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Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 111 Winter / Hiver 2015 COA / ACO Dr. Robin R. Richards President / Président Dr. John Antoniou Secretary / Secrétaire Mr. Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4150 Ouest, rue Sainte-Catherine West Suite 450, Westmount, QC H3Z 2Y5 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Dr. Marc Isler Editor-in-Chief / Rédacteur en chef Dr. Peter Lapner Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

Access to Orthopaedic Care in Canada Robin R. Richards, M.D., FRCSC President, Canadian Orthopaedic Association

ince my last COA Bulletin message to the membership, the Annual Meetings of the South African, British, Australian and New Zealand Orthopaedic Associations have taken place. It has been an honour and a privilege for Barb and I to represent the COA at these meetings. We have met many friends, old and new, and been reminded time and again of Canada’s leadership in the orthopaedic world. I have learned that many of the challenges we face with respect to training, human resource planning, quality of care and leadership are similar to those faced by our international colleagues. I have also learned that the public/private hybrid systems that exist in the abovementioned countries provide a credible level of access to orthopaedic surgical care. Elizabeth Church, writing in the Globe and Mail on November 10, 2015, reported that “Ontario patients lack immediate access to family doctors when sick”. A report by Health Quality Ontario (HQO) revealed that less than one-half of Ontario residents can get an appointment with their primary care provider within 48 hours when sick. Dr. Joshua Tepper, CEO of HQO, stated that the report provides a “flag” for problem areas since primary care is the gateway to the rest of the system. Wait times for diagnostic scans and surgery are posted on a government web site in Ontario. The wait time posted for a MRI where I work is 234 days. The provincial wait times for lumbar disc surgery, forefoot surgery and total knee replacement are 314, 220 and 219 days respectively. Given that these times represent the time after patients have waited for a surgical consultation, it would not be unreasonable to ask if these access times are acceptable? Canadians pay for our cherished health care with high taxes. Unfortunately, when the wait for non-urgent musculoskeletal care is examined - it is evident that access is delayed. Your Executive has developed a position statement on Access to Care. This statement clearly advocates for timely access to orthopaedic care. Assuming that the statement is ratified by the COA Board at its Mid Winter Meeting in early January, it will subsequently be distributed to the membership so that we can inform our patients and advocate on their behalf. Hopefully patients themselves will be more vocal in advocating for timely access. I was recently a faculty member at a shoulder surgery course in Las Vegas. The two Canadian faculty members (Dr. Mike McKee and myself) are restricted in the number of shoulder arthroplasties that can be performed on an The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450, Westmount, Quebec, H3Z 2Y5. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450 Westmount, Quebec, H3Z 2Y5

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

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

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

COA Bulletin ACO - Winter / Hiver 2015

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annual basis for budgetary reasons. I am not able to book another shoulder arthroplasty this fiscal year. Needless to say, this situation was somewhat mystifying to our American colleagues. Andre Picard, writing in the Globe and Mail on November 10, 2015 (“Honest talk about private health services in long overdue”), states that “Even the most ardent supporters of Medicare will grudgingly admit that a public health insurance plan cannot and should not pay for everything for everyone”. Eric Hoskins, Ontario’s Minister of Health and Long-term Care stated in a speech to the Empire Club on February 2, 2015 that every decision he would make as Minister would be centred on considerations of ensuring universality, improving access and delivering the highest quality of care. While such rhetoric is reassuring, the day-to-day reality with respect to access to orthopaedic care in Canada suggests that it is often delayed and we need to strongly advocate on our patients’ behalf for timely access to orthopaedic care. I trust that you are making plans to attend the Annual Meeting next year in Québec City. The meeting promises to be a great learning experience in a historic venue and represents a chance to learn, network and meet friends old and new! The pre-registration fee is included in your membership dues if you are an Active member of the COA. The Program Committee, led by Drs. Etienne Belzile and Mélissa Laflamme, met last month and is in the process of putting together an outstanding educational program. We received an astonishing number of abstract submissions this Fall! We would like to thank all of

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 27 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 43 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 52 our members who submitted research for presentation at this event. Notifications will be sent out shortly and more information about the scientific and social programs will be available in the New Year. Barb and I would also like to take this time to wish you and your loved ones a safe, healthy and happy Holiday Season. You are always welcome to reach me directly (robin.richards@sunnybrook.ca) at any time. I look forward to seeing you all again in 2016.

Accès aux soins orthopédiques au Canada Robin R. Richards, MD, FRCSC Président, Association Canadienne d’Orthopédie

epuis mon dernier mot à l’intention des membres dans le Bulletin de l’ACO, les congrès annuels des associations d’orthopédie d’Afrique du Sud, de Grande-Bretagne, d’Australie et de Nouvelle-Zélande ont eu lieu. Ce fut un honneur et un privilège pour ma conjointe, Barb, et moi d’y représenter l’ACO. Nous y avons rencontré beaucoup d’amis, nouveaux et anciens, et on nous a rappelé à maintes reprises le rôle de leader du Canada en orthopédie sur la scène mondiale. J’ai constaté que beaucoup des difficultés que nous éprouvons ici en matière de formation, de planification des ressources humaines, de qualité des soins et de leadership s’apparentent à celles que rencontrent nos collègues étrangers. J’ai aussi appris que les systèmes hybrides, qui marient secteurs public et privé, dans les pays susmentionnés fournissent un niveau crédible d’accès aux interventions orthopédiques. Elizabeth Church rapportait le 10 novembre 2015 dans le Globe and Mail que les patients ontariens n’ont pas un accès immédiat à un médecin de famille quand ils sont malades. Un rapport de Qualité des services de santé Ontario (QSSO) indique que moins de la moitié des résidants de l’Ontario peuvent obtenir un rendez-vous avec leur fournisseur de soins primaires dans les 48 heures quand ils sont malades. Le Dr Joshua Tepper, COA Bulletin ACO - Winter / Hiver 2015

président et chef de la direction de QSSO, a déclaré que le rapport fait ressortir les secteurs problématiques, puisque les soins primaires constituent la porte d’entrée du système de santé. Les temps d’attente pour les tests diagnostiques et les chirurgies sont affichés sur un site Web du gouvernement de l’Ontario. Le temps d’attente affiché pour une imagerie par résonance magnétique (IRM) dans l’établissement où je travaille est de 234 jours. Les temps d’attente provinciaux pour une chirurgie discale lombaire, une chirurgie à l’avant-pied et une arthroplastie totale du genou sont respectivement de 314, 220 et 219 jours. Puisque ces temps d’attente s’additionnent à l’attente pour une consultation en chirurgie, il me paraît normal de nous demander si de tels temps d’attente sont acceptables. Les Canadiens paient un impôt élevé pour financer notre précieux système de santé. Malheureusement, quand on s’attarde aux temps d’attente pour les soins de l’appareil locomoteur non urgents, il est évident que l’accès à ceux-ci est différé. Le Comité de direction de l’ACO a rédigé un énoncé de position sur l’accès aux soins orthopédiques, clairement en faveur d’un accès rapide aux soins. Advenant l’adoption de cet énoncé par le conseil d’administration de l’ACO à la Réunion d’hiver, début janvier, il sera transmis aux membres afin qu’ils puissent aviser les patients de cette position et la promouvoir en leur nom. Nous espérons que les patients se feront eux aussi entendre davantage sur cette question. J’étais jusqu’à récemment membre du corps professoral responsable d’un cours en

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chirurgie de l’épaule à Las Vegas. Les deux membres canadiens de ce corps professoral, soit le Dr Mike McKee et moi-même, ne peuvent procéder qu’à un nombre limité d’arthroplasties de l’épaule par année pour des raisons budgétaires. Je ne peux donc plus en faire d’ici la fin de l’exercice. Il va sans dire que nos collègues américains sont pour le moins perplexes face à une telle situation. André Picard affirmait le 10 novembre 2015 dans le Globe and Mail (« Honest talk about private health services in long overdue ») que même les plus fervents défenseurs du régime d’assurance-maladie admettent à contrecœur qu’un régime public ne peut pas et ne devrait pas payer pour tout et pour tout le monde. Eric Hoskins, ministre de la Santé et des Soins de longue durée de l’Ontario, a déclaré dans un discours à l’Empire Club, le 2 février 2015, que toute décision qu’il prendrait en tant que ministre serait axée sur le besoin d’assurer l’universalité, d’améliorer l’accès et d’offrir des soins de la plus grande qualité. Bien que ce genre de déclarations soient rassurantes, la réalité en matière d’accès aux soins orthopédiques au Canada montre qu’il y a souvent des délais et qu’il faut militer pour un accès rapide à ces soins pour nos patients.

J’espère que vous vous préparez déjà à la Réunion annuelle 2016 de l’ACO, à Québec. Ce devrait être une belle expérience professionnelle, dans un cadre historique, et une excellente occasion d’apprendre, de réseauter, de revoir de vieux amis et de faire de nouvelles rencontres! Les droits d’inscription sont inclus dans la cotisation annuelle de tous les membres actifs de l’ACO s’ils s’inscrivent à l’avance. Le Comité responsable du programme, sous la houlette des Drs Étienne Belzile et Mélissa Laflamme, s’est réuni le mois dernier et travaille à l’élaboration d’un formidable programme de formation. Et nous avons reçu un nombre hallucinant de précis cet automne! Nous souhaitons remercier tous les membres qui ont soumis le fruit de leurs recherches en vue d’une présentation à cette manifestation. Les avis connexes seront envoyés sous peu, et de plus amples renseignements sur les programmes scientifique et d’activités sociales seront diffusés au début de la nouvelle année. Barb et moi souhaitons aussi profiter de l’occasion pour vous souhaiter, à vos proches et à vous, une période des Fêtes empreinte de bonheur et en toute sécurité! Enfin, sachez que vous pouvez toujours me joindre directement à robin.richards@sunnybrook.ca. Au plaisir de vous revoir en 2016!

COA Global Surgery Committee Honours Dr. Spencer McLean

ife is not always fair. In June 2013, when Spencer McLean and Christina Frangou should have been preparing for the move to start Spencer’s orthopaedic trauma fellowship at UC Davis, Christina was instead preparing for Spencer’s funeral. Spencer died of complications of renal cancer agonizingly quick and unfairly young. On that day, our orthopaedic community lost a future great. Spencer had all the qualities to succeed and thrive. He had the basics: he was smart, technically able, well-trained and hardworking. But more importantly, he was insightful, passionate, enthusiastic and had a genuine innate empathy for patients and their families. Spencer’s death was a painful, tragic loss that should remind us all of the fragility of life and make us reflect on what we have achieved in our own lives. It certainly has for me. It should motivate us to be better surgeons, better colleagues, better spouses and better parents. -Dr. Paul Duffy, Calgary Team Broken Earth is establishing the Dr. Spencer McLean Travel Fellowship in Orthopaedic Trauma, which will bring a senior Haitian orthopaedic surgery resident to Canada for several months of training. Anyone wishing to donate to the fellowship can do so by visiting the Team Broken Earth web site at www.brokenearth.ca and clicking on ‘Donate Now’. Please make your donation in honour of Dr. Spencer McLean. The following is a reprint of an article written by Spencer’s wife, Christina Frangou, shortly after his death.

Dr. Spencer McLean and wife, writer Christina Frangou

COA Bulletin ACO - Winter / Hiver 2015

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Love Without Borders: Widow Follows Surgeon-husband’s Footsteps to Haiti Christina Frangou Calgary, AB

Editor’s note: Story originally published in Swerve magazine on November 5, 2013 (re-printed with permission)

t’s twilight in Port-au-Prince. I’m standing outside the emergency department at Hospital Bernard Mevs, Haiti’s only trauma and critical-care centre. Police officers rush by, long guns at their sides, as they carry in a wounded colleague. Behind me, I hear people trying to help a four-year-old girl who is having a seizure after falling off a building. Someone asks if we brought any body bags from Canada. A patient has died in the CT scanner. I think back to the e-mail my husband sent me when he was sitting in almost the same spot 10 months before. “It’s an eyeopening place, love, [one] that I would come back to again in an instant!!” He couldn’t come back so I came in his place. Five hours and 118 days earlier, my husband, Dr. Spencer McLean, died of complications from Stage IV kidney cancer. He was the best person I’ve ever met – a strong, hilarious man with a quick wit and kind heart. Spencer could go from straight face to full grin faster than anyone. It was his secret weapon. You’d be hit with that grin and suddenly, no matter what was going on, you felt at ease. At his funeral, someone wisely called him a “magician of life.” He used to come home from a night of call, crawl into bed, take my hand and whisper to me, “This, right now, is my favourite moment of the day.” He was diagnosed May 8 and died June 24. He died in the same week that he finished his orthopaedic surgery residency. His funeral was held the day we were supposed to leave for California to start his fellowship in orthopaedic trauma. He was 36 years old. Everything happened fast. Like an earthquake. One minute our life together was there; the next, it was gone. I am in Haiti’s capitol city now because Spencer spent a week at Hospital Bernard Mevs in January. He volunteered with Team Broken Earth, a Canadian non-profit started by Newfoundland orthopaedic surgeon Andrew Furey to continue the relief effort in Haiti following the catastrophic earthquake here in 2010. Broken Earth sends teams of Canadian health-care workers to Haiti for a week at a time, living and working at Bernard Mevs. They arrive as a complete surgical and emergency-care unit, COA Bulletin ACO - Winter / Hiver 2015

Empty makeshift wheelchairs outside Hospital Bernard Mevs during a visit by Team Broken Earth Calgary

and they try to fulfill some of the enormous burden of unmet surgical needs, educate local medical staff and contribute to building a sustainable health-care system throughout the impoverished country. Full disclosure: both Spencer and I (yes, I still use present tense and plural) believe strongly in Broken Earth and have raised funds for it. After Spencer passed away, I asked for donations in his memory to be directed to the organization. Spencer’s colleagues invited me to join them on this trip. They hope that, somehow, amid the chaos of the trauma centre, all of us might find some healing. There is nothing cushy about a Broken Earth mission: you live and breathe the madness of the hospital around the clock. It requires teamwork, camaraderie and very long hours. Two of the OR nurses on the Calgary team showered at night and slept in clean scrubs so they could quickly get up and go when called. That’s how round-the-clock things are. If you have dirty clothes, you hand-wash them yourself, just like the woman who hand-washes all of the hospital’s laundry in the gravel lot behind the dorms. It’s an intense place for anyone. I arrive with the 33-member team from Calgary at the Port-auPrince airport on a Saturday afternoon. Chaos reigns as we hunt for our duffle bags, jammed with everything from prosthetic legs to simulation babies used for teaching. People pull at bags, luggage rips open, someone shouts for baggage-claim receipts. Behind the melee, Scott Gillenwater, an American physiotherapist who arrived after the earthquake and stayed to become hospital coordinator, grins. He’s accustomed to bedlam. Before we’re past the airport doors, he shows the team a picture on his cellphone. It’s an image of a teenage girl who is waiting back at

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the hospital. A massive tumour has exploded on the lower half of her face, obliterating everything, including her mouth. “We hit the ground running,” says Dr. Paul Duffy, team leader and orthopaedic surgeon from Foothills Hospital who has volunteered in Haiti twice. The hospital is unlike any I’ve seen. High cement walls topped with razor wire encircle Bernard Mevs. Armed men guard the tall, orange gates; patients seek their approval to be admitted onto the grounds. Inside is the temporary triage tent. Patients wait there all hours, day and night, sometimes sleeping on the ground. A new triage unit is slated to open at the end of November, its newness incongruent beside the dinged-up hospital that somehow survived the earthquake. After the quake, the Haitian-owned private hospital became part of Project Medishare, a program from the University of Miami dedicated to Nurse Deanna Gorman checks in on a patient in the paediatric unit improving health care in Haiti. B.C. It took another two years but that’s exactly what we did on September 4, 2010. By First World standards, the hospital is dirty and disorganized. It consists of a series of small, blocky buildings: a tiny, poorly I don’t have the space or the strength to tell you how deeply stocked pharmacy, a shiny new paediatric ICU, a one-room we loved each other in our six years together. I will tell you this: emergency department. In one, Wilfrid Macena runs a prosa few weeks after he passed away, I was searching through old thetic lab. Wilfrid, a grinning former welder who lost his leg in receipts. In them, I found the password he’d set up for the lock the earthquake, manages teams of amputee football players he bought for his laptop on his trip to Haiti. I’d never seen the when he is not at the hospital. In another, amputees make password before. It was one word, in lower case: ilovemywife. clothing like uniforms for school kids. Carl, one of the sewers, was a rising star in Haitian basketball, “the Michael Jordan of Even in death, he overwhelms me. Haiti,” says Dr. Joanna Cherry, a doctor from the UK who cofounded Project Stitch. Carl lost the use of his legs when he was We delighted in being married to one another. We laughed a shot. Gun violence is rampant in Haiti. lot. We shared one set of dreams. That’s all gone now. My life as I knew it suddenly doesn’t exist anymore. A rupture in the All of Bernard Mevs would easily fit into one-third of the main earth. I don’t know what to do with my career, or if I should parking lot at Foothills Medical Centre. stay in Calgary. After a quick orientation, the first shift of Broken Earth physiI am quite lost without him. cians and nurses yank on their scrubs and head to work. The rest set about sorting beds and tacking up mosquito nets. We’ll There is little time for reflection as a wounded police officer sleep in bunk beds in four bedrooms, down the damp corridor arrives the first night. from the emergency department. At night, we hear all the commotion from the unit. One afternoon, I find a chicken wanderFor Team Broken Earth Calgary, he remains one of the unforing along our hallway. gettable characters of this trip. The thirty-something, whose name I cannot use for security reasons, was chasing a thief who We are 33 people and 26 beds. One team member will sleep suddenly stopped, turned around and shot the officer through on a pile of duffle bags on the floor. Married couples bunk two the chest. to a bed. Secretly, the shared accommodations stress me out. I suffer terrible nightmares of late. Several times a week, I wake In the first minutes, he appeared remarkably well, sitting up up shouting for Spencer. In one recurring dream, I am stranded and talking. Things changed fast as he began losing blood. Lots somewhere on a ski hill. I know he is nearby, but I’m missing of blood. Dr. Antoine Fortier, the team’s French-speaking surgisome vital piece of equipment that I need to get to him. I call cal oncology fellow, and plastic surgeon Fred Loiselle decided for him. That’s how I wake myself up. the officer needed to go to the operating room or he would die. Spencer and I met while skiing when he was in medical First, they had to get him to the X-ray hut. They squeezed the school. Our first date was the most comfortable, easy date stretcher through a maze of beds in emergency and found I’ve ever had. Six weeks later, he casually suggested we get themselves at a gravelly, bumpy ramp at the back. The IV poles married at a cat-skiing lodge outside his hometown of Fernie, COA Bulletin ACO - Winter / Hiver 2015

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wouldn’t attach to the stretcher so Fortier hung onto one with each hand. They bumped their patient along the dirt path, the officer shouting in pain with each bounce. Then, they gathered up speed and pushed him up another bumpy ramp to X-ray. “I thought, ‘Wow, is the whole week going to be like this?’” Fortier says later. Another complication: Bernard Mevs lacks a blood bank, and that night only one unit of blood was available. Hospital staff hunted down the officer’s family and sent them in to donate blood. The whole process took about three hours. “In Canada, you’d make sure you went to surgery like that,” says Fortier, snapping his fingers. “I was concerned that if we couldn’t move faster, he would die.” The officer underwent an emergency thoracotomy that night. Fortier said later that the police officer would not have survived if he’d Ilenie Padieu and Thomas Iwalla build a corset that will help correct a young girl’s spine arrived one night earlier. Broken Earth founder Furey calls moments like these “little wins.” All the little wins, he says, add up. For the police officer’s family, who sat at his side in the hospital courtyard over the next few days, this was no little win. It was everything. And so went the first 12 hours in Haiti. The next morning, we wake to patients lined up around the hospital. Word had been spread to rural villages, telling people that a specialty surgical team was coming. Many came by bus and some will wait all day to see a doctor or physiotherapist. A few tell us they have fasted in hopes that they might undergo surgery before nightfall. They suffer all kinds of injuries: adults with enormous tumours, quite rare in developed countries but not uncommon in Haiti; people with neglected injuries from the earthquake; kids with fractures that were never properly fixed. One child sports three wires sticking out of his lower leg—the remnant of some kind of rudimentary orthopaedic treatment. “I don’t even know what that is,” says one of the surgeons when he sees it. I tag along with orthopaedic surgeons Duffy and Ian Le, two of Spencer’s mentors. One Haitian brings in his son, a 12-year-old born with clubfeet. Dr. Le explains the surgery that he can do. The father nods. Le outlines the risks, including a small risk of infection and a smaller risk of amputation. The father balks. The word amputation is too much. I see many people with leg amputations at the hospital over the next seven days. Their stories remind me of a quote from the author C.S. Lewis, who lost his wife to cancer. Lewis wrote that losing your spouse is like having a leg amputated. The stump will always hurt, often badly. Time may heal the wound but your life will never be the same. You will walk again but only with crutches or a prosthetic leg. You will “never be a biped again,” he said. COA Bulletin ACO - Winter / Hiver 2015

It is the most accurate description of widowhood that I have read. Some of the injuries the surgeons see that morning-particularly recent injuries, known as “fresh trauma” – are no different than what they’d see back at home, says Le. But he’s never seen patients with injuries that date back years, or people who have undergone multiple failed operations. Everything else is different, too, he says. “When someone asks you how to keep a wound clean outside, I don’t know how you keep it clean when you don’t have a roof over your head.” I pop my head into the operating room. The only time I have ever seen my husband working as a surgeon is in the many photos taken in this room. I’ve looked at the pictures so many times that I know by heart the tile pattern in the wall. Broken Earth is making a plaque for Spencer that will hang nearby. Spencer wasn’t someone who always wanted to be a doctor. He wanted to be a pilot. His colour blindness killed that plan. So my sports-loving husband decided to study kinesiology instead. He started out his university career at McGill but came back west after one semester. He missed the mountains too much. Medicine followed naturally from there. From the first time he stepped into an operating room, Spencer was smitten. He thrived on the camaraderie in the OR. He liked the physicality of orthopaedic surgery. He loved the way surgery offers a visible solution to a problem: a patient can walk after being confined to a bed for months. Surgical residency is a long and difficult five years. Sometimes we went days without seeing each other. Still, we squeezed as much life into residency as we could. Countless mornings I picked him up from the hospital after a night of call. I’d bring

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our skis in the back of the truck so we could head straight to the mountains. We counted down the milestones throughout residency. Four years to go. Two years. Six months. Five days before the official end date of residency, Spencer was gone. In an act of incredible compassion, someone from the Royal College of Physicians and Surgeons of Canada flew to Calgary before he passed away to award him his papers in the hospital. That day was one of the happiest and one of the saddest of my life. It takes several days in Haiti before I can stay in the operating room for any length of time. One afternoon, the team travels to Port-auPrince’s general hospital to see patients who might be suitable candidates for surgery. One wing looks like a birthday cake that someone has smashed a fist through. The earthquake shattered much of the hospital, burying 100 Husband and wife team of John and Kelly Arraf hold the hands of Dashkar, 14, as anesthesiolnursing students and faculty. The damaged ogy resident Tiffany Rice starts anaesthesia portion is closed off, the remainder is still in Andrea Boone, an emergency physician from Foothills Medical operation. Centre, says people everywhere know what it is to grieve and feel loss. Dr. Boone has worked in the Central African Republic, We walk through the orthopaedic wards. Each room contains a the Congo and Botswana, as well as Haiti. “Loss is loss. Grieving dozen or so beds, and in each lies a patient, usually surrounded and suffering are part of being human. No matter where you by family. As we enter, patients hold out the X-rays that they are in the world, whether you lose your baby to malaria in keep at their beds. Many have been waiting years in the hosAfrica or complex congenital heart disease in Canada, the unipital. One 29-year-old man with an injured leg has been here fying human experience is grief, sadness and suffering.” for three years. Just waiting. Several surgeons tell me they are struck by how many of these patients do not need to remain Bernard Mevs’ emergency department fluctuates between in hospital. Perhaps they stay because they have nowhere else moments of quiet and moments of frenzy. At times, the doctors to go. find it uncomfortably still, especially in the dead of the night. Many Haitians refuse to go anywhere, even the hospital, after The orthopaedic team will select five or six patients to operate dark. on over the next few days. “What gets me is that every single person here could use an operation,” says Dr. Duffy. “You want Some days, so much drama happens in emergency that the to focus on the people you have helped but you can’t forget activity spills out the doorway and people stand watching the all the rest.” In the general surgery ward, the surgeons have commotion. Among the things doctors will see during the 15 minutes to select the handful of patients most in need. The week: a girl who was shot in the head by her father, a teeny ward is so devoid of colour that to stand at the entrance is like preemie with dislocated knees, a parade of kids and adults who looking at a black-and-white photograph. But the heat and the have fallen off ‘tap-taps,’ the brightly coloured vans crowding smells slap your face, a stark reminder that this is real. The team the streets of Port-au-Prince. rifles through a stack of charts to find out everything they can about these patients’ cancers. One night, a 53-year-old Haitian arrives at emergency with an intracranial bleed. His sister is part of the small class of paediatAs I look around the room, I’m struck by the same expression ric residents who are just a few weeks into their training. She is on the faces of family members. It’s written across the faces of on call when her brother arrives that night. two daughters whose mother is told she will need a mastectomy, and on the face of a mother who watches her pitiably The emergency team does everything they can to give the man thin teenage son sleeping as an IV drips chemotherapy into care that would be the standard in Canada: airway protection, his body. management of blood pressure if needed and an emergency CT scan of his head. But they can’t get a CT scan after hours at I know this look well. It is the terror of being faced with losing the hospital. Boone struggles with whether to send the man the person that you love the most. It doesn’t matter if you are in an ambulance, along with a member of the staff, to another lying on a mattress in the back of a breast-cancer clinic in Porthospital in the middle of the night—a huge risk in a city infaau-Prince or in a private room at Foothills Hospital. The feeling mous for its nighttime shootings. is the same.

COA Bulletin ACO - Winter / Hiver 2015

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That afternoon, the patient’s brother and father approach Ian Wishart, another of Broken Earth’s emergency physicians. They ask him if there’s anything more that could be done. He tells them, “you’ve done more than anyone.” The man is extubated and dies soon after. Dr. Wishart says later that he saw the family before they drove away. He walked up to the car. The resident put her hand up to the window and nodded at him. Wishart put his hand against the glass from the other side. “When I think back to this week, so many of my memories are moments like that,” he says. “It’s a lot of touching hands, holding hands. That’s what always stays with you.” Sometimes, I hear crying around the grounds of Bernard Mevs. We were warned in an orientation session that Haitians grieve in a very physical, demonstrative way. They wail Drs. Paul Duffy and Spencer McLean on a Team Broken Earth trip to Haiti or shriek or throw themselves on the ground. Sometimes, they do all three and more. When I hear loud cries, By week’s end, Broken Earth Calgary had performed 45 surgerI marvel at the energy that people can muster in grief. ies and treated unknown numbers of patients in emergency and physiotherapy. In my first moments after Spencer stopped breathing, it felt like I stopped inhaling, too. Everything was perfectly, horribly still. Seven days of hard medical work will not change Haiti but it I held his hand, put my head onto our arms and cried quietly. I does a make difference, says Duffy. “We can’t change the world whispered to him, over and over, “You were supposed to stay but we can change some people’s worlds.” with me.” One day, we meet Esther King at Bernard Mevs. Originally from B.C., Esther and her husband Frank moved to Haiti after the earthquake and now they run Tytoo Gardens, a medical clinic and orphanage a little more than an hour away from Port-auPrince. King brings 14-year-old Dashkar Verizon to Bernard Mevs, hoping someone can do something for her clubfeet. Dashkar was dropped off at an orphanage when she was an infant. Now, a tall and thin teenager in a bright sundress and frilly socks, her feet curve in so much that she shuffles along on the outside of her ankles. Painfully shy, Dashkar avoids eye contact. On the day of her surgery, Dr. Le performs a bilateral tissue release on both feet, loosening the taut tendons that pull her ankles inward. Her legs are casted; one yellow, one white. A few days later, Broken Earth volunteers visit the orphanage. Dashkar is lying on a sunbed outside when we arrive. She’s delighted with the gift of bright markers and a Barbie. For the first time in our three meetings, she smiles. It’s another little win.

COA Bulletin ACO - Winter / Hiver 2015

My husband wanted to come back to Haiti to change some people’s worlds. He couldn’t come back so I came in his place. I didn’t change anyone’s world. But I did learn something. Wherever we are in the world, we are all desperate to save the people we love the most.

Your COA / Votre association

The Next Generation of COA Members Rises to the Challenge Trinity Wittman Manager of Development and Advocacy Canadian Orthopaedic Association

he Canadian Orthopaedic Residents’ Association (CORA) Board is made up of resident representatives from each of the 17 Canadian orthopaedic programs, appointed annually by their respective Program Directors. To fulfill the mandate of serving resident colleagues, defining focal issues and guiding the COA in planning programs, the CORA Board meets face-to-face at the COA Annual Meeting and by teleconference throughout the year. The CORA Board encourages residents to get involved with research projects in their own programs and across Canada. If you have a successfully approved protocol and would like to seek support from residents in other programs, please contact your program’s CORA Board representative. The 2016 CORA Annual Meeting takes place the day prior to the COA Annual Meeting, and will be hosted on June 16, 2016 at the Hilton Québec City by CORA Co-Chairs, Drs. Pierre-Luc Blouin and Simon Corriveau-Durand from Université Laval. Highlights include a hot-topics symposium on ‘Leadership in Orthopaedics’, a paper session featuring exclusively Canadian resident research, and a social evening at Bistro l’Atelier. For more information about the meeting, please visit www.coraweb.org. All residents are invited to attend, and

attendance is free for residents who are COA Associate members. Please encourage your resident colleagues to fill in a free membership application by visiting http://coa-aco.org/ and clicking on ‘About the COA’. Don’t forget to submit your abstracts by January 31! Residents are on a roll! Based on increasing interest from Associate members in advocacy and current issues, the COA is adjusting the committee slate to include Resident Liaison positions on COA committees. This new initiative will lend a louder voice to Canadian residents, and will allow Associate COA members to stay in touch with the outstanding work being done by COA Active members. The CORA Board will elect representatives for each committee on an annual basis. Please join us in congratulating our new resident committee members! The CORA Board hopes to keep lines of communication open among Canadian residents, so do not hesitate to get in touch! To reach us or for more information about CORA, please contact Trinity Wittman at trinity@canorth.org.

La nouvelle génération prend le relais Trinity Wittman, Directrice du développement et des activités de défense des droits Association Canadienne d’Orthopédie

e conseil de l’Association canadienne des résidents en orthopédie (ACRO) est composé de résidents représentant chacun des dix-sept programmes d’orthopédie au Canada, et nommés par leur directeur de programme. Afin de concrétiser le mandat de l’ACRO, qui est de servir les résidents, de définir les enjeux centraux et de guider l’ACO dans la planification des programmes, le conseil se réunit pendant la Réunion annuelle de l’ACO, et par téléconférence le reste de l’année. Le conseil incite les résidents à prendre part à des projets de recherche dans le cadre de leur programme et ailleurs au pays. Si vous disposez d’un protocole approuvé et aimeriez obtenir le soutien de résidents d’autres programmes, n’hésitez pas à communiquer avec le représentant de votre programme au sein du conseil de l’ACRO.

La Réunion annuelle de l’ACRO aura lieu la veille de la Réunion annuelle de l’ACO, soit le 16 juin 2016, au Hilton Québec, et sera pilotée par les Drs Pierre-Luc Blouin et Simon Corriveau-Durand, de l’Université Laval. Parmi les faits saillants de la Réunion, il y aura un symposium sur des sujets chauds, consacré au leadership en orthopédie; une séance de présentation de précis réservée exclusivement à des projets de recherche menés par des résidents canadiens; ainsi qu’une soirée au Bistro L’Atelier. Pour de plus amples renseignements sur la Réunion, consultez www.coraweb.org. Tous les résidents sont les bienvenus, et l’inscription est gratuite pour les membres associés de l’ACO. Merci d’inciter vos collègues résidents à devenir membres de l’ACO. C’est gratuit! Il suffit de remplir la Demande d’adhésion fournie sur le site Web de l’ACO, à www.coa-aco.org/fr (cliquez sur « Qui nous sommes »). Et n’oubliez pas de soumettre vos précis d’ici le 31 janvier!

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Les résidents ont le vent dans les voiles! Vu l’intérêt croissant des membres associés pour la défense des droits et intérêts et les enjeux actuels, l’ACO procède à la modification de la composition de ses comités de sorte à y inclure un poste de représentant des résidents. Cette nouvelle initiative renforcera la voix des résidents canadiens, en plus de permettre aux membres associés de l’ACO de rester au courant du travail remarquable accompli par les membres actifs. Une fois l’an, le conseil de l’ACRO élira un représentant pour chaque comité. Veuillez vous joindre à nous pour féliciter nos nouveaux représentants au sein des comités!

Le conseil de l’ACRO favorise les échanges entre résidents canadiens; il ne faut donc pas hésiter à communiquer avec ses membres! Pour joindre le conseil ou obtenir de plus amples renseignements sur l’ACRO, écrivez à Trinity Wittman, à trinity@canorth.org.

6 Reasons to Follow the COA on Twitter

Six raisons de suivre l’ACO sur Twitter

1) Event announcements and deadlines • Let us remind you to submit your abstracts, register for COA and subspecialty meetings, apply for fellowships, and more.

1) Annonces et dates limites • Recevez des rappels sur la soumission de précis, l’inscription aux réunions de l’ACO et des sociétés des sous-spécialités, la soumission de candidatures aux bourses et plus encore.

(and Win Free Tickets to the COA Gala)

2) Contests • Tweet about the 2016 COA/CORA/CORS Annual Meeting using the hashtag #COAQuebec2016 for a chance to win two free tickets to the COA Gala at Espaces Dalhousie at the Port of Québec on Saturday, June 18, 2016. Contest deadline is April 29, 2016. 3) Job postings • Hard to find work? Keep your finger on the pulse. If you’re hiring, don’t forget to reach out to the COA to advertise the position. 4) Inspire colleagues • We are proud to support our members. Send us news from your orthopaedic community for re-tweeting.

(comme des billets gratuits pour le Souper-réception de l’ACO)

2) Concours • Envoyez des gazouillis sur la Réunion annuelle 2016 de l’ACO, de l’ACRO et de la SROC avec le mot-clic #COAQuebec2016 et courez la chance de gagner deux billets gratuits pour la Soirée-réception de l’ACO aux Espaces Dalhousie, dans le port de Québec, le samedi 18 juin 2016. Le concours prend fin le 29 avril 2016. 3) Offres d’emploi • Difficile de trouver du travail? Prenez constamment le pouls du milieu. Si vous embauchez, n’oubliez pas d’en aviser l’ACO pour qu’elle annonce votre poste.

5) Join the conversation • Share comments on hot-button issues in health and MSK care.

4) Sources d’inspiration • Nous sommes fiers de soutenir nos membres. Communiquez-nous les dernières nouvelles sur votre communauté orthopédique et nous les transmettrons à la twittosphère.

6) Live updates on-site • Stay in the know with real-time announcements from the Annual Meeting and other events.

5) Participation à la conversation • Faites connaître votre opinion sur les sujets chauds touchant les soins de santé et de l’appareil locomoteur.

Tweet! Tweet! We’re waiting to hear from you at @CdnOrthoAssoc.

6) Mises à jour en direct, sur place • Soyez avisé en temps réel de toute annonce sur la Réunion annuelle et d’autres manifestations. À vos claviers, c’est le temps de gazouiller! Nous attendons de vos nouvelles, à @CdnOrthoAssoc.

COA Bulletin ACO - Winter / Hiver 2015

Your COA / Votre association

What’s New at the 2016 Annual Meeting?

he COA Annual Meeting continues to evolve with the needs of its membership. Pre-registration fees now included with your Active member dues, early housing options as well as new and innovative program components are just some of the exciting new features being offered at the Québec City meeting next June. Put the Dates in Your 2016 Calendar Next year the COA Annual Meeting takes place from Thursday evening on June 16, beginning with the Opening Ceremonies at 17:30 and runs through until Sunday, June 19 early afternoon. More detailed preliminary program information will be available on www.coaannualmeeting.ca shortly. CHANGE in Pre-registration Fees If you are an Active member of the COA, your Annual Meeting pre-registration fees are now included in your annual membership dues. Remember to first pay your 2016 and any outstanding dues invoices in your account before you register for the Annual Meeting in the New Year. If you try to register without first paying your dues, the registration system will automatically lead you to the Membership Portal where you can settle your dues payments, and will then direct you back through the registration process. Remember to register by the April 29 pre-registration cutoff date in order to be eligible for the waived registration fees. Associate members of the COA will also have their Annual Meeting pre-registration fees waived if they register before the April 29 deadline. Read through the FAQ on this new registration and membership dues structure by clicking here. Early Housing Options We have opened up housing much earlier than usual; keeping in mind that Québec City is a very popular tourist destination in June. You can already book your accommodations at the two Annual Meeting hotels (Delta and Hilton) which are both conveniently attached to the Québec City Convention Centre where the COA and CORS Annual Meeting will be held. Visit the Travel and Hotel page at www.coaannualmeeting.ca to book your hotel rooms. New Program Components Due to the overwhelming popularity of last year’s “Fireside Chats” sessions, we will be offering these casual subspecialty-specific case sessions over two evenings during the program. Space is very limited and pre-registration is required for the Trauma, Hip, Knee, Foot and Ankle, Sports or Paediatric case sessions. The Fireside Chats sessions will be held at the end of the program day on Friday, June 17 and Saturday, June 18.

Posters will be presented in traditional physical format next year. Posters will be on display in the Exhibit Hall from Thursday, June 16 at 17:00 to Saturday, June 18 at 16:00. Poster guidelines will be available at www.coaannualmeeting.ca in the New Year. Look for the special display of the top scoring posters from the COA and CORS in the poster area as well. Questions to all poster authors are always welcome; they will be available during the President’s Reception Thursday evening. One of the exciting symposia being offered will explore transitional care in orthopaedics. Transitional care is especially important for patients with complex orthopaedic conditions such as developmental dysplasia of the hip, cerebral palsy, limb deficiencies, and osteogenesis imperfecta. These patients are treated by paediatric orthopaedic surgeons when they are children, but need continued follow-up and care beyond 18 years of age, and often face the challenge of finding appropriate adult orthopaedic surgeons to look after them. This symposium brings together experts in the field of transitional care, including an adult orthopaedic surgeon, a paediatrician working on a provincial transitional care program, a rehabilitation specialist, as well as paediatric orthopedic surgeons working in different settings. More information about the various symposia being featured in the scientific program will be included in the preliminary program. An interactive educational workshop on transitioning into practice including case studies, panel discussions and Q & A will be offered to new surgeons who are moving into active orthopaedic practice. Real-life cases of common practice challenges will be presented by the panel followed by small group discussions where participants troubleshoot solutions. Highlighted topics include a review of practice resources (setting up office, hiring and firing, billing, EMR) and support (clinical, business mentorship, how to avoid burnout etc.). This session is offered at no charge to all COA meeting participants; however pre-registration through the online meeting registration process is required. Out of This World Speakers We are pleased to welcome Dafydd “Dave” Williams as the Annual Meeting’s Opening Ceremonies Guest Speaker. With a passion for health care and risk management, prior to entering the Canadian Space Agency’s program, Dr. Dave Williams worked as an emergency room doctor and later as director of emergency services at Sunnybrook Health Sciences Centre in Toronto. Formerly the director for the McMaster Centre for Medical Robotics, where he led a team dedicated to developing innovative technologies to assist the development of local and remote patient care. Dr. Williams is one of the NASA space COA Bulletin ACO - Winter / Hiver 2015

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program’s most accomplished astronauts, setting records in spacewalking. The veteran of two space shuttle missions has logged more than 687 hours in space, including three spacewalks, the highest number of spacewalks ever performed in a single mission. Don’t miss Dr. Williams talk on Thursday, June 16 during the event’s Opening Ceremonies at 17:30.

Remember to evaluate the sessions through the COA App All session evaluation forms will be paperless and available through the COA App. Download the App before heading to Québec City by searching for the Canadian Orthopaedic Association in the App Store or in Google Play. Select the Session Evaluation tab after clicking on the navigation icon in the top left corner. Your input and feedback are much appreciated. Remember to take a moment after each session to complete the evaluation form.

Quoi de neuf à la Réunion annuelle 2016?

a Réunion annuelle de l’ACO continue d’évoluer en fonction des besoins de ses membres. L’inclusion dans la cotisation annuelle des membres actifs des droits applicables pendant la période de préinscription, la possibilité de réserver son hébergement plus tôt de même que des ajouts novateurs au programme ne sont que quelques exemples des nouveautés dans le cadre de la Réunion annuelle de Québec, en juin prochain. Dates à inscrire à votre calendrier 2016 La prochaine Réunion annuelle de l’ACO commencera le jeudi 16 juin, à 17 h 30, avec les cérémonies d’ouverture, et prendra fin le dimanche 19 juin, en début d’après-midi. Les détails sur le programme provisoire seront diffusés sous peu à www.coaannualmeeting.ca. CHANGEMENTS aux droits applicables pendant la préinscription Si vous êtes membre actif de l’ACO, votre cotisation annuelle comprend maintenant les droits applicables pendant la période de préinscription à la Réunion annuelle. Il ne faut donc pas oublier de régler votre cotisation pour 2016 et toute facture impayée dans votre compte avant de vous inscrire à la Réunion annuelle, au début de la nouvelle année. Si vous tentez de vous inscrire à la Réunion annuelle avant d’avoir payé votre cotisation, vous serez automatiquement dirigé vers le portail des services aux membres de l’ACO, où vous pourrez la régler; le système vous ramènera ensuite à la page d’inscription. Pour être admissible à l’annulation des droits d’inscription, vous devez vous inscrire avant la fin de la période de préinscription, le 29 avril. Les membres associés de l’ACO peuvent aussi s’inscrire gratuitement à la Réunion annuelle jusqu’au 29 avril. Pour lire la foire aux questions sur la nouvelle structure tarifaire applicable à l’inscription et aux cotisations, cliquez ici.

COA Bulletin ACO - Winter / Hiver 2015

Options d’hébergement accessibles plus tôt Nous avons activé la réservation des chambres beaucoup plus tôt que d’habitude, car Québec est une destination touristique très populaire en juin. Vous pouvez donc réserver votre chambre à l’un des hôtels associés à la Réunion annuelle (Delta et Hilton), qui sont tous deux reliés au Centre des congrès de Québec, où la Réunion annuelle de l’ACO et de la SROC aura lieu. Consultez la section « Destination », à www.coaannualmeeting.ca, pour réserver votre chambre. Ajouts au programme En raison de la forte popularité des « Discussions au coin du feu » à la dernière Réunion annuelle, ces séances d’études de cas par sous-spécialité se dérouleront sur deux soirs. Les places étant très limitées, l’inscription à l’avance est obligatoire pour les séances sur la traumatologie, la hanche, le genou, le pied et la cheville, la médecine sportive et la pédiatrie. Les « Discussions au coin du feu » auront lieu à la fin du programme du jour les vendredi et samedi 17 et 18 juin. Les affiches seront de nouveau présentées dans le format papier traditionnel l’an prochain. Elles seront disposées dans la salle d’exposition du jeudi 16 juin, à 17 h, au samedi 18 juin, à 16 h. Les directives pour les affiches seront publiées à www.coaannualmeeting.ca en début d’année. On trouvera également dans la salle d’exposition un stand spécial présentant les affiches de l’ACO et de la SROC ayant obtenu les meilleures notes. Les auteurs seront à votre disposition pendant la Réception du président, le jeudi soir, pour répondre aux questions sur leurs affiches, qui sont toujours les bienvenues. Parmi les symposiums intéressants offerts, mentionnons celui sur les soins de transition en orthopédie. Les soins de transition sont particulièrement importants pour les patients ayant un trouble orthopédique complexe, comme une dysplasie développementale de la hanche, la paralysie cérébrale, la déficience d’un membre ou une ostéogénèse imparfaite. Ces patients sont traités par un orthopédiste-pédiatre dès l’enfance, mais doivent continuer d’être suivis et de recevoir des

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soins à l’âge adulte, et la recherche d’un orthopédiste pour adultes qualifié s’avère souvent difficile. Ce symposium réunit des spécialistes des soins de transition, y compris un orthopédiste pour adultes, un pédiatre œuvrant au sein d’un programme provincial de soins de transition, un spécialiste en réadaptation, de même que des orthopédistes-pédiatres travaillant dans d’autres milieux. Le programme provisoire contiendra davantage de renseignements sur les différents symposiums proposés. Un atelier interactif sur la transition vers l’exercice de l’orthopédie comprenant des études de cas, des groupes de discussion et une séance de questions sera en outre proposé aux orthopédistes qui commencent à exercer activement. Des exemples réels de défis courants inhérents à l’exercice seront présentés par les spécialistes, puis abordés dans le cadre de discussions en petits groupes où les participants chercheront à y trouver des solutions. Entre autres sujets clés, mentionnons un examen des ressources (p. ex. création d’un cabinet, embauche et congédiement, facturation et dossiers médicaux électroniques) et du soutien (p. ex. clinique, mentorat en affaires et prévention de l’épuisement professionnel) nécessaires. La séance est gratuite pour tous les participants à la Réunion annuelle de l’ACO, mais l’inscription à l’avance par l’intermédiaire du système en ligne est obligatoire.

Des conférenciers extraordinaires Nous aurons le plaisir d’accueillir Daffydd (Dave) Williams à titre de conférencier invité aux cérémonies d’ouverture de la Réunion annuelle. Le Dr Williams est un passionné des soins de santé et de la gestion des risques. Avant de se joindre au programme de l’Agence spatiale canadienne (ASC), il a travaillé comme urgentologue, puis comme directeur du service des urgences au Sunnybrook Health Sciences Centre de Toronto. Il a aussi été directeur du McMaster Centre for Medical Robotics, où il dirigeait une équipe chargée de mettre au point des technologies novatrices favorisant la prestation de soins aux usagers locaux et à distance. Le Dr Williams est l’un des astronautes les plus accomplis du programme spatial de la NASA, ayant établi des records en matière de sorties dans l’espace : lors de ses 2 missions spatiales, il a cumulé plus de 687 heures dans l’espace, dont 3 sorties extravéhiculaires, ce qui représente le plus grand nombre de sorties dans l’espace jamais effectuées en une seule mission. Ne manquez pas l’allocution du Dr Williams, aux cérémonies d’ouverture, le jeudi 16 juin, à 17 h 30. Et bien sûr, il y a l’évaluation des séances à l’aide de l’application de l’ACO! Tous les formulaires d’évaluation des séances seront accessibles à partir de l’application de l’ACO. Téléchargez l’application avant de partir pour Québec en recherchant « The Canadian Orthopaedic Association » dans l’App Store d’iTunes ou dans Mes applis Android de Google Play. Sélectionnez ensuite l’onglet « Session Evaluation » en cliquant sur l’icône de navigation, dans le coin supérieur gauche. Votre soutien et votre participation sont grandement appréciés. Veuillez prendre quelques minutes après chaque séance pour remplir le formulaire d’évaluation.

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

Les contributions au Bulletin de l’ACO sont toujours les bienvenues! Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : cynthia@canorth.org COA Bulletin ACO - Winter / Hiver 2015

Your COA / Votre association

2016 COA Annual Meeting Keynote Speakers

Conférenciers principaux de la Réunion annuelle 2016 de l’ACO

Visit www.coaannualmeeting.ca for speaker biographies – select Attend > Speakers in the top menu bar

Rendez-vous à www.coaannualmeeting.ca/fr pour consulter la notice biographique des conférenciers principaux. Cliquez sur « Participez », dans le menu en haut de page, puis sur « Conférenciers ».

Opening Ceremonies Guest Speaker Dafydd “Dave” Williams, MD, CSA ret. During the Opening Ceremonies Thursday, June 16 • 17:30 Plenary Hall: 2000A, Level 2, Québec City Convention Centre

R.I. Harris Lecture Marc Swiontkowski, MD Friday, June 17 • 14:30 Plenary Hall: 2000A, Level 2, Québec City Convention Centre

Presidential Guest Speaker Kellie Leitch, PC MP O. Ont, FRCSC Saturday, June 18 • 14:30 Plenary Hall: 2000A, Level 2, Québec City Convention Centre

President Elect Address Peter B. MacDonald, MD, FRCSC COA President Elect Saturday, June 18 • 11:00 Plenary Hall: 2000A, Level 2, Québec City Convention Centre

COA Bulletin ACO - Winter / Hiver 2015

Conférencier aux cérémonies d’ouverture Dafydd (Dave) Williams, MD, ASC (à la retraite) Aux cérémonies d’ouverture Le jeudi 16 juin • 17 h 30 Salle plénière : Salle 2000A, niveau 2, Centre des congrès de Québec

Conférencier R.I. Harris Marc Swiontkowski, MD Le vendredi 17 juin • 14 h 30 Salle plénière : Salle 2000A, niveau 2, Centre des congrès de Québec

Conférencier invité par le président CP, députée, O.Ont, FRCSC Le samedi 18 juin • 14 h 30 Salle plénière : Salle 2000A, niveau 2, Centre des congrès de Québec

Allocation du président élu Peter B. MacDonald, MD, FRCSC Président élu de l’ACO Le samedi 18 juin • 11 h Salle plénière : Salle 2000A, niveau 2, Centre des congrès de Québec

Your COA / Votre association

How to Register for the 2016 Annual Meeting at No Charge Cynthia Vezina Manager, Membership Services & Communications Canadian Orthopaedic Association

016 is an exciting year for the COA as we introduce free annual meeting pre-registration for our Active and Associate members. Learn how to take advantage of this new membership benefit by reviewing the steps outlined in the flow charts below or by reviewing the FAQ available at: http://www.coa-aco-services.org/websites/quebec2016/index. php?p=26.

What you need to know now: - Membership dues renewal requests will be sent to you by e-mail early in the New Year along with a notification that Annual Meeting registration is open. - Once you pay your membership dues, register for the meeting before April 29 and your pre-registration fees will be waived. Registrations received after April 29 are subject to fees for all membership categories. - Registration opens in the New Year! If you still have any questions about your COA membership benefits, please contact me at cynthia@canorth.org or 514 874-9003 x3.

ACTIVE MEMBERS Pay Your Dues In mid-January you will receive an e-mail notification including a link to the COA’s Membership Portal where you can pay your dues invoice by credit card or cheque.

Click on the link in the dues renewal e-mail and select the “My Memberships” option on the left of the Membership Portal page.

Add a Voluntary Donation You may ADD a voluntary donation to either the COF or COAGS by clicking on the ‘Add a Donation’ option near the bottom of the page.

Register for the Annual Meeting by April 29! Follow the links to the online Annual Meeting registration system that will be posted on the COA web site or on the membership dues payment confirmation screen.

Add Your Subspecialty Society Dues NEW FOR 2016 ! You can also pay your subspecialty society membership dues at the same time as your COA dues. ADD these 2016 renewals to your cart by selecting the ‘Add Subspecialty Society Dues’ option near the bottom of the page.

If you try to register for the meeting without paying your dues first, you will be prompted to settle your outstanding invoice after logging in to the registration system.

Now You’re Ready to Register Once you have paid all outstanding COA membership dues invoices in your account, you are now ready to register for the COA Annual Meeting.

Do not create a new profile when registering for the meeting or paying your membership dues! All COA members already have an existing profile in the system. If you don’t know your password, follow the ‘Forgot Password’ instructions on the login page or contact cynthia@canorth.org

Follow the provided links to the Membership Portal to pay your membership dues. You will then be led back to the registration process where you can complete your Annual Meeting registration.

ASSOCIATE MEMBERS (RESIDENTS/FELLOWS)

Associate members of the COA are not required to pay annual membership dues. You will not receive a membership renewal invoice in the New Year.

Your membership will be renewed automatically on your behalf.

Register for the Annual Meeting by April 29! Follow the links to the online Annual Meeting registration system that will be posted on www.coa-aco.org or www.coaannualmeeting.ca.

Do not create a new profile when registering for the meeting! All COA members already have an existing profile in the system. If you don’t know your password, follow the ‘Forgot Password’ instructions on the login page or contact cynthia@canorth.org COA Bulletin ACO - Winter / Hiver 2015

Your COA / Votre association

Procédure d’inscription gratuite à la Réunion annuelle 2016 de l’ACO Cynthia Vezina Gestionnaire, Communications et services aux membres Association Canadienne d’Orthopédie

’année 2016 s’annonce excitante pour l’ACO, puisqu’elle offrira l’inscription gratuite à la Réunion annuelle aux membres actifs et associés. Pour savoir comment profiter de ce nouvel avantage, consultez les diagrammes ci-après, qui fournissent toutes les étapes à franchir. Vous pouvez aussi lire la foire aux questions sur le sujet, à www.coa-aco-services.org/ websites/quebec2016/index.php?p=27.

À savoir : - Les avis de cotisation à l’ACO seront envoyés par courriel dès janvier, avec l’avis du début des inscriptions à la Réunion annuelle. - Une fois votre cotisation dûment payée, inscrivez-vous à la Réunion annuelle avant le 29 avril pour profiter de l’annulation de vos droits d’inscription. Après cette date, tous les membres doivent payer les droits d’inscription applicables. - Vous pourrez vous inscrire au début de 2016. Si vous avez encore des questions sur les avantages de l’adhésion à l’ACO, communiquez avec moi, à cynthia@canorth.org ou au 514-874-9003, poste 3.

MEMBRES ACTIFS Payez votre cotisation À la mi-janvier, vous recevrez un courriel contenant un lien vers le portail des services aux membres de l’ACO, où vous pourrez régler votre cotisation par carte de crédit ou par chèque.

Cliquez sur le lien fourni, puis sélectionnez « Mes affiliations/dons », dans la partie gauche de la page.

Faites un don Vous pouvez AJOUTER un don à la Fondation Canadienne d’Orthopédie ou au comité Planète ortho de l’ACO. Vous n’avez qu’à cliquer sur « Faire un don », au bas de la page.

Inscrivez-vous à la Réunion annuelle d’ici le 29 avril! Il suffit de suivre les liens vers le système d’inscription en ligne, qui seront fournis sur le site Web de l’ACO, ou sur l’écran de confirmation de paiement de la cotisation.

Ajoutez les sous-spécialités NOUVEAUTÉ EN 2016! Vous pouvez payer votre cotisation à une société de sous-spécialité en même temps que celle à l’ACO. AJOUTEZ ces renouvellements pour 2016 à votre panier en cliquant sur l’option « Ajoutez les sous-spécialités », au bas de la page.

Si vous essayez de vous inscrire à la Réunion annuelle sans avoir d’abord payé votre cotisation, on vous invitera à la régler après avoir ouvert une session dans le système d’inscription.

MEMBRES ASSOCIÉS

(RÉSIDENTS OU BOURSIERS) Les membres associés de l’ACO n’ont pas à payer de cotisation annuelle. Vous ne recevrez donc aucune facture en début d’année.

COA Bulletin ACO - Winter / Hiver 2015

Votre adhésion est renouvelée automatiquement.

Inscrivez-vous Une fois toutes les factures à votre compte payées, vous pouvez vous inscrire à la Réunion annuelle de l’ACO.

Ne créez pas de nouveau profil pour vous inscrire à la Réunion annuelle ou payer votre cotisation! Tous les membres de l’ACO ont déjà un profil dans le système. Si vous ne connaissez pas votre mot de passe, cliquez sur « Mot de passe oublié? » et suivez les directives ou communiquez avec cynthia@canorth.org.

Suivez les liens fournis pour accéder au portail des services aux membres et payer votre cotisation. Le système vous ramènera ensuite au système d’inscription à la Réunion annuelle pour terminer la transaction.

Inscrivez-vous à la Réunion annuelle d’ici le 29 avril! Il suffit de suivre les liens vers le système d’inscription en ligne qui seront fournis sur www.coa-aco.org ou www.coaannualmeeting.ca. Ne créez pas de profil pour vous inscrire à la Réunion annuelle! Tous les membres de l’ACO ont déjà un profil dans le système. Si vous ne connaissez pas votre mot de passe, cliquez sur « Mot de passe oublié? » et suivez les directives ou communiquez avec cynthia@canorth.org.

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he COA strives to support its members throughout their entire career path. Follow the path to learn about the various membership services and benefits that apply to each stage of your orthopaedic career.

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2015 ABC Travelling Fellowship Tour

he American-British-Canadian (ABC) Travelling Fellowship was started in 1948 by Dr. Robert I. Harris of Toronto, Canada during his year as president of the AOA. It began as an exchange of orthopaedic surgeons between the United States of America, United Kingdom, and Canada. Over the ensuing years, the fellowship expanded with the addition of South Africa, Australia, and New Zealand. Ever since, the fellowship has been an invaluable opportunity for building collaborations, sharing knowledge, and developing friendships across the world. In alternating years, promising young orthopaedic surgeons from Canada and the USA visit the Commonwealth countries, while in intervening years, orthopaedic surgeons from the Commonwealth countries visit North America. We were privileged to make this trip as the 2015 ABC Travelling Fellows, and are happy to present our experiences during the fellowship tour. We (Rajiv and Kishore) are grateful to the COA for giving us the opportunity to be their ambassadors on this incredible tour.

Our five-week tour from April 22, 2015 to May 23, 2015 began in the United Kingdom and subsequently took us through Australia and New Zealand. We were greeted with the kindest hospitality and friendship throughout. Our travels taught us that as a global community of orthopaedic surgeons, we share the common challenge of providing high quality, value-based care. We were inspired to continue to improve how we train and educate residents, think about important research questions, and provide the best care for our patients. United Kingdom Upon our arrival in London, we were graciously welcomed by the British Orthopaedic Association (BOA) as well as The Bone and Joint Journal (BJJ). Our UK tour was meticulously organized thanks to David Limb (BOA honourary secretary), Hazel Choules, and Emma Storey.

Fellows Robert H. Brophy, MD Washington University Chesterfield, MO, USA Rajiv Gandhi MD, MSc University of Toronto Toronto, ON, Canada Sanjeev Kakar, MD, MRCS Mayo Clinic Rochester, MN, USA Hue H. Luu, MD University of Chicago Chicago, IL, USA Kishore Mulpuri, MBBS, MS, MHSc University of British Columbia Vancouver, BC, Canada Alpesh A. Patel, MD, FACS Northwestern University Chicago, IL, USA Suken A. Shah, MD Thomas Jefferson University Philadelphia, PA, USA

British Orthopaedic Association (BOA) lunch upon our arrival to London.

In London, we were fortunate to visit a number of prominent academic and clinical centres. Our first visit was to The Institute of Sport, Exercise and Health, a collaborative effort between the National Health Service and University College of London, directed by our host, ABC alumnus and current BJJ editor-in-chief, Professor Fares Haddad. Together, we engaged in healthy discussion about critical issues in academic medicine, including how to approach large amounts of data from national registries, poor quality science, and authorship for large multicentre RCTs.

COA Bulletin ACO - Winter / Hiver 2015

Your COA / Votre association

(continued from page 21)

We were later hosted by ABC alumni Mr. Robert Pollock and Professor Tim Briggs, who is also past president of the BOA. Together, over a traditional English breakfast, we discussed issues of access, outcomes, quality, training, registries, and cost of care. At the Royal National Orthopaedic Hospital in Stanmore, we were greeted by ABC alumnus Mr. William Aston and Professor Alistair Hart as guests of the 25th Annual Seddon Society, chaired by Professors Briggs and Hart. We learned that Sir Herbert Seddon was not only a world-renowned authority on polio, TB, brachial plexus and congenital dislocation of the hip, but also a former orthopaedic surgeon to Sir Winston Churchill. We were then hosted by ABC alumnus Mr. Pramod Achan at the Royal London and St. Bartholomew’s Hospital. For the main academic session of the day, all available trainees and consultants participated in a lively discussion of health-care innovations. Mr. Achan further presented us with a history of the ABC Travelling Fellowship and its links to St. Bartholomew’s and The Royal London Orthopaedics department. Our visit to London also included visits to a number of historic places such as the Churchill War Museum and Westminster Abbey. We were very privileged to visit Oxford next, and learn about the rich history of the city and University. We were warmly greeted by ABC alumni Professor Andy Carr and Mr. Duncan Whitwell, and were then taken for a tour of the Botnar Research Centre, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences and the Kennedy Institute. During the academic session, Professor Chris Lavy detailed the global health issues in orthopaedic surgery and the disparities that exist worldwide, especially within Africa as part of the Lancet Commission. Professor Keith Willet taught us how to effectively implement a quality framework to drive improvement, while Professor David Murray presented his experience with the evolution of the Oxford Unicondylar Knee Replacement. To wrap up the session, Professor Carr gave an educational presentation on his work in randomized controlled trials in shoulder surgery.

At the Hunterian Museum and Art Gallery in Glasgow, Scotland. COA Bulletin ACO - Winter / Hiver 2015

After Oxford, we traveled to East Anglia where we were greeted by Professor Simon Donell. We learned a great deal about the history of the hospital and the evolution of the Norwich Research Park, a place where the expertise within the University of East Anglia, Norfolk and Norwich University Hospitals is leveraged off to conduct MSK research. Our journey took us next to Leicester, where we met 2014 ABC fellow Mr. Rob Ashford. We were honoured to attend the annual award ceremony for the Leicester Tigers, a professional rugby team, where we sat with players during their celebrations and were acknowledged by the team. We had fascinating discussions with ABC alumnus Professor Angus Wallis, past BOA president Professor Dias, past British Orthopaedic Trainees Association president Mr. Jeya Palan, and Leicester University paediatric orthopaedic consultant Mr. Alwyn Abraham. We discussed issues ranging from differences in training systems, challenges facing trainees and consultants, and ways to encourage trainees to enter academic career paths within university systems. Heading north to Glasgow, Scotland, we were greeted by ABC alumni Mr. Sanjiv Patil and Mr. Dominic Meek. Together, we visited the Hunterian Museum and Art Gallery, where we learned about Sir William Hunter who played a major role in Britain’s 18th century scientific, cultural and social sciences from 1718-1783. Later, we proceeded to the Adam Smith Lecture Theatre within the University of Glasgow for an academic session hosted by Mr. Patil and Mr. Meek. The evening festivities included a dinner reception at The Royal College of Physicians and Surgeons of Glasgow, founded in 1599, and where, dressed in our traditional Scottish kilts, we met other previous ABC fellows including Mr. Huntley, Professor Hamblen and Miss Catherine Kellet. Upon arrival in Edinburgh, we were met by previous ABC fellows Professor Hamish Simpson, Leela Biant, and John Keating. Professor Simpson hosted us for dinner in his house, where we enjoyed a delicious home-cooked meal courtesy of

ABC fellows in traditional Scottish kilts at the Royal College of Physicians & Surgeons of Glasgow (RCPSG).

Your COA / Votre association

(continued from page 22)

Helen Simpson. We relaxed with the previous fellows and enjoyed Scottish hospitality at its finest. Despite some damp weather, our spirits were not dampened as our gracious hosts took us to visit the fairways of St. Andrew’s golf course, the home of golf. After returning, we enjoyed dinner at the Balmoral Hotel where we donned our traditional Scottish kilts and were greeted by numerous ABC alumni including Professor Charles Court-Brown, Professor Margaret McQueen, Professor McMaster, Miss Julie Mcbirnie, Mr. John Keating, Professor Simpson, Miss Leela Biant, and BOA President, Professor Colin Howie.

ians, we were very honoured and humbled at the opportunity to witness such tradition. Our last day in England was spent in London. After an exciting football match between Crystal Palace and Manchester United, courtesy of Professor Haddad, we retired to the Royal College of Surgeons of England before heading to Australia.

For the academic portion, we visited the Chancellors Building in the Royal Infirmary of Edinburgh that included several impressive lectures from orthopaedic trainees that have completed their PhDs in orthopaedic research. After a quick train ride to Newcastle, we were met by previous ABC fellow Mike Reed and his wife, Alex. After a guided tour of the Roman town of Corbridge, we proceeded to Hexham General Hospital which is one of 15 hospitals that make up the Northumbria NHS trust. We had an enthralling academic session comprised of lectures by the local trainees, consultants and some of the current ABC fellows.

With Professor Haddad at the English Premier League game between Manchester United and Crystal Palace.

Australia Upon our arrival to Perth, any remnants of jet lag disappeared quickly once we were greeted by 2012 ABC alumnus Professor Piers Yates and a white sandy beach! After spending the morning with our clinical mentors, we enjoyed surf boat rowing at North Cottesloe beach where we learned the nuances of this sport with an emphasis on teamwork. The academic session, chaired by Professor Yates & Professor Richard Carey Smith, was at the Fiona Stanley Hospital and attended by faculty and trainees. Upon arrival in Sydney, we met with ABC alumnus Professor David Little and took part in the Sydney Harbour Bridge Climb. This was a climb of over 7000 steps reaching 450 metres above sea level, providing unprecedented views of downtown Sydney. We subsequently had dinner with Professor Little and Professor Bruce Foster - previous ABC fellow and recipient of the Order of Australia - who kindly travelled from Adelaide to be with us. At the Combined Services Orthopaedic Society (CSOS) Annual Conference at Fenham Barracks in Newcastle-upon-Tyne.

On our last day in Newcastle, we were privileged to attend the Combined Services Orthopaedic Society annual conference at Fenham Barracks, Newcastle Upon Tyne, hosted by Professor Simpson and Lt. Col. David Cloke. We were educated on important research work currently underway within the military. Dinner was an event that we will never forget. It was a black tie occasion with the armed forces – the RAF, Army and Navy – dressed in their traditional evening military dress at Anzio House, Royal Marine Reserve, Quayside in Newcastle. As civil-

We had a fascinating academic session at the Children’s Hospital in Westmead, where we met numerous consultants and trainees and discussed important innovations in health care, such as 3-D printing. Upon arrival in Melbourne, we were met by our local host and 2014 ABC alumnus, Mr. Phong Tran, and his assistant Sarah. The attention to detail was palpable and the welcome so warm. After checking in to our hotel, we headed to our academic session at the Royal Australasian College of Surgeons in East Melbourne. The attendance and academic value was excellent.

COA Bulletin ACO - Winter / Hiver 2015

Your COA / Votre association

(continued from page 23)

A highlight of the tour was our visit to the Melbourne Cricket Ground to attend an Aussie Rules Football match between Melbourne and Hawthorne. This was a special afternoon as we were hosted in one of the corporate hospitality boxes, where we had a chance to meet many of the trainees. Later, we had a specially-arranged dinner menu of traditional Australian cuisine, including kangaroo meat and barramundi fish. We were joined by former ABC fellows Mr. Jonathan Rush (1978), Professor Kerr Graham (1992), Professor Richard de Streiger (1998), Mr. Alasdair Sutherland (2008) and Mr. Phong Tran (2014). This was a tremendous opportunity to see how the ABC fellowship has shaped careers and friendships over time. New Zealand We then moved on to Queenstown, New Zealand, where we were immediately struck by the sheer beauty before us. We were surrounded by snow-capped mountain tops and beautiful lakes as we met our NZ hosts, including 2014 ABC alumnus Brendan Coleman and 2012 ABC alumnus Gordon Beadle.

Watching Aussie rules football (AFL) at the Melbourne Cricket Ground (MCG).

A leadership forum was held where we discussed issues including but not limited to teamwork, identifying and facing up to ones’ fears, balance and behavioural issues, training, education, and methods of identifying and setting up safeguards in the management of underperforming trainees. Activities included bike riding, golf, and a 50M bungee jump off the Kawarau suspension bridge.

For our final day on tour, we enjoyed a stimulating academic session at Auckland City Hospital. We were joined by the faculty from Middlemore, Auckland City, North Shore and Starship Hospitals. Collectively, they boast a total of 15 ABC fellows from 1956 to 2016.

After we arrived in Christchurch, we learned about the postearthquake recovery efforts that occurred several years before. We visited Leinster Orthopaedic Centre at St. Georges Medical Centre and met 1990 ABC alumnus and previous president of NZOA, Professor Gary Hooper. During lunch, we discussed the public-private set up, the no-fault liability system within the public system, and the insurance system to cover trauma care. We attended further academic sessions at the University of Otago, Christchurch, hosted by Mr. Gordon Beadle and Professor Gary Hooper. We were warmly received and were audience to excellent talks from the ABC fellows, trainees, and faculty including Professor Hooper and 1980 ABC fellow, Professor Alastair Rothwell. After a fun round of golf at Christchurch Golf Club, we went for dinner at “The Local” in Riccarton House. The camaraderie shown by our hosts typified the superb hospitality we received during our visit to the South Island of New Zealand.

When we arrived in Auckland, greeted by 2014 ABC fellow Brendan Coleman, we were taken sailing on a boat designed for the 2003 Americas Cup race in the Waitemata harbour.

After the academic day, we all prepared ourselves for the long journey home. The excitement we felt at the prospect of returning to see our long-missed friends and family was offset with the realism that today marked the end of a trip of a lifetime. Since we had embarked upon this journey five weeks before, we had been treated royally by all the staff at the COA, AOA, BOA, AuOA, and NZOA, as well as trainees, consultants, local hosts and past ABC fellows. Through interacting with past alumni and hearing experiences of the ABC fellowship, we have learned the true meaning of the tour; namely, leadership, inspiration and collaboration. As one sits back and reflects on the past five weeks, the true meaning of friendship comes to the fore, not only towards the people we met at each of our host sites but also amongst each other. We truly have become friends for life as we embark upon the next chapters of our journey, TOGETHER AS THE 2015 ABC FELLOWS.

Renseignez-vous!

’ACO s’efforce de soutenir ses membres pendant tout leur cheminement professionnel. Suivez le parcours pour en savoir davantage sur les services et autres avantages offerts aux membres à chaque étape de leur carrière en orthopédie.

Du tout début de votre formation jusqu’à votre retraite, l’ACO est là pour vous!

COA Bulletin ACO - Winter / Hiver 2015

L’ACO EST LÀ POUR VOUS, À CHAQUE ÉTAPE DE VOTRE CARRIÈRE EN ORTHOPÉDIE

Association canadienne d’orthopédie

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• Être la voix nationale des soins orthopédiques au Canada Assister à • Consulter les énoncés des congrès de position de l’ACO annuels à l’étranger pour soutenir les Profiter de droits réduits efforts locaux aux congrès annuels des de défense des Approfondir associations d’orthopédie droits et intérêts ses connaissances d’Afrique du Sud, de Consulter les webdiffusions Grande-Bretagne, de la Réunion annuelle, d’Australie et de www.orthoevidence.com, le Bone & Nouvelle-Zélande Joint Journal et Bone & Joint 360

Participer Devenir une Joindre référence un comité de l’ACO

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• www.coa-aco.org • Médias sociaux • Bulletin de l’ACO • Dépêche de l’ACO – Bulletin électronique hebdomadaire

Assister à la Réunion annuelle de l’ACO et de la SROC

S’ouvrir sur le monde

Présenter le fruit de ses recherches

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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

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

Accelerated Treatment of Hip Fractures An Introduction to this Edition’s Debate

he incidence of fragility fractures of the hip continues to rise along with the mean age of our population and the burden that this injury places on our health-care system cannot be overstated. Non-operative treatment of hip fractures carries a very high risk of complications related to the respiratory, urinary, and circulatory systems in addition to the risk of skin complications related to prolonged bed immobilization. Operative management is typically chosen due to the benefits of pain relief and early mobility despite the known risk of mortality in the mid- and long-term. Given that the risk of complications related to hip surgery rises with longer non-operative management, the timing of surgery may have a significant effect on perioperative morbidity and longer-term outcomes.

Data comparing time-to-operating room for hip fracture patients has been drawn largely from retrospective studies and case series given the inherent challenges in conducting randomized controlled trials in this population. The question of optimal timing will become increasingly important given the limited resources and financial constraints on our health-care system. The answers provided by ongoing and future studies should help to inform treatment decisions for these patients. I hope that you enjoy the following feature. Thank you to Drs. Ward & Nauth, as well as Dr. Chaudhry et al. for their contributions. Peter Lapner, M.D., FRCSC Scientific Editor, COA Bulletin

Hip Fractures Should be Treated Within 48 Hours Sarah Ward, M.D., FRCSC Lecturer, University of Toronto, Division of Orthopaedic Surgery, St. Michael’s Hospital Aaron Nauth, M.D., FRCSC Assistant Professor, University of Toronto, Division of Orthopaedic Surgery, St. Michael’s Hospital Toronto, ON

ip fractures represent a significant burden to the Canadian health-care system, with an estimated annual incidence of approximately 32,550 in 20151. The annual cost for the acute care management of hip fractures in Canada is estimated at $622,840,008, which does not include the additional cost of outpatient care, prescription medications and indirect costs2. Beyond the financial burden, hip fractures carry a significant risk of morbidity and mortality, with estimates of 30-day mortality ranging from 5-10% and one-year mortality as high as 30%3-5. Hip fracture patients are at risk for a wide variety of complications, including cardiovascular events such as stroke and myocardial infection, venous thromboembolism, bleeding, infection, pressure sores, pain and permanent reductions in mobility. For the past 25 years or more, the optimal timing of hip fracture surgery in order to minimize perioperative morbidity and mortality has been the subject of ongoing debate within the orthopaedic literature. Multiple studies have shown that long operative delays, generally of 48 hours or greater, are associated with higher morbidity and mortality as well as longer length-of-stay6-14. In fact, evidence that delays greater than 48 hours are associated with poorer outcomes is sufficiently strong that best practice guidelines published in multiple jurisdictions worldwide now recommend that surgery should be undertaken within 48 hours following hip fracture15-18. In

Canada, hip fracture fixation within 48 hours has been set as a quality benchmark by the federal, provincial and territorial governments. Based on 2014 data published by the Canadian Institute for Health Information (CIHI), this target is being met for 84% of hip fracture patients across Canada, with provincial rates ranging from a low of 63% in PEI to 91% in Manitoba19. Evidence that hip fracture fixation on a more urgent basis (i.e. earlier than 48 hours) reduces morbidity or mortality has been limited to date. While several investigations have shown improvements in outcomes with surgery undertaken as early as within 12 hours20-24, other studies have either shown no impact of surgical delay12,14,25, or effects that seem to be highly associated with the presence of multiple comorbidities12,26-28. These studies support the notion that surgical delay is often longer in sicker patients, who require greater preoperative optimization, and hence higher mortality in these patients is more likely related to their underlying medical conditions than to surgical delay. Recently, there has been interest in exploring ultra-early surgical intervention for hip fractures20,29, with the goal of undertaking surgery within 12 or even six hours of admission. While expediting surgical care of hip fracture patients is certainly attractive, particularly if it can be tied to better performance on outcomes such as morbidity and mortality, it does require rapid mobilization of considerable resources, involving multiple services (including orthopaedics, internal medicine, and anaesthesia). Ultra-early hip fracture management also necessitates the prioritization of hip fracture patients over other urgent surgical cases, which may not be warranted in the absence of clear outcome benefits. Furthermore, targeting surgery within six hours of admission for all hip fracture patients would no doubt increase the proportion of these cases being done after hours, as opposed to during regularly scheduled OR time. Interestingly, Adie30 showed that outcomes improved when COA Bulletin ACO - Winter / Hiver 2015

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

hip fractures were scheduled into the next available OR block (generally within one to two days of admission), rather than being done after hours. The authors hypothesized that this finding may be attributed to better staff supervision of daytime operative procedures and more experienced OR teams being available during regular daytime hours. While accelerated care for hip fractures may, in the future, be shown to be superior to the current standard of operating within the first 48 hours, it will be very important to ensure that surgical quality does not decrease with additional after hours surgeries, thereby offsetting any purported benefit. Quality may well be an important factor to consider within the current paradigm, as Ho31 showed that variation in mortality between jurisdictions could not be clearly associated with differences in surgical delay or patient comorbidities and therefore must be related to other factors that differed between the hospitals being investigated. If this is the case, then it would seem prudent to focus our current efforts on minimizing variability in hip fracture care between jurisdictions rather than drastically reducing the targeted time to surgery, as an overall quality improvement strategy may have greater impacts on hip fracture mortality within the system as a whole than would a move to ultra-early surgical care. In summary, based on the current evidence, it is our opinion that hip fractures should be treated within 48 hours, in accordance with the abundance of current international published guidelines. Ultra-early surgery, with hip fractures being fixed within six hours, has not been demonstrated to be superior to fixation within 48 hours and places a significant burden on the services involved in caring for hip fracture patients. Such a shift in the standard of care cannot be supported without high level evidence that this approach is superior. Large numbers of hip fractures occur each year in Canada and the burden is likely to increase in coming years. Necessitating operative management of hip fractures within six hours will increase the afterhours burden on operating rooms and would necessitate prioritization over other urgent cases. In addition, it may lead to an undesirable decrease in surgical quality. There is clearly a need for high-level evidence from large scale, multicentre randomized trials showing a clear benefit to ultra-early surgery for hip fractures prior to undertaking such a dramatic shift in the standard of care.

4. Lisk R., Yeong K. Reducing mortality from hip fractures: a systematic quality improvement. BMJ Qual Improv Report 2014;3:1. 5. Brauer C.A., Coca-Perraillon M., Cutler D.M., Rosen A.B. Incidence and mortality of hip fractures in the United States. JAMA. 2009 Oct 14;302(14):1573-9. 6. Doruk H., Mas M.R., Yildiz C., Sonmez A., Kyrdemir V. The effect of the timing of hip fracture surgery on the activity of daily living and mortality in elderly. Archives of Gerontology and Geriatrics 39 (2004) 179–185. 7. Gdalevich M., Cohen D., Yosef D., Tauber C. Morbidity and mortality after hip fracture: the impact of operative delay. Arch Orthop Trauma Surg (2004) 124 : 334–340. 8. McGuire K.J., Bernstein J., Polsky D., Silber J.H. Delays until surgery after hip fracture increases mortality. Clin Orthop Relat Res. 2004 Nov;(428):294-301. 9. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important?. J Bone Joint Surg Am. 2005 Mar;87(3):483-9. 10. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care. 2007;19:170–6. 11. Radcliffe T.A., Henderson W.G., Stoner T.J., Khuri S.F., Dohm M., Hutt E. Patient risk factors, operative care, and outcomes among older community-dwelling male veterans with hip fracture. J Bone Joint Surg Am. 2008;90:34-42. 12. Rae H.C., Harris I.A., McEvoy L., Todorova T. Delay to surgery and mortality after hip fracture. ANZ J. Surg. 2007; 77: 889–891. 13. Shiga T., Wajima Z., Ohe Y. Is operative delay associated with increased mortality of hip fracture patients? Systematic review, meta-analysis, and meta-regression. Can J Anaesth. 2008 Mar;55(3):146-54.

References

14. Siegmeth A.W., Gurusamy K., Parker M.J. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br. 2005 Aug;87(8):1123-6.

1. Osteoporosis Canada. Make the First Break the last: Fracture Liaison Services. Appendix B. 2013.

15. Brener S. Optimal timing of hip fracture surgery: a rapid review. April 2013, Health Quality Ontario.

2. Tarride J.E., Hopkins R.B., Leslie W.D., Morin S., Adachi J.D., Papaioannou A., Bessette L., Brown J.P., Goeree R. The burden of illness of osteoporosis in Canada. Osteoporos Int (2012) 23: 2591-2600.

16. National Clinical Guideline Centre. Hip fracture. The management of hip fracture in adults. London (UK): National Institute for Health and Clinical Excellence (NICE); 2011 Jun. 27 p. (Clinical guideline; no. 124).

3. Librero J., Peiró S., Leutscher E., Merlo J., Bernal-Delgado E., Ridao M, Martínez-Lizaga N., Sanfélix-Gimeno G. Timing of surgery for hip fracture and in-hospital mortality: a retrospective population-based cohort study in the Spanish National Health System. BMC Health Serv Res. 2012 Jan 18;12:15. doi: 10.1186/1472-6963-12-15.

17. Minimum standards for the management of hip fracture in the older person. Chatswood (Australia): New South Wales Agency for Clinical Innovation; 2014.

COA Bulletin ACO - Winter / Hiver 2015

18. Scottish Intercollegiate Guidelines Network. Management of hip fracture in older people: A national clinical guideline. 2009.

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

19. Canadian Institute for Healthcare Information. Benchmarks for treatment and wait time trending across Canada. 2014. Available from: http://waittimes.cihi.ca. Accessed 31 October 2015.

26. Elliott J., Beringer T., Kee F., Marsh D., Willis C., Stevenson M. Predicting survival after treatment for fracture of the proximal femur and the effect of delays to surgery. Journal of Clinical Epidemiology 56 (2003) 788–795.

20. Uzoigwe C.E., Burnand H.G., Cheesman C.L., Aghedo D.O., Faizi M., Middleton R.G. Early and ultra-early surgery in hip fracture patients improves survival. Injury. 2013 Jun;44(6):7269.

27. Grimes J.P., Gregory P.M., Noveck H., Butler M.S., Carson J.L. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112:702–709.

21. Beringer T.R., Crawford V.L., Brown J.G. Audit of surgical delay in relationship to outcome after proximal femur fracture. Ulster Medical Journal 1996;65(1): 32-38.

28. Roche J.J., Wenn R.T., Sahota O., Moran C.G. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005 Dec 10;331(7529):1374.

22. Bottle A., Aylin P. Mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006 Apr 22;332(7547):947-51.

29. HIP ATTACK Investigators. Accelerated care versus standard care among patients with hip fractures: the HIP ATTACK pilot trial. CMAJ 2014;186(1): E52-E60.

23. Simunovic N, Devereaux P.J., Sprague S., Guyatt G.H., Schemitsch E., Debeer J., Bhandari M. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ. 2010 Oct 19;182(15):1609-16.

30. Adie S., Harris I.A., Thorn L., McEvoy L., Naylor J.M. Nonemergency management of hip fractures in older patients. Journal of Orthopaedic Surgery 2009;17(3):301-4.

24. Weller I., Wai E.K., Jaglal S., Kreder H.J. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg [Br] 2005;87-B:361-6.

31. Ho V., Hamilton B.H., Roos L.L. Multiple approaches to assessing the effects of delays for hip fracture patients in the United States and Canada. Health Serv Res. 2000 Mar;34(7):1499518.

25. Smektala R., Endres H.G., Dasch B., Maier C., Trampisch H.J., Bonnaire F., Pientka L. The effect of time-to-surgery on outcome in elderly patients with proximal femoral fractures. BMC Musculoskeletal Disorders 2008, 9:171

Hip Fractures Should Be Treated Within Six Hours Harman Chaudhry, M.D., Resident Physician, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON Amal Bessissow, M.D., FRCPC, Assistant Professor, Department of Medicine, McGill University, Montreal, QC PJ Devereaux, M.D., PhD, FRCPC, Professor, Department of Clinical Epidemiology and Biostatistics, McMaster University, Hamilton, ON Mohit Bhandari, M.D., PhD, FRCSC, Professor and Chair, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON

here are several compelling reasons for orthopaedic surgeons to focus on improving hip fracture care. Patient outcomes following hip fracture are dire. Within 30 days of sustaining a hip fracture, almost 10% of patients will die; by one year, that number increases to one in three patients1. The situation among survivors is no better, as functional decline and loss of independence is alarmingly common2. While poor outcomes after hip fracture have traditionally been attributed to underlying patient frailty – and indeed frailty certainly plays a role – emerging evidence is beginning to recognize that there may be something inherent to the hip fracture itself which precipitates

poor outcomes. For instance, in a recent large national population-based study, age- and preoperative morbidity-matched patients still demonstrated a six-fold higher risk of mortality and a 2.5-fold higher risk of major perioperative complications after hip fracture as compared to after elective hip arthroplasty3. This led the authors to postulate that there was something inherent to the hip fracture itself that may lead to excessive mortality. If true, decreasing the effect of the acute facture and associated physiologic processes – through earlier surgery, for instance – may decrease morbidity and mortality rates after hip fracture. There is strong biologic rationale for this hypothesis4. Hip fractures result in bleeding (from the fracture site), pain, and immobility. Together, these initiate various physiologic processes; specifically pro-inflammatory, hypercoagulable, and catabolic stress states are initiated within the patient. Over a prolonged exposure (for instance, over the ensuing 48 hours), these physiologic states lead to the post-fracture medical complications that are frequently encountered, including myocardial infarctions, strokes, and thromboembolic disease. It is biologically plausible that earlier surgery (and the associated earlier mobilization) can curtail the degree of exposure to this harmful pathophysiology, thereby reducing post-fracture morbidity and decreasing mortality rates after hip fracture. COA Bulletin ACO - Winter / Hiver 2015

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

There is observational evidence that supports this hypothesis. A systematic review and meta-analysis on early surgery for hip fracture identified 16 comparative observational studies5. In the adjusted mortality analysis, the odds of death were nearly 20% lower with earlier surgery. Uzoigwe and colleagues have also explored the possibility that “ultra early” surgery may lead to an even greater reduction in mortality6. In their study, they were able to show that the odds of a patient dying after hip fracture followed a gradient, with the lowest odds of death in the first 12 hours (i.e., the earliest timeline evaluated). This was recently replicated with more recent data by Parker and colleagues, who also included a six-hour timeframe in their analysis7. Although they were unable to find a benefit in the six-hour timeframe over the 12-hour timeframe, the number of patients meeting the six-hour threshold was small. Unfortunately, observational studies do have their limitations. Despite even the most optimal matching (e.g., of age, comorbidities, etc.), residual confounding remains a possibility in observational study designs. This would mean, for instance, the early-surgery benefit observed may be attributable to healthier patients receiving earlier surgery (e.g., because they do not require medical optimization preoperatively), instead of the true effect of early surgery per se. On the other hand, it is also possible that these observational studies have underestimated the positive effect of early surgery, simply because patients have not received surgery early enough (i.e., within six hours, in the “most acute” phase of the fracture). Unbiased experimental evidence is required to make a definitive conclusion regarding the potential benefit of very early surgery. In this regard, there is an ongoing clinical trial that will aid in resolving this dispute. The HIP ATTACK trial is a multi-national, multi-centred randomized controlled trial comparing accelerated medical clearance and surgery (i.e. within six hours of diagnosis) to standard care (i.e., within 48 hours of diagnosis) for hip fracture on a number of medical and surgical outcomes, including mortality. The pilot trial was recently published8. While demonstrating a trend towards benefit for earlier surgery, this trial was underpowered to make any definitive conclusions. Enrollment in the definitive clinical trial is now well underway, with several Canadian centres at the forefront of recruitment, and many more planning to initiate recruitment in the near future. This trial will serve to confirm (or refute) the existing hypothesis regarding the benefit of early surgery for hip fracture, and provide evidence to better inform future clinical decision-making and health-care policy. The status quo for hip fracture outcomes remains unacceptable. There is a strong case to be made that surgery within six hours can lead to better outcomes as compared to the current standard of care. However, we hope that an ongoing clinical trial – the HIP ATTACK trial – will help definitively resolve this controversy.

COA Bulletin ACO - Winter / Hiver 2015

References 1. Brauer C.A., Coca-Perraillon M., Cutler D.M., Rosen A.B. Incidence and mortality of hip fractures in the United States. JAMA. 2009;302:1573-1579. 2. Wiktorowicz M.E., Goeree R., Papaioannou A., Adachi J.D., Papadimitropoulos E. Economic implications of hip fracture: health service use, institutional care and cost in Canada. Osteoporosis International. 2001;12:271-278. 3. Le Manach Y., Collins G., Bhandari M., Bessissow A., Boddaert J., Khiami F., Chaudhry H., De Beer J., Riou B., Landais P., Winemaker M., Boudemaghe T., Devereaux P.J. Outcomes After Hip Fracture Surgery Compared With Elective Total Hip Replacement. JAMA. 2015;314:1159-1166. 4. Bessissow A., Chaudhry H., Bhandari M., Devereaux P.J. Accelerated versus standard care in hip fracture patients: does speed save lives? J Comp Eff Res. 2014 Mar;3:115-118. 5. Simunovic N., Devereaux P.J., Sprague S., et al. Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ 2010;182:16091616.f 6. Uzoigwe C.E., Burnand H.G., Cheesman C.L., Aghedo D.O,. Faizi M., Middleton R.G. Early and ultra-early surgery in hip fracture patients improves survival. Injury. 2013;44:726-729. 7. Bretherton C.P., Parker M.J. Early surgery for patients with a fracture of the hip decreases 30-day mortality. Bone Joint J. 2015 Jan;97-B:104-108. 8. Hip Fracture Accelerated Surgical Treatment and Care Track (HIP ATTACK) Investigators. Accelerated care versus standard care among patients with hip fracture: the HIP ATTACK pilot trial. CMAJ. 2014;186:E52-E60.

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

Complications and Pitfalls of Distal Radius Fracture Treatment

r. Thomas Goetz (University of British Columbia) moderated a hand symposium at the 2015 COA Annual Meeting held this past June entitled Complications and Pitfalls of Distal Radius Fracture Treatment which included presentations by four distinguished speakers from across Canada. The symposium’s objectives were to review best evidence for treatment options for distal radius fractures (DRF), discuss treatment complications and their management, examine treatment of DRF malunion, and discuss the distal radio-ulnar joint instability (DRUJ) in DRF and the importance of ulnar styloid fracture.

Each of the symposium’s speakers has provided a summary of their presentation delivered at the Annual Meeting. We are pleased to feature the results of this interesting symposium and would like to thank Drs. Grewal, Daneshvar, Bowen, and Goetz for their participation – Ed.

Evidence-based Treatment of Distal Radius Fractures Ruby Grewal, M.D., MSc, FRCSC Roth McFarlane Hand and Upper Limb Centre Associate Professor, Division of Orthopedics University of Western Ontario London, ON

espite an abundance of published articles related to distal radius fractures (DRF), there is still little evidence to definitively guide treatment decisions. In 2009, the American Academy of Orthopaedic Surgeons (AAOS) published a guideline and evidence-based report on the treatment of distal radius fractures1. Unfortunately, the majority of the factors considered in their report did not have adequate supporting evidence to provide definitive treatment recommendations. While there was moderate evidence to support operative fixation for DRF with post reduction radial shortening >3mm, dorsal tilt >10⁰, and/or intra-articular displacement/step-off >2mm, many of the other treatment recommendations had inconclusive evidence. For example, the report stated that they were unable to recommend for or against operative treatment for patients >55 years with DRF, for or against locking plates in patients >55 years who were treated operatively, and for or against any one specific operative method for fixation of DRF, as the evidence was inconclusive. The current evidence indicates that while radiographic outcomes are superior in elderly patients that receive operative treatment for their DRF, the clinical outcomes are not vastly different between those treated operatively and non-operatively. A case control study by Egol et al.2 comparing the operative (n=44) and non-operative treatment (n=46) of unstable distal radius fractures in patients aged ≥ 65 years found that radiographic outcomes were better with ORIF, however at one year there was no difference in DASH scores, complications or ROM between groups. There was a five kg grip strength and a 3.3° advantage in supination for the ORIF group, but the clinical relevance of this is not known. Limitations of this study include a lack of standardized surgical treatment and there may have

been a selection bias as the non-operative group consisted of patients that were offered surgery but declined for various reasons. A prospective randomized trial3 comparing ORIF (volar locked plates) (n=36) to closed reduction and casting (n=37) in healthy, independent patients ≥ age 65 with an unstable DRF resulted in similar conclusions. They found that radiographic outcomes and grip strength were better with ORIF at all time points with a 3.7 kg advantage at six months and 3.4 kg advantage at one year for the operative group. However, there were no differences in levels of pain, range of motion, DASH scores, and PRWE scores at six months or one year and there were more complications seen in the ORIF group (13 vs. five, p<0.05). To summarize the results of these two studies, radiographic alignment may be better with ORIF, however alignment is not related to outcomes in this age group. Previous reports demonstrate that only one in eight malunions result in a poor outcome in patients ≥65 years of age4. The decision to operate in older patients can be difficult. With the varying physical demands and health status of elderly patients presenting with DRF, it is difficult to make blanket treatment recommendations in this population. The following are factors on which surgeons place importance when making treatment decisions for patients over the age of 50: dorsal comminution, discontinuity of the volar cortex after reduction, presence of an ulnar neck fracture, volar tilt before and after closed reduction, ulnar variance after CR (>3mm), step-off at the articular surface (>2mm) and patient factors including age, involvement of the dominant hand and subjective usage during occupational and recreational activities5. Once the decision to operate has been made, there are many options for fixation method ranging from K-wires, to external fixation (Ex Fix), different types of internal fixation and now most commonly, volar locking plates (VLP). At this time, whether any one method of fixation is superior to another has not been proven. COA Bulletin ACO - Winter / Hiver 2015

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

There have been many RCT’s dedicated to the comparison of fixation methods and a recent meta-analyses comparing the outcomes of VLP to K-wire fixation. Chaudhry et al.6 compared results of VLP to K-wire fixation, including all studies with extraarticular and intra-articular DRF’s, and cases using adjunctive external fixation, as long as the intent was to use only K-wires where possible, and external fixation was used in less than 25% of the procedures. They found a slight advantage in the VLP group (DASH scores on average 7.5 points better than with pinning) however, the difference did not exceed the ten point threshold that was established as the minimum for clinical importance. At final follow-up (either six and/or 12 months), the mean DASH score was only 3.8 points lower in the VLP (seven trials, n=875; 95% CI, 1.2–6.3; p=0.004). There was a small advantage in wrist flexion and supination with VLP (<5⁰) at three months, but no difference at six or 12 months. There were no differences in radiographic outcomes. The superficial wound infection rate was higher in K-wires (all successfully treated with oral antibiotics) but otherwise no difference in complications between the two treatment groups. The authors concluded that although the possibility of a small clinically important difference at three months could not be excluded, the magnitude of improvement by 12 months was most likely imperceptible between the two treatment arms.

and result in good outcomes, we must ensure our trainees are well-versed in all fixation methods.

Margaliot et al.7 also conducted a meta-analysis reviewing 46 articles (n=917 patients) comparing external fixation to ORIF and they found there was no clinically or statistically signiﬁcant differences in pooled grip strength, wrist ROM, radiographic alignment, pain, and physician-rated outcomes. The complications were different among the two groups with the external fixation group experiencing higher rates of infection, hardware failure, and neuritis while the ORIF group had higher rates of tendon complications and early hardware removal.

5. Kodama N., Imai S., Matsusue Y. A simple method of choosing treatment of distal radius fractures. J Hand Surg Am 2013;38(10):1896-1905.

With a lack of evidence providing definitive treatment guidelines on when to operate for certain age groups or which fixation method to use, surgeons must consider each case on the basis of individual patient factors and fracture characteristics. As Koval et al.8 have demonstrated a trend away from traditional fixation methods (i.e. percutaneous pinning, Ex Fix) towards an increasing use of ORIF with VLP, we have a new generation of orthopaedic surgeons who are not well trained in techniques other than VLP. While VLP are very user friendly

References 1. http://www.aaos.org/research/guidelines/DRFguideline. asp 2. Egol K.A., Walsh M., Romo-Cardoso S., Dorsky S., Paksima N. Distal radius fractures in the elderly: operative compared with nonoperative treatment. J Bone Joint Surg Am. 2010;92(9):1851-1857. 3. Arora R., Lutz M., Demi C., Krappinger D., Haug L, Gabi M. A prospective randomized trial comparing nonoperative treatment with volar locking plate fixation for displaced and unstable distal radius fractures in patients 65 years of age and older. J Bone Joint Surg Am. 2011;93(23):2146-2153. 4. Grewal R., MacDermid J.C. The risk of adverse outcomes in extra-articular distal radius fractures is increased with malalignment in patients of all ages but mitigated in older patients. J Hand Surg Am 2007;32(7)962-970.

6. Chaudhry H., Kleinlugtenbelt Y.V., Mundi R., Ristevski B., Goslings J.C., Bhandari M. Are Volar Locking Plates Superior to Percutaneous K-wires for Distal Radius Fractures? A Metaanalysis. Clin Orthop Relat Res 2015;473(9):3017-3027. 7. Margaliot Z., Haase S.C., Kotsis S.V., Kim H.M., Chung K.C. A meta-analysis of outcomes of external fixation versus plate osteosynthesis for unstable distal radius fractures. J Hand Surg Am 2005;30(6):1185-1199. 8. Koval K.J., Harrast J.J., Anglen J.O., Weinstein J.N. Fractures of the distal part of the radius. The evolution of practice over time. Where’s the evidence? J Bone Joint Surg Am 2008;90(9):18551861.

Complications of Closed and Open Treatment of Distal Radius Fractures Parham Daneshvar, M.D., FRCSC Hand and Upper Extremity Surgery Clinical Assistant Professor, UBC Vancouver, BC

istal radius fractures (DRF) account for 1/6th of fractures seen in the emergency department. Their treatment includes closed reduction and casting/splinting versus

COA Bulletin ACO - Winter / Hiver 2015

an array of operative procedures. No matter the treatment, these fractures are associated with a variety of complications outlined in detail by McKay and colleagues1. These complications can be categorized into acute, sub-acute and delayed. This article will focus on acute carpal tunnel syndrome, fixation failure, tendon injury, and complications associated with nonoperative management.

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

Acute carpal tunnel syndrome (CTS) is defined by worsening progressive median nerve symptoms. It should be differentiated from initial symptoms associated with nerve injury from the actual trauma which is neuropraxic in nature. The incidence of acute CTS is reported as 5.48.6% in the literature. Risk factors associated with acute CTS include: high-energy trauma, multiple reduction attempts, and increased initial displacement (specifically >35% translation)2,3. This acute complication requires immediate surgical intervention. Carpal tunnel release can be carried out effectively using a separate Figure 1 ulnar incision used in traditional carpal tunnel release (CTR). However, the release can also be performed using an extension of the FCR incision often used in DRF volar plate fixation, and extending it into the palm as described by Weber and Sanders, and performing a hybrid FCR-CTR4,5. This approach has been shown to relieve the carpal tunnel pressure and is safely away from the recurrent motor branch of the median nerve and the palmar cutaneous nerve6 (Figure 1). Loss of reduction after fixation of DRFs is troubling, yet common. Early intervention is key in dealing with loss of reduction especially in cases of intra-articular fractures. It is debatable if every DRF requires early (first visit) radiographs after fixation. It is advisable to obtain early radiographs after fixation of the very unstable, and intra-articular DRFs. This will allow for timely intervention if reduction has been lost, before fracture consolidation. The consequences of an intra-articular malunion can be devastating especially if the fragments involved lead to radiocarpal instability. Such is the case with the dreaded subchondral/distal fracture of the volar lunate facet fragment (Figure 2). This fragment has been a focus of attention by wrist surgeons especially in cases of very distal fractures as loss of fixation in this fragment can lead to collapse of the radio-carpal joint and significant morbidity7,8. The fixation of this fragment can be very challenging and inadequate with standard volar plating. Different methods have been proposed to deal with these distal fractures such as fragment-specific fixation, suture fixation to the volar plate, and external fixation to off-load the fragment. Particular attention should be paid to these fractures, and early postoperative radiographic and, if needed, CT imaging should be taken to monitor the maintenance of the reduction.

scopic views can assist the surgeon in identifying of prominent screws13. Interestingly, EPL ruptures are seen in higher rates in undisplaced or minimally-displaced DRFs than in displaced fractures. This may be a result of auto release of the tendon from the groove of the EPL in displaced fractures. In less traumatic fractures, the EPL is left in its groove with an intact extensor retinaculum and a bony prominence at the fracture site may place further stress on the tendon11. Closed treatment of DRFs is not without problems and is associated with 17% incidence of complications for cast treatment alone and 21% for those requiring closed reduction and cast treatment1. Loss of reduction is common post-reduction and it can be difficult to predict who is more prone to reduction loss. Lafontaine and colleagues described five criteria which they found predictive of instability: initial dorsal angulation, comminution, intra-articular involvement, associated distal ulna fracture, and age over 6014. Tornetta and colleagues validated this criteria to predict final radial height, inclination and ulnar

Figure 2

Tendon ruptures often occur as a late complication and are associated with both closed and open treatment of DRFs. Although ruptures are uncommon, they are significant complications and are central to designs of many DRF implants. The incidence of tendon ruptures is about twice as high in patients treated surgically. Almost all tendon injuries associated with closed treatment of DRFs are extensor pollicis longus (EPL) ruptures9-12. Whereas the most common rupture associated with volar plating is flexor pollicis longus (FPL) rupture followed by flexor digitorum profundus (FDP). Appropriate plate placement and ensuring that screws are not prominent can reduce these ruptures. Dedicated intra-operative fluoro-

variance, but did not observe an association with final dorsal tilt. They found the ability to hook the distal volar cortex over the proximal cortex to have high correlation with final volar tilt and prevention of reduction loss15. DRFs are one of the most common injuries encountered by the orthopaedic surgeon. It is important to have an appreciation for how significant these fractures can be and acknowledge that despite significant advances in the treatment of these fractures, we continue see high rates of complications.

COA Bulletin ACO - Winter / Hiver 2015

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

(continued from page 33)

References 1. McKay, S.D., et al., Assessment of complications of distal radius fractures and development of a complication checklist. J Hand Surg Am, 2001. 26(5): p. 916-22. 2. Dyer, G., et al., Predictors of acute carpal tunnel syndrome associated with fracture of the distal radius. J Hand Surg Am, 2008. 33(8): p. 1309-13. 3. Itsubo, T., et al., Differential onset patterns and causes of carpal tunnel syndrome after distal radius fracture: a retrospective study of 105 wrists. J Orthop Sci, 2010. 15(4): p. 518-23. 4. Weber, R.A. and W.E. Sanders, Flexor carpi radialis approach for carpal tunnel release. J Hand Surg Am, 1997. 22(1): p. 1206. 5. Gwathmey, F.W., Jr., et al., Volar plate osteosynthesis of distal radius fractures with concurrent prophylactic carpal tunnel release using a hybrid flexor carpi radialis approach. J Hand Surg Am, 2010. 35(7): p. 1082-1088 e4. 6. Pensy, R.A., et al., Single-incision extensile volar approach to the distal radius and concurrent carpal tunnel release: cadaveric study. J Hand Surg Am, 2010. 35(2): p. 217-22. 7. Harness, N.G., et al., Loss of fixation of the volar lunate facet fragment in fractures of the distal part of the radius. J Bone Joint Surg Am, 2004. 86-A(9): p. 1900-8.

8. Melone, C.P., Jr., Articular fractures of the distal radius. Orthop Clin North Am, 1984. 15(2): p. 217-36. 9. White, B.D., et al., Incidence and clinical outcomes of tendon rupture following distal radius fracture. J Hand Surg Am, 2012. 37(10): p. 2035-40. 10. Bentohami, A., et al., Complications following volar locking plate fixation for distal radial fractures: a systematic review. J Hand Surg Eur Vol, 2014. 39(7): p. 745-54. 11. Roth, K.M., et al., Incidence of extensor pollicis longus tendon rupture after nondisplaced distal radius fractures. J Hand Surg Am, 2012. 37(5): p. 942-7. 12. Chapman, D.R., et al., Complications of distal radial fractures: pins and plaster treatment. J Hand Surg Am, 1982. 7(5): p. 509-12. 13. Ozer, K., et al., Comparison of 4 fluoroscopic views for dorsal cortex screw penetration after volar plating of the distal radius. J Hand Surg Am, 2012. 37(5): p. 963-7. 14. Lafontaine, M., D. Hardy, and P. Delince, Stability assessment of distal radius fractures. Injury, 1989. 20(4): p. 208-10. 15. LaMartina, J., et al., Predicting alignment after closed reduction and casting of distal radius fractures. J Hand Surg Am, 2015. 40(5): p. 934-9.

Distal Radius Osteotomy for Malunion: Indications, Options and Technique Vaughan Bowen, MB, ChB, M.D., FRCSC, FAADEP Clinical Professor in Orthopaedic Surgery Head of the Hand Program University of Calgary Calgary, AB

t used to be thought that distal radius fractures did well but higher expectations, nowadays, have caused us to realize that these injuries are associated with a high complication rate and poor results are commonly seen after both non-operative and operative treatment. Malunion is the most common complication of distal radius fractures and can be classified as extra-articular and intraarticular. The most common extra-articular malunions are associated with loss of palmar tilt, shortening, loss of radial inclination and rotational malalignment. Intra-articular malunions are characterized by step and/or gap deformities in either the distal radius articular surface or at the distal radioulnar joint (DRUJ).

COA Bulletin ACO - Winter / Hiver 2015

Clinical Features Not all malunions are associated with poor function but close questioning will often reveal that patients do not like their aesthetic appearance and are unhappy because of reduced range of motion, poor grip strength and pain. Loss of forearm supination and pain from ulnocarpal impaction are the most common adverse consequences of Colles type fractures. Median neuropathy is also more common than previously recognized. Management Options Surgical options fall into three different categories: 1. Operations to restore normal anatomical relationships Radius osteotomy Ulna recessional osteotomy 2. Operations to restore motion DRUJ release DRUJ arthroplasty Biological Synthetic Proximal row carpectomy

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

3. Operations to reduce pain Arthrodesis Complete wrist fusion Partial wrist fusion Wrist denervation Arthroplasty Biological Synthetic Some of these procedures may achieve more than one aim. For instance, ulna recessional osteotomy restores normal anatomical relationships at both the ulna carpal joint and the DRUJ as well as reducing or eliminating pain from ulnocarpal impaction and improving forearm rotation. The operation also tightens up the soft tissues and ligamentous structures on the ulnar side of the wrist, eliminating subtle (and sometimes not so subtle) instabilities. Radius Osteotomy: Indications and Contra-indications The reduction parameters for distal radius fractures are now well-established. Osteotomies for malunion are not indicated by radiographic features; rather they are for symptoms: pain, loss of motion, poor aesthetic appearance and problems associated with malalignment and/or instability in the midcarpal joint or at the DRUJ. Contra-indications for osteotomy are post-traumatic arthritis at the radiocarpal joint or DRUJ, CRPS, severe stiffness or poor general health. Age is not a contra-indication. New fixation devices have made poor bone quality less important but it should still be considered. Instabilities should be carefully evaluated. Some may be improved by radius osteotomy. Others may be better managed by alternate reconstructive procedures such as DRUJ arthroplasty. Surgical Technique Should you use a volar or a dorsal approach? There are advocates for both volar and dorsal approaches. Both have advantages and disadvantages. My preference is for volar plating because the plate is more deeply buried, away from adjacent tendons, and the approach allows for the median nerve to be decompressed if needed. How do you assess the correction? The radiographic parameters of reduction are used as guides in surgical planning. Intra-operative radiographic imaging is used to monitor progress. Tilted images, in line with the distal radius articular surface, help to avoid articular surface screw penetration. What is the best way to fix the osteotomy? My preference is to use a volar locking plate with the capability of inserting a large number of small screws, at different angles, into the distal fragment. What is the safest way to cut the osteotomy? The osteotomy should be cut with a thin oscillating saw, protecting the adjacent tendons with Hohmann retractors. The dorsal cortex should be grooved but the final breakthrough should be with gentle leverage, using a wide osteotome, in order to minimize the risk of extensor tendon transection.

How do you make distraction possible? Distraction, to gain length, is prevented by tight soft tissue structures. The brachioradialis tendon should be cut and reattached or lengthened. The dorsal periosteum is the main problem. This should be completely divided, including the tight ulna band, either (with care) through the osteotomy or by using a separate small dorsal incision. How do you do the distraction? Fix the plate to the distal fragment, suitably angled for the planned correction. Do the angle correction and temporarily fix it with K-wires in the small holes in the shaft of the plate. Check it radiographically and adjust as needed. When satisfactory, put a screw loosely into the distal end of the slot in the main shaft of the plate. Put a K-wire each side of the plate close to the osteotomy site to form a channel preventing ulnar/radial deviation of the distal fragment during distraction. Remove the temporary fixation K-wires and distract. One person pulls hard on the hand, another pushes the proximal end of the plate, a third tightens the screw, which is now more proximal in the slot. If more than one cm of length is needed, it is usually better to correct the angular deformity with the radius osteotomy and to shorten the ulna to balance forearm bone length. What do you use to fill the defect created by distraction? Iliac crest bone is less commonly used nowadays. Local new bone from the osteotomy site, combined with synthetic bone substitutes, can be used for small corrections. Allograft cancellous chips are commonly used for larger defects. Is it necessary to obtain full correction of every parameter? The aim is to correct the patientâ€™s clinical problem. Full radiographic correction is not essential. What are the common complications of corrective osteotomy? Soft tissue swelling and stretching may cause wound closure problems, neuropathies and postoperative stiffness. Late internal fixation problems and inadequate correction can also occur. Are there any other technical issues to consider? Care should be taken to insure that the internal fixation screws are not too long. The prominent dorsal cortex just proximal to the radiocarpal articular surface is not the main dorsal surface of the radius. It is Listerâ€™s tubercle, the peak of which is three or four mm above the main dorsal surface. The tips of screws appearing to be perfectly placed radiographically could, therefore, be right into the extensor tendons, especially the EPL. This is a cause of rupture. Screw lengths should be such that their tips are well short of the radiographic dorsal cortex. If the median nerve needs to be decompressed, it should be noted (and it is not well-known) that the site of compression after trauma (fractures or dislocations of the wrist) is at the wrist crease, about two to three cm proximal to the site where it is compressed in idiopathic carpal tunnel syndrome.

COA Bulletin ACO - Winter / Hiver 2015

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 35)

What about ulnar sided problems: ulna styloid avulsion, DRUJ instability? The analysis of ulnar sided problems is an essential part of preoperative planning. They may or may not need treatment in addition to the distal radius osteotomy.

Suggested Reading Prommersberger K.J., Pillukat T., Muhidorfer M., van Schoonhoven J. Malunion of the distal radius. Arch Orthop Trauma Surg 132:693-702, 2012.

Results Osteotomy has been shown to not only improve the aesthetic appearance of the wrist but to also reduce pain, improve motion (both wrist and forearm) and increase grip strength.

The Distal Radio-ulnar Joint in the Distal Radius Fracture Thomas Goetz, M.D., FRCSC Vancouver, BC

tability of the distal radial-ulnar joint (DRUJ) is dependent upon normal anatomy, namely the TFCC, the DRUJ capsule, the pronator quadratus, the interosseous membrane, and the ECU subsheath. Displaced fractures of the distal radius, in which the distal fragment is significantly displaced from the normal anatomic position, will result in injury to the stabilizing structures of the DRUJ. Multiple studies have attempted to identify the structures that are considered most critical for DRUJ stability. However, the more pertinent question is perhaps: ’What is the minimum requirement for stability’. It has been shown that any single stabilizer is sufficient to maintain stability in the setting of normal or restored bony anatomy1. Restoration of DRUJ stability requires restoration of the bony anatomy of the distal radius. When this is done, the DRUJ is almost always stable most likely due to the role of the single remaining stabilizing structure, the interosseous membrane. In cases that involve complete stripping of all structures from the ulnar head, the only remaining structure normally identified as having a role in DRUJ stability is the interosseous membrane. After anatomic restoration of anatomy, complete stability of the DRUJ can be achieved without repair of any soft tissue structures. After open reduction internal fixation of distal radius fractures with volar plating, the DRUJ should be examined for stability in both dorsal and volar directions and in neutral, pronated and supinated positions. If the DRUJ is stable, no rotational immobilization is required. If the DRUJ is stable through a range (usually supination), immobilization in that position of stability is required. In the rare case of an unstable DRUJ, the quality of distal radius reduction should be re-assessed and immobilization should be maintained in a reduced position (usually supination), along with cross pinning of the DRUJ or repair of the soft tissue about the DRUJ, depending on level of surgeon comfort and degree of instability.

COA Bulletin ACO - Winter / Hiver 2015

Rarely after ORIF may the DRUJ be irreducible. In these circumstances open reduction may be required to remove the offending block to reduction which may be due to either a fracture fragment, the extensor digiti quinti, or the extensor carpi ulnaris. The recommended technique of open reduction of the DRUJ is through a dorsal approach through the fifth extensor compartment2. Evidence suggests that the ulnar styloid fracture is an extension of the soft tissue injury to the ulnar side of the wrist. The presence of an ulnar styloid fracture may indicate a higher degree of injury, but does not require treatment. Ulnar styloid fractures through the base do not require fixation after anatomic fixation of the distal radius, unless instability persists after anatomic ORIF of the radius. Studies examining outcomes of distal radius fractures associated with ulnar styloid fractures do not show worse outcomes with untreated styloid fractures when compared with no styloid fracture in terms of instability, strength, range of motion and functional outcome3. Loss of rotation after a distal radial fracture is most likely due to malunion or prolonged immobilization. It is more common after external fixation of the radius. Typically, supination is lost due to obliteration with scar of the volar saccular recess of the DRUJ capsule into which the ulnar head normally moves. References 1. Gofton W.T., Gordon K.D., Dunning C.E., Johnson J.A., King G.J. Soft-tissue stabilizers of the distal radioulnar joint: an in vitro kinematic study. The Journal of hand surgery. 2004 May;29(3):423-31. 2. Adams B.D. Anatomic Reconstruction of the Distal Radioulnar Ligaments for DRUJ Instability. Tech Hand Up Extrem Surg. 2000 Sep;4(3):154-60. 3. Kim J.K., Koh Y.D., Do N.H. Should an ulnar styloid fracture be fixed following volar plate fixation of a distal radial fracture? J Bone Joint Surg Am. 2010 Jan;92(1):1-6.

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

Critical Appraisal Series: Validity and Reliability Neil Saran, M.D., FRCSC Division of Orthopaedic Surgery McGill University Montreal, Quebec

n critiquing orthopaedics research we often concentrate on the study design, population studied, methods utilized, outcomes measured and results of a study. We often fail to assess the validity and reliability of the outcome tools or measurements that are used to answer the hypothesis. Without valid and reliable outcome measures, the conclusion of any research hypothesis must be challenged. So what is validity? And reliability? On a daily basis we perform measurements. In scoliosis clinic we monitor progression of the spine deformity by measuring Cobb angles at intervals. In sports clinic we grade ACL laxity during an anterior drawer test or Lachman test. In trauma clinic we measure volar tilt and radial inclination to help decide on treatment of distal radius fractures. Whether we realize Figure 1 it or not, we are constantly performing meas- Graph of three hypothetical methods to measure the difference between a patientâ€™s mechanical and anatomical femoral axis. While method A is both valid and reliable, method B is valid but urements. In addition to simple measure- not reliable and method C is reliable but not valid. ments such as thigh girth, long bone angulation, and limb length discrepancy, we often use multi-item Validity questionnaires to measure patient satisfaction, condition-speThe validation of a new measurement tool typically requires cific function through scores such as the Harris Hip Score, and considerable effort. In the case of outcomes questionnaires, health-related quality of life through instruments such as the the authors of the new tool must demonstrate various forms Short Form-36 (SF-36). In research, we use these measurements of validity such as content validity, construct validity and to draw conclusions based on statistical analyses performed on criterion-related validity. the acquired data. If the outcome tool or instrument used for a particular study fails to measure that which we try to measure, Content validity refers to how well item(s) of an instrument or the measurement was not performed in a reproducible manreflect the characteristic that they are attempting to measure. ner, the conclusions drawn must be challenged. For example the items in an outcome developed to determine body image disturbance related to scoliosis should focus on Validity refers to how accurately something is measured. For body image and not on other aspects of scoliosis such as pain. example, when a Cobb measurement is performed, how accuContent validity is generally determined by an expert panel rately does it represent the true curvature of scoliosis? If a new that rates the utility of each item in the instrument. technique to measure Cobb angles using a 3D reconstruction of the spine is developed, how do we know it is actually measConstruct validity refers to how well the instrument assesses uring the scoliotic curvature? Reliability refers to the repeatthat which it claims to assess. Construct validity can be quanability or consistency of a finding. If a test is repeated and the tified by comparing how well the instrument correlates to results are the same or closely similar, it is considered to be other existing instruments that measure a similar domain or reliable. If a Cobb angle measurement is performed by the characteristic. For example, when validating the Body Image same person on a different day, will it be similar (intraobserver Disturbance Questionnaire â€“ for Scoliosis, Auerbach et al.1 reliability)? If it is measured by someone else, will the results compared the scores of the new instrument with domains be similar (interobserver reliability)? To provide useful informafrom previous existing instruments that assess body image and tion, a measurement must be both valid and reliable. general appearance.

COA Bulletin ACO - Winter / Hiver 2015

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 37)

Criterion validity assesses an instrument’s relationship to a reference criterion standard or “gold standard.” For example, in order to validate femoral version measurements obtained from 3D reconstructions of the hip using low dose biplanar radiography, Pomerantz et al2. compared the new measurement to an existing gold standard which consisted of a CT scan measurement of femoral version. While validity of a measurement tool is important, it is equally important to ensure that the data was gathered without error and without bias. It is vital that procedures and standards for the collection of valid instruments are followed to avoid systematic error that can creep into data through lack of standardization, calibration and training. Reliability Reliability of a measurement tool can be determined through various methods of quantifying the variation seen when using the measurement tool. Examples include interobserver reliability, intraobserver reliability, intrasubject reliability, and internal consistency. Interobserver reliability refers to the variation of a measurement taken by different observers. A well-known example of interobserver variation occurs when measuring Cobb angles for scoliotic spine deformity. Between a radiologist, a resident, a fellow and a staff, the measurements can easily vary by 10-20 degrees. Interobserver reliability is generally measured using the kappa statistic for categorical data, weighted-kappa for ordinal data, and the intraclass correlation coefficient for continuous data. Intraobserver reliability refers to the variation seen when the same observer performs the exact same measurement at different times. For example, when quantifying the amount of distal femoral valgus that exists in a patient with genu valgum, the same physician may measure the mechanical lateral distal femoral angle (mLDFA) as 79 degrees on the day the radiograph was taken but 76 degrees on the day of surgery despite the fact that the measurement was performed on the original radiograph. Intrasubject reliability measures the amount of variation that occurs when a test is repeated in the same individual at different times. For example, the Cobb angle measurement of a scoliosis may change depending on the time of day the radiograph was taken. It is possible that Cobb angle measurement of a radiograph performed early in the morning shortly after awakening may be slightly smaller than when compared to a radiograph that is performed several hours into the day. When inter-subject variations are high, it is important to attempt to control for such variations. Internal consistency reliability refers to how well the individual items in an instrument correlate to one another and how well they measure the same characteristic. An instrument is felt to have internal consistency reliability when all the items that make up a construct have general agreement between all the items. Internal consistency is generally measured using Cronbach’s Alpha.

COA Bulletin ACO - Winter / Hiver 2015

While there are many ways to statistically quantify reliability, they are typically presented with a coefficient that measures between zero and one with one being perfect agreement and zero representing an agreement that is no better than chance alone. The closer the coefficient is to one, the more agreement there is between observations. When small changes in a measurement affect outcomes, it becomes imperative to utilize measures that are extremely reliable. Reliability and Validity It can be argued that if a measurement is not reliable, then it should not be considered valid. However, in a group or population setting, the results can be valid even though a test is not reliable for each individual in that population. For example, let’s assume that there are three different tools to measure the difference between femoral mechanical and femoral anatomic axis. Tools A and B are both valid in the population setting as their average value centres around the true value of the measurement3. Tool A is reliable as the measures are repeatable; whereas, tool B is not reliable due to the large spread in the measurements. While Tool C is reliable, it is not valid. In a population study, both Tools A and B could be utilized because of group validity3; whereas, in an individual setting, only Tool A should be used as it is both valid and reliable. The validity and reliability of individual measurements and multiple item instruments are key to the robustness of a study. When evaluating a study or using a measurement to help develop a clinical plan, one must be aware of the validity and reliability of such measurement tools. References 1. Auerbach J.D., Lonner B.S., Crerand C.E., Shah S.A., Flynn J.M., Bastrom T., Penn P., Ahn J., Toombs C., Bharucha N., Bowe W.P., Newton P.O. Body image in patients with adolescent idiopathic scoliosis: validation of the Body Image Disturbance Questionnaire--Scoliosis Version. J Bone Joint Surg Am. 2014 Apr 16;96(8):e61. 2. Pomerantz M.L., Glaser D., Doan J., Kumar S., Edmonds E.W. Three-dimensional biplanar radiography as a new means of accessing femoral version: a comparitive study of EOS three-dimensional radiography versus computed tomography. Skeletal Radiol. 2015 Feb;44(2):255-60. 3. Gordis, L. (2009). Epidemiology. Philadelphia, PA: Elsevier.

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

System-based Management of Hip and Knee OA Aileen Davis, PhD Senior Scientist, UHN Rhona McGlasson, PT, MBA Executive Director Bone and Joint Canada

steoarthritis (OA) is a chronic disease that results in changes to the structure of the joint including the breakdown of cartilage. The initial symptoms of OA include some mild joint pain and/or swelling and/or stiffness, which can lead to reductions in physical activity levels. For individuals who experience disease progression – as the joint degenerates, symptoms fluctuate becoming gradually more severe such that further medical interventions are required. Management for OA starts with primary prevention where strategies are needed to reduce the incidence of OA through reducing the major risk factors of injury and obesity. Once the disease has started, the system-based management strategies need to align with the disease state as outlined in the following model. The guidelines for the management of OA recommend education and exercises as effective methods of symptom management. For a few individuals, the symptoms will progress to the point additional medical management including access to surgery for consultation for a hip and knee replacement is required. Bone and Joint Canada (BJC) has been undertaking an initiative to develop a systems approach to the management of OA through a coordinated strategy to implement evidence-based practice wherever possible across the disease continuum.

Working with the researchers from Denmark, BJC has launched the “GLA:D Canada” program at the Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre where it will be offered to individuals who are being assessed for hip and knee replacement surgery and who wish to have access to conservative management. Over the next few months BJC will be identifying opportunities to launch GLA:D Canada nationally through other partner organizations including within the primary care and the wellness sectors. Medical Management of OA While education and exercise are the foundations of OA management across the spectrum of symptom severity, a number of individuals may require additional medical therapy accessed through their primary care provider. BJC has undertaken a program review to identify factors that ensure a successful primary care program. Through this review the following factors were identified: 1. Linkages to medical management through the primary care physician 2. Mechanism to link individuals to specialist consultation 3. Program includes: a. Education to promote self-management b. Exercise program that is: i. Evidence-based ii. Promotes neuromuscular stabilization of the lower extremity iii. Can be encompassed into the individual’s daily functional routine 4. Mechanism to link individuals to community services 5. Ongoing support for questions and concerns 6. Uses outcome measures to track improvement to promote sustainability of improvements

GLA:D Canada In Denmark a program called GLA:D (Good Life with osteoArthritis in Denmark) has successfully helped individuals with OA to reduce their symptoms and increase their levels of function and physical activity. This education and neuromuscular exercise program has been effective for individuals who have mild, occasional knee and hip pain, (suggestive of early degenerative symptoms or “pre OA”), as well as moderate disease and even severe symptoms, where they are waiting to undergo joint replacement surgery.

COA Bulletin ACO - Winter / Hiver 2015

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 39)

Information about number of programs across Canada that have been identified will be posted on the BJC web site. Appropriateness for Hip or Knee Replacement Surgery Approximately, 10% of people with hip and knee OA experience increasing symptoms that cannot be successfully managed by conservative therapies. These individuals require a surgical consultation with an orthopaedic surgeon regarding the option of joint replacement surgery. BJC hosted a meeting attended by surgeons, clinicians, including nurses and physiotherapists, researchers, as well as individuals who work in policy. The decision for surgery is made by the patient in consultation with the surgeon, however, there are many system factors that need to be taken into consideration to ensure that the patient and the surgeon have the right amount of information and time to make an informed decision.

A summary of the factors that were discussed includes: • Effective and respectful patient decision process including time to discuss with family • Evidence of failed conservative management in an evidence-based program • Standardized process throughout surgery and recovery built on best clinical practices • Patient education to address their expectations from the surgery • Effective intake process • Timely access and active management of resources including operating room time • Standardized feedback loop to primary care • Data system that effectively promotes decision-making • Funding aligns with program and incentivizes the system for performance Further work will be undertaken to develop recommendations on the design of a health-care system to ensure the right patients are getting to surgery at the right time. Further information on each of these initiatives is available through the BJC web site at www.BoneandJointCanada.ca

Two Reports from OrthoEvidence - Feedback Requested

OA members are invited to review and provide comment on the following two reports issued by OrthoEvidence on Identifying Musculoskeletal Interventions with Low Levels of Efficacy in the Knee as well as Identifying Musculoskeletal Interventions with Limited Levels of Efficacy in the Shoulder & Elbow. Simply click on each title to access the corresponding report. The plan will be for the COA to submit these reports to the Choosing Wisely Canada organization as a COA recommendation. We encourage your comments and feedback which may be directed to Trinity Wittman: trinity@canorth.org at the COA Office.

COA Bulletin ACO - Winter / Hiver 2015

Deux rapports d’OrthoEvidence – Rétroaction demandée

es membres de l’ACO sont invités à consulter et commenter deux rapports publiés par OrthoEvidence : « Identifying Musculoskeletal Interventions with Low Levels of Efficacy in the Knee » et « Identifying Musculoskeletal Interventions with Limited Levels of Efficacy in the Shoulder & Elbow ». Il suffit de cliquer sur le titre du rapport pour y accéder. L’ACO compte recommander ces rapports à la campagne Choisir avec soinMC. Merci de communiquer vos commentaires à Trinity Wittman, à trinity@canorth.org, aux bureaux de l’ACO.

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*Based on 556 CT scans. 1. Capello W, et al. Clin Orthop Relat Res. 2006;453:75–80. 2. Incavo SJ, et al. J Arthroplasty. 2008;23:670–676. 3. Australian Joint Replacement Registry Annual Report. 2012. 4. Study of accurate stem seating in benchtop testing: Stryker RD Test Report RD-13-029. Test results for 0915A-P04: in-vitro comparison of Secur-Fit Advanced to Secur-Fit Max press-fit designs in Sawbones during impaction loading. 5. Stryker RD Test Report RD-13-023. Determination of Secur-Fit Advanced neck lengths and head centers. 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. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: OmniFit, Secur-Fit, SOMA, Stryker. All other trademarks are trademarks of their respective owners or holders. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. SECUFA-AD-1 © 2013 Stryker Corporation. All rights reserved. Printed in the USA.

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

Sunny Ways My Friends, Sunny Ways Doug Thomson Chief Executive Officer Canadian Orthopaedic Association

ing economy and the inevitable “we had no idea that the Tories left the Treasury THAT broke” in the time-honoured fashion of blaming the outgoing government.

So what does it mean for the health-care file in this country? The Liberals promised a welcome new approach to health at the federal level. They committed to re-engage on the health file and signaled their intention to play a stronger leadership role in health. Beyond their platform commitments, the Liberals have sent strong messages to the community that it intends to approach the health file differently:

s Prime Minister-designate Justin Trudeau stood before an election night crowd in Montreal on October 19, he quoted former Prime Minister Sir Wilfrid Laurier, saying: “Sunny ways my friends, sunny ways.” Laurier first employed the phrase in 1895, in response to the Manitoba Schools Question, a political crisis sparked when the premier of Manitoba, Thomas Greenway, withdrew public funding for Catholic and Protestant denominational schools and establishing a system of tax-supported, non-sectarian public schools. The removal of this funding from Catholic schools in particular was of great importance to the province’s French-speaking minority, and, by extension, to the province of Quebec. The next year, Laurier, the francophone Catholic leader of the Liberal Party, won an election fought on the issue, ending the rule of the Conservative Party, which had led the country almost continuously since 1867. The Canadian Encyclopedia describes Laurier’s position on the crisis like so: His approach, he said, would be to conduct an investigation, seek out the facts, and then use conciliation. He called it “sunny ways,” evoking the Aesop fable in which the sun and the wind compete to see which can force a man to take off his coat. The wind makes the man to cling more tightly to his garment, while the sun’s warmth induces him to take it off. The sunny approach worked for Laurier and no doubt it has also worked for Justin Trudeau – but for how long? In 2015, the Liberals were seen by Canadians as most embodying change. “Real Change” ultimately beat out “Ready for Change”. Impressively, the party that has governed for 70 of the last 100 years was able to cast itself as a more transformational choice that the NDP. A post-election poll by Forum Research found 28% of Canadians cast their ballot based on “the need for change”. The new government has a crowded agenda from legalization of marijuana to clipping the wings of F-35s to pension reform to infrastructure. Vying for legislative time, love and attention will be Liberal promises to increase funding for the CBC and the arts, deliver on electoral reform, enact all of the recommendations of the Truth & Reconciliation Commission, consult on a national education framework, the Trans Pacific Partnership agreement deliberations, a national child-care plan and a new Health Accord and Pharmacare Plan. First up will be the tax of the top 1% to support the middle class and to harvest some low-hanging fruit (marijuana, exiting Syria, 25k refugees, etc.) to show that election promises were kept. After that, it is going to be a battle for attention - I expect that we will hear, early and often, that “we have a four-year plan”. The agenda is busy and the runway is long. Legislative headway will need to be made against a backdrop of a weaken-

• • • • •

Stronger federal leadership role in health Provincial collaboration Willingness to engage with stakeholders and experts Evidence-based decision making Commitment to action

If indeed the Trudeau government is serious about a changed approach to health (and I have no reason to believe that they are not) this will mean new opportunities for organizations such as the COA. There will be new opportunities to engage decision makers, a new openness to dialogue and policy debate. But we must also be mindful of what new approaches should be considered, and the other influencers who will impact decision making. • The COA represents an important community that government wants to, and needs to, hear from. If we mirror the success and forward-looking enthusiasm of the Alberta Bone and Joint Health Institute on a national basis, using best evidence to drive innovation, this can be a powerful message to Ottawa on how to deliver best value and reduce waste in health care across the country. • Knowledge and expertise will be valued differently. • Being active at federal and provincial levels of government is crucial. • The tone of discourse will be almost as important as the outcomes. Positive, cooperative, solutions-oriented – not doom and gloom – this is a natural for orthopaedics in the country (see: Alberta’s Bone and Joint Health Institute – bridging MSK car’s knowledge-to-action gap. Bulletin Spring 2015) • Getting a commitment on a new proposal will be challenging vs. existing promises to keep. • Focus may require more smaller “wins” that target specific issues/populations. If Prime Minister Trudeau finds it impossible to deliver on all of his election promises, he won’t be the first leader to disappoint some of his supporters. Laurier won in 1896 with the overwhelming support of Quebec voters, then turned around and forged a compromise on the Manitoba Schools Question that arguably diminished the status of the French language in the country as a whole. Sunny ways can win elections, but they don’t always lead to sunny days. The views and opinions expressed in this article are those of the author. COA Bulletin ACO - Winter / Hiver 2015

Right from the Start. Remove or convert? We planned ahead so you don’t have to. We knew it was important to design the Equinoxe® system with convertibility in mind to give you options in the event of a revision. A study of 67 patients showed the benefits of platform stems, including reduced operating room time, which may save hospitals thousands of dollars per case.1,2

These are the results of the cited study. Individual results may vary.

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

n REVISABILITY n SCAPULAR

NOTCHING

22 of 22 Equinoxe stems were able to be revised without removal.

STEM Converted Removed (Equinoxe)

OR Time (min)

145

211

Est. Blood Loss (cc)

280

500

Post-Op Constant Score 75

Complications

n STABILITY / ROTATION n COMPONENT LOOSENING

Go to www.exac.com/equinoxestudies to view the research. 1. Crosby LA. et al. Revision Total Shoulder Arthroplasty with and without Humeral Stem Removal: How Much of a Difference Does It Make in the Overall Results? Trans of the 23rd Annual BESS Scientific Meeting. 2012. 2. Macario A. “What Does One Minute of Operating Room Time Cost?,” Journal of Clinical Anesthesia, vol. 22, no. 4, pp.233-236, Jun. 2010.

www.exac.com 905-765-1117

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

COA Bulletin ACO - Winter / Hiver 2015

Information you and your patients can trust. Reliable, surgeon-approved resources to help your patients’ understanding and help you to reclaim time.

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Foundation / Fondation

J. Edouard Samson Award 2014 Recipient: Dr. Paul E. Beaulé

he Canadian Orthopaedic Foundation awarded its 2014 J. Edouard Samson Award to Dr. Paul E. Beaulé, The Ottawa Hospital, University of Ottawa. The premier award for orthopaedic research in Canada, the $15,000 J. Edouard Samson Award recognizes the best career orthopaedic research over a period of five years or more at a Canadian centre. Dr. Beaulé’s research project is titled Understanding the Etiology and Cause of Osteoarthritis (OA) of the hip: A multi-disciplinary approach. In explaining the evolution of his research hypothesis, Dr. Beaulé writes, “The cam deformity associated with femoroacetabular impingement (FAI) has been thought to be a cause of OA. However, there is still a lack of understanding in regards to when and how the cam deformity puts the hip at risk of osteoarthritis. This is particularly true in regards to its etiology, where different theories have been proposed including high activity levels in early adulthood, unrecognized slipped capital femoral epiphysis and abnormal growth of the physis. My work has therefore focused on when the cam deformity forms as well as understanding what clinical factors determine who is at risk of developing hip symptoms/degenerative changes, using high resolution imaging and three-dimensional motion analysis. We hypothesized that the cam deformity develops during the period of skeletal maturation and that abnormal hip mechanics associated with the cam deformity lead to early hip degeneration. We further hypothesize that the cam deformity is not a reactive deformity but rather a pathological deformity with its own tissue characteristics. This, in turn, leads to increased localized stress seen in the acetabulum, causing bone remodeling as well as increased shear stress at the bone/cartilage interface, resulting in cartilage failure.”

Dr. Paul E. Beaulé receives the J. Edouard Samson Award from Dr. Geoffrey Johnston, Chair of the COF Board

hip osteoarthritis cases potentially saving the Canadian healthcare system up to $1.7 billion over the next five years and further savings beyond.

Dr. Beaulé and his team used MRI techniques to confirm a biological gradient to the cam deformity to determine the risk of cartilage damage and development of hip pain. Using three-dimensional motion and force plate analysis, the research team demonstrated that patients with symptomatic cam FAI had decreased pelvic mobility compared to normal individuals and that stresses secondary to the impingement are localized in the acetabular subchondral bone layer. These findings provided insight into the role of acetabular orientation in the pathomechanism of FAI as well as validating the dynamic concept whereby the cam lesion causes an “outside-in” damage to the articular cartilage.

The results of this multi-disciplinary research program involving diagnostic imaging, biomechanics and motion analysis will help clinicians to better determine who may most benefit from surgical intervention for correction of a cam deformity. In addition, these findings can now open doors to the development of prevention programs during skeletal maturation and non-surgical treatment options such as activity modification and exercise programs. Correction of the underlying bony abnormality is critical and could actually delay and/or prevent arthritis and provide new directions for disease modifying osteoarthritic drugs. Dr. Beaulé’s research illustrates the critical importance of a multi-disciplinary team approach.

Findings of the research to date confirm the cam deformity as a cause of hip degeneration as well as the pathomechanism of early stiffening of the subchondral bone plate due to mechanical overloading from the impinging cam deformity. In addition, the identification of additional risk factors provides insight as to why certain individuals are at greater risk than others. Finally the presence of the cam deformity at the time of skeletal maturation and its absence prior to physeal closure confirms its developmental nature as well as being a primary cause of degenerative changes within the hip joint. As a result, early intervention to correct this deformity promises to reduce

The Board of Directors of the Canadian Orthopaedic Foundation congratulate Dr. Beaulé on his award, and look forward to reading more as his research progresses. Dr. Beaulé joins a list of extraordinary orthopaedic researchers who have received the J. Edouard Samson Award. Read about all of the past Samson Award winners on the COF web site at http://whenithurtstomove.org/grants-and-research/previous-grant-and-award-recipients/.

COA Bulletin ACO - Winter / Hiver 2015

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Foundation / Fondation

Dr Paul E. Beaulé – Lauréat 2014 du Prix J.-Édouard-Samson

n 2014, la Fondation Canadienne d’Orthopédie a remis le Prix J.-Édouard-Samson au Dr Paul E. Beaulé, de L’Hôpital d’Ottawa, affilié à l’Université d’Ottawa. Principal prix canadien en recherche orthopédique, le Prix J.‑Édouard-Samson, d’une valeur de 15 000 $, reconnaît la meilleure recherche en orthopédie menée sur une période d’au moins 5 ans dans un centre canadien. Le projet de recherche primé du Dr Beaulé s’intitule Understanding the Etiology and Cause of Osteoarthritis (OA) of the hip: A multi-disciplinary approach (comprendre l’étiologie de l’arthrose de la hanche : une approche multidisciplinaire). Le Dr Beaulé décrit l’évolution de son hypothèse de recherche comme suit : « On croit que l’arthrose résulte entre autres d’une déformation de la jonction du col et de la tête fémorale, c’està-dire d’un conflit fémoro-acétabulaire de type came. Cela dit, on sait encore peu de choses sur le moment où cette déformation accroît les risques d’arthrose de la hanche et le processus connexe. Et c’est particulièrement vrai quand on s’attarde à l’étiologie, puisque diverses théories existent, y compris celles des activités intensives au début de l’âge adulte, d’une épiphysiolyse fémorale supérieure non diagnostiquée et d’une croissance anormale du cartilage de conjugaison. Mes recherches portent donc sur le moment où le conflit fémoro-acétabulaire de type came commence et la compréhension des facteurs cliniques qui permettent d’établir les personnes à risque de développer des symptômes ou des changements dégénératifs à la hanche à l’aide de l’imagerie à haute résolution et d’une analyse cinétique tridimensionnelle. Nous postulons que le conflit fémoro-acétabulaire de type came se développe pendant la maturation squelettique et que le fonctionnement anormal de la hanche qui en découle provoque une dégénérescence articulaire précoce. Nous postulons en outre qu’il n’est pas réactif, mais pathologique, avec ses propres caractéristiques tissulaires. Cela mène à une intensification de la contrainte subie par l’acétabulum, et donc à un remodelage osseux et à une amplification de la force de cisaillement à l’interface os-cartilage, qui se traduisent par des lésions du cartilage. » [traduction] Le Dr Beaulé et son équipe ont utilisé des techniques d’imagerie par résonance magnétique (IRM) pour confirmer le gradient biologique du conflit fémoro-acétabulaire de type came de sorte à établir les risques de lésions du cartilage et l’évolution de la douleur à la hanche. À l’aide d’une analyse cinétique tridimensionnelle et de données obtenues à la plateforme de force, l’équipe de recherche a montré que les patients atteints d’un conflit fémoro-acétabulaire de type came symptomatique présentent une mobilité pelvienne réduite, et que des contraintes secondaires touchent la couche osseuse sous-chondrale de l’acétabulum. Ces constats permettent de mieux comprendre le rôle de l’orientation acétabulaire dans ce pathomécanisme et de valider le concept dynamique voulant que les lésions découlant d’un conflit fémoro-acétabulaire de type came endommagent le cartilage articulaire de l’extérieur vers l’intérieur.

Les conclusions à ce jour confirment que le conflit fémoro-acétabulaire de type came est l’une des causes de la dégénérescence de la hanche, en plus d’être le pathomécanisme à l’origine de la raideur précoce de la plaque sous-chondrale, puisqu’il provoque une surchage mécanique. De plus, l’établissement de nouveaux facteurs de risque permet de mieux comprendre pourquoi certaines personnes sont plus à risque. Enfin, la présence d’un conflit fémoro-acétabulaire de type came pendant la r maturation squelettique D Paul. E. Beaulé et son absence avant la soudure de la plaque de croissance confirment qu’il est lié au développement et qu’il s’agit d’une des causes principales de dégénérescence articulaire de la hanche. Ainsi, une correction précoce de ce conflit pourrait permettre la réduction des cas d’arthrose à la hanche et se traduire par des économies pour le système de santé canadien pouvant atteindre 1,7 milliard de dollars sur 5 ans, et plus encore à long terme. Ce projet de recherche multidisciplinaire axé entre autres sur l’imagerie diagnostique, la biomécanique et l’analyse cinétique aidera les cliniciens à mieux dépister les personnes les plus susceptibles de bénéficier d’une correction chirurgicale du conflit fémoro-acétabulaire de type came. De plus, ces conclusions peuvent maintenant mener à l’élaboration de programmes de prévention pendant la maturation squelettique et à une série de traitements non chirurgicaux, comme les programmes d’exercice et de modification de l’activité physique. Il est essentiel de corriger l’anomalie osseuse sous-jacente, ce qui pourrait retarder voire prévenir l’arthrite, en plus de fournir de nouvelles pistes dans l’élaboration d’anti-arthrosiques modificateurs de la maladie. Les travaux du Dr Beaulé montrent l’importance capitale d’une approche multidisciplinaire. Le conseil d’administration de la Fondation Canadienne d’Orthopédie félicite le Dr Beaulé et a hâte de constater ses progrès dans ses recherches. Le Dr Beaulé succède à une série de chercheurs en orthopédie d’exception qui ont reçu le Prix J.‑Édouard-Samson. Pour en savoir plus sur les lauréats précédents de ce prix, voir le site Web de la Fondation, à http://whenithurtstomove.org/fr/ grants-and-research/previous-grant-and-award-recipients/.

COA Bulletin ACO - Winter / Hiver 2015

Foundation / Fondation

Canadian Orthopaedic Foundation Welcomes Three New Directors

his fall the Canadian Orthopaedic Foundation is delighted to welcome three new Directors to the Board: Drs. Rick Buckley, Kevin Hildebrand and Ross Leighton.

Dr. Richard Buckley, Foothills Medical Centre, Calgary, Alberta, has been on the active medical staff in Calgary since 1990. He is a Professor in the Department of Surgery, in the Division of Orthopaedic Trauma. His clinical practice is that of orthopaedic trauma and he is extremely active in teaching undergraduate and post graduate medicine. He has been involved in the Orthopaedic Trauma Fellowship in Calgary, with nearly 50 International Fellows under his tutelage. He is also active in the research front. Dr. Buckley is a member of the Association for Study of Internal Fixation (ASIF) (AO). He has been a member of the Orthopaedic Trauma Association since 1990. Dr. Buckley has also been active in the Canadian Orthopaedic Association (COA) and has served on and chaired the Membership Committee, acted as COA Advisor to the Canadian Society of Orthopaedic Technologists and was Chairman and Founder of the Canadian Orthopaedic Resident Forum (a resident review course). Dr. Buckley’s present research focus is almost exclusively related to trauma and he is an active member within the Canadian Orthopaedic Trauma Society. When asked about his interest in joining the COF Board, Dr. Buckley points to the importance of the Foundation’s growing research program. He says, “My interest in orthopedics when I was a young surgeon was the clinical side where surgery seemed to be the answer to most problems. Now, it is more clear to me that research is the most important part of what we stand for. That must be our shining light and what will give us direction for the future.” Dr. Kevin A. Hildebrand is the Chief of Orthopaedic Surgery and a Professor in the Department of Surgery at the University of Calgary and Alberta Health Services – Calgary Zone. He obtained his Medical Degree and completed an orthopaedic surgery residency at the University of Calgary. Fellowship training included Sport Medicine at the University of Calgary, postdoctoral research in ligament healing at the University of Pittsburgh and upper extremity surgery at the Hand and Upper Limb Centre University of Western Ontario. He joined the University of Calgary in 1998. Dr. Hildebrand’s research interest is primarily in post-traumatic elbow contractures and to a lesser extent in hip fracture care. He has received funding from the Canadian Orthopaedic Foundation, Canadian Institutes of Health Research, Alberta Heritage Foundation for Medical Research, American Foundation for Surgery of the Hand, Worker’s Compensation Board – Alberta, and Department of Defense of the United States Army. He received the J. Eduoard Samson Award and with his graduate student Michael Monument, the Robert Salter Award from the Canadian Orthopaedic Foundation. COA Bulletin ACO - Winter / Hiver 2015

Dr. Hildebrand served on the Canadian Orthopaedic Research Society (CORS) Executive for five years, being the President in 2004-2005. Currently, Dr. Hildebrand is an Executive Committee member of the McCaig Institute for Bone and Joint Health, University of Calgary. “I have received support from the Foundation for my research and I am a regular COF donor,” says Dr. Hildebrand. “I welcome this opportunity to participate in the Foundation to ensure continued support for the research community and ultimately our orthopaedic patients.” Dr. Ross Leighton is a Professor of Surgery at Dalhousie University in Halifax, Nova Scotia, with an interest in Orthopaedic Trauma and the care of the acute Trauma Victim. As Provincial Trauma Director for Nova Scotia he was instrumental in setting up a state of the art Trauma system in Nova Scotia. Dr. Leighton runs a fellowship program in trauma and arthroplasty at Dalhousie University out of the QEII Health Sciences Centre. He is currently the President of the Nova Scotia Orthopaedic Society and Medical Staff at the QEII. He is also the President of the Canadian Orthopaedic Trauma Society. The Foundation’s research program is what drew Dr. Leighton to the Canadian Orthopaedic Foundation and he looks forward to contributing on the Board of Directors. Dr. Geoffrey Johnston, Chair of the Board of the Canadian Orthopaedic Foundation, says “We are fortunate to have Drs. Buckley, Hildebrand and Leighton on our Board. They join other orthopaedic surgeon Board members Chad Coles, Étienne Belzile, Erin Boynton, Stewart Wright, Bill Dust, Pierre Guy and me to further the mission of the COF, to fund orthopaedic surgical research and education, to support orthopaedic patient education and to advocate for best orthopaedic care. Certainly these three new Directors are power hitters on the Canadian orthopaedic scene, and we look forward to their energy and contribution to the Board.” For further details about the COF Board members, visit http://whenithurtstomove.org/about-us/board-of-directors/.

Foundation / Fondation

Trois nouveaux membres au sein du conseil d’administration de la Fondation Canadienne d’Orthopédie

et automne, la Fondation Canadienne d’Orthopédie a eu le plaisir d’accueillir trois nouveaux membres au sein de son conseil d’administration, soit les Drs Rick Buckley, Kevin Hildebrand et Ross Leighton. Le Dr Richard Buckley, du Centre médical Foothills, à Calgary, en Alberta, est un membre actif du corps médical de Calgary depuis 1990. Il est professeur à la division d’orthopédie traumatologique du département de chirurgie. Sa pratique clinique est axée sur l’orthopédie traumatologique, et il est extrêmement actif dans l’enseignement de la médecine aux étudiants des premier, deuxième et troisième cycles. Il a collaboré au milieu de la formation supérieure en orthopédie traumatologique à Calgary, où il a supervisé près de 50 étudiants de partout dans le monde. Enfin, il est aussi actif dans le secteur de la recherche. Le Dr Buckley est membre de l’Association for Osteosynthesis/ Association for the Study of Internal Fixation (AO/ASIF) et membre de l’Orthopaedic Trauma Association depuis 1990. Il joue aussi un rôle actif au sein de l’Association Canadienne d’Orthopédie (ACO), dont il est membre et où il a présidé le Comité d’admission; il a été conseiller de l’ACO auprès de La Société canadienne des technologistes en orthopédie, de même que président et fondateur du Canadian Orthopaedic Resident Forum (cours de préparation pour les résidents). Les recherches du Dr Buckley sont actuellement presque exclusivement axées sur la traumatologie; il est membre actif de la Société canadienne d’orthopédie traumatologique (COTS). Quand on l’interroge sur les raisons pour lesquelles il se joint au conseil d’administration de la Fondation, le Dr Buckley cite l’importance de son programme de soutien à la recherche, en pleine expansion. « Quand je suis devenu orthopédiste, mon intérêt était clinique, puisque la chirurgie semblait répondre à la majorité des problèmes. Maintenant, il m’apparaît évident que la recherche est l’aspect le plus important de ma profession. Ce doit être notre phare, ce qui nous guide dans notre progression. » Le Dr Kevin A. Hildebrand est chef du département de chirurgie orthopédique et professeur du département de chirurgie de l’Université de Calgary et d’Alberta Health Services, à Calgary. Il a obtenu son diplôme de médecine et effectué sa résidence en orthopédie à l’Université de Calgary. Sa formation supérieure comprend la médecine sportive à l’Université de Calgary, des recherches postdoctorales sur la guérison des ligaments à l’université de Pittsburgh et la chirurgie aux membres supérieurs au Hand and Upper Limb Centre de l’Université Western. Il a joint l’équipe de l’Université de Calgary en 1998. Les recherches du Dr Hildebrand portent principalement sur les contractures musculaires au coude à la suite d’un traumatisme et, dans une moindre mesure, sur le traitement des fractures de la hanche. Il a reçu du financement de la Fondation Canadienne d’Orthopédie, des Instituts de recherche en santé du Canada, de l’Alberta Heritage Foundation for Medical Research, de l’American Foundation for Surgery of the Hand, du Workers’

Compensation Board (WCB) Alberta et du département de la défense américain. Il a reçu le Prix J.-Édouard-Samson et, conjointement avec Michael Monument, étudiant sous sa supervision, il a accepté la Bourse Robert B. Salter de la Fondation Canadienne d’Orthopédie. Le Dr Hildebrand a siégé au conseil d’administration de la Société de recherche orthopédique du Canada (SROC) pendant cinq ans, et en a assumé la présidence en 2004-2005. Il est aujourd’hui membre du comité de direction du McCaig Institute for Bone and Joint Health de l’Université de Calgary. « La Fondation m’a soutenu financièrement dans mes recherches et je lui renvoie régulièrement l’ascenseur, explique le Dr Hildebrand. Je suis heureux d’avoir l’occasion de participer aux activités de la Fondation afin d’assurer le maintien du soutien au milieu de la recherche et, au bout du compte, aux patients en orthopédie. » Le Dr Ross Leighton est professeur de chirurgie à l’Université Dalhousie, à Halifax, en Nouvelle-Écosse; il s’intéresse à l’orthopédie traumatologique et aux soins en cas de trauma aigu. À titre de directeur provincial de la traumatologie, il a joué un rôle clé dans l’établissement d’un système à la fine pointe en Nouvelle-Écosse. Le Dr Leighton dirige un programme de formation supérieure en traumatologie et arthroplastie à l’Université Dalhousie, à partir du Queen Elizabeth II Health Sciences Centre. Il occupe actuellement la présidence de la Nova Scotia Orthopaedic Society, en plus d’être à la tête du corps médical du Queen Elizabeth II Health Sciences Centre. Il assume en outre la présidence de la Société canadienne d’orthopédie traumatologique (COTS). C’est le programme de recherche de la Fondation qui a amené le Dr Leighton à s’intéresser à la Fondation, et il a hâte de contribuer aux activités de son conseil d’administration. Le Dr Geoffrey Johnston, président du conseil d’administration de la Fondation Canadienne d’Orthopédie, a déclaré : « Nous avons beaucoup de chance d’avoir les Drs Buckley, Hildebrand et Leighton au sein du conseil. Avec les autres orthopédistes qui le composent, soit les Drs Chad Coles, Étienne Belzile, Erin Boynton, Stewart Wright, William Dust, Pierre Guy et moi-même, ils poursuivent la mission de la Fondation, qui est de financer la recherche et la formation en orthopédie, soutenir la sensibilisation des patients et militer pour les meilleurs soins orthopédiques possible. Il est évident que ces trois nouveaux venus sont de véritables poids lourds de l’orthopédie au Canada, et nous sommes très heureux de l’énergie qu’ils vont insuffler au conseil. » Pour plus de renseignements sur les membres du conseil d’administration de la Fondation, consultez http://whenithurtstomove.org/fr/about-us/board-of-directors/. COA Bulletin ACO - Winter / Hiver 2015

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

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COA Bulletin ACO - Winter / Hiver 2015

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

Surgeons’ Questions Answered Adam O’Neill, BSc, MBA, CHS adam.oneill@sunlife.com Conor Pollock, BComm, CFP, CHS conor.pollock@sunlife.com

his article is a response to several of the most common questions and feedback we received both during and after the ICL on transition planning that we held during the 2015 COA Annual Meeting in Vancouver. Each topic was raised multiple times, as a question from the floor, in the feedback forms, or in discussions with surgeons. These topics are also frequent concerns for many of our clients in other medical specialties across Canada. Should I incorporate? Forming a professional corporation confers a number of very valuable advantages including tax minimization, income splitting opportunities, control over how income is taken and in what form, reduced after tax cost of insurance, and much more. In many situations, the benefits of incorporation are amplified when a spouse or partner’s situation is taken into account. However, there are many factors affecting the decision and every surgeon should discuss the pros and cons with their holistic financial planner (in conjunction with their accountant) to ensure all factors are considered. Can I incorporate? Many orthopaedic surgeons in Canada are able to incorporate and set up a professional corporation, while others may have some hurdles, or be outright prevented from incorporating. Many of those who face hurdles or are currently prevented from incorporating may find that avenue opening at some point in the future. There is a trend among several specialties (including pathologists), of negotiating with employers to allow for incorporation. Given the rapid changes happening in the Canadian medical landscape, we expect much more flexibility in the future for physicians of all types. What do I do with my corporation at retirement? The best course of action for a professional corporation at retirement really depends on several key factors. If the corporation is saleable, (especially if it can be sold through a share sale) then you may be able to take advantage of the Lifetime Capital Gains Exemption (LCGE), which currently shelters $813,600 of capital gains per shareholder. If a surgeon and their spouse are both owners of the corporation, a total of $1,627,200 of capital gains can be sheltered. At a 48% marginal tax rate, this leads to the removal of $195,000 of tax. This scenario is currently fairly rare, and there are a number of other requirements in order to use this exemption, but we expect this to be more commonplace in the future. If the corporation is not saleable (which is the most common scenario), there are still a number of benefits to be had in retirement. If a physician is no longer practicing, then the professional corporation transitions into an investment corporation, essentially a holding company. There is no need to wind down

this new corporation, as many of the benefits such as income splitting, lower tax rates, and sheltered insurance policies are still accessible. Funds can still be flowed out to you and your spouse through the corporation as either salary or dividends, and taking of income can continue to generate RRSP contribution room if desired. Corporately held life insurance can continue to be sheltered, and in many cases, can be collaterally assigned, and borrowed against, providing a tax-free income stream to supplement taxable income (especially important after age 71, at which point individuals must begin RRIF withdrawals). What should I do with my life insurance policy(ies)? There are a number of strategies to consider when determining what to do with your life insurance after retirement. If the policies are held outside of a corporation, they can be used as a tool to flow retained earnings out in a tax sheltered manner. If the policies are corporately held, they continue to be sheltered, and become a very powerful estate asset to pass wealth on taxfree to children, to fund a trust structure, or as a charitable gift. Corporately owned life insurance policies held until the death of a physician can be used to flow retained earnings out of the company (through the capital dividend account), and this amount can be enhanced through additional strategies. In short, there is a wide range of strategies available for life insurance at retirement, and very rarely is there a financial case to be made for terminating the policy and taking the cancellation value. What is the best way to leave a charitable gift? There are a number of strategies to use to maximize the benefit of a charitable gift in your estate plan. Several of these strategies can have significant implications on your current tax, or on the tax return of your estate. Unused or unclaimed charitable donation tax credits can be carried forward for up to five years, and charitable tax credits in the year of death can be carried back and applied to the year prior to death. An ideal gifting strategy maximizes the gift given, while also maximizing the tax reduction to you or your estate. Donating capital property In many cases, people choose to donate property which may have capital gains, such as land, or investments. Donating this type of property itself (as opposed to selling the property and donating the proceeds), increases the actual gift as a portion of the capital gain is included. When this gift consists of publically-traded securities or mutual funds, the taxable capital gains which must be reported is eliminated. Another form of property that can receive special tax treatment is employee stock options. A charitable gifting plan needs to look at all of your assets (and potentially those of your spouse) to determine the most ideal strategy.

COA Bulletin ACO - Winter / Hiver 2015

Training & Practice Management / Formation et gestion d’une pratique (continued from page 53)

Significant gifts during your lifetime For those who wish to make large or ongoing gifts during their lifetimes, establishing a “donor advised fund” may be an attractive option. This is essentially an endowment fund, which allows the individual to receive an immediate tax receipt, without having to decide immediately which charity or charities will receive the gift. Additionally, all growth and income inside the fund will accrue on a tax-free basis. Making gifts in your will It is important to clearly name the charitable organization in your will, including the address, formal legal name and chapter or branch of the organization. It is also advisable to consider an alternate beneficiary in the case that the primary is no longer a charity or in existence at the time of your passing. It is also important to include language that allows for the property to be gifted “in kind”. This ensures assets do not have to be sold immediately (at a potentially disadvantageous time), and that the capital gain can be managed as discussed above.

If you have any additional questions or concerns you would like addressed either in a future article, an ICL, or through an individual consultation, please contact us through our e-mail addresses at the top of the article.. Disclaimer: The information provided in the article has been provided to the COA by Sun Life Assurance Company of Canada and is for informational purposes only. It may not reflect all current rules, regulations, or laws for your province of residence and it may not pertain to your situation. Because every person’s situation is unique, it is important to consult a professional to obtain advice that relates to your particular circumstances.

Direct Beneficiary Designations Another strategy is to name a charity as the beneficiary of a registered asset (RRSP, RRIF, TFSA), or an insurance policy. While this will avoid probate, your estate may still be liable for any taxes owing (as in the case of an RRSP/RRIF). Planned gifting using insurance Many people opt to use life insurance to fund their estate gifting goals. This often amplifies the total size of the gift, and may be more attractive for individuals who own a corporation. The tax credit can be taken either annually (with the payment of the policy premiums, or at time of death, with different structures required for each). Charitable remainder trust In some cases, an individual may wish to ensure an income for another party for their life, and allocate any remaining capital to a charity (to be gifted after the death of the living beneficiary). In these situations a charitable remainder trust structure can be a powerful option. With all of the above gifting strategies and others, it is important to discuss your goals and seek the council of a licensed and knowledgeable professional. What estate issues do I need to be aware of and when should I begin the estate planning process? All individuals, and certainly all surgeons, should have valid and up to date estate documents in place. This includes health and property powers of attorney in place for each spouse, and corporate wills and powers of attorney where appropriate. Every surgeon should have an estate plan as soon as they begin practice. However, more in-depth estate planning (usually focused on structuring inheritances, charitable gifts, and tax minimization) often begins in earnest after retirement. Clearly identifying what your estate goals are, and not just maximizing the size of the estate is a key step, all too frequently missed. As with all of the other topics discussed in this article, the advice of a knowledgeable professional or team of professionals should be sought from the outset.

COA Bulletin ACO - Winter / Hiver 2015

ADVERTISING SPACE AVAILABLE The COA Bulletin, the official journal of the Canadian Orthopaedic Association, has been declared by our membership as one of the most valuable membership services. By placing your advertisement in the COA Bulletin, you will be communicating with the largest number of Canada’s leading orthopaedic specialists. Don’t miss out on this kind of opportunity! Become a part of our publication cycle by contacting Cynthia Vezina at the COA Office - Tel: (514) 874-9003 ext. 3 or e‑mail: cynthia@canorth.org and details will be forwarded to you.

ESPACE PUBLICITAIRE Le Bulletin, publication officielle de l’Association Canadienne d’Orthopédie (ACO), a été désigné par nos membres comme l’un des services les plus utiles que nous leur offrons. Placer une annonce dans le Bulletin de l’ACO assure une visibilité inégalée auprès des orthopédistes les plus influents au pays. Ne manquez pas cette occasion! Pour faire partie de notre cycle de publication, communiquez avec Cynthia Vezina, au bureau de l’ACO, au 514-874-9003, poste 3, ou à cynthia@canorth.org.

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

2016 Canadian Shoulder & Elbow Society (CSES formerly JOINTS Canada) Annual Shoulder Course January 28-29 janvier Ottawa, ON E-mail/Courriel : cpd@toh.on.ca Web Site/Site Int. : http://www.coa-aco.org/CSES/ CSES-meetings/ AAOS 2016 Annual Meeting March 1-5 mars COA RECEPTION = THURSDAY, MARCH 3 @ 18:00 RECEPTION DE L’ACO = LE JEUDI 3 MARS @ 18 H Orange County Convention Centre, Orlando, FL Web Site/Site Int. : www.aaos.org 29th St. Justine Paediatric Review Course (SPORC) / 29e Cours de mise à jour en orthopédie pédiatrique March 9-11 mars Montreal, QC E-mail/Courriel : joelle.fortier.hsj@ssss.gouv.qc.ca Web Site/Site Int. : http://saac.chu-sainte-justine. org/sporc2016-fr.html The 14th Annual Canadian Orthopaedic Resident Forum (CORF) April 1-4 avril Calgary, AB Contact(er) : Tracy Burke 403 922-4427 E-mail/Courriel : corf@ucalgary.ca

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2016 June 16-19 juin Québec City, QC

2017 June 16-18 juin Ottawa, ON

2018 June 21-23 juin Victoria, BC

COA Bulletin ACO - Winter / Hiver 2015

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

EXTEND YOUR

KNOWLEDGE

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

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COA Bulletin ACO - Winter / Hiver 2015

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Your COA membership includes pre-registration to the COA Annual Meeting* Active and Associate members of the COA can now take advantage of free pre-registration to the COA Annual Meeting when they renew their membership dues. Your participation helps advance orthopaedics across Canada. Register before April 29 and join us for the largest annual gathering of our community. * Pre-registration to the COA Annual Meeting is included for all Active members of the COA who have fully paid all ouststanding membership dues and have registered for the Annual Meeting by April 29. Pre-registration to the COA Annual Meeting is included for all Associate members of the COA who register by April 29.

Votre adhésion à l’ACO comprend la pré-inscription à la réunion annuelle de l’ACO* Les membres actifs et associés de l’ACO peuvent désormais bénéficier de la préinscription gratuite à la réunion annuelle de l’ACO lors du renouvellement de leur adhésion. Votre participation contribue à l’avancement de l’orthopédie au Canada. Inscrivez-vous avant le 29 avril et soyez des nôtres lors du plus grand rassemblement annuel de notre communauté. *La pré-inscription à la réunion annuelle de l’ACO est comprise dans l’adhésion de tous les membres actifs qui ont payé intégralement toutes les cotisations de membre dues et qui s’inscriront à la réunion annuelle avant le 29 avril. La pré-inscription à la réunion annuelle est comprise pour tous les membres associés de l’ACO qui s’inscriront avant le 29 avril.

Help Us Be Ready For You | Aidez-nous à nous préparer à vous accueillir We anticipate strong registration activity for the COA Annual Meeting and your event team is working hard to ensure that our gathering will be the best yet! To ensure we are best able to meet our logistical objectives, kindly take a moment to inform us of your attendance intentions. Go to COAAnnualMeeting.ca/MyVisit and complete our short survey. Nous prévoyons recevoir un grand nombre d’inscriptions à la réunion annuelle de l’ACO et l’équipe organisatrice travaille fort afin que ce rassemblement soit encore meilleur que les précédents! Afin que nous soyons aptes à atteindre nos objectifs en matière de logistique, nous vous prions de prendre quelques minutes pour nous informer de votre présence. Rendez-vous sur le site COAAnnualMeeting.ca/MyVisit et remplissez le bref sondage.

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Canadian Orthopaedic Asssociation

Published on Dec 22, 2015

Winter 2015 coa bulletin #111

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

Winter 2015 coa bulletin #111

Published on Dec 22, 2015

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

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