Physician-patient communication: a lost art? J Am Acad Orthop Surg. 2002;10(2):95-105. 3. Black K.P., Armstrong A.D., Hutzler L., Egol K.A. Quality and Safety in Orthopaedics: Learning and Teaching at the Same Time: AOA Critical Issues. J Bone Joint Surg Am. 2015;97(21):1809-15.
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4. Huntington B., Kuhn N. Communication gaffes: a root cause of malpractice claims. Proceedings (Baylor University Medical Center). 2003;16(2):157-61. 5. Levinson W. Physician-patient communication. A key to malpractice prevention. Jama. 1994;272(20):1619-20. 6. Levinson W., Roter D.L., Mullooly J.P., Dull V.T., Frankel R.M. Physician-patient communication. The relationship with malpractice claims among primary care physicians and surgeons. Jama. 1997;277(7):553-9. 7. Janssen S.J., Teunis T., Guitton T.G., Ring D., Herndon J.H. Orthopaedic Surgeons’ View on Strategies for Improving Patient Safety. J Bone Joint Surg Am. 2015;97(14):1173-86. 8. Spitzberg B.H. (Re)Introducing communication competence to the health professions. Journal of public health research. 2013;2(3):e23. 9. Berkhof M., van Rijssen H.J., Schellart A.J., Anema J.R., van der Beek A.J. Effective training strategies for teaching communication skills to physicians: an overview of systematic reviews. Patient education and counseling. 2011;84(2):152-62. 10. Wouda J.C., van de Wiel H.B. Education in patient-physician communication: how to improve effectiveness? Patient education and counseling. 2013;90(1):46-53. 11. Falcone J.L., Claxton R.N., Marshall G.T. Communication skills training in surgical residency: a needs assessment and metacognition analysis of a difficult conversation objective structured clinical examination. Journal of surgical education. 2014;71(3):309-15. 12. Dwyer T., Glover Takahashi S., Kennedy Hynes M., Herold J., Wasserstein D., Nousiainen M., et al. How to assess communication, professionalism, collaboration and the other intrinsic CanMEDS roles in orthopedic residents: use of an objective structured clinical examination (OSCE). (14882310 (Electronic)). 13. Ponton-Carss A.C., Donnon T., Kortbeek J.B. Two for one: surgical skills and CanMEDS roles--a combined course for surgical residents. Journal of surgical education. 2014;71(3):419-25. 14. Cote L., Laughrea P.A. Preceptors’ understanding and use of role modeling to develop the CanMEDS competencies in residents. Academic medicine : journal of the Association of American Medical Colleges. 2014;89(6):934-9. 15. Schopper H, Rosenbaum M, Axelson R. ‘I wish someone watched me interview:’ medical student insight into observation and feedback as a method for teaching communication skills during the clinical years. BMC medical education. 2016;16(1):286.
Training & Practice Management / Formation et gestion d’une pratique
Is Your Boat Going to Sink or Float? path for a small minority of surgeons, for the vast majority it is a matter of when to incorporate rather than if to incorporate.
Adam O’Neill, B.Sc., IMBA, CLU, CHS Advisor Andrew Sheppard, IMBA, CHS Advisor
Sun Life Financial Investment Services (Canada) Inc.
s part of our mandate to educate and empower the COA membership on financial strategies, this will be the first installment of an ongoing series aiming to help orthopaedic surgeons across Canada avoid common and costly mistakes sometimes made by physicians in managing their personal and business finances. We will be looking initially at one family, who share characteristics with many of you, and will walk through some of the strategies that can be employed to achieve significant improvements in security, efficiency, and financial wealth. If you have any questions about the information contained in this or any subsequent articles, please reach out to us directly by phone or e-mail through the link provided on the COA web site to COAplan.ca or contact your financial advisor. Building a solid plan to meet your financial goals can be described in the following way; setting up a plan to meet your long-term financial goals is like building a boat. You gather all of the materials that you need, you follow a blueprint and when you are finished building it, you push it down to the water and hope it floats! Although there is some truth to this, it is best to reduce the amount of reliance we put in hoping that our financial plan floats. Assurances are achieved by focusing on a process that offers a much higher degree of sophistication and provides a greater level of confidence. We believe strongly that what matters most to Canadian surgeons is how well their plan performs. What’s most important, in any financial structure, is not how much you make, but how much you get to keep, spend, and pass on. Some surgeons that we work with have goals that include ensuring a comfortable lifestyle for themselves and their family, minimizing taxes (both in practice and in their estates), providing security and protection for all that life throws their way, providing an effective transfer of wealth to the next generation, the creation of a charitable legacy of some kind, and achieving efficiency and tax management in both their medical practice and personal finances. This can be achieved by a solid plan design, clear investment strategies, estate planning, and lower investment management and planning fees. First steps Canadian surgeons should consider when building a plan 1) Incorporation The first step for a vast majority of physicians in Canada is incorporation. This is the initial action which lays the groundwork and foundation for nearly all of the subsequent and more complex strategies which come after. While it is possible that incorporation is not the best
The act of incorporation can create a number of benefits, but tax management is the primary advantage for surgeons. A corporation allows a surgeon to withdraw income from their corporation in the form of dividends. Dividends are taxed more favourably than income. The difference in tax can be considerable depending on the level of income that is being generated and the amount of money required to maintain lifestyle. The challenge to this strategy is that money is left inside the corporation and when invested, the gains are taxed at a very high tax rate. An excellent way to address this is with insurance.
2) Insurance A common tax reduction strategy for incorporated surgeons in Canada is the use of permanent life insurance as a sheltered investment vehicle. Most of you have likely already heard of this from your advisor, accountant, or a colleague.
Permanent life insurance inside a corporation creates a tax advantaged investment vehicle. The strategy is so powerful because it affects both taxation on investment returns inside the corporation, and taxation on the withdrawal of capital from the corporation under certain situations.
3) Taxation on investment returns inside the corporation Gains on passive investments held inside a corporation are taxed at a very high tax rate. This can lead to physicians opting for very safe, low return generating investments. Certain types of permanent life insurance allow you to accumulate cash inside them. The investments inside the policy benefit from deferred tax on gains while they remain in the policy. Compounding those gains, tax-free, leads to more growth over time. The surgeon also maintains the freedom to decide when and how to eventually access those funds. 4) Taxation on the withdrawal of capital from the corporation The Capital Dividend Account (CDA) is a “nominal” account (i.e. not an actual account, but a conceptual account), used to determine the amount of capital which can be removed or withdrawn from a corporation as a tax-free dividend. Most of the death benefit from a corporately held permanent life insurance policy can be posted to the CDA. Proper use of the CDA can greatly reduce tax at several key life events, especially upon the death of the surgeon or their spouse.
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Training & Practice Management / Formation et gestion d’une pratique (continued from page 41)
Case study Let’s take a look at a fictitious surgeon, Rob, and his family. We’ll use Rob, his practice, and his family for the next few installments of this series, and describe how different strategies affect them. All of the numbers discussed, and more detailed explanations of the strategies used, are available upon request through the COAplan.ca web site, or by e-mail request through the contacts at the end of this article. We will also be using Rob and his family, and many of the strategies discussed, at our session in Ottawa at this year’s COA Annual Meeting. The family Rob is a 55-year-old orthopaedic surgeon in Ontario, with a successful and established practice at a community hospital. He earns $600k per year, with annual expenses of $150k. Rob is married to Mary, who is a 45-year-old manager at a pharmaceutical company, with a salary of $120k. They have two children; 19-year-old Claire, who is in her first year of undergrad and hopes to go to medical school, and 14-year-old Rob Jr. who is an aspiring DJ. Their finances Rob has been earning money personally and paying $172,604 in taxes per year on his $450k of reported income ($600k less expenses and RRSP contributions). Mary pays income tax on her full salary which amounts to $24,509 in tax (after RRSP contributions), leaving her with $73,891 after tax and RRSP contributions. Rob and Mary need $125k of after-tax dollars to cover their lifestyle expenses. Rob and Mary don’t have a particular love for managing their money; they have been relying on a friend who works at the bank to assist him. They’re both making contributions to an RRSP investment account at the bank up to the maximum amount that they can. They also have quite a bit of money sitting in a regular low interest bank account. Rob and Mary know that they could be more efficient with their money but they aren’t sure what they should be doing. Their insurance Rob has also bought several insurance policies throughout his life, but has never really sat down and done a thorough assessment of his family’s needs, or looked at designing a protection plan with those needs in mind. He has some disability coverage he bought in medical school, and has a term life insurance policy for himself. Mary has a small term life insurance policy as well. All of Rob’s coverage is held personally, outside of his corporation. Incorporation strategy After sitting down with his advisor and planning team, Rob decides to follow their advice and incorporate. By incorporating, Rob’s corporation pays tax on the full $450k of revenue at a rate of 15% which equals $67,500. However, because Rob only needs to take out enough money from the corporation to make up the difference between the after-tax income that Mary is bringing in and the $125k they need for expenses, his overall taxes paid are significantly decreased.
Rob takes $54,100 as dividends, triggering $2,975 of tax. This gives Rob and Mary $125,016 of after-tax dollars to cover their expenses. Rob is no longer making RRSP contributions as he is not realizing income through his withdrawals. In this example, just through this alteration of how Rob takes his income, Rob and Mary have reduced their taxes paid by $102,129 and left $328,400 remaining inside the corporation which can be invested inside universal life insurance policy. The investment will grow tax-deferred inside the policy, and the investments held inside the policy will be used to cover the cost of the insurance premium.* As well, if Rob were to pass away, the majority of the funds inside the policy would flow through the CDA tax-free to Mary. Note: Returns on investments held inside the policy may not be guaranteed. Conclusion This strategy is an example of the significant benefit that can be gained by working with a team of professionals who are able to assist you set up your cash-flow system to help ensure that you are not losing potential gains. You work hard for your money. You should keep as much of it as you can. *As mentioned above, all of the specifics of this strategy, including a detailed spreadsheet comparing Rob’s initial set-up to the revised structure, are available upon request. As this is the first installment in this series, we will have a new spreadsheet and strategy document for each new strategy we implement for Rob and his family. For the initial documents on Rob and this first strategy’s implementation and effects, please send an e-mail request to the contact info listed below or visit COAplan.ca using the link in the Membership Benefits section found in the Membership tab on the COA web site (www.coa-aco.org) References used in our calculations. https://simpletax.ca/calculator http://www.ey.com/ca/en/services/tax/tax-calculators-2016-personal-tax
Adam O’Neill*, B.Sc., IMBA, CLU, CHS 416-366-8771 ext. 2212 Andrew Sheppard*, IMBA, CHS Advisor 416-363-8880 *Mutual funds distributed by Sun Life Financial Investment Services (Canada) Inc.
COA Bulletin ACO - Summer / Été 2017
Training & Practice Management / Formation et gestion d’une pratique
Early History of Orthopaedics in British Columbia Robert W. McGraw M.D., FRCSC COA Past President, 1990
e are privileged to practice orthopaedics. Our heritage is rich and enviable. To fully appreciate our coveted corrected orthopaedic tree, we must know its roots. In this entitled age, we should be obliged to pause and reflect on the contributions of our forefathers.
moustache. He moved to Ladysmith, BC and then to Trail, BC where he built the city’s first hospital which later became the C. S. Williams Clinic.
To examine the more than hundred-year history of orthopaedics in British Columbia, it is appropriate to divide the course of its evolution into three phases.
A nurse, Lillian Shepherd, came to Trail from Baie-des-Chaleurs which is where Jacques Cartier landed in 1535. She had been educated in Boston and Ottawa and was as strong-willed as Patterson Sr. himself. While operating, Patterson Sr. lost his temper and threw some instruments. She disapproved and threw the rest of the instruments onto the floor. As a result of this scrimmage, they developed an affection or an affinity and married soon after. They left for Europe where Patterson Sr. obtained his FRCS in Edinburgh. He also made visits to Vienna and Germany before returning to Vancouver (Vancouver General Hospital and St. Paul’s Hospital) where Patterson Sr. began his practice as a specialist surgeon.
1) Pre-World War II. In this edition, I will begin by describing the career of the first orthopaedic surgeon in British Columbia, F. P. Patterson Sr. and will also discuss the lives of four other pioneer orthopaedic surgeons that followed: J. R. Naden, H. H. Boucher, D. E. Starr and F. P. Patterson Jr.
At the time, W. A. McConkey was the first intern at Vancouver General Hospital. His son was A. S. (Art) McConkey, orthopaedic surgeon at St. Paul’s. Art McConkey was the father of orthopaedic surgeon, Pat McConkey, and the grandfather of orthopaedic surgeon, Mark McConkey.
In keeping with any retrospective reflection, there will be omissions for which the writer apologizes. Future editions of the COA Bulletin will cover:
In 1912, Dr. Pete McLennan was to be the first surgeon at VGH. He was instrumental in having a consent form adopted that absolved surgeons of any blame and gave them freedom of action at surgery.
“The farther you look backward, the farther forward you will see.” (Churchill)
2) Post-World War II and the beginning of academic orthopaedics in British Columbia, including the 1950 opening of the University of British Columbia Medical School and the 1951 creation of the Division of Orthopaedic Surgery. 3) The final chapter will review the creation of the only Department of Orthopaedics in Canada in 1984 and, as a consequence, the creation of 10 divisions within the Department of Orthopaedics at the University of British Columbia. The son of an Irish shipbuilder and an English mother, F. P. Patterson Sr. was born in St. Martins, New Brunswick in 1876. He was an excellent student with high marks in algebra, astronomy and bible study. The latter was a surprise to many interns and nurses who were subjected to his wrath and profanity when he was a surgeon. He obtained his medical degree from McGill when he was 21 years old. Patterson Sr. failed in an attempt to start a practice F. P. Patterson Sr. (the first in St. Martins because of his orthopaedic surgeon in British young looks, in spite of a large Columbia)
Vancouver General Hospital public ward and semi-private ward COA Bulletin ACO - Summer / Été 2017
Training & Practice Management / Formation et gestion d’une pratique (continued from page 43)
1914 When World War I broke out, Patterson Sr. was a medical officer and went with the Irish Fusiliers to Salonika, Greece in 1915. Mrs. Patterson was pregnant with their second child. Patterson was expecting a girl and chose the name, Margaret Elizabeth. He was impatient and wanted the child delivered before his departure to Greece. He apparently drove his expectant wife over bumpy roads, hoping to hasten delivery. On the day of embarkation, a son was born instead. Patterson Sr. said that he might as well have the same name, since he could not think of anything else. Patterson Sr. was invalided out of Europe and returned to spend one year at the Christie Street Military Hospital in Toronto. There, he became friends with Drs. Clarence E. Starr and W. E. Gallie, and other well-known trauma surgeons. It was at this time when he decided to confine his work to orthopaedics, which would make him a pioneer in the west. No surgeon in Toronto was yet confined to orthopaedics, although there were a number of French-speaking orthopaedic surgeons who were fully specialized. He then returned to VGH, St. Paul’s Hospital, Shaughnessy Military Hospital and the Children’s Hospital on 59th Avenue in Vancouver. Frank Patterson Sr. established himself in orthopaedics by perseverance and dedication. Because of his knowledge and experience, he became very busy with more and more complicated problems. Seventy-five percent of the patients at VGH were charity patients. This was long before hospital and medical insurance existed. It was the staff surgeon’s obligation to treat these patients without any remuneration. In the 1920s, he was the only orthopaedic surgeon in the province. The late Dr. Leslie Mitchell came to see Patterson Sr. to ask for a job. He told Mitchell that there was “no room for any more orthopaedic surgeons in British Columbia” and sent him on his way. Mitchell returned to Detroit, went on to become Chief of Orthopaedics at Henry Ford Hospital, President of the American Orthopaedic Association, and is remembered by the osteotomy bunionectomy that bears his name. Patterson Jr., many years later, would describe his father as an unusual man of very high intellect. “He was hated, feared and loved. Children loved him. He was very kind to them, often paying their hospital bills and bringing gifts to them”. In 1937, Patterson Sr. had painful jaundice. He had, for many years, experienced peptic ulceration and bleeding. His doctors diagnosed carcinoma of the pancreas. Patterson disagreed. He had a common duct obstruction due to old adhesions. Following surgery, he died of a paralytic ileus and electrolyte imbalance. A few moments before his demise, he said to Mrs. Patterson, “death is only another adventure. Why don’t you all go away and rest and not worry”. At the time of his death at St. Paul’s Hospital, the nurse in attendance was Christian Leighton, who, incidentally, was my late mother’s closest friend. “To have known the father is to have known the son.” COA Bulletin ACO - Summer / Été 2017
Dr. John R. (Jack) Naden The next prominent figure to emerge was the late John R. Naden. Born in Greenwood, BC in 1902, he interned at the VGH and had a major interest in orthopaedics. Few interns wanted to work with Dr. Patterson Sr. as he was considered too difficult, demanding and abusive. Naden knew what he wanted. He was actually threatened with dismissal by the superintendent at VGH for spending too much time with Dr. Patterson Sr. J. R. Naden Patterson Sr. asked Dr. W. E. Gallie to give Naden a resident position in Toronto. The same occurred with Dr. Paul Steele in Pittsburgh. Naden then returned to Vancouver in 1930 as assistant to F. P. Patterson Sr. After 18 months of practicing with Patterson Sr., Naden missed a diagnosis of “surgical scarlet fever’’, now known as streptococcal infection. The next day, Patterson bought Naden a general practice in Princeton, BC so he could “learn about people and disease”. Two years later, Naden returned and formed a partnership with Patterson Sr. At the time, Patterson Sr. was heavily involved in politics and was leader of the provincial Conservative Party, but unfortunately, Patterson Sr.’s health was deteriorating. In 1936, Naden became Chief of Orthopaedics at VGH when Patterson Sr. was 60 years of age. The staff then consisted of J. R. Naden, Patterson Sr. and H. H. Boucher. Naden was a tireless worker in spite of a hip disability. He was thought to have the largest orthopaedic practice in the world operating six mornings a week and seeing patients from 1:30 to 8:00pm. It was not unusual for him to see 100 Workers’ Compensation cases in one day, with two cases in one examining room at a time. He likely had the most experience in the world with Roger-Anderson external fixation. J. R. Naden was invited to the British Orthopaedic Association Annual Meeting to discuss John Charnley’s new technique of central dislocation arthrodesis of the hip joint. This procedure was performed without internal fixation and employed a hip spica. Naden conceived a novel form of internal fixation, whereby the new Kuntscher nail could be introduced through the ileum, across the hip joint and into the femur. He asked Patterson Jr. to find a patient, preferably a young man, who needed a hip arthrodesis. In no time, such a patient was found and the operation was carried out without complication. When Naden discussed his innovation of Charnley’s operation before
Training & Practice Management / Formation et gestion d’une pratique (continued from page 44)
the British Orthopaedic Association, Sir Reginald Watson Jones commented that Charnley had just been “out-Charnleyed” by Jack Naden. The irony of this is that Naden underwent a hip arthrodesis for avascular necrosis by R. I. Harris of Toronto. In the postoperative period, a new casting material was utilized, similar to fiberglass, which nearly cost Naden his life. He became unconscious due to acidosis from inhaling acetone. Fortunately, the cause was recognized in time, the immobilization was removed, his life was saved, but he went on to develop a non-union from the surgery. He was president of the Canadian Orthopaedic Association in 1953. When the medical school opened in 1950, Dr. Naden stepped down graciously and completed his career as Chief Medical Officer at the Workers’ Compensation Board where he retired at age 65. H. H. (Hammy) Boucher
Dr. Donald E. Starr Dr. Starr was a Toronto graduate trained in orthopaedics at Johns Hopkins, Baltimore and the Ruptured and Crippled in New York under Phillip D. Wilson Sr. (now the Hospital for Special Surgery). In 1941 (during World War II), there were very few orthopaedic surgeons available and Naden was the only one at VGH. He was desperate for assistance and recruited Don Starr to join him.
Dr. Boucher was born in Chilliwack in 1899 and graduated from McGill University. He coached Canadian football and won many championships in what was then, the Big Four League.
Starr was qualified, exu- D.E. Starr berant, friendly, and technically adept. I can personally attest to this as I assisted him in the operating room as a medical student.
Boucher was interested in orthopaedics, spending a lot of time at the Outpatient Department of VGH and used to assist Patterson Sr. in surgery.
F. P. Patterson Jr.
On one occasion, F. P. Patterson was changing to operate and H.H. Boucher Boucher was not. “What’s the matter with you, Boucher? Don’t you want to work and learn something?” Boucher replied, “Dr. Patterson, yesterday you said I was no good and never would be, so I didn’t think I should scrub.” Patterson replied, “Well, Boucher, what I said was true, wasn’t it? Now get to work and learn something or do you want to be a foolish football coach all your life?” Boucher scrubbed. Patterson then said, “Yesterday, I phoned a friend of mine, Professor Steindler in Iowa, and he is going to take you on for training.” Boucher became one of the leading orthopaedic surgeons in British Columbia, gaining national and international recognition, particularly for his pioneer work in screw fixation in the spine.
Dr. Starr had aortic stenosis and underwent an early Star valve procedure at the Mayo Clinic and died soon thereafter at a young age of a staphylococcal infection.
F. P. Patterson Jr. was born by a breech delivery by Dr. Pete McLennan at the VGH in 1915. He graduated from Kitsilano High School in Vancouver and attended UBC for two years where he didn’t perform very well. His father, Patterson Sr., then a member of the Board of Governors of the University of British Columbia, was ashamed of his son’s performance and suggested he study elsewhere. Patterson Jr. enrolled in McGill University and failed bota- F.P. Patterson Jr. as a young child ny in his first year, causing his father to be furious. When Patterson Jr. told his father that he intended to become a medical doctor, Patterson told him that he didn’t have the brains or energy to do so. After the supplemental examination, Patterson Jr. went to see the Dean of Medicine, Dr. Charles Martin. Patterson Jr. was surprised to learn that his father had already written the Dean, saying, “If my son applies to Medicine, don’t take him in. He is much more interested in extra-academic activities than scholarly pursuits.” COA Bulletin ACO - Summer / Été 2017
Training & Practice Management / Formation et gestion d’une pratique (continued from page 45)
Dean Martin said that he would accept the application, on the condition that he left the McGill football team and obtain the money for the fees and microscope. He told Patterson Jr. that if he was not successful by Christmas, he’d be kicked out and Martin would make sure he did not get in to any other medical school. In 1936, after first-year Medicine at McGill, Patterson Jr. returned home. His father quizzed him about his answers to the anatomy questions which he had passed. Patterson Sr. concluded, “The standards at McGill must have fallen quite a bit over the years”. During the summers while he was in medical school, Patterson Jr. was dissecting in the morgue, attending outpatient clinics, and in the operating room at the insistence of his father. He wanted to intern in Toronto and was interviewed by Dr. W. E. Gallie who told him, “We don’t take McGill men here”. To which Patterson Jr. replied, “Maybe it’d be good a thing if you took the odd McGill man. It might be good for the University of Toronto and the Toronto General Hospital.” According to Patterson Jr., Gallie was very gracious and marvelous, and just roared with laughter and said, “I think you’ve got a good point.” Patterson received the appointment and was the only intern at Toronto General Hospital who did not graduate from the University of Toronto. Patterson Jr. began orthopaedic training under Dr. R. I. Harris, who had just started the first orthopaedic service in Toronto. One day, while working with Harris, Patterson Jr. developed abdominal pain. Dr. Bill Bigelow, (senior resident, who went on to become an outstanding cardiac surgeon), diagnosed appendicitis which was confirmed by Gallie. Patterson Jr. then assisted R. I. Harris with a hip procedure and was left to close the wound while Dr. Harris went to dinner. Harris returned to operate on Patterson Jr., beginning with an incom- F.P. Patterson Jr plete spinal anaesthetic and a subsequent general anaesthetic. A normal appendix was removed. Patterson Jr. became quite ill and a variety of diagnoses were made. He went on to receive M & B 693 which was one of the early antimicrobials, sulfonamide. This gave him severe gastritis. A business friend of his brought him a bottle of Walker’s Imperial Rye Whiskey. The following day, Patterson said he was a lot better.
During his internship, Patterson Jr. joined the Royal Canadian Air Force. With little to no orthopaedic education, he was posted to Jericho Beach Air Force Station in Vancouver where he worked with J. R. Naden and Donald Starr. In 1945 (end of World War II), he returned to Vancouver as Dr. Naden’s assistant. Patterson Jr. had no formal training, no specialist qualifications, and no certificate. In 1947, he went to the Hospital for Sick Children where he did a year of R. I. Harris surgery, most of which was orthopaedics with A. B. LeMesurier. During this time, Dr. Naden returned to Toronto for treatment of his non-union by Dr. R. I. Harris. Naden insisted on Roger-Anderson external fixation which Patterson Jr. applied for the revised hip arthrodesis. In 1947, Patterson successfully sat the fellowship examination. That same year, he returned to Vancouver and Dr. Naden became his patient for pin tract infections. The drainage from the pin sites was colloquially referred to as “Seattle serum”. Dr. H. H. Boucher was Acting Chief of Surgery at VGH and the orthopaedic staff consisted of Drs. Boucher, Naden, Starr and Patterson Jr. Each year there were 950 orthopaedic discharges plus 1,344 fracture patients, for a total of Patterson Jr. joined the Royal Canadian 2,294 patients. There were Air Force 3,434 operations. In 1950, the University of British Columbia Medical School opened and Dr. H. Rocke Robertson was appointed professor and head of the Department of Surgery. In 1951, Dr. Robertson appointed F. P. Patterson Jr. as head of the newly created Division of Orthopaedic Surgery and the era of academic orthopaedics in British Columbia had begun. To be continued!
COA Bulletin ACO - Summer / Été 2017
Training & Practice Management / Formation et gestion d’une pratique
GLA:D™Canada : What Does This Mean for My Patients? Aileen Davis, PhD Senior Scientist, Krembil Research Institute, University Health Network Rhona McGlasson, PT, MBA Executive Director Bone and Joint Canada
ne in ten adult Canadians has osteoarthritis (OA). Hip and knee OA can cause pain and disability that can reduce an individual’s mobility and quality of
There are no Canadian guidelines for the management of hip and knee OA and previous work by Bone and Joint Canada identified only five programs across the country supporting non-surgical management of OA. These programs exist in Ontario, Alberta, Quebec and British Columbia, and each were closely aligned with rheumatology with some relationship to orthopaedics. Nationally, we need to develop a coordinated approach to the management of OA that addresses the factors that provide challenges for program implementation, delivery and access. These patient and system factors include: - the prevalence of OA risk factors such as obesity and musculoskeletal injury; - patients’ lack of knowledge of management strategies including appropriate types and levels of exercise; - lack of services including diagnosis for early OA; - variability in health care providers and scopes of practice across the country; and , - the variation in public versus private options available for OA services. To address the burden of OA in Canada and overcome these challenges, we need to develop a standard approach to provision of non-surgical management. Multiple international guidelines provide evidence for OA management that are now being translated into clinical programs. The evidence supports the following interventions: - The first line of treatment, which is appropriate for all individuals, includes exercise, education and weight control or loss (where appropriate). - The second line adds interventions such as assistive devices, braces and medications. - The third line of treatment is surgery, which is provided to 5-10% of people with OA. However, even patients with moderate to severe OA benefit from the first line treatment of exercise, education and weight control to manage their day-to-day symptoms. Dr. Ewa Roos, a researcher from Denmark, developed and implemented Good Life with Osteoarthritis in Denmark (GLAD®). GLAD® is an evidence-based program that provides a standard approach addressing these first line components of care. It includes two education sessions (with an optional third
session where a prior program participant serves as a motivational speaker) and 12 neuromuscular exercise sessions. Neuromuscular exercise addresses the abnormal muscle patterns and strength and losses that develop with OA. Multiple studies have shown the benefits of exercise.
BONE JOINT CANADA
The GLA:D® program, through the inclusion of neuromuscular exercise, focuses on muscle activation and dynamic joint stability with proper limb alignment to prevent inappropriate stresses through the joint. The program is designed with four exercise stations that, when used together, build increased muscle awareness and improved muscles patterns into the person’s everyday life – specifically the daily activities of going up and down steps and standing and sitting which often result in pain. Using this approach, as the person improves their exercise performance, they are encouraged to activate the correct muscle groups when undertaking their various daily activities. People completing the GLA:D® program have a 30-40% reduction in symptoms. With less symptoms, participants are encouraged to be more physically active which aids in management of other chronic conditions. The 32% increase in physical activity at the end of the program has been sustained through one-year follow-up in more than 10,000 people in Denmark. Delivered in a group format, there is peer support and a camaraderie that enhances participation. This group format also ensures that the program is affordable. So who is appropriate for GLAD®? GLAD® will benefit individuals who have hip or knee OA as their primary diagnosis and who are experiencing symptoms, usually pain or stiffness, or functional limitations at any stage of the disease. It is safe and effective for both non-surgical patients and patients waiting for surgery helping them manage their daily symptoms, especially where they have a long wait for surgery. For surgical candidates, participation in GLAD® also has been shown to increase muscle strength and joint stability and confidence that leads to faster recovery post-surgery. The GLA:D™Canada program is now available in Ontario, BC, Alberta, and is launching in the Atlantic region and the Prairies. Information on site locations is updated as sites launch and can be found at www.gladcanada.ca Questions about the GLA:D™Canada program, including information on how to get a program established within your area, can be directed to Rhona McGlasson at Rhonaamcglasson@gmail.com The Canadian Orthopaedic Foundation is proud to be the first organization outside of Denmark to be licensed to offer the GLA:D program.
COA Bulletin ACO - Summer / Été 2017
Training & Practice Management / Formation et gestion d’une pratique
Making the Most of Your Free Subscription to the Bone & Joint Journals
s an Associate or Active Member* of the COA, you receive an online subscription to The Bone & Joint Journal (formerly JBJS British Volume) and digest journal Bone & Joint 360. If you have not yet activated your online access, you can do so quickly and easily by entering your journal customer number here http://tiny.cc/bjjactivate. If you do not know your customer number, e-mail email@example.com. If you have activated your online access to The Bone & Joint Journal (BJJ) and Bone & Joint 360 make sure you are getting the most out of your subscription! Read through these important tips and click through the various links within the article to learn more. Access to BJJ’s entire archive In addition to your online access to all articles in BJJ as soon as they are published, you have the entire online archive available at your fingertips, all the way back to 1948, all online and completely for free. Download PDFs of articles to read offline at your leisure or while you travel, from your phone, tablet or laptop. Browse by specialty within BJJ To find articles that are truly relevant to you in BJJ, search online using the 10 specialty categories – Children’s Orthopaedics, Foot & Ankle, Hip, Knee, Oncology, Research, Shoulder & Elbow, Spine, Trauma, Wrist & Hand. BJJ has a team of Specialty Editors, each an expert in their field, to ensure all orthopaedic specialties within the journal are represented, and the papers being published are truly reflective of the current landscape within orthopaedics. BJJ’s Content Collections BJJ has created online Content Collections, which you have complete access to. Collections are chosen by BJJ’s Editor-in-Chief Professor Fares Haddad, and currently include COA Bulletin ACO - Summer / Été 2017
Hip Preservation Surgery, Total Elbow Arthroplasty, Reverse Shoulder Replacement, with more planned throughout the year. CME Program Remember to take full advantage of BJJ’s recently relaunched CME program, available only to those who have access to the journal online. It is ACCME-accredited by the Mayo clinic so you can get a recognized credit for successfully completing a course. Bone & Joint 360 – concise, global, essential Complete online access to digest journal Bone & Joint 360 is also included in your journal access as an Associate or Active* Member of the COA. Bone & Joint 360 is truly a unique publication, created to save busy orthopaedic surgeons time and written by an authoritative, expert Editorial Board led by Editor-inChief, Mr Ben Ollivere. Why read Bone & Joint 360? Bone & Joint 360 provides quick, concise summaries of the global orthopaedic literature from over 55 international journals in each issue. When reading 360 online, RoundUp360 gives an expert overview, separated out by the 10 specialties used in BJJ. It is an ideal way to briefly engage with what your peers are publishing in the wider orthopaedic community. You can download an entire issue of 360 as a PDF to read offline. Plus, when you read 360 online, all the articles referenced in the summaries are linked to the original paper and journal they are published in, should you wish to purchase the full-text to read further. Bone & Joint Publishing’s open access journals The Society also publishes three open access journals – Bone & Joint Research, EFORT Open Reviews and the Journal of Children’s Orthopaedics alongside The Bone & Joint Journal and Bone & Joint 360. As these journals are fully open access, all published articles are online only and completely free to read, with no restrictions to anyone.
Training & Practice Management / Formation et gestion d’une pratique (continued from page 48)
Bone & Joint Research (BJR) is gold open access and has been created specifically with the orthopaedic research community in mind. BJR publishes papers across the whole spectrum of the musculoskeletal sciences. Started in 2011, the journal has gone from strength to strength and has a 2015 Impact Factor of 2.425. Read the latest issue and the online archive at www.bjr.boneandjoint.org.uk. Now in its second year and the official journal of EFORT, EFORT Open Reviews (EOR) is an open access journal publishing instructional review articles across the whole field of orthopaedics and traumatology. Articles from international experts across the orthopaedic specialties provide an authoritative resource for trainees as well as supporting practicing orthopaedic surgeons in keeping updated on the latest clinical and scientific advances. Read the latest articles online at www.efortopenreviews.org.
Completing the line-up of Bone & Joint Publishing’s open access journals, the Journal of Children’s Orthopaedics (JCO) is the official publication of the European Paediatric Orthopaedic Society (EPOS). JCO publishes articles with a focus on clinical practice, diagnosis and treatment of disorders unique to paediatric orthopaedics, as well as on basic and applied research. Read the latest issue plus the entire online archive at http://online.boneandjoint.org.uk/jco. At Bone & Joint Publishing, we hope you take full advantage of all the benefits that come with your online subscription to our collection of journals as part of your COA membership. If you have any questions about your access, please e-mail firstname.lastname@example.org and the team will be very happy to help you. *practicing in Canada
#nofilter Staying Out of Trouble on Social Media Tips for the Orthopaedic Surgeon James Yan, M.D. Harman Chaudhry, M.D., MSc Resident Physicians, Division of Orthopaedic Surgery, McMaster University Hamilton, ON
n today’s world of social media, physicians have never before been so connected with the social, cultural, and political world around them. Many medical practitioners - orthopaedic surgeons included - have used social media to enhance medical education, market their practices, draw new patient referrals, or to network and collaborate. Moreover, many have also pushed the boundaries of advocacy to positively influence social and political discourse. However, along with the benefits of this increased mainstream exposure, there comes the perennial risk of inadvertently offending, being misinterpreted, or of going ‘viral’ for all the wrong reasons. As more modalities and mainstream uses of social media evolve, orthopaedic surgeons must develop tactics to capitalize on the enormous potential of social media while mitigating the risks. Here we present some tips for orthopaedic surgeons to stay on top of the game.
Tip #1: Maintain professionalism in both personal and professional online profiles Social media has challenged the ability to compartmentalize our personal and professional lives. Sometimes the boundary between the personal and professional is obvious, such as when maintaining confidentiality of a specific patient encounter. But this is not always the case. For instance, for many residents and early-career surgeons, the advent of social media occurred during their secondary school or college years. While this has enabled them to be far more comfortable using these platforms, they may also be more accustomed to viewing these as part of their personal and social space. A recently published study that assessed publicly accessible Facebook profiles of American urology residents found nearly half (40%) of the profiles contained unprofessional material1. Orthopaedic surgeons, especially those with a public profile, or those looking to transition their existing personal profiles into professional ones, should curate and review previous posts to remove potentially unfavourable material.
COA Bulletin ACO - Summer / Été 2017
Training & Practice Management / Formation et gestion d’une pratique
(continued from page 49)
Tip # 2: Clear communication is key Another risk with using social media as a professional is having one’s words misinterpreted by the intended (or unintended) audience. We recommend strongly considering the wording of a message and how it can be interpreted before sharing information via social media (or even e-mail or text message) as these messages can easily be copied, forwarded, ‘screenshot-ed’, and shared elsewhere. Further, lacking the ability of conveying tone through the written word can lead to a message’s intent being misconstrued, particularly if comments are made with a sarcastic intent. One can easily be accused of being mean-spirited or, worse yet, a cyberbully through a literal interpretation without context. Media such as Twitter have added to this difficulty through character limits, which potentially convolute an author’s intended final message. One tactic ‘tweeters’ can use is to provide brief snippets with links to a blog or full article that further elaborates the reasoning behind their comments.
taining professionalism outside the workplace5. Understanding that social media has magnified the primacy of professionalism for everyone - both online and offline - is imperative.
Tip #3: Understand social media’s impact – even if you don’t actively participate The Colleges of Physicians and Surgeons throughout Canada have repeatedly emphasized that professionalism is expected of physicians both inside and outside the formal workplace setting2. Unfortunately, even with the application of tight controls to self-authored digital content, physicians must recognize that their personal lives can end up online without their knowledge or consent. Recent news reports bring this possibility into stark reality. Take, for example, the story of a resident trainee in Florida, whose actions outside the hospital setting were video-recorded and shared online, amassing over eight million views and ultimately leading to her dismissal from clinical duties3. Closer to home, allegations of cyber-bullying among physicians in Ontario were recently reported by the Toronto Star4 - a story which subsequently prompted a reminder from the College of Physicians and Surgeons of Ontario about main-
1. Koo K., Ficko Z., Ann Gormley E. Unprofessional content on Facebook accounts of US urology residency graduates. BJU Int. doi:10.1111/bju.13846.
Tip #4: Practice makes perfect Despite the risks, social media and e-communications have enormous potential and are among the growing number of tools that orthopaedic surgeons will be increasingly using in their practices. As a disruptive technology, they compel orthopaedic residents, young staff, and well-established senior surgeons to adapt rapidly, whether they choose to be active participants or not. Orthopaedic residents and surgeons are encouraged to hone their use of social media tools much like they sharpen their skills with the scalpel - through continual practice, reflection, and refinement towards perfection. References
2. Professionalism beyond the clinical encounter. https:// www.cmpa-acpm.ca/serve/docs/ela/goodpracticesguide/ pages/professionalism/Behaviour/respect_for_others-e. html. 3. Teproff C. Miami doctor suspended after video of her attacking Uber driver goes viral. Miami Hearld. January 21, 2017. 4. Boyle T. Ontario doctors ‘distressed’ over wave of bullying, infighting. Toronto Star. February 27, 2017. 5. Gerrace R. Bullying is never acceptable. MD Dialogue. 2017;13(1):7-8.
A Book Celebrating the History of Paediatric Orthopaedics
n 2017, the French Paediatric Orthopedic Society (SOFOP) celebrates its 40th anniversary.
To celebrate this event, a French book on the History of Paediatric Orthopaedics written by surgeons practicing in France, Switzerland, USA and Canada under the guidance of Pr. Rémi Kohler has been published by Sauramps Medical (see flyer on next page). To appreciate all the progress achieved in this field of orthopaedics, there is nothing better than taking a look back at how far we’ve come. DDH, club foot, scoliosis, bone tumours, trauma, limb length discrepancies as well as bracing are revisited: the good (and not so good ideas) show the development of this relatively young subspecialty.
COA Bulletin ACO - Summer / Été 2017
A chapter on the history of the scientific societies (EPOS, POSNA, SOFOP) describes how paediatric orthopaedics constantly raises the level of care for children. Visit : www.livres-medicaux.com or refer to the flyer on the next page to order a copy.
La Société Française d’Orthopédie Pédiatrique (SOFOP) fête en 2017 ses 40 ans. Notre Société a souhaité, pour cette occasion, éditer un livre anniversaire ayant pour thème « l’histoire de l’orthopédie pédiatrique ». Quoi de plus passionnant en effet que de pouvoir se retourner vers le passé et d’observer les progrès réalisés? Ce livre étudie l’histoire des pathologies auxquelles nous sommes quotidiennement confrontés : traumatologie, scoliose, pied bot, inégalités de longueur des membres inférieurs, luxation congénitale de la hanche, tumeurs osseuses, appareillage, handicap, etc. On pourra ainsi mesurer, au fil des chapitres, le cheminement des pensées depuis la reconnaissance de ces affections jusqu’aux progrès actuels ; de grands noms de l’orthopédie apparaissent ici et là, qui ont fait cette histoire. Certaines idées se sont avérées géniales -d’autres moinsmais le mérite de tous ces médecins, plus ou moins anonymes, aura été de vouloir progresser pour apporter toujours plus de confort et de guérisons aux enfants malades. Ainsi ce survol est-il une belle leçon d’humilité ! Les auteurs viennent d’horizons très différents : certains exercent en France, d’autres en Suisse, au Canada ou aux USA. Ils nous font partager leur vision de cette histoire, avec le recul rendu possible par leur expertise et leur expérience des sujets abordés. La coordination de l’ouvrage a été assurée par un lyonnais féru d’histoire de notre spécialité, Rémi Kohler, Professeur honoraire d’orthopédie pédiatrique ; il a suivi de près cette véritable épopée, récente, au cours de laquelle sont d’ailleurs nées les principales sociétés savantes consacrées à cette « hyperspécialité » (SOFOP, EPOS, POSNA). Nous le remercions vivement d’avoir mené à bien ce travail de mémoire. Professeur Jérôme Cottalorda Président (2017) de la SOFOP
UNE HISTOIRE DE L’ORTHOPÉDIE PÉDIATRIQUE sous la direction de Rémi Kohler Isbn : 979 103030 099 4 300 pages près de 200 illustrations mars 2017
table des matières Remerciements Préface (Jérôme Cottalorda) D’où venons-nous ? Qui sommes-nous ? (Henri Carlioz) Avant-propos (Rémi Kohler) Références générales Nicolas Andry de Bois-Regard ; l’inventeur du mot « orthopédie » (Rémi Kohler)
QuelQueS gRandeS PathOlOgieS
La luxation congénitale de la hanche : histoire de son traitement et de son dépistage (Rémi Kohler)
La maladie de Legg Calvé Perthes : une affection reconnue il y a un siècle mais encore mystérieuse (Rémi Kohler, Joël Lechevallier, Julien Leroux)
Histoire du traitement du pied bot varus équin (Rémi Kohler, Pierre Chrestian, Roger Parot, Franck Chotel)
Histoire du traitement de la scoliose (Rémi Kohler, Jean-Claude Rey, Richard Zayni)
Une histoire de l’orthopédie pédiatrique Histoire du traitement chirurgical des inégalités de longueur des membres inférieurs chez l’enfant (François Fassier)
Histoire des maladies osseuses constitutionnelles (Pierre Journeau, Eva Polirsztok)
Reconnaissance et traitement de l’ostéogénèse imparfaite (François Fassier) Histoire du traitement des tumeurs osseuses malignes de l’enfant (Gérard Bollini, Michel Panuel, Corinne Bouvier, André Nicolas, Xavier Muracciole)
Histoire du traitement des fractures chez l’enfant (Pierre Lascombes)
Histoire de l’appareillage en orthopédie pédiatrique (Philippe Fourny, Jérôme Cottalorda, Jean Paysant, Didier Pilliard)
Histoire du handicap à travers les âges et les civilisations (Jérôme Cottalorda, Vincent Gautheron)
leS SOCiétéS SavanteS
CREPO-GEOP-SOFOP : 40 années d’orthopédie pédiatrique française (Joël Lechevallier, Rémi Kohler) Histoire de l’EPOS (European Paediatric Orthopaedic Society) (Pierre Lascombes) Histoire de l’orthopédie pédiatrique nord-américaine (Canada et USA) et de la POSNA (Pediatric Orthopedic Society of North America) (Dennis R. Wenger, James D. Bomar) Epilogue : un passé plein d’avenir (Rémi Kohler)
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THE LARGEST GATHERING OF CANADA’S ORTHOPAEDIC COMMUNITY. JOIN US IN OTTAWA DURING CANADA’S 150TH ANNIVERSARY CELEBRATIONS.
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To learn more visit zimmerbiomet.com. Zimmer Biomet Canada, 2323 Argentia Road., Mississauga, Ontario. L5N 5N3 1. Nicoll, D. and Rowley, DI. Internal rotational error of the tibial component is a major cause of pain after total knee replacement. Journal of Bone and Joint Surgery (British) 92-B:1238-44; 2010. 2. Barrack, Robert L., et al. Component Rotation and Anterior Knee Pain After Total Knee Arthroplasty. Clinical Orthopaedics and Related Research. Number 392, pages 46–55. 3. Matsuda, et al. Effect of femoral and tibial component position on patellar tracking following total knee arthoplasty. American Journal of Knee Surgery. 14:152-156; 2001. 4. Bedard, M. et al. Internal rotation of the tibial component is frequent in stiff total knee arthroplasty. Clinical Orthopaedics and Related Research, Vol. 469, no. 8, pages 2346–2355; 2011. 5.Martin, et al. Maximizing Tibial Coverage Is Detrimental to Proper Rotational Alignment, CORR January 2014. 6.Dai, Y., et al. Anatomical Tibial Component Design Can Increase Tibial Coverage and Rotational Alignment Accuracy: A Comparison of Six Contemporary Designs. Knee Surg Sports Traumatol Arthrosc. 22:2911–2923; KSSTA 2014. 7.Indelli, et al. Relationship between Tibial Baseplate Design and Rotational Alignment Landmarks in Primary Total Knee Arthroplasty. Hindawi Publishing Corporation Arthritis. Volume 2015, Article ID 189294, 8 pages. 8. Jin, C., et al. How Much Does the Anatomical Tibial Component Improve the Bony Coverage in Total Knee Arthroplasty? The Journal of Arthroplasty. In Press 2017. Online http://dx.doi. org/10.1016/j.arth.2016.12.041. © 2017 Zimmer Biomet All content herein is protected by copyright, trademarks and other intellectual property rights owned by or licensed to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or in part, without the express written consent of Zimmer Biomet. This material is intended for health care professionals. Distribution to any other recipient is prohibited. For product information, including indications, contraindications, warnings, precautions, potential adverse effects and patient counseling information, see the package insert and zimmerbiomet.com. Not for distribution in France. Check for country product clearances and reference product specific instructions for use. The persons depicted in this advertisement are models and not actual recipients of Zimmer Biomet products. Zimmer, Inc., 1800 West Center Street, Warsaw, IN 46580, USA © 2017 Zimmer Biomet