COA Bulletin #114 Fall 2016 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

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

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

BULLETIN

114

A Time for Mentorship – Read COA President, Dr. Peter B. MacDonald’s President Elect Address See page 7

L’heure est au mentorat –

Lisez l’allocution du Dr Peter B. MacDonald à titre de président élu Page 7

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Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 114 Fall / Automne 2016 COA / ACO Peter B. MacDonald President / Président Kishore Mulpuri Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Femi Ayeni Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: 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.

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.

2016 Annual Meeting Breaks Attendance Record Peter B. MacDonald, M.D., FRCSC President, Canadian Orthopaedic Association

e were all treated to an excellent Annual Meeting this past June in Québec City amidst some spectacular weather, an outstanding scientific program and a wonderful city where we were able to socialize and catch up with old friends and colleagues. Our host city’s beauty and culture was in fine form treating us to the perfect summer setting. I am pleased to report that we experienced an all-time attendance record at this year’s Annual Meeting – a direct result of the pre-registration fees being waived for Active members for the first time under the COA’s new dues structure.

The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4060 St. Catherine Street West, Suite 620, Westmount, Quebec, H3Z 2Z3. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: cynthia@canorth.org

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

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

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

COA Bulletin ACO - Fall / Automne 2016

Your COA / Votre association

(continued from page 5)

Special thanks are extended to the Local Arrangements and Program Committees led by Drs. Michèle Angers and Etienne Belzile respectively, as well as to Doug Thomson and the COA office staff including Cynthia Vezina, Meghan Corbeil and Trinity Wittman. The Annual Meeting ran so smoothly thanks to their organization skills and hard work. Our guest lecturers were outstanding this year. The R.I. Harris Lecture, delivered by Dr. Marc Swiontkowski, provided an interesting perspective from a long-time supporter of the COA from south of the border. Dr. Dave Williams enlightened us with insights learned through his spectacular career that uniquely includes medicine, space exploration and hospital administration. Dr. Kellie Leitch gave us a glimpse of the political landscape in Ottawa as both an orthopaedic surgeon and an influential politician and former cabinet minister. You can see more highlights from this year’s Annual Meeting on page 14 of this edition of the COA Bulletin. I would be also remiss if I didn’t pay tribute to my predecessor, Dr. Robin Richards, who, along with Barb, was steady at the helm during this past year and left big shoes for me to fill. Sherry and I are humbled, honoured and excited to represent so many talented and innovative people who form the membership of our great organization. Although not without our challenges, we have a lot to be thankful for and need to cherish the opportunities we have as we move forward.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 27 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 57 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 62 Please mark your calendar for next year’s Annual Meeting being held from June 15-18, 2017 in Ottawa - another great venue to celebrate our profession and our national heritage. Following this article, I am pleased to share the address I delivered at the recent Québec City Annual Meeting as President Elect entitled “A Time for Mentorship”. If you have any questions, I invite you to contact me at president@canorth.org. Thank you.

Participation record à la Réunion annuelle 2016 Peter B. MacDonald, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

n juin dernier, nous avons eu droit à une excellente réunion annuelle à Québec : le temps était spectaculaire, le programme scientifique exceptionnel, et la ville superbe. Nous avons pu profiter de ce cadre enchanteur pour socialiser et prendre des nouvelles de vieux amis et de collègues. La beauté et les activités culturelles caractéristiques de notre ville hôte étaient à leur zénith en cette période estivale. Je suis d’ailleurs heureux de vous annoncer que nous avons enregistré une participation record, grâce à l’annulation des droits d’inscription à l’avance pour les membres actifs, une nouveauté de l’ACO. Un merci tout spécial aux comités organisateur et responsable du programme, dirigés par les Drs Michèle Angers et Étienne Belzile, respectivement, ainsi qu’à Doug Thomson et au personnel de l’ACO, soit Cynthia Vezina, Meghan Corbeil et Trinity Wittman. Si la Réunion annuelle s’est déroulée aussi rondement, c’est grâce à leur sens de l’organisation et à leur travail acharné. Et nos conférenciers invités étaient tout aussi exceptionnels. La Conférence R.I. Harris, prononcée par le Dr Marc Swiontkowski, nous a permis de profiter de la perspective intéressante de cet ami de longue date de l’ACO qui réside au sud de la frontière. Le Dr Dave Williams nous a quant à lui transmis de lumineuses idées forgées au fil d’une carrière spectaculaire et unique COA Bulletin ACO - Fall / Automne 2016

englobant médecine, exploration spatiale et administration hospitalière. La Dre Kellie Leitch nous a donné un aperçu du paysage politique à Ottawa, à la fois à titre d’orthopédiste et de politicienne influente et ancienne ministre. Vous trouverez d’autres faits saillants de la Réunion annuelle 2016 à la page 16 du présent numéro du Bulletin de l’ACO. Je m’en voudrais également de ne pas rendre hommage à mon prédécesseur, le Dr Robin Richards. Avec sa femme, Barb, il a tenu la barre de main de maître toute l’année, et lui succéder constitue tout un défi. Sherry et moi sommes honorés, touchés et emballés à l’idée de représenter les gens talentueux et novateurs qui forment notre belle organisation. Même si la tâche n’est pas simple, nous sommes privilégiés et devons chérir les occasions qui se présentent à nous. Vous pouvez déjà noter les dates de notre prochaine réunion annuelle : elle se déroulera du 15 au 18 juin 2017, à Ottawa. Un autre cadre fantastique où célébrer notre profession et notre patrimoine national. C’est en outre avec grand plaisir que je vous transmets ci-après l’allocution que j’ai prononcée à titre de président élu à la Réunion annuelle de Québec, intitulée « L’heure est au mentorat ». Si vous avez des questions, n’hésitez pas à m’écrire, à president@canorth.org. Merci!

Your COA / Votre association

We are pleased to share the President Elect Address delivered by Dr. Peter B. MacDonald on Saturday, June 18 during the COA Annual Meeting held in Québec City with our members.

C’est avec grand plaisir que nous vous transmettons ci-après l’allocution prononcée par le Dr Peter B. MacDonald à titre de président élu à la Réunion annuelle de Québec, le samedi 18 juin.

A Time for Mentorship / L’heure est au mentorat

onoured guests, including our members from our host province of Québec, fellow members, ladies and gentlemen.

The theme of my address today is mentorship. It is so relevant to all of us whether it be in academic practice guiding trainees or community practice guiding junior partners.

As your incoming President, I am truly appreciative that you have selected me to be the representative of our Canadian Orthopaedic Association. I will do my utmost to uphold the values of the COA.

Webster’s dictionary defines a mentor as a “trusted counselor or guide; tutor or coach”. In Greek mythology, specifically “The Odyssey” by Homer, Mentor was the servant of Odysseus. When Odysseus sailed off to the Trojan War – a journey of two decades – he entrusted the care of his son, Telemachus, to Mentor. Mentor became a tremendous role model and guardian, taking responsibility for the boy’s emotional and intellectual development.

Merci, Robin, pour ta présentation. Distingués invités et collègues, représentants de Québec, notre ville hôte, Mesdames et Messieurs, Je suis sincèrement honoré que vous m’ayez accordé votre confiance en tant que président de l’Association Canadienne d’Orthopédie. Sachez que je veillerai au respect des valeurs de l’Association au mieux de mes compétences. Sherry and I wanted to especially thank Robin and Barbara for their steady and strong leadership and dedication to the Association over the past year. I can think of no finer a person to follow in this role other than Robin who I have admired for so many years with his brilliant insight, his logical and steady approach to problems and for his incredible sense of humour.

I had great mentorship in my life starting with the stewardship of my parents, D.I. and Peggy MacDonald. My dad studied economics at the University of Toronto and was the city of Winnipeg’s top administrator officer in the 70’s. He was a standup, non-nonsense intellectual and well-read individual, revered by many, and was a steady and strong influence in my life. My mother was of Irish catholic roots, hard working and somewhat strict in enforcing values and hence the family of seven children - all high-achieving: two doctors, lawyer/judge, a writer, a teacher, a professor and financial executive. My own wonderful family has also been an inspiration to me, starting with my wife Sherry, who has been my best friend and soul mate since our marriage in 1984. She has been a steady partner and advisor along life’s journey and has also done 90% of the work in raising our three children: Lindsey, a primary care sports physician; Carling, a medical school grad; and Duncan, on the path to becoming an accountant. They have all been a constant source of joy in my life. I truly feel that I am the luckiest man alive.

Immediate Past President, Dr. Robin Richards, presents Dr. MacDonald with the COA Jewel of Office. Le Dr Robin Richards, président sortant, remet la médaille présidentielle de l’ACO au Dr MacDonald.

It a special honour to accept this challenge in the province of Québec, which has contributed so much to the rich history of the COA. The first ever COA meeting was held in Montréal in June 1945 at the Mount Royal Hotel with 24 members in attendance.

Dr. Peter and Mrs. Sherry MacDonald with their children, Carling, Duncan and Lindsey. Le Dr MacDonald, sa femme, Sherry, ainsi que leurs enfants, Carling, Duncan et Lindsey. COA Bulletin ACO - Fall / Automne 2016

Your COA / Votre association

(continued from page 7)

My own mentors have included some of the greatest teachers in Canadian orthopaedics including Drs. Pete Fowler and Rich Hawkins. The mentorship they showed me and others, not only during fellowship but in subsequent years through their fellowship societies, have inspired me to try to do the same for the students, residents and fellows that we have been lucky enough to train in our program. I have been fortunate to learn from some great leaders who have preceded me. They represent absolute professionalism, strong character, commitment to family, absolute honesty, and selflessness. In short, they are ideal mentors. I would to also like to mention all of the other mentors I have had throughout the Canadian orthopaedic community and beyond including Drs. Merv Letts, Garth Johnson, Bill Rennie, Bob Jackson and the list goes on. I have had great friends, colleagues and co-researchers across Canada including Drs. Bob Litchfield, Nick Mohtadi, Bob McCormack, Peter Lapner, Laurie Heimstra and special mention to my colleague, the late Warren Froese. Je dois aussi reconnaître le support de l’équipe de la clinique Pan Am et celle de programme d’orthopédie de l’Université du Manitoba, ainsi que de mes collègues d’entraînement, qui m’aident à traverser les stress de la vie. Je suis chanceux d’avoir eu le privilège de traiter certains grands athlètes professionnels et amateurs au fil des ans. Dans l’ensemble, comme un collègue m’a dit récemment, c’est un boulot assez cool. I also have to acknowledge the great team at the Pan Am Clinic and at the University of Manitoba orthopaedic program who are not only extremely competent but fun to work with and in the process, have become great mentors themselves to the residents and fellows. I owe much of what we have accomplished to our great research team at the Pan Am Clinic Foundation under the direction of Dr. Jeff Leiter. They work tirelessly on our behalf to support research, education of community and outreach within our discipline. I have been lucky and honoured to look after some great athletes through professional and amateur sports over the years as well as meet some inspiring patients. All in all, as a colleague recently said to me, a pretty cool job. My residents and, particularly, my fellows are so rewarding to be involved with. Witnessing the metamorphosis from tentative medical students to competent fellows to practicing surgeons is a source of tremendous satisfaction for me. Next to the satisfaction of treating patients and, occasionally, being able to facilitate an improvement in their quality of life, mentorship is the most rewarding part of my professional life. How exactly do we mentor? My own mantra, which may be termed as “Pete’s Pearls”, involves the following advice that is actively and passively imparted on trainees needing stewardship. Time management, including making time for family, time for exercise and time for friends, is an important part of the recipe. The art of keeping one’s life in balance is crucial for the survival of those involved in busy professional lives. Getting family COA Bulletin ACO - Fall / Automne 2016

involved and interested in your work is one important way of sharing the journey, and lets them understand what takes up so much of your time and energy. We should prefer to look forward instead of dwelling on the successes or failures of the past. We should tend to be a glass half full person. Too often I see practitioners succumb to the negativity that they create around them. We should try to impart a warmth and friendliness to coworkers and patients and try to keep our ego in check with an atmosphere of courtesy and respect. We should try to cultivate an appetite for reinvention, which is necessary in a field like medicine that changes constantly. Any of you who are familiar with physicians will know embracing change does not come naturally – but it is critical. Above all, when the going gets tough, don’t complain – just work harder. And remember the three characteristics of a great physician: honesty, integrity and a desire to give back. Although these general guidelines may be useful, the challenges facing our trainees are deep and significant. This has created an atmosphere of burnout, which is now just as common as ever, and most related to the non-medical aspects of medicine such as increasing red tape and bureaucracy. Le principal facteur de stress est le marché de l’emploi et le chômage de nos diplômés. Selon moi, ce sera le défi le plus important pour l’ACO d’aujourd’hui. Les derniers chiffres démontrent que plus de cent cinquante diplômés en orthopédie sont sous-employés. Bien qu’il n’y ait pas de solution simple, les efforts de l’ACO pour convaincre les différents programmes de formation de diminuer le nombre d’admissions ainsi que pour mettre l’accent sur la transition de fin de carrière pour nos membres séniors aideront certainement à atténuer ce problème. Il faudra du temps pour que ces changements paraissent dans le système et, entre-temps, nous devons démontrer une attitude de compassion. Chief among those stressors are the job market and unemployment of our graduates. This, in my mind, is the most important challenge before the COA today and the most recent data collected are running over 150 under-employed orthopaedic graduates. Although there is no simple solution, the COA’s efforts to convince programs to decrease the number of training spots along with a focus on late career transition for our senior members will go a long way toward addressing this issue. It will take time for these changes to flush through the system and in the meantime, we need to have a compassionate attitude and look to bring on as many new graduates as possible though appropriate safe use locums, welcoming junior surgeons into our practice wherever possible and creative measures such as job sharing. In the meantime, trainees must remain as patient and optimistic as possible. Residency and fellowship should be considered a continuous job interview that will lead to employment with a hard work ethic combined with a collegial attitude.

Your COA / Votre association

(continued from page 8)

How else is the COA relevant in today’s orthopaedic practice? We remain the only glue that keeps the Canadian orthopaedic community together. This includes representing our training programs at the Royal College with issues such as competencybased training. A connection to the Canadian Orthopaedic Foundation, under the leadership of Dr. Geoff Johnston, that is now stronger than ever in the efforts to support research and education. The COA also keeps us in tune with the latest developments affecting our professional lives including the weekly COA Dispatch and the Bulletin. Social media through Twitter is becoming a bigger part of spreading the word. Position statements and advocacy are ways for the COA to take a stand on important matters with other governing bodies and with government. Recent position statements on access to care, late career transition and unemployment are examples of topical issues we have thought through and defined our position on. This exemplifies how the COA can help us navigate though the many challenges throughout our career. Our office staff, consisting of Doug Thomson, Trinity Wittman, Cynthia Vezina and Meghan Corbeil, run a first class organization and work tirelessly on our behalf. They will make my term as president an enjoyable and rewarding one as they guide me, and the Executive, through the year that lies ahead. We have a great Executive and our immediate past leaders have carved a path that has made the organization relevant and meaningful in challenging times. Let us cherish and celebrate our national organization as they support other areas like travelling fellowships, links to other organizations and the Choosing Wisely campaign. With the rise in subspecialization, the COA has kept pace with subspecialty sessions throughout the meeting and fostering all of the various subspecialty societies while still keeping them close to the COA. Revenons à notre système de santé, une source de fierté canadienne, mais aussi une source de frustrations par son incapacité à fonctionner à son plein potentiel. Que son financement soit privé ou public devrait être sans importance, tant que les principes de qualité, d’accès et d’efficacité des services sont respectés. Comme le regretté Cy Frank nous a enseigné, nous ne devrions pas avoir peur de nous impliquer dans ce système. Let’s get back to our medical system, which is a source of Canadian pride but also frustration based on under achievement of its potential. Whether we evolve through a publiclyfunded or private path should be irrelevant as long as the principles including quality, access and cost-effectiveness are adhered to. As the late Cy Frank taught us, we shouldn’t be afraid to get involved in that evolution and not only be interested in our narrow piece of the system but rather in the entire path that the patient takes along the journey of musculoskeletal care. We all need to learn about doing more with less and maximizing efficiency and quality through partnerships, trimming fat and lean management. We need to do a better job on the preventative side and we should help foster campaigns that improve the overall health of the population that we serve. We need to turn the tangled webs and convoluted paths into a more streamlined and efficient system. This will come through innovation and thinking outside the box and will result in a

Dr. MacDonald delivers his President Elect Address at the Annual Meeting in Québec City. Le Dr MacDonald prononce son allocution à titre de président élu à la Réunion annuelle de Québec.

more balanced system of supply and demand - not through just spending more money. Energy and optimism will help this cause and we could argue that mentorship has never been so important. In fact, the COA is currently exploring models of efficient and effective musculoskeletal care from across the country that we can build on as we look to the future. In the book “The Element”, Ken Robinson uses Death Valley, one of the hottest, driest and most desolate places on earth as an analogy. One year a remarkable thing happened, after an extremely rare rainstorm, flowers began to blossom everywhere after years of absolute drought. We too can take even the toughest and most challenging situations and with mentorship, cause people around us to blossom. As Michelangelo once said - the greatest danger for most of us lies not in setting our aim too high, but setting our aim too low and achieving our mark. This is not the time to aim low and be content with an easy success. It’s time to think big! These are challenging times in health care and in Canadian orthopaedics. The official motto of the COA is from Latin “Pietate, Arte et Scientia Corrigere”, which means “With compassion, skill and knowledge we correct, straighten or set right”. I invite you all to work with your Executive and I in the coming year as we make the COA even more of a brighter beacon towards a better Canadian orthopaedic community. I thank you for this honour and I promise to work hard on your behalf. Merci beaucoup! COA Bulletin ACO - Fall / Automne 2016

Your COA / Votre association

Introducing Dr. Alastair Younger as the COA Bulletin’s New Editor in Chief

e are pleased to introduce Dr. Alastair Younger as the new Editor in Chief of the COA Bulletin and Chair of the COA’s Surgeon & Internal Communications Committee. Dr. Younger is a long-standing COA member having previously served on the Association’s Board of Directors, Exchange Fellowships Committee, Nominating Committee and Program Committee. He has been a NATF fellow and an ABC travelling fellow. Dr. Younger is founding member and past president of the Canadian Orthopaedic Foot and Ankle Society (COFAS) and has received the Roger Mann Award from the American Orthopaedic Foot and Ankle Society (AOFAS) three times, and the Takakura Prize from the International Federation of Foot and Ankle Societies (IFFAS) in 2014. Having grown up near St. Andrews in Scotland and completing his medical degree in Aberdeen in 1985, he trained for a short time in the National Health Service before moving to Canada to do a Masters in Kinesiology at Simon Fraser University. He completed his residency at the University of British Columbia (UBC) and a Masters in Surgery at the same time between 1990 and 1995. After a fellowship in arthritis surgery at Harvard University in Boston in 1997, Dr. Younger went to Seattle to pursue a fellowship in foot and ankle surgery. He then returned to UBC and St. Paul’s Hospital in 1998 to take over the role of teaching residents foot and ankle surgery, and established a fellowship and research program.

Under Dr. Younger’s leadership, the COA’s Surgeon & Internal Communications Committee are pursuing potential publishing opportunities for COA members in peer-reviewed journals, working on a redesigned and improved COA web site that will be launched next Spring and are discussing various new Bulletin features that will be introduced over the next couple of editions. “There is a lot of potential for growth within the COA’s communications projects. A much more streamlined and user friendly web site that better showcases the Association’s services and projects will be a tremendous benefit that we look forward to offering to next year,” says Dr. Younger. “We hope to be able to offer publishing opportunities for our members through partnerships with other journals as well as introduce new running features in the COA Bulletin.” Any suggestions for Dr. Younger and the Surgeon & Internal Communications Committee can be directed through Cynthia Vezina cynthia@canorth.org at the COA Office. We would like to thank Dr. Marc Isler for his many years of leadership and innovation as the Bulletin’s previous Editor in Chief and Chair of the Surgeon & Internal Communications Committee.

Le Dr Alastair Younger devient rédacteur en chef du Bulletin de l’ACO

ous sommes heureux de vous présenter le Dr Alastair Younger, nouveau rédacteur en chef du Bulletin et président du Comité des communications internes et avec les orthopédistes de l’ACO. Membre de longue date de l’ACO, il a entre autres été membre du conseil d’administration, du Comité des bourses de voyage, du Comité des candidatures et du Comité responsable du programme de la Réunion annuelle. Il a également été lauréat de la Bourse de voyage nord-américaine (VNA) et de la Bourse de voyage américano-britanno-canadienne (ABC). Le Dr Younger est membre fondateur et président sortant de la Société Orthopédique Canadienne pour le Pied et la Cheville (SOCPC), en plus d’avoir reçu le prix Roger Mann de l’American Orthopaedic Foot & Ankle Society (AOFAS) à trois reprises, de même que le prix Takakura de l’International Federation of Foot and Ankle Societies (IFFAS) en 2014.

COA Bulletin ACO - Fall / Automne 2016

Le Dr Younger grandit près de St. Andrews, en Écosse, et obtient son grade en médecine à Aberdeen, en 1985. Après un cours stage au National Health Service, il s’installe au Canada pour faire une maîtrise en kinésiologie, à l’Université Simon Fraser. Entre 1990 et 1995, il effectue concurremment sa résidence et sa maîtrise en chirurgie à l’Université de la Colombie-Britannique. Après une spécialisation en interventions chirurgicales pour traiter l’arthrite à l’université Harvard, à Boston, en 1997, il se rend à Seattle pour en suivre une autre axée sur le pied et la cheville. Il revient ensuite à l’Université de la Colombie-Britannique et au St. Paul’s Hospital, en 1998, pour enseigner la chirurgie du pied et de la cheville aux résidents et créer un programme de spécialisation et de recherche. Sous la houlette du Dr Younger, le Comité des communications internes et avec les orthopédistes de l’ACO cherche diverses possibilités de publication pour les membres dans des revues à comité de lecture, travaille à la refonte du site Web, dont le

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lancement est prévu au printemps, et discute de nouvelles rubriques pour le Bulletin qui seront introduites graduellement dans les prochains numéros.

Pour faire des suggestions au Dr Younger et au Comité des communications internes et avec les orthopédistes, écrivez à Cynthia Vezina, à cynthia@canorth.org, aux bureaux de l’ACO.

« Les projets de communication de l’ACO ont un excellent potentiel de croissance. Un site Web plus convivial et simplifié qui présente mieux les services et projets de l’Association sera un incroyable avantage pour les membres, et nous avons hâte de le leur offrir dès l’an prochain, déclare-t-il. Nous espérons aussi leur donner des possibilités de publication grâce à des partenariats avec d’autres revues et introduire de nouvelles rubriques dans le Bulletin. »

Nous remercions le Dr Marc Isler pour ses nombreuses années de leadership et d’innovation à titre de rédacteur en chef du Bulletin et de président du Comité des communications internes et avec les orthopédistes.

The COA’s 2017 ABC Fellows Drs. Wade Gofton and David Sheps

rs. Wade Gofton (University of Ottawa) and David Sheps (University of Alberta) have been selected as the COA’s 2017 American-British-Canadian (ABC) travelling fellows.

Dr. Wade Gofton is an Associate Professor in the Department of Surgery and Department of Innovation and Medical Education at the University of Ottawa. His clinical focus is in orthopaedic trauma and lower extremity reconstruction. He completed his MD in 1999 and orthopaedic training in 2004 at the University of Western Ontario. He completed his clinical fellowship at Sunnybrook Hospital and his Masters in Medical Education at the University of Toronto in 2006. Dr. Gofton’s academic focus has been on the assessment of competence in the post-graduate trainee and the safe integration of new skills in the practicing physician. He was involved in the development of the OSCORE and OCAT, entrustmentbased assessment tools for operative competence and competence in the clinic environment. Dr. Gofton heads the Surgical Education Research Group in Ottawa and is Director of the Surgical Education Research Fellowship at the uOSSC. He works with a number of fellows and physicians in a variety of specialties to further scholarship in medical education. He sits on a number of Royal College committees related to education and assessment and is a CanMEDs Clinician Educator. Dr. David Sheps received his medical degree at the University of Manitoba in 1997 and completed his residency in orthopaedic surgery at the University of Saskatchewan in 2002. Following his residency, he completed a shoulder surgery fellowship at the University of Alberta in 2003 and an elbow and wrist surgery fellowship at the University of Calgary in 2006. Concurrent with his fellowship in elbow and wrist surgery, Dr. Dr. David Sheps, Sheps fulfilled the requirements of 2017 ABC Fellow a Master of Science in Epidemiology at the University of Calgary. In 2011, Dr. Sheps attended the Sauder School of Business at the University of British Columbia

in Vancouver where he completed a Master of Business in Health Care Administration the following year. He currently practices orthopaedic surgery in both Edmonton and Vancouver. He is an attending orthopaedic surgeon at the Sturgeon Community Hospital in St. Albert, at the Glen Sather Sports Medicine Clinic in Edmonton, and the False Creek Surgical Centre in Vancouver. His Dr. Wade Gofton, clinical practice includes the treat- 2017 ABC Fellow ment of shoulder, elbow and wrist disorders, with a particular focus on the arthroscopic treatment of shoulder disorders. As part of the upper extremity group at the Sturgeon Community Hospital, Dr. Sheps also treats traumatic injuries of the shoulder, elbow and wrist. He has been Facility Medical Director of the Sturgeon Community Hospital since 2012. In addition to his clinical practice, Dr. Sheps serves as an Assistant Clinical Professor of Orthopaedics at The University of Alberta. His research interests include the treatment and outcomes of shoulder, elbow and wrist disorders, as well as the epidemiology of shoulder and elbow injuries. He has published papers in the Bone & Joint Journal, The Journal of Shoulder & Elbow Surgery, Shoulder & Elbow and Current Orthopaedic Practice. Drs. Gofton and Sheps were selected from a pool of applicants by the COA’s Exchange Fellowships Committee this past spring. They will tour centres in Europe with five additional ABC fellows from the United States for five weeks in the spring of 2017. We wish them both safe travels and a most enjoyable tour! Stay tuned for a summary of their experience in a future edition of the COA Bulletin. Congratulations!

COA Bulletin ACO - Fall / Automne 2016

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NATF Fellowship Application Deadline = December 30

Bourse de voyage VNA Date limite de soumission des demandes : le 30 décembre

pplications for the North American Travelling Fellowship (NATF) are now being accepted until December 30, 2016. This dynamic fellowship is open to surgeons who have completed their residency training in Canada up to three years ago. The tour of Canadian and American centres will begin in the Fall of 2017. We encourage all eligible members to apply. Complete criteria and a downloadable application form can be found at www.coa-aco.org.

’ACO accepte les demandes pour la Bourse VNA jusqu’au 30 décembre 2016. Cette bourse stimulante est offerte aux orthopédistes qui ont terminé leur résidence au Canada au cours des trois dernières années. La tournée des centres canadiens et américains participants commencera à l’automne 2017. Nous invitons tous les membres admissibles à faire une demande. Vous trouverez tous les détails et un formulaire sur le site web de l’ACO : www.coa-aco.org.

New Member Benefit – Access to Clinical Orthopaedics and Related Research® (CORR)

Nouvel avantage pour les membres : Accès gratuit à Clinical Orthopaedics and Related Research®

e are pleased to announce that through the end of 2017, all COA members will have full-text access to Clinical Orthopaedics and Related Research®.

ous sommes heureux de vous annoncer que, jusqu’à la fin de 2017, tous les membres de l’ACO bénéficieront d’un accès complet à Clinical Orthopaedics and Related Research® (CORR®).

This benefit is being provided at no charge to members as the result of a collaboration with CORR® and its parent society, the Association of Bone and Joint Surgeons. As you may know, CORR® is a high-impact, general-interest orthopaedic journal, which publishes the latest clinical and basic research. Over the last several years, CORR® has undergone a number of changes, and it now also publishes numerous monthly columns, commentaries, features, and interviews with authors. Each month, the COA will e-mail you CORR’s electronic table of contents so you can see what is in that issue, and you can access the fulltext content.

Cet avantage est offert sans frais aux membres grâce à une collaboration avec CORR® et sa société mère, l’Association of Bone and Joint Surgeons. Comme vous le savez peut-être, CORR® est une revue orthopédique d’intérêt général très influente qui présente les dernières recherches cliniques et fondamentales. Au cours des dernières années, CORR® a beaucoup changé; elle comprend maintenant un éventail de chroniques mensuelles, de lettres au rédacteur, d’articles-vedettes et d’entrevues avec des auteurs. Tous les mois, l’ACO vous fera parvenir la table des matières électronique de CORR® pour que vous puissiez prendre connaissance du contenu du numéro. Vous aurez accès à tout le contenu.

How to access CORR® 1) Log in to the COA web site www.coa-aco.org with your e-mail address and password. 2) Select “My COA Services” in the left hand menu of the Membership Portal. 3) Find the link to CORR® as well as to other subscription benefits you receive through your COA membership. If you have any questions or require assistance, please contact Cynthia Vezina cynthia@canorth.org at the COA Office.

COA Bulletin ACO - Fall / Automne 2016

Accès à CORR® : 1) Ouvrez une session sur le site Web de l’ACO, à www.coa-aco.org, à l’aide de vos courriel et mot de passe. 2) Cliquez sur « Mes services de l’ACO », dans le menu de gauche du portail des services aux membres. 3) Trouvez le lien vers CORR® et les autres abonnements auxquels votre adhésion à l’ACO vous donne droit. Si vous avez des questions ou besoin d’aide, n’hésitez pas à communiquer avec Cynthia Vezina, aux bureaux de l’ACO, à cynthia@canorth.org.

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Ottawa Annual Meeting Accommodations – Be sure to book early!

anada is celebrating its 150th anniversary in our nation’s capital city next summer – many of these festivities will take place around the same time as the COA Annual Meeting also being held in Ottawa from June 15-18. Ottawa is expecting a large number of visitors next summer so we encourage our members to book their hotel rooms early. The COA has a room block in the Westin Ottawa (where the COA meeting will be held). Don’t wait for registration to open – go ahead and book your accommodations now! To reserve a room, please visit www.coaannualmeeting.ca and click on the Hotels tab on the homepage. A preliminary meeting schedule can be found in the Program section. Inquiries? Contact meetings@canorth.org

Hébergement à Ottawa pendant la Réunion annuelle : N’oubliez pas de réserver tôt!

’été prochain, notre capitale sera au cœur des célébrations du 150e anniversaire du Canada, et bon nombre des festivités se dérouleront aux alentours de la Réunion annuelle de l’ACO à Ottawa, du 15 au 18 juin. Comme notre ville hôte devrait donc recevoir un grand nombre de visiteurs l’été prochain, nous invitons nos membres à réserver leur chambre tôt. L’ACO a déjà réservé un bloc de chambres au Westin Ottawa, où la Réunion aura lieu, alors n’attendez pas que la période d’inscription soit commencée : réservez votre chambre dès aujourd’hui! Pour réserver une chambre, rendezvous à www.coaannualmeeting.ca, puis cliquez sur l’onglet « Hôtels », dans le haut de la page. Vous pouvez également consulter le programme provisoire de la Réunion annuelle en cliquant sur l’onglet « Programme ». Vous avez des questions? Écrivez à meetings@canorth.org.

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Québec City Annual Meeting Wrap-up

Another Outstanding Program and Record Attendance Doug Thomson CEO, Canadian Orthopaedic Association

his past June, over 475 orthopaedic surgeons, 250 residents and fellows, and 70 allied health professionals enjoyed the usual COA-inspired fine (outstanding!) weather in Québec City and, what members have come to expect, a top notch program with as many as five concurrent sessions that offered something for everybody - no matter what your subspecialty interests were. As always at our Annual Meetings, education was the main event. Given the depth and breadth of the program this year, we met in the modern and comfortable meeting rooms of the Québec City Convention Centre. In their roles as Program Co-chairs, Dr. Dave Williams presenting during the Opening Ceremonies Drs. Etienne Belzile and Mélissa Laflamme designed a program that offered members an unprecedented Presidential Guest Speaker, Dr. Kellie Leitch, addressed the level of choice. The program stats are telling. In all, there were attendees with a fascinating talk on what happens behind over 230 podium presentations, 120 posters (chosen from the political scenes in Ottawa and her current bid to lead the approximately 550 abstracts submitted last Fall), a complete Conservative party. subspecialty day, two hands-on workshops, 10 Instructional Course Lectures and eight symposia. All packaged neatly into a The education program also included an impressive roster of two and one half day meeting that allowed attendees to depart guest speakers including Dr. Jacques de Guise as the Macnab for home on Sunday afternoon. Lecturer, Dr. Richard Hawkins, Dr. Steve Olson (OTA President), Prof. Matthieu Assal from Switzerland and Dr. Hans Larsen from Complete abstracts for all papers and posters are available on Haiti. the COA web site. Once again, this year’s symposia proved to be very popular - a tribute to the criteria and high expectations set by the Program Co-chairs. To qualify for consideration, the symposia had to challenge and inform current orthopaedic knowledge and practice, or celebrate orthopaedic achievement. And each of them, in their own distinct way, did just that. Several of the symposia are available for viewing as webcasts on the COA Live Learning Centre (www.coa-aco.org) thanks to education grants from our industry partners. This year’s Opening Ceremonies featured Dr. Dave Williams as our first guest speaker. Dr. Williams gave an excellent presentation about his experiences as a member of the Canadian Space Agency and his work and travel on the space shuttles Columbia and Endeavour and the International Space Station. This year’s R.I. Harris Lecturer, Dr. Marc Swiontkowski, delivered an engaging address on The Status of Canadian Orthopaedic Surgery; A View from South of the Border. R.I. Harris Lecturer, Dr. Mark Swiontkowski COA Bulletin ACO - Fall / Automne 2016

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In the effort to offer enhanced value to our membership, members of the COA Executive Committee and staff met with a select group of meeting attendees during a focus group discussion held during one of the session breaks. Participants identified two key areas of focus that require improvement in order for the Association to be considered relevant, representative and necessary to its membership: 1) lobbying and advocacy initiatives need to be front and centre; 2) the COA Annual Meeting should be better tailored to accommodate the entire membership and not only the subspecialized academic surgeon. The valuable feedback and suggestions we received during the focus group session surrounding the Annual Meeting are being discussed with 2017 Program Committee. Stay tuned for changes and improvements that we look forward to introducing at next year’s Annual Meeting. We would like to thank the focus group participants for their suggestions and engagement. Overall, your ratings and comments about the Québec City meeting have been very positive and encouraging. Thanks are especially owed to Dr. Michèle Angers for her tremendous work organizing the overall meeting in her role as Local Arrangements Chair. Québec City lived up to its reputation for friendliness, hospitality and fun, and the education program set a new benchmark for content.

Dr. Simon Kelley, 2015 CORS Founders’ Medal recipient, presenting an update on his research

We hope that you are already making plans to join us in Ottawa next June. You could learn more about this event by making regular visits to www.coaannualmeeting.ca.

2017 Ottawa Annual Meeting Web Site Make regular visits to www.coaannualmeeting.ca for complete information about our upcoming Annual Meeting being held from June 15-18, 2017 in beautiful Ottawa, Ontario. A program at a glance as well as hotel information is currently available and new information is updated frequently.

Dr. Jacques de Guise presents the Macnab Lecture during the CORS Annual Meeting.

COA Bulletin ACO - Fall / Automne 2016

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Récapitulation de la Réunion annuelle de Québec Encore un programme exceptionnel et une participation record! Doug Thomson Directeur général, Association Canadienne d’Orthopédie

cinante sur les coulisses de la scène politique à Ottawa et son actuelle course à la direction du Parti conservateur.

Le programme scientifique comprenait en outre une liste impressionnante de conférenciers invités, dont le Dr Jacques de Guise, qui a présenté la Conférence Macnab, le Dr Richard Hawkins, le Dr Steve Olson, président de l’Orthopaedic Trauma Association (OTA), le Pr Matthieu Assal, de Suisse, et le Dr Hans Larsen, d’Haïti.

n juin dernier, plus de 475 orthopédistes, 250 résidents et boursiers et 70 professionnels des soins de santé connexes ont profité à Québec du beau (superbe!) temps qui agrémente immanquablement les réunions de l’ACO ainsi que d’un programme de premier ordre, comme s’y attendent maintenant les membres. En effet, il y en avait pour tous les goûts, peu importe la sous-spécialité, car on a offert jusqu’à cinq séances concurrentes. Et comme c’est toujours le cas à notre réunion annuelle, les séances scientifiques étaient au cœur de la manifestation. Vu l’ampleur du programme de cette année, nous nous sommes réunis dans les salles modernes et accueillantes du Centre des congrès de Québec. Les coprésidents du Comité responsable du programme, les Drs Étienne Belzile et Mélissa Laflamme, avaient en effet conçu un programme qui donnait aux membres un choix sans précédent. Les chiffres en disent long : en tout, on a présenté plus de 230 exposés, 120 affiches (sélectionnées parmi quelque 550 précis soumis l’automne dernier), une journée des sous-spécialités, 2 ateliers pratiques, 10 conférences d’enseignement et 8 symposiums. Tout cela en une réunion de deux journées et demie, de sorte que les participants ont pu rentrer chez eux dès dimanche après-midi. Les précis intégraux de tous les exposés et de toutes les affiches sont disponibles sur le site Web de l’ACO. Encore une fois, les symposiums offerts cette année se sont avérés très populaires, ce qui témoigne des critères et fortes attentes établis par les coprésidents du Comité responsable du programme. Pour être considéré, tout symposium proposé devait questionner et pousser les connaissances et pratiques actuelles en orthopédie, ou célébrer des réalisations dans le domaine. Et c’est ce que chacun a fait, à sa façon. Plusieurs des symposiums sont disponibles en webdiffusion par l’intermédiaire du COA Live Learning Centre, à www.coa-aco.org, grâce à des subventions à l’éducation de nos partenaires de l’industrie. Cette année, c’est le Dr Dave Williams qui était conférencier invité aux cérémonies d’ouverture. L’excellente allocution du Dr Williams portait sur son expérience à l’Agence spatiale canadienne, dans les navettes spatiales Columbia et Endeavour ainsi qu’à la Station spatiale internationale. Le Dr Marc Swiontkowski, conférencier R.I. Harris de cette année, a quant à lui prononcé une allocution fort intéressante, intitulée « La chirurgie orthopédique au Canada aujourd’hui : Perspective de nos voisins du Sud ». De son côté, la conférencière invitée par le président de l’ACO, la Dre Kellie Leitch, a offert aux participants une allocution fasCOA Bulletin ACO - Fall / Automne 2016

Le Dr Hans Larsen, président de la Société haïtienne de chirurgie orthopédique et traumatologique

Afin de toujours bonifier les avantages de l’adhésion, des membres du Comité de direction et du personnel de l’ACO ont rencontré des participants dans le cadre d’un groupe de discussion organisé pendant l’une des pauses entre les séances. Ces participants ont cerné deux domaines clés où des améliorations sont nécessaires pour accroître la pertinence, la représentativité et l’utilité de l’ACO aux yeux de ses membres, soit 1) le lobbying et la défense des droits et intérêts, qui doivent être au cœur de ses activités; et 2) la Réunion annuelle, qui devrait être plus adaptée à l’ensemble des membres, plutôt qu’axée sur les orthopédistes universitaires spécialisés. La rétroaction et les suggestions des plus pertinentes que nous avons obtenues à ce sujet pendant cette discussion ont été transmises au Comité responsable du programme de la Réunion annuelle 2017. D’ailleurs, des changements et améliorations seront apportés à la prochaine réunion annuelle, et nous avons hâte de vous

Site Web de la Réunion annuelle 2017, à Ottawa Consultez régulièrement le site www.coaannualmeeting.ca pour obtenir tous les renseignements sur la prochaine réunion annuelle, qui aura lieu du 15 au 18 juin 2017, dans la magnifique ville d’Ottawa, en Ontario. L’aperçu du programme ainsi que des renseignements sur l’hébergement sont déjà en ligne, et le site est régulièrement mis à jour.

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Le Dr Robin Richards et les présidents du groupe Carousel

Le Dr John Antoniou, nommé deuxième président élu de l’ACO à la Séance de travail tenue le 18 juin, à Québec

en faire part! Nous aimerions en profiter pour remercier les participants à ce groupe de discussion pour leurs suggestions et leur intérêt.

lesse, d’hospitalité et de haut lieu du divertissement, et le programme éducatif a établi un nouveau standard d’excellence en matière de contenu.

Globalement, les évaluations et commentaires pour la Réunion de Québec sont très positifs et encourageants. Il nous faut remercier plus particulièrement la Dre Michèle Angers pour son travail exceptionnel à la présidence du Comité organisateur. Québec s’est montrée à la hauteur de sa réputation de gentil-

Nous espérons que vous faites déjà vos plans pour la Réunion d’Ottawa, en juin prochain. Pour en savoir plus à ce sujet, consultez régulièrement le site www.coaannualmeeting.ca.

Awards of Distinction

The 2016 Recipients of the COA Award of Merit and Presidential Award for Excellence Robin Richards, M.D., FRCSC Immediate Past President Canadian Orthopaedic Association

lease join us in congratulating this year’s recipients of the COA’s awards of distinction. Recipients were presented with their awards during the Opening Ceremonies of the COA Annual Meeting held this past June in Québec City. The Canadian Orthopaedic Association Award of Merit is presented for excellence in at least two of the following areas: • Service to the profession in the field of medical organization as it relates to orthopaedic surgery specifically; • Service to the people of Canada in raising the standards of orthopaedic care in Canada; • Personal contributions to the advancement of orthopaedic research, orthopaedic education, health-care organization or orthopaedic education of the public. It was a great pleasure for me to present the 2016 COA Award of Merit to Dr. John J. Murnaghan.

Dr. John J. Murnaghan receives the 2016 COA Award of Merit from Dr. Robin Richards

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Dr. John Murnaghan completed his orthopaedic training at the University of Toronto in 1987. He completed fellowships in arthroscopy and lower limb reconstructive surgery at The Toronto General/Mount Sinai Hospitals before completing his Masters of the Arts in Education Administration at the University of Illinois in 1989. He went on to join the orthopaedic staff at The Wellesley Hospital in Toronto in 1990. John led the Resident as Teacher program in the Department of Surgery at the University of Toronto for 15 years. He relocated his practice to the Holland Orthopaedic and Arthritic Centre after hospital restructuring in 1998. More recently, Dr. Murnaghan, in collaboration with Dr. Oleg Safir, designed and implemented the Basic Arthroplasty Rotation for the Competency-based Curriculum for the Division of Orthopaedics in Toronto.

Marc and Barb are founding members of the Canadian Association of Medical Teams Abroad (CAMTA). CAMTA has been providing both adult and paediatric orthopaedic surgery to the underprivileged people of Ecuador for the past 15 years. The group started with a skeleton crew of nineteen people on a one-week mission in 2001, and has since proudly expanded to two teams of nearly 50 committed volunteers each, travelling to Ecuador for close to a total of three weeks annually. The mission now provides training experiences for students (medical, nursing and other) as well as residents (family, orthopaedic and anaesthesia), planting the seed for their future interest in offering time and skills to underprivileged populations. Please join us in congratulating this year’s award recipients.

John is currently an Education Consultant to the Canadian Orthopaedic Association Basic Science Course and recently served two terms as the Chair of the COA’s Continuing Professional Development Committee. His numerous contributions to the COA educational programs include the addition of the Fireside Chats sessions and increased high-quality education-based symposia and workshops at our Annual Meetings. The COA Presidential Award for Excellence is presented for excellence in at least two of the following areas: • Service to the profession in the field of orthopaedic surgery; • Service to the people of Canada in raising the standards of orthopaedic care in Canada; • Personal contributions to the advancement of the art and science of orthopaedic surgery. I was honoured to present this year’s Award for Excellence to Dr. Marc and Mrs. Barb Moreau. Dr. Marc Moreau is a peadiatric orthopaedic surgeon at the Stollery Children’s Hospital in Edmonton Alberta and has been in practice since 1979. He is a Clinical Professor at the University of Alberta where he is involved in teaching and research into spinal deformity in both the clinical and basic science areas. He is the Assistant Dean of Admissions to the University of Alberta School of Medicine and Dentistry and has held this position since 2000. Dr. Moreau was President of the Canadian Orthopaedic Association from 2007-2008 and has served on multiple COA committees throughout his career. Marc and Barb Moreau are presented with the COA’s 2016 Presidential Award for Excellence by Dr. Robin Richards

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Resident Successes at CORA 2016 Annual Meeting

anadian residents convened in Québec City on June 16 for the CORA 2016 Annual Meeting. Co-chairs Drs. Pierre-Luc Blouin and Simon Corriveau-Durand from Université Laval were pleased to host a packed room of their colleagues from coast to coast for a morning of resident research presentations and posters, followed by an afternoon symposium on leadership, and capped off by a well-attended evening social event. A sincere thank you to abstract reviewers, as well as paper session moderators Drs. Jean Lamontagne and Stéphane Pelet, and symposium speakers Drs. Robert Turcotte, Neil White, Stéphane Pelet and Major Russell Eyestone, for their time and commitment to resident education. Their contribution to the residents’ program was extremely valuable and enriching.

Board members would like to remind residents to keep an eye on your inbox to stay up to date on a number of resident opportunities, including the COFAS Scholarship Program, the Bones and Phones Legacy Scholarship (based on contribution to enhancing MSK care in the community; deadline March 31), and the COA Global Surgery (COAGS) Call for Resident Bulletin Articles. For more information on these initiatives, please contact Trinity Wittman at trinity@canorth.org.

Congratulations are extended to the recipients of the top paper awards presented on site: • First Prize - J.A. Nutter Award Sponsored by Sanofi, makers of Synvisc One Dr. Jason Shin (University of Saskatchewan) • Second Prize - Alexandra Kirkley Award Ujash Sheth (University of Toronto) • Third Prize – COA Award John Morellato (University of Ottawa) • New this year! First Prize Poster Award Jeremy Kubik (University of Calgary) The abstracts for these top papers follow this article. Mark your calendar! The 2017 CORA meeting will be held on June 15 in Ottawa. We would like to welcome Drs. Lisa Lovse and Bogdan Matache from University of Ottawa as the new cochairs. The call for abstracts is open until January 31, and we hope to break last year’s record for resident abstract submissions. For more info, visit www.coraweb.org.

Drs. Pierre-Luc Blouin and Simon Corriveau-Durand from Université Laval chaired the 2016 CORA Annual Meeting

The CORA Board, consisting of resident representatives from each of the 17 orthopaedic programs, held its annual face-toface meeting on June 17, and had a lively discussion about resident recruitment, surgeon employment, models of care, and resident research. A number of COA committee chairs have invited the CORA Board to elect resident positions, and CORA is looking forward to fostering its ongoing partnership with the COA. The full COA committee slate can be seen HERE. Welcome, new committee members!

CORA session in progress COA Bulletin ACO - Fall / Automne 2016

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J.A. Nutter Award Sponsored by Sanofi, makers of Synvisc One First Prize CORA Paper $1000 - Dr. Jason Shin, University of Saskatchewan Characterization of Posterior Glenoid Bone Loss in Posterior Shoulder Instability Jason J. Shin, University of Saskatchewan Adam B. Yanke, Rachel M. Frank, Nikhil N. Verma, Brian J. Cole, Anthony A. Romeo, Matthew T. Provencher Purpose: Although glenoid bone loss has been well characterized in the setting of anterior shoulder instability, little has been written in the literature in the setting of posterior instability. The purpose of this study was to characterize the morphology and location of posterior glenoid bone loss in patients with posterior instability utilizing computed tomography (CT). Method: Clinical data was selected for patients with posterior shoulder instability that had undergone posterior stabilization (open or arthroscopic) or posterior osseous augmentation (distal tibia or iliac crest). The axial cuts were segmented and reformatted in three-dimensions for glenoid analysis using Osirix software. From this three-dimensional model, the following was calculated: percent bone loss (Nobuhara), total arc of the defect (degrees), glenoid version, and a clock-face description (start point, stop point, and average of direction-all normalized to right shoulder). Pearson correlation coefficients were performed using significance of p < 0.05.

Results: Forty-nine shoulders from 49 patients were reviewed. Twenty patients (average age 26.5 years; 95% males) had evidence of posterior glenoid bone loss and were included for evaluation. Defects on average involved 13.7+/-8.6% of the glenoid (range, 2-3.5%). The average start time (assuming all right shoulders) on the clock face was 10 o’clock +/- 40 minutes and stopped at 6:25 +/- 35 minutes. The average direction of the defect pointed towards 8:14 +/- 23 minutes. The percent bone loss correlated with the total arc of the defect (Pearson: 0.93, P < 0.05, R^2:0.86). The direction of bone loss moved more postero-superiorly, as the defect became larger (Pearson: 0.63, P < 0.05, R^2: 0.40). Conclusion: Posterior bone loss associated with posterior glenohumeral instability is typically directed posteriorly at 8:14 on the clock. As defect get bigger, this direction moves more posterosuperiorly. This information will help guide clinicians in understanding the typical location of posterior bone loss aiding in diagnosis, cadaveric models and treatment.

Alexandra Kirkley Award Second Prize CORA Paper $500 - Dr. Ujash Sheth, University of Toronto Practice Patterns in the Care of Acute Achilles Tendon Ruptures: Is There an Association with Level I Evidence Ujash Sheth, University of Toronto David Wasserstein, Richard Jenkinson, Rahim Moineddin, Hans Kerder, Susan Jaglal Purpose: Over the last decade, there has been a growing body of level I evidence supporting the ‘functional’ nonoperative management (i.e., early range of motion and early weight bearing) of acute Achilles tendon ruptures. Despite this emerging evidence, there have been very few studies evaluating its uptake. Our primary objective was to determine whether the findings from a landmark Canadian trial assessing the optimal treatment strategy for acute Achilles tendon ruptures influenced the practice patterns of orthopaedic surgeons in Ontario, Canada over a 12-year time period. As a second objective we examined whether patient and provider predictors of surgical repair utilization differed before and after dissemination of the landmark trial results.

COA Bulletin ACO - Fall / Automne 2016

Method: Using provincial health administrative databases, we identified Ontario residents ≥ 18 years of age with an acute Achilles tendon rupture from April 2002 to March 2014. The proportion of surgically repaired ruptures was calculated for each calendar quarter and year. A time series analysis using an interventional autoregressive integrated moving average (ARIMA) model was used to determine whether changes in the proportion of surgically repaired ruptures were chronologically related to the dissemination of results from a landmark Canadian trial by Willits et al. (first quarter, 2009). Spline regression was then used to independently identify critical time-points of change in the surgical repair rate to confirm our findings. A multivariate logistic regression model was used to assess for differences in patient (baseline demographics) and provider (hospital type) predictors of surgical repair utilization before and after the landmark trial.

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Results: From the second quarter of 2002 to the first quarter of 2010 the surgical repair rate remained constant at ~21%, however, by the first quarter of 2014 it fell to 6.5%. A statistically significant decrease in the rate of surgical repair (P<0.001) was observed after the results from a landmark Canadian trial were presented at a major North American conference (February 2009). Both teaching and non-teaching hospitals demonstrated a decline in the surgical repair rate over the study period, however, only the decrease seen at non-teaching hospitals was found to be significantly associated with the dissemination of landmark trial results (P<0.001). All other predictors of surgical repair utilization remained unchanged in the before-and-after analysis with the exception of patients £ 30 years of age having a higher odds of undergoing surgical repair after the trial when compared to those ≥ 51 years of age.

Conclusion: The current study demonstrates that large, welldesigned randomized trials, such as the one conducted by Willits et al. can significantly change the practice patterns of orthopaedic surgeons. Moreover, the decline in surgical repair rate observed at both teaching and non-teaching hospitals suggests both academic and non-academic surgeons readily incorporate high quality evidence into their practice.

COA Award Third Prize CORA Paper $500 - Dr. John Morellato, University of Ottawa The Effect of Varying Tension of a Suture Button Construct in Fixation of the Tibiofibular Syndesmosis - Evaluation Using Stress Computed Tomography John Morellato, University of Ottawa Hakim Louati, Andrew Bodrogi, Andrew Stewart, Steve Papp, Allan Liew, Wade Gofton Purpose: Suture button fixation has been shown to have decreased syndesmosis malreduction rates however there have been no studies assessing the optimal biomechanical tension of these constructs. The purpose of this study was to assess optimal tensioning of suture button fixation and its ability to maintain reduction under loaded conditions using a novel stress computed tomography (CT) model. Method: Ten cadaveric lower limbs disarticulated at the knee were used. The limbs were placed in a modified external fixator jig that allows for the application of sustained torsional (5 newton metres, Nm), axial (500 newtons, N) and combined torsional/axial (5Nm/500N) loads. Baseline unloaded and loaded CT scans were obtained. The syndesmosis and the deep deltoid ligament complex were then sectioned. The limbs were then randomized to receive a suture button construct tightened at 4 kg force (loose) or 8 kg (standard) or 12 kg (maximal) of tension. Seven previously validated measurements and two angles were taken from the axial CT scans. These included measures of medial-lateral translation (measurements ML and C) a measure of anterior-posterior translation (measurements AP, D, and E, and D/E ratio), and two angles; one angle (Angle 1) created by a line parallel to the incisura and the axis of the fibula and a second angle (Angle 2) created by the inner surfaces of the malleoli at the level of the tibiotalar joint. Each measurement was taken at baseline and compared with the three loading scenarios.

Results: Posterolateral Translation Under all fixation tensions, posterolateral fibular translation was observed (measurement A). This was maximal with the 4 kg fixation with the application of combined loading conditions (6.84 mm). Measurement B, measured at the posterior incisura, did not show any differences in the loaded conditions. Medial/Lateral translation Under torsional loading, 5.03mm and 5.23mm of lateral translation of the fibula was observed (ML and C respectively). This was only observed with 4 kg fixation only. With the 12 kg tension fixation without load, medial translation (ML=1.69mm) of the fibula was observed signifying over compression. Anterior/Posterior Translation Significant posterior translation was observed across all fixation tensions under torsional and combined loading (AP and D/E) with a maximum value of 6.42mm in the 4 kg repair. Rotation Under combined loading conditions, significant external rotation was observed as measured by Angle 1, with the 4 kg and 8 kg tension repair of 9.25° and 10.80° respectively. There was no significant rotation seen with the 12 kg repair. Significant external rotation was also observed as measured by Angle 2 with torsional loading with the 4 kg repair only (11.71°). There were no significant differences with respect to the 8 kg and 12 kg fixation. Conclusion: Suture button constructs must be appropriately tensioned to maintain reduction and re-approximate the degree of physiological motion at the distal tibiofibular joint. These constructs also demonstrate over compression of the syndesmosis however the clinical effect of this remains to be determined. COA Bulletin ACO - Fall / Automne 2016

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CORA First Prize Poster Award $250 - Dr. Jeremy Kubik, University of Calgary Evaluating the Utility of the Lateral Elbow Radiograph in Articular Olecranon Reduction: An Anatomic and Radiographic Study Jeremy Kubik, University of Calgary Prism Schneider, Ryan Martin Purpose: The surgical reduction of intra-articular olecranon fractures is judged primarily on the lateral elbow radiograph, as orthogonal articular imaging is not obtainable. Cross-sectional imaging of olecranon fractures initially perceived as simple on the lateral radiograph may in fact have comminution, suggesting that our interpretation of the olecranon articular surface on a single radiograph may be inadequate. The complex anatomy of the olecranon articular surface likely contributes to this discrepancy. Given its articular surface is composed of two trochlear notches sloped at approximately 45 degrees to each other, the articular tangent seen on the lateral radiograph is unlikely to be a true representation of the entire articular surface as the X-ray beam is only tangential to a limited portion of the articular ulna. As such, surgeons may fail to recognize olecranon articular malreduction intra-operatively, resulting in poor postoperative outcome. We sought to determine surgeon accuracy in identifying intra-articular olecranon malreductions on the lateral elbow radiograph. Method: Six human fresh-frozen cadaveric elbow specimens were sagitally sectioned in 5mm increments after olecranon dissection, preservation of soft tissue envelope, and rigid fixation of the elbow in an external fixator. Three distinct patterns of central intra-articular olecranon malreduction were created

in each elbow using a ruler and a standard bone saw. Perfect lateral elbow radiographs were taken of each malreduction for a total of 36 images. These images were randomized along with 36 X-rays of normal cadaveric olecranons, and the 72-image series was presented to four blinded trauma-trained surgeons to determine if the olecranon was malreduced or anatomic. Surgeons interpreted the same image series on two separate occasions separated by a minimum of six weeks. Percent correct was recorded and inter- and intra-observer reliability was calculated. Results: Fellowship-trained orthopaedic trauma correctly identified olecranon malreductions only 72% of the time on the lateral elbow radiograph. Subgroup analysis revealed a trend towards better identification of malreduction when the proximal articular olecranon surface was displaced. Moderate interrater reliability was found, with a Fleiss’ Kappa statistic of 0.43, 95% CI (0.33, 0.53). Intra-rater reliability revealed moderate agreement with an intra-class correlation coefficient ranging from 0.56-0.66. Conclusion: Intra-articular olecranon malreductions are inconsistently recognized by trained trauma surgeons on the lateral elbow radiograph. Therefore, articular incongruity may still be present post-surgical fixation of comminuted olecranon fractures. As olecranon fractures are intrinsically intra-articular and necessitate anatomic reduction, we must further define the radiographic anatomic representation of the articular olecranon in order to improve surgical reduction and clinical outcomes.

Can Global Surgical Care Become an Academic Pursuit? Introducting UBC’s Graduate Certificate Program at the Branch for International Surgical Care Norgrove Penny, CM, M.D., FRCSC Victoria, BC

he last decade has seen a burgeoning interest in global surgical care and the glaring disparities between higher and lower income countries. Global health and global surgery initiatives have sprung up amongst many academic and professional organizations, including the formation of the COA Global Surgery (COAGS) Committee in 2015. Last year the Lancet Commission on Global Surgery was published, announcing that fully five billion people in the world do not have access to safe and affordable surgical care. After years of neglect, this document, along with the World Bank including “Essential Surgery” in the newest edition of their Disease Control Priorities publication, and the passing of the World COA Bulletin ACO - Fall / Automne 2016

Health Assembly resolution 68.15 on emergency and essential surgical care, has finally catapulted the issue of surgical care disparity onto the world stage and should capture the attention of world leaders and funders in health care. Many COA members have participated in missions and projects over the years, providing surgical care and training to under-resourced communities out of a desire to see a more just and equitable world. Most of us have learned the lessons of outreach surgical care on the ground, exchanging anecdotes and experiences as best we can along the way. But is it now possible to turn a more academic lens on global surgery? Can global surgery become a subject of academic scrutiny in the hopes of developing practice standards as we see elsewhere in academic pursuit?

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The Branch for International Surgical Care at the University of British Columbia was established in 2009 for just such a purpose. The Branch now offers a Graduate Certificate in Global Surgical Care. To our knowledge this is the only such academic program in global surgical care in the world.

University of British Columbia, Vancouver, Canada

OUR MISSION:

Confronted by the reality of underserved populations we will lead, partner, educate and serve to realize safe surgical care for all.

Four on-line graduate courses are available: SURG510: Surgical Care in International Health. This introductory course paints a wide landscape on the issues and complexities of global surgical care, introducing the unmet burden of disease caused by the lack of surgical care, international initiatives, ethical concerns, and different models of volunteerism and surgical care partnership. SURG512: Global Disability: A Surgical Care Mandate. Examines the burden of unnecessary disability created by lack of access to surgical care. Can orthopaedic surgeons imagine a world where fractures are not reduced, osteomyelitis not drained, congenital deformities not reconstructed, and arthritic joints not replaced? What can we do about it? SURG514: Surgical Care in Humanitarian Disaster Response. Orthopaedic surgeons have a critical part to play in humanitarian disaster response and trauma care is in our collective DNA. The earthquake in Haiti became a dramatic example of how important it is to know the right way to respond in this very specialized field. SPPH540: Program Planning and Evaluation with a Surgical Care Focus. This course, run within the School of Population & Public Health, prepares students to plan, run and evaluate a global health program, and may be integrated with an overseas project.

Aquire and enhance your knowledge of Global Surgery:

graduate online GLOBAL SURGICAL CARE courses SURG 510 - Surgical Care in International Health SURG 512 - Global Disability: A Surgical Care Mandate SURG 514 - Surgical Care in Humanitarian Disaster Response SPPH 540 - Program Planning and Evaluation with a Surgical Care Focus Courses available in September and January To register or for further details contact: Branch for International Surgical Care, University of British Columbia 604 875 5372 I surgery.international@ubc.ca I internationalsurgery.med.ubc.ca

The Branch is now working to integrate their courses into a graduate degree program within the School of Population and Public Health. It will then be possible to undertake a Masters Degree in Public Health (MPH) with a specialty in global surgical care. The courses are delivered entirely online (no classes on campus or summer residences), designed to allow health professionals to continue their studies with minimal work disruption. Students include practicing surgeons from all over the world who perform surgical outreach on a voluntary basis and wish to expand their knowledge base. Others are not surgeons at all but are interested in global health from an administrative or research perspective. What is very evident is that young people, particularly surgical residents, are passionate about the issues of global health and want to make a difference with their skills and enthusiasm. These courses will launch them on a career path so much more grounded than what was available to those of us who had to learn our lessons through the school of hard knocks!

Course work focuses on surgical care as an overarching theme, including anaesthesia and the support teams required to ensure a surgical result. This moves us out of the silo of our specialty niche, and even out of the comfort zone of orthopaedic surgery, and back to our common roots as surgical providers and our first love of enriching lives through surgery. I would like to invite any COA member, and particularly orthopaedic residents interested in global surgical care, to take advantage of one or more courses, or to even complete the certificate program. For more information, please visit www.internationalsurgery.med.ubc.ca or e-mail surgery.international@ubc.ca. The COA Global Surgery (COAGS) Committee is pleased to share Canadian global health initiatives. If you are interested in COAGS featuring your organization in the Bulletin, please contact trinity@canorth.org.

COA Bulletin ACO - Fall / Automne 2016

Your COA / Votre association

Dr. Reginald Herbert Yabsley September 13, 1936 - June 12, 2016

t is with deep sadness that we announce the passing of Reginald Herbert Yabsley, M.D., FRCSC, Professor Emeritus of Orthopaedic Surgery at Dalhousie University. He died peacefully on June 12, 2016 in Halifax, NS. He was born in St. John’s, NL on September 13, 1936 to Reginald and Doris Yabsley (nee Stick), now deceased. He was a beloved husband, father, brother, grandfather, uncle and father-in-law to his wife, Shirley, his children, Susan, Bart (Nancy), Andrew and Jennifer (Johan), his grandchildren, Meghan, Erin and Jonas, his brother and sister-in-law, Richard and Paula, nieces, Jillian and Paige, and nephew, Peter. He will be missed more than we can say. Reg graduated from Dalhousie Medical School in 1960. He went on to become Chief of Orthopaedic Surgery at the Victoria General Hospital in Halifax, NS from 1969-1989, was Chairman and Program Director of the Division of Orthopaedic Surgery at Dalhousie University from 1970-1989 and was Program Director for the affiliated orthopaedic Training Program between Memorial University of St. John’s, NL and Dalhousie University, Halifax, NS between 1984-1989. Under his direction, the first training program in orthopaedics, fully accredited by the Royal College of Physicians and Surgeons of Canada, was established in 1970. In 1991, Reg served as the President of the Canadian Orthopaedic Association.

All of his accomplishments are too numerous to mention here, however no person could be more suited for his chosen profession in life and he cherished all of the people with whom it brought him into contact. He truly loved caring for his patients and the relationships that his work allowed him to enjoy with doctors, nurses, technicians and the entire hospital staff. His decades-long partnership with his assistant, Carolyn MacDonald, both a colleague and a friend, was one he particularly treasured. His family would like to say a special thank you to Dr. Frank Lo and to the staff of the ICU 5.2 and IMCU 3rd floor of the QEII Health Science Centre for their wonderful care of our loved one. http://obits.dignitymemorial.com/dignity-memorial/ obituary.aspx?n=Reginald-Yabsley&lc=3758&pid=180318555& mid=6966982

Dr. Brett Kilb 1987-2016

e cannot express the depth of our pain as we announce the passing of Brett Kilb, loving husband of Jessica, son of Brad Kilb & Bonnie MacRae-Kilb, brother of Justin, Brad Jr., Bryn, Jodi & Jamey. Sharing our loss are Jessica’s parents Ingrid & Howard Zerr, grandparents Simone & Ken MacRae, Connie Zerr & many other family & friends. Brett passed suddenly while jogging with his wife. He was conducting medical research in Barcelona. A graduate with degrees in Kinesiology & Medicine from the University of Calgary & a Master’s degree from the Harvard School of Public Health, 28-year old Brett impacted many lives with his caring, compassionate & loving manner. Abstracted from http://www.legacy.com/obituaries/ calgaryherald/obituary.aspx?pid=181467125 A Tribute to Brett Kilb from the UBC Orthopaedic Residents A memorial was held for Brett Kilb on September 21, 2016 in his hometown of Calgary. Over 600 people attended the ceremony with another 200 people watching via a live stream. A large group of UBC residents past and present as well as faculty members were in attendance. We came as a group already well aware of how amazing a person, physician and surgeon Brett COA Bulletin ACO - Fall / Automne 2016

was to us in Vancouver. He was a true pillar in our orthopaedic program at UBC who will be sorely missed. Being able to meet with and hear from people from so many different aspects of Brett’s life, we were able to see that we were but one small part of this amazing man’s life. Whether it was stories of his national level motocross or volleyball skills, his elementary school antics or his desire and ability to help anyone who needed it without a second thought, it was always with that classic bright-eyed Brett smile. Across all the stories and memories of Brett, the same themes of a humble, kind-hearted soul with endless energy and curiosity always shone through. Brett was a one-of-a-kind, hard-working resident willing to do whatever it took to answer his next burning question. Taking a year off to pursue his Masters at Harvard was an obvious extension of his already impressive work ethic. We, as his co-residents, know that he was of the hardest working among us, always a

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research project or two on the go while at the same time staying late to provide the most personal care to all his patients. He was most certainly in the 99th percentile in academics but more than that, he was adored by all his patients as well as all those he worked with in the Vancouver hospitals. Brett always ensured we stayed close as a resident group: Those who work hard need to play hard too! He always kept the electronic music soundtrack up to date for our anatomy dissection sessions and could always be counted on for his annual rooftop party for the Vancouver Firework festival. The support we have all received from our program and the orthopaedic community during this difficult time has meant so much to all of us. More than that, it also speaks volumes to how far reaching Brettâ&#x20AC;&#x2122;s influence has been with his mentors who have been affected by him on much more than just a professional level. As you may know, a memorial fund has been set up through UBC to honour Brettâ&#x20AC;&#x2122;s legacy (http://memorial.supporting.ubc. ca/brett-kilb). Having accomplished more in his 28 years than many do in a life twice as long, there is so much we can all learn

from the way Brett lived. We owe it to those who never had a chance to know, to work with, to think with, or to laugh with Brett to ensure they can also benefit from what he has accomplished and all that he was set out to accomplish. Brett truly lived larger than anyone we knew, with the next adventure for him and his wife Jess always just around the corner. As residents in a demanding specialty like orthopaedics, always working towards the light at the end of the tunnel, we can all take a lesson out of Brettâ&#x20AC;&#x2122;s book: To live each day bursting at the seams with passion for what we do, compassion for those we treat and kindness and respect for those we do it with. Our hearts go out to his wife Jess, his parents Bonnie and Brad, his family, friends and colleagues far and wide. Brett will continue to hold an important part in all our hearts and lives as well. His spirit, inspiration and legacy will live on through our program at UBC. UBC Orthopaedic Residents

UBC orthopaedic residents pictured here with Brett (second from left in front row) on their annual retreat held only two short weeks before his passing.

COA Bulletin ACO - Fall / Automne 2016

INTRODUCING

TRIATHLON TRITANIUM ®

Orthopaedics

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

FONT: Helvetica with bell curve

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

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

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COA Bulletin ACO - Fall / Automne 2016

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

Letters to the Editor

Subject: High Tibial Osteotomy for the Management of Medial-sided Knee Osteoarthritis in the Middle-aged Patient (COA Bulletin #113 Summer 2016 edition) Dear Editor,

he authors are to be congratulated for an excellent summary of the subject matter, and I agree with the main conclusions. However, there are errors in the assumptions that the “...lateral closing wedge osteotomy...has been shown to predispose to patella baja” and that “medial opening wedge osteotomy acts instead to increase patellar height”. In the former, for example, the reference paper’s osteotomies were casted postop., likely resulting in patellar tendon scarring and/or contracture. Because of the confusion in the literature on this subject, I looked Response: Dear Dr. Portner, Thank you very much for your insightful feedback regarding our COA article entitled, “High Tibial Osteotomy for the Management of Medial-sided Knee Osteoarthritis in the Middle-aged Patient”. You make an excellent point about the impact of postoperative immobilization and rehabilitation on the incidence of patella baja following high tibial osteotomy. As you discuss, an opening wedge osteotomy is more likely to predispose to patella baja from a purely biomechanical standpoint. Certainly the length of immobilization, alterations in tibial slope, and inconsistencies in the measurement indices confound the findings in the literature. Your paper (CORR(2014) 472:3432-3440) is a very interesting and relevant discussion of these issues. I am particularly intrigued by your use of a “combined” osteotomy to address the concern with

at the effect of different types of osteotomies on patellar height (CORR(2014) 472:3432-3440), with no cast immobilization and rapid rehabilitation. 100% of lateral closing wedge osteotomies raised the patella, while 100% of opening wedges lowered it, as expected biomechanically. Interestingly, the example shown displays borderline low patella at 20 degrees plateau-patella angle preop., with definite patella baja postop at 15-16 degrees. The tibial slope has also been increased by approximately five degrees, another potential problem with opening wedge osteotomies. Oliver Portner, MDCM, FRCSC patellar height. It would be valuable to see longer term follow-up on your cohort of patients with respect to time to union and functional outcomes. Interestingly, your preliminary results appear to suggest that a combined osteotomy may be superior to either of the traditional approaches. Thank you for sharing this interesting paper, and for your important comments regarding our review. Kindest regards, Michaela Kopka, M.D., Elmar Herbst, M.D., Volker Musahl, M.D. University of Pittsburgh Medical Centre Department of Sports Medicine We value your feedback and comments on any articles that are published in the COA Bulletin. Send your letters to the editor through Cynthia Vezina: cynthia@canorth.org at the COA Office.

Horizons

A new COA Bulletin feature

he practice of orthopaedic surgery continues to evolve. We are faced with an explosion of information stemming from published cutting-edge research (bench and clinical). Likewise, an increasingly informed public has rapid access to information about novel therapies and surgical techniques. Oftentimes the best way to integrate evidence-based practice and innovative treatments is unknown or challenging. To add some perspective on how to approach emerging and/or controversial topics, we are excited to introduce this new Horizons feature in the COA Bulletin. In the Horizons articles, thought leaders from various subspecialties will provide insights based on their extensive clinical experience and ongoing research. The goal of this new feature is to “shed some light” on the best way forward. I would thank to thank Drs. Tim Daniels and Andrew Dodd from the COA Bulletin ACO - Fall / Automne 2016

University of Toronto for contributing to this first Horizons feature and I look forward to working with future contributors to this new section. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

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

Total Ankle Replacement on the Cusp of Standard of Care for End-stage Ankle Arthritis Timothy Daniels, M.D., FRCSC Andrew Dodd, M.D., FRCSC Toronto, ON

he role of total ankle replacement (TAR) for end-stage ankle arthritis (ESAA) continues to evolve at a rapid pace. Though ankle arthrodesis/fusion (the alternative to TAR) performs well, our patients are asking for more. Now, almost every major orthopaedic company has a total ankle system of its own, and with an increase in choices, comes new challenges. While the urge to stay with what is tested and true (and familiar) is understandable, if this were the case, the current orthopaedic community would still be performing fusions of hips, knees, shoulders and elbows (rather than TKR and THR). Few residents graduating today ever see these surgeries; yet many experienced orthopaedic surgeons remember the days when these were frequently performed. More than ever it is imperative to remember the basic orthopaedic principles for TAR: relief of pain, anatomic alignment and restoration of function. The current goal of the foot and ankle orthopaedic community is to (a) make TAR a viable alternative to a fusion, and (b) as reliable as hip and knee replacements. The implant design and surgical technique for TAR continue to improve in longevity and outcomes. The importance of deformity correction, as well as appropriate ligament balancing of the ankle, is now more thoroughly understood. In the appropriate patient, TAR is on the verge of replacing arthrodesis as the standard of care in patients over the age of 65 years; and its outcomes are approaching the same reliability as a TKR. Ankle arthritis often presents in a younger population than hip and knee arthritis patients and with a multiplanar deformity. The functional surface area of the ankle is one-third of that of the hip and knee with at least three times the force distribution. It is the first major articulation which transfers the ground reactive forces to the rest of the body. In addition, there are a number of complex peritalar articulations directly beneath which need to be taken into consideration when correcting multiplanar deformities of the hindfoot. When compared to a hip/knee, the complexity of a TAR is at minimum comparable to a primary THR/TKR. The importance of a successful implant for any particular ankle/patient cannot be underemphasized. In cases with more substantial deformity, which is up to 40% of cases, a TAR is comparable to a complex THR/TKR revision. One of the major developments in TAR is the improved surgical techniques and the surgeon’s familiarization or expertise with procedures so as to appropriately balance the foot around the prosthesis. Though arbitrary, previous cut-offs of 15 to 20 degrees of talar-coronal plane deformity have been recommended by experts in the field. Information provided largely by the foot and ankle reconstruction database of the Canadian Orthopedic Foot and Ankle Society (COFAS) has demonstrated that longevity and outcomes of TAR are improving, even in the

presence of substantial deformity. This database is a registry of TARs performed in Toronto, Halifax and Vancouver. This has provided invaluable information to the foot and ankle community worldwide. A systematic approach to a deformity correction is now considered as important as the implantation of the ankle itself. Without this approach, surgeons cannot expect a desirable outcome. In addition to actually implanting a TAR, it is important for the treating surgeon to understand that multiple ancillary surgical procedures are required in 75% of the patients. Deformity and/ or instability above/below the TAR cause asymmetric loading of the polyethylene and this leads to early failure. A coronal-plane deformity in TAR is common and deformity of >10 degrees is present in up to 40% of patients. Only a portion of this deformity is localized to the tibial plafond due to boney erosions; therefore, the solution is not as simple as filling the defect with cement or metal augments. Ancillary procedures can be as simple as an Achilles tendon lengthening, or as complex as peri-articular joint fusions, osteotomies, tendon transfers and/or allograft tendon or ligament reconstruction. The goal of these ancillary procedures is to create a balanced, plantigrade foot beneath the TAR. Major ankle joint/hindfoot/midfoot deformities may need to be managed in staged surgeries (i.e. correction of deformity first, followed by TAR in a separate surgical setting) – this is not only safer for the patient, but it allows for a more complex and severe deformity correction. The talar valgus ankle arthritis is less common than the talar varus, but both are surgically challenging. The valgus deformity results from various etiologies – the most common being deltoid ligament insufficiency. The deltoid ligament is the most important stabilizer of the talus in the ankle mortise. Whether due to trauma, recurrent instability, or adult-acquired flatfoot deformity, incompetence of the deltoid ligament leads to instability of the talus in the coronal, sagittal, and transverse planes (pronation, external rotation and plantar flexion). This can lead to progressive valgus deformity, asymmetric loading and, eventually, arthritis of the ankle. Chronic deltoid instability resulting from recurrent ankle sprains in the non-neuromuscular flexible subtle pes cavus foot is becoming increasingly recognized as a cause of end-stage ankle arthritis. When correcting talar valgus deformities, understanding the etiology is important as it influences the surgical procedures performed. For example, deformity correction in the Stage IV adult-acquired flat foot deformity is entirely different than the deformity correction of talar valgus caused by recurrent ankle sprains – the latter results in a compensatory varus position (internal rotation) of the subtalar joint complex (a ping-pong deformity) whereas the former is associated with a valgus (external rotation) peritalar deformity. Understanding these subtleties will prevent rapid failure of the TAR. These type of TAR failures have been blamed on poor reliability of the implant as opposed to a lack of understanding of how to correct complex musculoskeletal deformity. COA Bulletin ACO - Fall / Automne 2016

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Much of the literature on TAR focuses on varus ankle deformity due to its higher prevalence. Valgus ankle arthritis and its underlying deltoid ligament insufficiency remains a challenging problem. Further research into (a) the ideal method of deltoid ligament reconstruction and (b) clinical outcomes following deltoid ligament reconstruction is necessary to adequately address these difficulties. Large, longitudinal studies are necessary to investigate the long-term outcome of TAR in the setting of valgus ankle arthritis. Data registry has been invaluable in the THR and TKR

arthroplasty literature. As the current ankle arthroplasty data collection lags behind, we encourage all Canadian centres performing high-volume TAR to get involved with the COFAS ankle arthritis database. The groundwork is already in place for Canada to continue to be a leader in the development and maintenance of ankle arthroplasty registry. Only through collaboration and ongoing research will patient outcomes from TAR continue to improve.

Graft Choice in Anterior Cruciate Ligament Reconstruction Introduction to this edition’s clinical debate “

planted, pivoted and heard a pop!” This is a classic account in the history of an anterior cruciate ligament (ACL) injured knee. One would think that with an injury so common in athletes, there would be a pre-defined and consistent surgical procedure. However, once an active individual or highlevel athlete elects to have surgery to reconstruct the ACL, the debates and controversies will soon follow.

The ideal autograft choice for an ACL reconstruction is the focus of this edition’s debate. Experts from Gothenburg University, McGill University and the Université de Montréal and Western University discuss the pros and cons of using the following autografts: patellar-bone tendon-bone, quadriceps tendon and hamstring tendons. I hope you enjoy their insights and apply important concepts to your practices. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

Bone-patellar Tendon-bone Graft Eric Hamrin Senorski2, PT Christopher D Murawski3, BS Jón Karlsson1,2, M.D., PhD Kristian Samuelsson1,2, M.D., PhD Department of Orthopaedics, Sahlgrenska University Hospital, Mölndal, Sweden 2 Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden 3 Department of Orthopaedic Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA 1

revision ACL reconstruction30,1. It is for these reasons that the PT autograft has been referred to as the “gold standard” in ACL reconstruction for the last three decades7,26. In addition, the width of a PT autograft can be tailored to match footprint anatomy and size, which is a theoretical advantage when compared with other graft options, particular hamstring tendon (HT) autograft. Depending on the size of the patient’s patellar tendon, a graft up to 12mm with a cross-sectional area of 35mm2 can be obtained while still safely retaining sufficient tendon on either side of the graft (Figure 1)21.

he graft choice for anterior cruciate ligament (ACL) reconstruction has been a hot topic for decades. The patella tendon14,12 autograft has its primary and inherent advantages in the native bone plugs at each end of the graft. The bone plugs provide a natural tendonto-bone fixation, thereby entailing improved graft healing16,3,1. Additionally, the bone plugs enable an interference fit with the bone tunnels created during ACL reconstruction, which also Figure 1 makes the PT autograft an excellent choice for Bone-patellar tendon-bone autograft harvested for anterior cruciate ligament reconstruction

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Proponents of other graft choices for ACL reconstruction will often cite the morbidity of the harvest site as the primary reason for avoiding the utilization of PT autograft1. While concerns do exist regarding quadriceps deficit, osteoarthritis, anterior knee pain and sensory disturbance after PT harvest, complications associated with other ACL reconstruction grafts shall not be forgotten. These include the potential for increased knee laxity, hamstrings deficit and pain, tunnel widening, sensory deficit and anterior knee pain. Laxity and Rotational Stability Recent evidence suggests no differences in anterior-posterior and rotational knee-joint laxity between the PT and HT autografts in mid- and long-term comparative studies26,1. However, PT grafts are supported with superior results in terms of residual laxity in the short-term when compared to quadruple HT grafts. Intuitively, the reduced short-term laxity of the PT graft may be explained by the more rapid healing, known as ligamentization, due to the native bone plugs and resultant bone-to-bone healing3,10,11. There is a theoretical disadvantage often highlighted in the literature with regards to the risk of elongation of the ACL graft and potential graft failure caused by early aggressive rehabilitation, thereby imparting large tensile forces on the autograft15. This criticism has not been confirmed in a highlevel study26; however, it can be argued that the PT graft with enhanced healing through bone plugs at each end of the graft may be adequate to tolerate early rehabilitation compared with other ACL autografts3,11. Revision Frequency The large Scandinavian Knee Ligament Registries are a unique source of data with detailed information on more than 50,000 patients who have undergone ACL reconstruction. Studies from these registries report that PT autografts used for ACL reconstruction entail a decreased risk of revision surgery23,24. However, it must be noted that PT autografts are far less utilized for primary ACL reconstruction in the registries, therefore creating bias. It is also important to bear in mind that such registries are hypothesis-generating, and thus do not prove causality13. This decreased revision frequency compared with the HT autografts cannot be seen in the recent randomized controlled trials (RCT) with long-term follow-up25,4,6,28. Moreover, further information, such as the rehabilitation protocol utilized and the degree to which anatomic ACL reconstruction was performed is important to know and consider. It is reasonable to suggest that the rehabilitation protocol must be tailored to graft choice. As one example, HT autograft likely requires a longer time to healing and rehabilitation than PT autograft owing to the increased tendon-to-bone healing time. This information is not available in the context of current registries. Pain Anterior knee pain and pain on kneeling are frequently reported complications encountered after the use of PT autografts in ACL reconstruction20,26,1. However, studies with mid- and long-term follow-up report that the symptoms decrease with time20,6. Nevertheless, it is important to assess the patients’ demands of their knee in regard to activities of daily living, work, sporting activities, hobbies and religious beliefs. Graft choice should be individualized to each patient’s needs; in the case of PT autograft, it is important to not jeopardize daily function with potential symptoms of persistent anterior knee pain.

Table 1. Ultimate strength and stiffness of the native ACL and commonly utilized autografts.

Graft type Native ACL Quadruple Hamstring Bone-Patella Tendon-Bone Quadriceps Tendon

Ultimate Strength (N) 2 160 4 590 2 977 2 352

Stiffness (KN/m) 292 861 620 463

ACL; Anterior Cruciate Ligament

Osteoarthritis In addition to knee stability, a long-term goal of ACL reconstruction is to minimize the risk of post-traumatic osteoarthritis. Osteoarthritis is perhaps the most dreaded of the potential long-term sequela after ACL reconstruction and can result in persistent knee pain and disability in an otherwise relatively young, healthy and active group of patients22. It is well established that an ACL injury and subsequent reconstruction is associated with a higher risk of osteoarthritis26,4. Additionally, it has been suggested previously that the use of PT grafts is more likely to lead to osteoarthritis, especially to the patellofemoral joint25. Despite this, several recent RCTs17,4,6,28 with a long-term follow-up up ranging from 10-16 years found no difference in the presence of osteoarthritis between PT and HT autografts after ACL reconstruction. Return to Sport The question of ‘when is a return to sport possible?’ is considered important for many patients, but especially in those patients who participate at a high or professional level of athletic play. In a comprehensive meta-analysis2, the use of PT autograft had a higher odds of returning to the pre-injury level of sport. However, in the same study2, HT autograft was associated with higher odds of returning to any sport participation and also sports at a competitive level. The question of which graft is superior in terms of return to sport remains heretofore unanswered. Nevertheless, for high-level athletes participating in pivoting sports, such as American football, some favour the PT autografts for ACL reconstruction12. This is also likely explained by the enhanced healing through the bone plugs at both ends of the PT autograft as compared to other graft choices3,7,26. Donor Site Morbidity The donor site morbidity and subsequent loss of knee extension strength has been a frequently reported concern19,20. In addition, the PT harvest may also cause an iatrogenic injury to the infrapatellar nerve branch of the saphenous nerve, resulting in a sensory deficit of the anterior knee19,20. Several studies confirm these concerns; however, the impaired strength is temporary and patients are reported to recover at mid- and long-term follow-ups19,6. Nevertheless, both factors (temporary impaired strength and potential sensory deficit) should be considered before ACL reconstructive surgery. Biomechanical Aspects The advantage(s) of the bipolar bone plugs on PT autografts has been described previously. In contrary to the PT autograft, the HT autograft is stronger and stiffer biomechanically8,18. Ultimate strength and stiffness of the most commonly utilized ACL autografts are presented in Table 121,29. However, the COA Bulletin ACO - Fall / Automne 2016

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absence of bone plugs at both ends of the graft may entail a risk of tunnel widening based on the assumption of longitudinal and transverse movements of the graft27. Tunnel widening has been associated with HT graft, and better fixation techniques are requested27,5. In contrast, no correlation had been reported between tunnel widening and either knee laxity or patient-reported outcome26. Preoperative evaluation Finally, a further advantage of the PT graft is that the preoperative thickness of the PT graft can easily be assessed using an MRI assessment in multiple planes9. Other graft choices, such as HT autograft, require more technical care and skill of the orthopaedic surgeon since the graft length is assessable only after harvest. References 1. Anderson, M. J., et al. (2016). A Systematic Summary of Systematic Reviews on the Topic of the Anterior Cruciate Ligament. Orthop J Sports Med 4(3): 2325967116634074. 2. Ardern, C. L., et al. (2014). Fifty-five per cent return to competitive sport following anterior cruciate ligament reconstruction surgery: an updated systematic review and meta-analysis including aspects of physical functioning and contextual factors. Br J Sports Med 48(21): 1543-1552. 3. Aune, A. K., et al. (2001). Four-strand hamstring tendon autograft compared with patellar tendon-bone autograft for anterior cruciate ligament reconstruction. A randomized study with two-year follow-up. Am J Sports Med 29(6): 722-728. 4. Barenius, B., et al. (2014). Increased risk of osteoarthritis after anterior cruciate ligament reconstruction: a 14-year follow-up study of a randomized controlled trial. Am J Sports Med 42(5): 1049-1057. 5. Biswal, U. K., et al. (2016). Correlation of tunnel widening and tunnel positioning with short-term functional outcomes in single-bundle anterior cruciate ligament reconstruction using patellar tendon versus hamstring graft: a prospective study. Eur J Orthop Surg Traumatol 26(6): 647-655. 6. Bjornsson, H., et al. (2016). A Randomized Controlled Trial With Mean 16-Year Follow-up Comparing Hamstring and Patellar Tendon Autografts in Anterior Cruciate Ligament Reconstruction. Am J Sports Med. 7. Carmichael, J. R. and M. J. Cross (2009). Why bone-patella tendon-bone grafts should still be considered the gold standard for anterior cruciate ligament reconstruction. Br J Sports Med 43(5): 323-325. 8. Chan, D. B., et al. (2010). A biomechanical comparison of fan-folded, single-looped fascia lata with other graft tissues as a suitable substitute for anterior cruciate ligament reconstruction. Arthroscopy 26(12): 1641-1647.

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9. Chan, K. W., et al. (2012). Using magnetic resonance imaging to determine preoperative autograft sizes in anterior cruciate ligament reconstruction. Bull NYU Hosp Jt Dis 70(4): 241-245. 10. Claes, S., et al. (2011). The “ligamentization” process in anterior cruciate ligament reconstruction: what happens to the human graft? A systematic review of the literature. Am J Sports Med 39(11): 2476-2483. 11. Dong, S., et al. (2015). Ligamentization of Autogenous Hamstring Grafts After Anterior Cruciate Ligament Reconstruction: Midterm Versus Long-term Results. Am J Sports Med 43(8): 1908-1917. 12. Erickson, B. J., et al. (2014). Anterior cruciate ligament reconstruction practice patterns by NFL and NCAA football team physicians. Arthroscopy 30(6): 731-738. 13. Granan, L. P., et al. (2009). The Scandinavian ACL registries 2004-2007: baseline epidemiology. Acta Orthop 80(5): 563567. 14. Harris, J. D., et al. (2013). Return-to-Sport and Performance After Anterior Cruciate Ligament Reconstruction in National Basketball Association Players. Sports Health 5(6): 562-568. 15. Heijne, A. and S. Werner (2007). Early versus late start of open kinetic chain quadriceps exercises after ACL reconstruction with patellar tendon or hamstring grafts: a prospective randomized outcome study. Knee Surg Sports Traumatol Arthrosc 15(4): 402-414. 16. Hoffmann, R. F., et al. (1999). Initial fixation strength of modified patellar tendon grafts for anatomic fixation in anterior cruciate ligament reconstruction. Arthroscopy 15(4): 392399. 17. Holm, I., et al. (2012). No differences in prevalence of osteoarthritis or function after open versus endoscopic technique for anterior cruciate ligament reconstruction: 12-year follow-up report of a randomized controlled trial. Am J Sports Med 40(11): 2492-2498. 18. Iriuchishima, T., et al. (2014). Evaluation of ACL mid-substance cross-sectional area for reconstructed autograft selection. Knee Surg Sports Traumatol Arthrosc 22(1): 207-213. 19. Liden, M., et al. (2007). Patellar tendon or semitendinosus tendon autografts for anterior cruciate ligament reconstruction: a prospective, randomized study with a 7-Year follow-up. Am J Sports Med 35(5): 740-748. 20. Maletis, G. B., et al. (2007). A prospective randomized study of anterior cruciate ligament reconstruction: a comparison of patellar tendon and quadruple-strand semitendinosus/gracilis tendons fixed with bioabsorbable interference screws. Am J Sports Med 35(3): 384-394. 21. Noyes, F. R., et al. (1984). Biomechanical analysis of human ligament grafts used in knee-ligament repairs and reconstructions. J Bone Joint Surg Am 66(3): 344-352.

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22. Oiestad, B. E., et al. (2010). Knee function and prevalence of knee osteoarthritis after anterior cruciate ligament reconstruction: a prospective study with 10 to 15 years of follow-up. Am J Sports Med 38(11): 2201-2210.

26. Samuelsson, K., et al. (2009). Treatment of anterior cruciate ligament injuries with special reference to graft type and surgical technique: an assessment of randomized controlled trials. Arthroscopy 25(10): 1139-1174.

23. Persson, A., et al. (2014). Increased risk of revision with hamstring tendon grafts compared with patellar tendon grafts after anterior cruciate ligament reconstruction: a study of 12,643 patients from the Norwegian Cruciate Ligament Registry, 2004-2012. Am J Sports Med 42(2): 285-291.

27. Struewer, J., et al. (2012). Prevalence and influence of tibial tunnel widening after isolated anterior cruciate ligament reconstruction using patella-bone-tendon-bone-graft: longterm follow-up. Orthop Rev (Pavia) 4(2): e21.

24. Rahr-Wagner, L., et al. (2014). Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the danish registry of knee ligament reconstruction. Am J Sports Med 42(2): 278-284. 25. Sajovic, M., et al. (2011). Quality of life and clinical outcome comparison of semitendinosus and gracilis tendon versus patellar tendon autografts for anterior cruciate ligament reconstruction: an 11-year follow-up of a randomized controlled trial. Am J Sports Med 39(10): 2161-2169.

28. Webster, K. E., et al. (2016). Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction: A 15-Year Follow-up of a Randomized Controlled Trial. Am J Sports Med 44(1): 83-90. 29. Woo, S. L., et al. (2002). The effectiveness of reconstruction of the anterior cruciate ligament with hamstrings and patellar tendon . A cadaveric study comparing anterior tibial and rotational loads. J Bone Joint Surg Am 84-a(6): 907-914. 30. Yazdanshenas, H., et al. (2015). Patellar tendon donor-site healing during six and twelve months after Anterior Cruciate Ligament Reconstruction. J Orthop 12(4): 179-183.

What About the Quads Tendon Graft? Emilie Sandman, M.D., M.Sc., FRCSC, Hôpital du Sacré-Coeur de Montréal

Paul A. Martineau, M.D., FRCSC, ABOS, SCOSM McGill University Health Centre (MUHC) Montréal, QC

any techniques for anterior cruciate ligament (ACL) reconstruction exist and the debate over the different graft options has long been a favourite among orthopaedic sport medicine specialists. Many grafts types have been described and characterized fairly extensively in the literature. Each method is associated with its own set of potential advantages and disadvantages. Indeed, studies have reported that ACL reconstructions performed with hamstring autografts are at potential risk for reduced knee flexion strength, increased laxity, hematoma formation postoperatively, delayed or failure of graft incorporation due to the soft tissue-bone interface, tunnel enlargement, and possible variable graft size1-5. Meanwhile, ACL reconstructions with bone-patellar tendon-bone autografts (BPTB) autografts have been described to be at potential risk for decreased quadriceps strength, loss of knee extension, patellar tendon rupture or patellar fracture, anterior knee pain, discomfort with kneeling activities and early osteoarthritis1,5-7. Despite the excitement in the 90s surrounding allografts as a graft option, more recently, this option has fallen out of favour in the younger population due to the reported increased failure rate compared to autografts8.

Figure 1 Quadriceps autograft preparation: a) soft tissue only; b) soft tissue plus patella bone block (Photos Courtesy of Dr. Alan Getgood)

But what about the quadriceps tendon (QT) autograft? Orthopaedic surgeons often forget to include the QT autograft as an option for ACL reconstruction in their treatment algorithm. In 2010, during the American Academy of Orthopaedic Surgeons Annual Meeting, only 1% of surgeons admitted to COA Bulletin ACO - Fall / Automne 2016

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using this type of graft9. In fact, the senior author of this article, despite having a tertiary care academic practice with referrals for complex knee instability and being the orthopaedic surgeon of a professional hockey and football team, belongs to the 99% of surgeons not using the QT autograft. Therefore, this review was as much a learning experience for us as we hope it will be for the reader. Marshall et al.10 were the first to describe the use of the QT graft in 1979 and since then, the initial technique has been modified throughout the years. Blauth11 was the pioneer for the QT graft attached to a patellar bone block and in 2003, Theut et al.12 described the free QT graft technique. Recent studies have demonstrated that the QT can be an excellent graft choice for ACL reconstructions. Indeed, preoperative graft thickness can be templated with using magnetic resonance imaging (MRI) and it has been shown that a QT graft has a higher cross-sectional area than a BPTB graft, as well as greater ultimate strength5,13-16. Moreover, Xerogeanes et al.17 evaluated MRI scans and found that the quadriceps tendon anatomy was reproducible for volume and length. Conversely, they found that BPTB grafts usually have sufficient size, but variable length, and that hamstring grafts have generally good length, but variable volume. They also found that the distal 6cm of the QT had a 275% larger mean volume when compared to the patellar tendon and that the QT had 88% higher proposed intraarticular portion of graft volume versus the patellar tendon. Finally, they discovered that the QT graft length was correlated with patient height, where 90% of the patients measuring â&#x2030;Ľ66 inches tall had a QT graft greater than 7cm. Furthermore, Ma et al.18 looked at the difference in graft maturity at six months post-ACL reconstruction on MRI between the QT with a patellar bone block versus hamstring autografts. They found that QT grafts had a greater MRI-evaluated graft maturity level than hamstring tendon grafts. Thus, surgeons could theoretically individualize the choice of their graft type and modify the time for a return to sports accordingly. Meanwhile, Shani et al.19 studied the material and structural properties between 10mm QT autografts and BPTB autografts. They found that QT grafts had a significantly greater ultimate load to failure, a higher mean stiffness and almost twice the cross-sectional area when compared to BPTB grafts. Sasaki et al.1 illustrated in their study that QT and hamstring autografts both restored the kinematics of the knee close to normal and found no statistically significant differences between the two grafts for in situ forces and kinematics. In addition, Slone et al.5 in a systematic review, outlined advantages of the use of QT autografts. Indeed, they found that the QT autograft provides good stability with similar results when compared to BPTB and hamstring autografts, comparable results for functional outcomes, no difference for range of motion compared to BTPB grafts and lower donor-site morbidity, as well as similar complication rates. Thus, QT autografts are a good reliable alternative option for initial ACL reconstruction or for revision surgeries. However, as they mentioned in their review, QT autografts may be associated with certain complications, such as possible hematoma formation if the lateral perforating vessels are injured, hemarthrosis if the suprapatellar pouch is violated, retraction of the rectus femoris after harvesting and possible cosmetic concerns. It has also been shown that the tendinous size of the QT autograft can be harvested with good consistCOA Bulletin ACO - Fall / Automne 2016

ency for length, depth and width (7-8cm, 6-7mm, 9-10mm respectively) compared to BPTB grafts which have an average depth of 4mm and a mean width of 10mm and variable length5,20-23. Moreover, Theut et al.12 support the choice of using a QT autograft for initial and revision ACL reconstructions, since the QT has a high cross-sectional area, making it a strong graft. This technique provides minimal postoperative morbidity, with a claimed decreased incidence in patellofemoral symptoms, as well as providing high patient satisfaction. Finally, it has been shown that patients who were operated for an ACL reconstruction with QT and BPTB autografts had similar outcomes at two years postoperatively; however, patients with a QT autograft had statistically significant lower complaints of anterior knee pain and numbness than those with a BPTB graft22,24. However, from the studies describing the use of QT autograft, it seems that interference screw fixation of the bone plug and the soft tissue portion of the QT graft is the most common method of fixation of these grafts. Therefore, given the consistent length of QT graft of 7-8cm, graft fixation options may be limited. In conclusion, recent studies have shown that orthopaedic surgeons can consider the QT autograft as a graft option for the treatment of initial or revision ACL reconstructions, due to its low morbidity, excellent mechanical and structural properties and good clinical outcomes. References 1. Sasaki, N., et al., Biomechanical evaluation of the quadriceps tendon autograft for anterior cruciate ligament reconstruction: a cadaveric study. Am J Sports Med, 2014. 42(3): p. 72330. 2. Nakamura, N., et al., Evaluation of active knee flexion and hamstring strength after anterior cruciate ligament reconstruction using hamstring tendons. Arthroscopy, 2002. 18(6): p. 598-602. 3. Barrett, G.R., et al., Reconstruction of the anterior cruciate ligament in females: A comparison of hamstring versus patellar tendon autograft. Arthroscopy, 2002. 18(1): p. 46-54. 4. Clatworthy, M.G., et al., Tunnel widening in anterior cruciate ligament reconstruction: a prospective evaluation of hamstring and patella tendon grafts. Knee Surg Sports Traumatol Arthrosc, 1999. 7(3): p. 138-45. 5. Slone, H.S., et al., Quadriceps tendon autograft for anterior cruciate ligament reconstruction: a comprehensive review of current literature and systematic review of clinical results. Arthroscopy, 2015. 31(3): p. 541-54. 6. Kartus, J., et al., Complications following arthroscopic anterior cruciate ligament reconstruction. A 2-5-year follow-up of 604 patients with special emphasis on anterior knee pain. Knee Surg Sports Traumatol Arthrosc, 1999. 7(1): p. 2-8. 7. Jarvela, T., P. Kannus, and M. Jarvinen, Anterior knee pain 7 years after an anterior cruciate ligament reconstruction with a bone-patellar tendon-bone autograft. Scand J Med Sci Sports, 2000. 10(4): p. 221-7.

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8. Tejwani, S.G., et al., Revision Risk After Allograft Anterior Cruciate Ligament Reconstruction: Association With Graft Processing Techniques, Patient Characteristics, and Graft Type. Am J Sports Med, 2015. 43(11): p. 2696-705. 9. van Eck, C.F., K.D. Illingworth, and F.H. Fu, Quadriceps tendon: the forgotten graft. Arthroscopy, 2010. 26(4): p. 441-2; author reply 442-3. 10. Marshall, J.L., et al., The anterior cruciate ligament: a technique of repair and reconstruction. Clin Orthop Relat Res, 1979(143): p. 97-106. 11. Blauth, W., [2-strip substitution-plasty of the anterior cruciate ligament with the quadriceps tendon]. Unfallheilkunde, 1984. 87(2): p. 45-51. 12. Theut, P.C., et al., Anterior cruciate ligament reconstruction utilizing central quadriceps free tendon. Orthop Clin North Am, 2003. 34(1): p. 31-9. 13. Kim, D., et al., Biomechanical evaluation of anatomic singleand double-bundle anterior cruciate ligament reconstruction techniques using the quadriceps tendon. Knee Surg Sports Traumatol Arthrosc, 2015. 23(3): p. 687-95. 14. Fink, C., et al., Minimally invasive harvest of a quadriceps tendon graft with or without a bone block. Arthrosc Tech, 2014. 3(4): p. e509-13. 15. Kim, S.J., et al., Comparison of single- and double-bundle anterior cruciate ligament reconstruction using quadriceps tendon-bone autografts. Arthroscopy, 2009. 25(1): p. 70-7. 16. Harris, N.L., et al., Central quadriceps tendon for anterior cruciate ligament reconstruction. Part I: Morphometric and biomechanical evaluation. Am J Sports Med, 1997. 25(1): p. 23-8.

17. Xerogeanes, J.W., et al., Anatomic and morphological evaluation of the quadriceps tendon using 3-dimensional magnetic resonance imaging reconstruction: applications for anterior cruciate ligament autograft choice and procurement. Am J Sports Med, 2013. 41(10): p. 2392-9. 18. Ma, Y., et al., Graft maturity of the reconstructed anterior cruciate ligament 6 months postoperatively: a magnetic resonance imaging evaluation of quadriceps tendon with bone block and hamstring tendon autografts. Knee Surg Sports Traumatol Arthrosc, 2015. 23(3): p. 661-8. 19. Shani, R.H., et al., Biomechanical Comparison of Quadriceps and Patellar Tendon Grafts in Anterior Cruciate Ligament Reconstruction. Arthroscopy, 2016. 32(1): p. 71-5. 20. Waligora, A.C., N.A. Johanson, and B.E. Hirsch, Clinical anatomy of the quadriceps femoris and extensor apparatus of the knee. Clin Orthop Relat Res, 2009. 467(12): p. 3297-306. 21. DeAngelis, J.P. and J.P. Fulkerson, Quadriceps tendon-a reliable alternative for reconstruction of the anterior cruciate ligament. Clin Sports Med, 2007. 26(4): p. 587-96. 22. Shelton, W.R. and B.C. Fagan, Autografts commonly used in anterior cruciate ligament reconstruction. J Am Acad Orthop Surg, 2011. 19(5): p. 259-64. 23. Cooper, D.E., Biomechanical properties of the central third patellar tendon graft: effect of rotation. Knee Surg Sports Traumatol Arthrosc, 1998. 6 Suppl 1: p. S16-9. 24. Geib, T.M., et al., Anterior cruciate ligament reconstruction using quadriceps tendon autograft: intermediate-term outcome. Arthroscopy, 2009. 25(12): p. 1408-14.

Hamstring Tendon Autograft for Anterior Cruciate Ligament Reconstruction is Reproducible with Good Long-term Outcomes Kyla Huebner MSc, M.D., PhD Alan Getgood, MPhil, M.D., FRCS (Tr&Orth) Division of Orthopaedic Surgery, Western University Fowler Kennedy Sports Medicine Clinic London, ON

randomized clinical trials evaluating the various grafts options. Reconstructions can be done with either allograft or autograft tissue. Graft options include bone-patellar-bone, quadriceps tendon, hamstring tendon, tibialis anterior tendon, tibialis posterior tendon, and Achilles tendon.

When considering which graft to use, there are many variables to take into account. It is imperative that several things be considered when making this decision: 1) graft failure; 2) patient factors such as age, gender and activity level; 3) postoperative complications such as pain, infection, donor site morbidity and DVT; 4) cost; 5) technical ease; and 6) validity and reliability of the graft.

nterior cruciate ligament (ACL) injuries are common, with ACL reconstruction surgery being widely performed worldwide. ACL reconstruction is economically advantageous and increases quality of life compared to nonoperative strategies1. There are several graft options, including autoand allografts. The choice of graft has been one of the most debated topics in orthopaedics since the 1990’s, with multiple

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Autografts have multiple advantages including decreased risk of disease transmission of HIV and hepatitis, they are irradiation-free, and cost significantly less when compared to their allograft counterparts. Allografts also have the potential for rejection and delayed graft incorporation. The sterilization process of allografts alters material properties and has been associated with decreasing tissue strength and leads to graft failure. Hamstring autografts were shown to have three-fold lower failure rates compared to tibialis posterior allografts2. Traditionally, patellar tendon autograft was considered the â&#x20AC;&#x153;gold standardâ&#x20AC;?3,4. However, with technological advances, other graft options have increased in popularity. Hamstring tendon graft is now the most common graft option; it has been used in roughly 84% of cases in Denmark and Sweden5, 44% of cases in the United States according to the Multicentre Orthopaedic Outcome Network, and 60% of cases in Norway according to the Norwegian National Knee Ligament Registry6. Hamstring tendon grafts typically consist of the gracilis tendon and semitendinosus tendon (Figure 1 & 2), with the quadrupled single semitendinosus tendon graft also gaining in popularity. There are several techniques in making the graft ACL from these tendons with the doubled gracilis and semitendinosus creating a four-strand graft, having the best outcomes for strength, function and longevity. In vitro studies have demonstrated that four-strand hamstring tendon grafts have been shown to have greater strength and elasticity in materials testing compared to patellar tendon grafts7. However, this has not been proven in vivo. In an early Cochrane review, results showed that patellar tendon grafts had greater static stability with a loss of extension, while hamstring tendon grafts were associated with a loss of flexion and knee flexor strength8. These early changes appear to be insignificant in long-term analysis9, suggesting that hamstring tendon grafts are a viable option for long-term knee function.

Figure 1 Four-strand hamstring graft preparation consisting of doubled semitendiosus and gracilis tendons

One of the reasons why hamstring tendon graft use has become so popular is that harvesting the tendons is an easy and reproducible technique with good long-term results. Hamstring harvest can be done through a small incision and the bone tunnels can be made through the same harvest incision resulting in improved cosmesis. Also hamstring tendon harvest is technically less demanding than patellar tendon or COA Bulletin ACO - Fall / Automne 2016

Figure 2 Intra-articular position of hamstring graft ACL reconstruction

quadriceps tendon harvest and does not risk patellar fractures like bone-patellar-bone harvest. Therefore, one might suggest to surgeons who have lower volume ACL reconstruction practices that hamstring tendon grafts are the safest option. Long-term studies have not only demonstrated that hamstring tendon grafts have good results, but that they are not inferior to other graft options10. Hamstring tendon grafts have similar postoperative pain to other graft options11, donor site morbidity and knee function are also similar to alternative methods12,13,14. However, recent studies from the Danish and Swedish registries have shown a hamstring graft size less than 8mm is correlated with higher rates of graft failure15. There is a 1.7% failure in grafts greater than 8mm, as opposed to 13.6% failure in grafts less than 7mm16. This is an important consideration when using hamstring grafts, particularly in patients with diminutive hamstring tendons, and exemplifying why the use of a four-strand graft is preferred. As a result, it is our preference to triple the tendons to make a five- or six-stranded graft in cases where a four-strand construct is less than 8mm in diameter. Furthermore, Mohtadi et al. have recently demonstrated increased complication rates, including hamstring injury, meniscal tears, arthrofibrosis, persistent effusion, periostitis, nerve irritation, infection, and higher rates of graft failure of hamstring tendon grafts compared to patellar tendon grafts14, indicating that patellar tendons may be a better graft choice for young patients returning to pivoting sports. In addition, multiple meta-analyses suggest that bone-patellar-bone grafts might be superior in regaining rotational stability as indicted by KT-1000 arthmometer values, Lachman tests, and pivotshift tests17,18,19. Danish registry results have also shown that hamstring tendon grafts are associated with increased risk of revision in young patients20. In addition to increased failure with rotational activities Magnussen et al. demonstrated that <1% of hamstring grafts in patients over 20 years old failed where 14.3% of hamstring grafts in patients under 20 failed16. However, in an older population, hamstring tendon grafts result in good clinical results, high patient satisfaction levels and appropriate return to activity21, and have been associated with significantly less pain with kneeling8,14. In a randomized clinical trial examining longer-term outcomes, early differences between hamstring tendon grafts and patellar tendon grafts, such as losses in flexion or extension range of motion,

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 36)

laxity, knee pain and rates of osteoarthritis were not apparent at 15-year follow-up9. This suggests that in the long-term, hamstring tendon and patellar tendon grafts have comparable results. In conclusion, hamstring tendon grafts are a reliable choice for ACL reconstruction in specific patient populations. Their ease of harvest and reproducibility, decreased kneeling pain, adequate return to baseline function, low cost, and good longterm outcomes make it an ideal graft choice for older patients and young patients who are not returning to pivoting sports. References 1. Mather R.C., Koenig L., Kocher M.S., Dall T.M., Gallo P., Scott D.J, Bach B.R., Spindler K.P.; MOON Knee Group. Societal and economic impact of anterior cruciate ligament tears. J Bone Joint Surg Am. 2013 Oct;95(19):1751-9. doi: 10.2106/ JBJS.L.01705. 2. Bottoni C.R., Smith E.L., Shaha J., Shaha S.S., Raybin S.G., Tokish J.M., Rowles D.J. Autograft Versus Allograft Anterior Cruciate Ligament Reconstruction: A Prospective, Randomized Clinical Study With a Minimum 10-Year Follow-up. Am J Sports Med. 2015 Oct;43(10):2501-9. doi: 10.1177/0363546515596406. 3. Aglietti P., Buzzi R., D’Andria S., Zaccherotti G. Arthroscopic anterior cruciate ligament reconstruction with patellar tendon. Arthroscopy. 1992 Dec;8(4):510-6. doi;10.1016/07498063(92)90017-6 4. Buss D.D., Warren R.F., Wickiewicz T.L., Galinat B.J., Panariello R. Arthroscopically assisted reconstruction of the anterior cruciate ligament with use of autogenous patellar-ligament grafts. Results after twenty-four to forty-two months. J Bone Joint Surg Am. 1993 Sep;75(9):1346-55. 5. Granan L.P., Forssblad M., Lind M., Engebretsen L. The Scandinavian ACL registries 2004-2007: baseline epidemiology. Acta Orthop. 2009 Oct;80(5):563-7. doi: 10.3109/17453670903350107. 6. Magnussen R.A., Granan L.P., Dunn W.R., Amendola A., Andrish J.T., Brophy R., Carey J.L., Flanigan D., Huston L.J., Jones M., Kaeding C.C., McCarty E.C., Marx R.G., Matava M.J., Parker R.D., Vidal A., Wolcott M., Wolf B.R., Wright R.W., Spindler K.P., Engebretsen L. Cross-cultural comparison of patients undergoing ACL reconstruction in the United States and Norway. Knee Surg Sports Traumatol Arthrosc. 2010 Jan;18(1):98-105. doi: 10.1007/s00167-009-0919-5. 7. Biuk E., Zelić Z., Rapan S., Ćurić G., Biuk D., Radić R. Analysis of biomechanical properties of patellar ligament graft and quadruple hamstring tendon graft. Injury. 2015 Nov;46 Suppl 6:S14-7. doi: 10.1016/j.injury.2015.10.040. 8. Mohtadi N.G., Chan D.S., Dainty K.N., Whelan D.B. Patellar tendon versus hamstring tendon autograft for anterior cruciate ligament rupture in adults. Cochrane Database Syst Rev. 2011 Sep;7(9):CD005960. doi: 10.1002/14651858.CD005960.pub2.

9. Webster K.E., Feller J.A., Hartnett N., Leigh W.B., Richmond A.K. Comparison of Patellar Tendon and Hamstring Tendon Anterior Cruciate Ligament Reconstruction: A 15-Year Followup of a Randomized Controlled Trial. Am J Sports Med. 2016 Jan;44(1):83-90. doi: 10.1177/0363546515611886. 10. Bourke H.E., Gordon D.J., Salmon L.J., Waller A., Linklater J., Pinczewski L.A. The outcome at 15 years of endoscopic anterior cruciate ligament reconstruction using hamstring tendon autograft for ‘isolated’ anterior cruciate ligament rupture. J Bone Joint Surg Br. 2012;94:630-7. Doi;10.1302/0301-620X.94B5. 11. Gupta R., Kapoor D., Kapoor L., Malhotra A., Masih G.D., Kapoor A., Joshi S. Immediate post-operative pain in anterior cruciate ligament reconstruction surgery with bone patellar tendon bone graft versus hamstring graft. J Orthop Surg Res. 2016 Jun;11(1):67. doi: 10.1186/s13018-016-0399-5. 12. Kautzner J., Kos P., Hanus M., Trc T., Havlas V. A comparison of ACL reconstruction using patellar tendon versus hamstring autograft in female patients: a prospective randomised study. Int Orthop. 2015 Jan;39(1):125-30. doi: 10.1007/s00264-0142495-7. 13. Razi M., Sarzaeem M.M., Kazemian G.H., Najafi F., Najafi M.A. Reconstruction of the anterior cruciate ligament: a comparison between bone-patellar tendon-bone grafts and fourstrand hamstring grafts. Med J Islam Repub Iran. 2014 Nov;28:134. 14. Mohtadi N., Barber R., Chan D., Paolucci E.O. Complications and Adverse Events of a Randomized Clinical Trial Comparing 3 Graft Types for ACL Reconstruction. Clin J Sport Med. 2016 May;26(3):182-9. doi: 10.1097/JSM.0000000000000202. 15. Conte E.J., Hyatt A.E., Gatt C.J., Dhawan A. Hamstring autograft size can be predicted and is a potential risk factor for anterior cruciate ligament reconstruction failure. Arthroscopy. 2014 Jul;30(7):882-90. doi: 10.1016/j.arthro.2014.03.028. 16. Magnussen R.A., Lawrence J.T., West R.L., Toth A.P., Taylor D.C., Garrett W.E. Graft size and patient age are predictors of early revision after anterior cruciate ligament reconstruction with hamstring autograft. Arthroscopy. 2012 Apr;28(4):52631. doi: 10.1016/j.arthro.2011.11.024. 17. Li S., Su W., Zhao J., Xu Y., Bo Z., Ding X., Wei Q. A metaanalysis of hamstring autografts versus bone-patellar tendon-bone autografts for reconstruction of the anterior cruciate ligament. Knee. 2011 Oct;18(5):287-93. doi: 10.1016/j. knee.2010.08.002. 18. Li S., Chen Y., Lin Z., Cui W., Zhao J., Su W. A systematic review of randomized controlled clinical trials comparing hamstring autografts versus bone-patellar tendon-bone autografts for the reconstruction of the anterior cruciate ligament. Arch Orthop Trauma Surg. 2012 Sep;132(9):1287-97. doi: 10.1007/s00402-012-1532-5.

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19. Xie X., Liu X., Chen Z., Yu Y., Peng S., Li Q. A meta-analysis of bone-patellar tendon-bone autograft versus four-strand hamstring tendon autograft for anterior cruciate ligament reconstruction. Knee. 2015 Mar;22(2):100-10. doi: 10.1016/j. knee.2014.11.014.

21. Struewer J., Ziring E., Oberkircher L., Schüttler K.F., Efe T. Isolated anterior cruciate ligament reconstruction in patients aged fifty years: comparison of hamstring graft versus bonepatellar tendon-bone graft. Int Orthop. 2013 May;37(5):80917. doi: 10.1007/s00264-013-1807-7.

20. Rahr-Wagner L., Thillemann T.M., Pedersen A.B., Lind M. Comparison of hamstring tendon and patellar tendon grafts in anterior cruciate ligament reconstruction in a nationwide population-based cohort study: results from the danish registry of knee ligament reconstruction. Am J Sports Med. 2014 Feb;42(2):278-84. doi: 10.1177/0363546513509220.

Make the FIRST Break the LAST with Fracture Liaison Services Katie Cvitkovitch, PDt (c)1 Victoria Elliot-Gibson, MSc2 Diane Theriault, M.D., FRCPC, CCD1 1. Osteoporosis Canada; 2. St. Michael’s Hospital OECP

pproximately half of all patients who sustain a hip fracture warned us they were coming; they had previously broken another bone – a ‘signal’ fracture – before breaking their hip1-4. Effective drug treatments can reduce future fracture risk by 50% for patients presenting with fragility fractures5. These treatments have been available for 20 years and yet, 80% of Canadians who sustain a fragility fracture still do not receive treatment for their underlying osteoporosis6-8. This is the post-fracture osteoporosis care gap which is allowing the cycle of recurring fractures to continue at great expense to both patients’ quality of life and the health-care system. The only truly effective solution: Fracture Liaison Service (FLS) FLS is a specific model of care where a dedicated coordinator captures fragility fracture patients, on a system-wide basis, and determines their future fracture risk with the purpose of facilitating effective treatment for high-risk patients. FLS is the most effective secondary fracture prevention method to ensure that fragility fracture patients are identified, investigated and treated, if indicated, to lower their risk of future fracture9,10. In 2016, secondary fracture prevention is still a missed opportunity in many orthopaedic settings. Orthopaedic inpatient wards and outpatient clinics are optimal locations for identification of fragility fracture patients. Benefits of FLS include: • Reduced incidence of subsequent fractures11-13 • Maintaining the quality of life and independence of seniors who have been “spared” from a fracture • Lower mortality for patients seen in an FLS13 • Reduced disruption to patient flow in the health-care system by:

COA Bulletin ACO - Fall / Automne 2016

- decreasing pressure on already scarce orthopaedic resources - freeing up capacity for elective surgery - decreasing pressure on long-term care beds and demand for home care • Significant cost-savings to the health-care system14-16 St. Michael’s Osteoporosis Exemplary Care Program The first FLS in Canada, the Osteoporosis Exemplary Care Program (OECP), was founded in 2002 by Dr. Earl Bogoch, orthopaedic surgeon at St. Michael’s Hospital in Toronto. Under Dr. Bogoch’s leadership, the OECP/FLS at St. Michael’s is dedicated to closing the post-fracture care gap. The FLS manages 350 to 450 fracture patients annually. The OECP coordinator identifies women ≥40 years of age and men ≥50 years of age who present to the hospital’s inpatient ward and outpatient fracture clinic with a fragility fracture of the distal radius, proximal humerus, proximal femur and vertebra. The coordinator then investigates, through bone mineral density (BMD) testing and assessing risk factors, to determine their future fracture risk and provides education on nutrition and fracture risk reduction strategies to the patient, and when appropriate, refers the patient to an osteoporosis specialist or back to their primary care provider (PCP) to ensure appropriate treatment is initiated. The key features of identification, investigation and initiation of treatment are common to all FLSs and are aptly named the “3 i’s of FLS”. The OECP has demonstrated success at capturing patients at risk for future fractures and initiating testing and treatment to help prevent them17. The OECP also undergoes iterative modifications and improvements based on program performance outcomes and qualitative study results. One main improvement in the program was the systematic, rather than ad hoc, inpatient geriatric and rheumatology service established in 2009. The rate of inpatient consultation increased from 21% to 84%18.

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As reported at the American Society of Bone and Mineral Research Annual Meeting in Atlanta in September 2016, data reporting the outcomes of the OECP from December 2010 to November 2013 revealed that 94% of high risk, treatment naïve fragility fracture patients were assessed by a specialist or a primary care physician; 70% were prescribed/recommended pharmacotherapy in addition to calcium and vitamin D19. These findings are significant for this patient population, as we know typically in other jurisdictions, less than 20% ever receive osteoporosis treatment6-8.

References

Using very conservative assumptions, a cost-effectiveness analysis14 of the OECP done soon after implementation concluded that a hospital that hired an osteoporosis coordinator who manages 500 patients with fragility fractures annually could reduce the number of subsequent hip fractures from 34 to 31 in the first year, with a net hospital cost savings of $48,950 (Canadian dollars in year 2004 values). Those benefits would compound over time. Other economic evaluations done in Canada also demonstrate cost effectiveness of fracture prevention programs14-16.

3. Port L., Center J., Briffa N.K., Nguyen T., Cumming R., Eisman J. Osteoporotic fracture: missed opportunity for intervention. Osteoporos Int. Sep 2003;14(9):780-784.

St. Michael’s OECP has also informed much of the work behind the Ontario Osteoporosis Strategy FLS. Ensuring Quality FLS in Canada and Worldwide FLS is becoming recognized worldwide as the standard of care for fragility fracture patients. Many national and international osteoporosis organizations, including Osteoporosis Canada (OC), International Osteoporosis Foundation (IOF), National Osteoporosis Foundation (NOF - USA), National Osteoporosis Society (NOS - UK) and Osteoporosis New Zealand (ONZ) have directed their advocacy efforts to support the implementation of quality FLS. Many, including OC, IOF, NOS and ONZ have published clinical standards for FLS. Osteoporosis Canada has been a global leader in advocating for quality FLS. The 8 Essential Elements of a Fracture Liaison Service were developed by expert advisors to help guide new and existing FLSs towards success. OC’s FLS Registry features Canadian FLSs meeting the 8 Essential Elements and is now available online at http://www.osteoporosis.ca/wp-content/ uploads/Final-Quality-Standards-March-2015-English.pdf Become an FLS Champion A recent survey (2015) of 130 COA members conducted by Osteoporosis Canada revealed that 89% feel there is a benefit in initiating pharmacotherapy for high risk patients to prevent subsequent fragility fractures. Once educated about the function of FLS, 80% of respondents felt that FLS is key to helping close the care gap20. Orthopaedic surgeons are extremely well positioned to be the leaders for the implementation of quality FLS and ensuring the post-fracture care gap is closed. OC is the pre-eminent source of FLS information in Canada. For FLS tools and resources, go to www.osteoporosis.ca/fls or contact Katie Cvitkovitch kcvitkovitch@osteoporosis.ca

1. Gallagher J.C., Melton L.J., Riggs B.L., Bergstrath E. Epidemiology of fractures of the proximal femur in Rochester, Minnesota. Clin Orthop Relat Res. Jul-Aug 1980(150):163171. 2. McLellan A., Reid D., Forbes K., et al. Effectiveness of strategies for the secondary prevention of osteoporotic fractures in Scotland (CEPS 99/03): NHS Quality Improvement Scotland; 2004.

4. Edwards B.J., Bunta A.D., Simonelli C., Bolander M., Fitzpatrick L.A. Prior fractures are common in patients with subsequent hip fractures. Clin Orthop Relat Res. Aug 2007;461:226-230. 5. Papaioannou A., Morin S., Cheung A.M., et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. Nov 23 2010;182(17):1864-1873 6. Papaioannou A., Giangregorio L., Kvern B., Boulos P., Ioannidis G., Adachi J.D. The osteoporosis care gap in Canada. BMC Musculoskelet Disord. Apr 6 2004;5:11. 7. Papaioannou A., Kennedy C.C., Ioannidis G., et al. The osteoporosis care gap in men with fragility fractures: the Canadian Multicentre Osteoporosis Study. Osteoporos Int. Apr 2008;19(4):581-587. 8. Bessette L., Ste-Marie L.G., Jean S., et al. The care gap in diagnosis and treatment of women with a fragility fracture. Osteoporos Int. Jan 2008;19(1):79-86. 9. Sale J.E., Beaton D., Posen J., et al. Systematic review on interventions to improve osteoporosis investigation and treatment in fragility fracture patients. Osteoporos Int. 2011;22:2067-2082. 10. Ganda K., Puech M., Chen J.S., et al. Models of care for the secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporos Int. 2013;24:393-406. 11. Lih A., Nandapalan H., Kim M., Yap C, Lee P., Ganda K., Seibel M.J. Targeted intervention reduces re-fracture rates in patients with incident non-vertebral osteoporotic fractures: a 4-year prospective controlled study. Osteoporos Int. 2011 Mar;22(3):849-58. 12. Astrand J., Nilsson J., Thorngren K.G. Screening for osteoporosis reduced new fracture incidence by almost half: a 6-year follow-up of 592 fracture patients from an osteoporosis screening program. Acta Orthop. 2012 Dec;83(6):661-5. 13. Huntjens K.M., van Geel T.A., van den Bergh J.P., van Helden S., Willems P., Winkens B., Eisman J.A., Geusens P.P., Brink P.R. Fracture Liaison Service: Impact on subsequent nonvertebral fracture incidence and mortality. J Bone Joint Surg Am. 2014 Feb 19; 96(4):e29.

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(continued from page 39)

14. Sander B., Elliot-Gibson V., Beaton D.E., Bogoch E.R., Maetzel A. A coordinator program in post-fracture osteoporosis management improves outcomes and saves costs. J Bone Joint Surg Am. Jun 2008;90(6):1197-1205. 15. Yong J.H., Masucci L., Hoch J.S., Sujic R., Beaton D. Costeffectiveness of a fracture liaison service-a real-world evaluation after 6 years of service provision. Osteoporos Int. 2016 Jan;27(1):231-40. 16. Majumdar S.R., Lier D.A., Beaupre L.A., Hanley D.A., Maksymowych W.P., Juby A.G., Bell N.R., Morrish D.W. Osteoporosis case manager for patients with hip fractures: results of a cost-effectiveness analysis conducted alongside a randomized trial. Arch Intern Med. 2009 Jan;169(1):25-31.

18. Victoria Elliot-Gibson, personal communication, September 9, 2016 19. Bogoch E., Elliot-Gibson V., Beaton .D, Josse R., Sale J., Norris E. 2016 Fracture Risk Specific Treatment Initiation Rates in an Orthopaedic Fracture Liaison Service. J Bone Miner Res 30 (Suppl 1). Available at http://www.asbmr.org/Itinerary/ PresentationDetail.aspx?id=b616afc3-069c-4a24-89795f12b2e8389f Accessed September 8, 2016. 20. Tufescu T., Bhandari M., Williamson L. et al. The Role of the Orthopaedic Surgeon in Osteoporosis Management for Hip Fracture Patients. Canadian Orthopaedic Association Bulletin. 2015;110:33-34.

17. Bogoch E.R., Elliot-Gibson V., Beaton D.E., Jamal S.A., Josse R.G, Murray T.M. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am. 2006;88(1):25-34.

Editor’s Response to

Make the FIRST Break the LAST with Fracture Liaison Services Alastair Younger, M.D., FRCSC Editor in Chief, COA Bulletin

would like to thank Katie Cvitkovitch, Victoria Elliot-Gibson and Diane Theriault for their contribution to the COA Bulletin. The work done by the authors and Dr. Earl Bogoch is highly commendable in the treatment of osteoporosis within the fracture population. As always, a service so simple and effective raises a number of questions as to how to make the treatment effective across Canada. The administration of such programs is the limiting factor, ensuring that every Canadian gets access to appropriate care. As pointed out in the article, much of the treatment needs to focus on vitamin D deficiency. Vitamin D is cheap, and the deficiency rates are again on the rise. The history of vitamin D deficiency is one of the most fascinating in medicine and remains an ongoing story starting with rickets in industrial Victorian-era cities. However a period of hypervitaminosis D occurred in the 1930’s secondary to over fortification of foods after the cause and treatment was discovered. The current deficiency is likely in part secondary to the successful campaigns to prevent skin cancer, and the increasing time spent indoors by our youth.

COA Bulletin ACO - Fall / Automne 2016

However, who carries the burden of the administration of programs, and are programs the answer? Surgeons’ offices are already overloaded with paperwork and expectation that all surgeons can create a reliable net is not feasible. Equally funding through industry partnership results in bias towards expensive treatments that may be ineffectual or harmful, as shown by the bisphosphonate-induced femoral fractures we have all treated, and the hypervitaminosis D seen in the 1930’s. Instead, we need to lobby our health ministries and provincial and national health ministries and organizations towards making a change that will benefit all Canadians that is evidencebased, free from industry bias and cost-effective. One Canadian success story is the addition of vitamin D to milk and margarine. Similar simple solutions – to ensure that every Canadian gets enough vitamin D but not too much – would go a long way in preventative care.

More possibilities

1) AXSOS-PO-1 Petersik A, Virkus WW, Burgkart R, von Oldenburg G. Evidence-based �it assessment of anatomic distal medial tibia plates. Poster session presented at: OTA 2014. 29th Annual Meeting of the OTA; 2014 Oct 15-18; Tampa, FL.

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 su 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 produc uct. 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 af�iliated entities own, use or have applied for the following trademarks or service marks: AxSOS 3, SOMA, Stryker. All other trademarks are trademarks of their respective owners or holders. AXSOS-FL-2 Rev. 1, 11-2015 Copyright © 2015 Stryker

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

Management of Glenohumeral OA in the Young Patient

lenohumeral arthritis in the younger patient is a challenging problem. This COA Bulletin feature on the management of the young arthritic patient will address the pros and cons of the various surgical treatment options. I would like to thank all of the authors for contributing to this feature.

George S. Athwal, M.D., FRCSC Guest Editor, COA Bulletin St. Joseph’s Health Care Western University, Roth | McFarlane Hand and Upper Limb Centre London, ON

Arthroscopic Management of the Young Arthritic Shoulder R. Kyle Martin, M.D. Jason Old, M.D., FRCSC Assistant Professor Pan Am Clinic University of Manitoba Winnipeg, MB

lenohumeral joint arthritis in the young patient presents a challenge for the treating physician. While shoulder arthroplasty is a reliable option for older patients, it may not be acceptable for young patients who wish to maintain a high level of physical activity because of concerns over implant longevity. Arthroscopic procedures for the management of shoulder arthritis are appealing because they are minimally invasive, joint preserving, and do not “burn any bridges” if arthroplasty is performed at a later date. However, there is a paucity of published research on the subject and the indications, technique, and results remain poorly defined1. According to published reports, the goals of arthroscopic management as an index procedure in shoulder arthritis are to identify and address the non-chondral sources of pain, characterize the degree of joint degeneration, and achieve temporary improvement in symptoms in an effort to delay shoulder arthroplasty2,3. Arthroscopy has also been proposed as a method to allow the surgeon the opportunity to assess the morphology of the joint to help plan for future surgical procedures more accurately2. The mainstay of arthroscopic management involves joint lavage, debridement and chondroplasty, with the addition of other procedures based on the individual pathology present. Shoulder stiffness is ubiquitous in non-inflammatory shoulder arthritis, and capsular release, removal of loose bodies and resection of impinging osteophytes are generally recommended to address the underlying causes in such cases2–4. It is believed that capsular release acts to decrease joint contact pressures and can improve pain5. Range of motion has been shown to increase following capsular release, and function

COA Bulletin ACO - Fall / Automne 2016

can be greatly improved in many patients2,5,6. The removal of posterior and inferior osteophytes can also increase shoulder range of motion2. Additional procedures proposed to address associated pathology in the management of shoulder arthritis include: synovectomy, rotator cuff repair, labral repair, distal clavicle excision, biceps tenotomy or tendodesis, and subacromial decompression1–3. Millett et al. also advocate axillary neurolysis in select cases in addition to chondroplasty, capsular release, synovectomy, subacromial decompression, loose body removal, microfracture, and biceps tenodesis as part of their comprehensive approach7. It is difficult to draw firm conclusions regarding the utility of these procedures in the setting of glenohumeral arthritis, due to the small number and heterogeneity of cases in the literature. The arthroscopic management of focal, full-thickness articular cartilage defects of the glenohumeral joint is a distinct topic that also warrants discussion. While there has been considerable attention given in the literature to the management of chondral defects of the knee, there is relatively little information pertaining to the optimal treatment for chondral defects in the shoulder. Microfracture and debridement are the most commonly utilized arthroscopic techniques, owing to their ease of use and low cost. Other options include autologous chondrocyte implantation (ACI), autologous matrix-induced chondrogenesis (AMIC), osteochondral drilling, and autograft or allograft plugs8–10. While generally positive results have been published in the literature for all of these techniques, the quantity and quality of the evidence for these techniques is not sufficient to allow any clear recommendations8. Arthroscopic surgery for the treatment of shoulder arthritis has been shown to be successful in the short term, with improvement in range of motion and pain scores. Better outcomes have been reported in patients with mild to moderate disease and as the degree of osteoarthritis increases, the results of arthroscopic intervention become less predictable1,2,4,6. Risk factors for poor results and revision to arthroplasty after arthro-

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 42)

scopic management include the presence of grade IV bipolar arthritis, large osteophytes, and joint space <2mm7,9,11. In a recent systematic review and meta-analysis by Sayegh et al., arthroscopic debridement was found to be an efficacious shortterm treatment option in this patient population and was associated with minimal risk of complications1. However, this review was based on only five case series with a total of 147 shoulders and a mean follow-up of less than 27 months. In the prospective case series by Millett et al., average follow-up was less than two years and six of 30 shoulders underwent revision to arthroplasty7. This suggests that even in the short term, results of arthroscopic treatment are not universally favourable, and that the medium and long-term results remain undetermined. In summary, arthroscopic management of glenohumeral arthritis in the young, active patient is a treatment option that warrants consideration in patients who remain symptomatic despite maximal conservative treatment. Arthroscopic intervention is probably best suited for patients with relatively mild radiographic changes and some remaining joint space. Patients considering arthroscopic intervention should be counseled that the results of the procedure beyond the short-term are unknown and that it may delay, but is not likely to prevent, a future arthroplasty.

5. Richards, D.P., Burkhart, S.S.: Arthroscopic debridement and capsular release for glenohumeral osteoarthritis. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2007;23:1019–1022. 6. Denard, P.J.: Management of Glenohumeral Arthritis in the Young Adult. J Bone Jt Surg Am 2011;93:885. 7. Millett, P.J., Horan, M.P., Pennock, A.T., Rios, D.: Comprehensive Arthroscopic Management (CAM) Procedure: Clinical Results of a Joint-Preserving Arthroscopic Treatment for Young, Active Patients With Advanced Shoulder Osteoarthritis. Arthrosc J Arthrosc Relat Surg 2013;29:440–448. 8. Gross, C.E., Chalmers, P.N., Chahal, J., Van Thiel, G., Bach, B.R., Cole, B.J., Romeo, A.A.: Operative treatment of chondral defects in the glenohumeral joint. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2012;28:1889–1901. 9. Cuéllar, A., Ruiz-Ibán, M.Á., Cuéllar, R.: The Use of AllArthroscopic Autologous Matrix-Induced Chondrogenesis for the Management of Humeral and Glenoid Chondral Defects in the Shoulder. Arthrosc Tech 2016;5:e223–e227.

References

10. Millett, P.J., Huffard, B.H., Horan, M.P., Hawkins, R.J., Steadman, J.R.: Outcomes of Full-Thickness Articular Cartilage Injuries of the Shoulder Treated With Microfracture. Arthrosc J Arthrosc Relat Surg 2009;25:856–863.

1. Sayegh, E.T., Mascarenhas, R., Chalmers, P.N., Cole, B.J., Romeo, A.A., Verma, N.N.: Surgical Treatment Options for Glenohumeral Arthritis in Young Patients: A Systematic Review and Meta-analysis. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2015;31:1156– 1166.e8.

11. Van Thiel, G.S., Sheehan, S., Frank, R.M., Slabaugh, M., Cole, B.J., Nicholson, G.P., Romeo, A.A., Verma, N.N.: Retrospective analysis of arthroscopic management of glenohumeral degenerative disease. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc 2010;26:1451– 1455.

2. Disorders of the shoulder: diagnosis & management. (Wolters Kluwer/Lippincott Williams & Wilkins: Baltimore, MD, 2014). 3. Skelley, N.W., Namdari, S., Chamberlain, A.M., Keener, J.D., Galatz, L.M., Yamaguchi, K: Arthroscopic Debridement and Capsular Release for the Treatment of Shoulder Osteoarthritis. Arthrosc J Arthrosc Relat Surg 2015;31:494–500. 4. Barlow, J., Abboud, J.: Surgical options for the young patient with glenohumeral arthritis. Int J Shoulder Surg 2016;10:28.

COA Bulletin ACO - Fall / Automne 2016

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

Biologic Glenoid Resurfacing: An Effective Alternative in the Treatment of Osteoarthritis in the Young Active Patient Ben Jong, M.D. Danny P. Goel, M.D., MSc, FRCSC University of British Columbia, Department of Orthopedic Surgery Vancouver, BC

he treatment of glenohumeral osteoarthritis (OA) in the young patient remains a challenging problem. While total shoulder replacement or hemiarthroplasty are viable options, glenoid loosening, early revision and chronic pain are real risks in patients whose lifestyles may accelerate wear rates1,2. Biologic glenoid resurfacing (BGR) is a form of interposition arthroplasty combining hemiarthroplasty3â&#x20AC;&#x201C;12 with a chosen graft secured to a reamed glenoid surface3. While the clinical literature supporting BGR may appear limited, we would argue that an understanding of graft composition combined with technical considerations support this procedure as a valid option. Biological Graft: Basic Science Considerations Biomechanical studies have demonstrated both shear and compressive forces on the glenoid13,14. A major challenge of BGR, therefore, is selection of a graft material that is best able to resist these native forces. Standard grafts have included anterior capsule and fascia lata. Autogenous anterior capsule (ACap) is readily available during the surgical procedure. Histologic examination reveals the capsule to have a complex pattern of circular and radial fiber bundles, with a substantial amount of cross-linking. Gohlke et al. suggest that this may indicate adaptation to shear stresses15. However, the capsular graft is relatively thin and this is potentially at risk for failure when resisting both shear and compressive forces. Fascia lata (FL) has a unidirectional collagen alignment, in keeping with its function16. Similarly, GraftJacket6 (a tendon augmentation graft) has demonstrated a high tension to failure17. These grafts are likely best suited to resist tensile forces in line with the fibres, but may provide limited ability to resist shear or compression. In contrast, two other anatomical structures may prove more versatile: the lateral meniscus and the Achilles tendon. A lateral meniscus allograft (LMA), while reasonably thick, is useful in converting compressive forces into hoop stresses18,19. The mesh network organization of collagen fibers of the meniscal surface could potentially distribute shear stress18, suggesting that LMA may be suitable for BGR.

COA Bulletin ACO - Fall / Automne 2016

The primary function of the Achilles tendon (ATen) is transmission of muscle force. However, the fibers of the ATen are not strictly longitudinally aligned; in fact, there is a variable degree of spiraling and winding of the collagen20. Furthermore, the tendon has a wavy configuration when at rest, rather than a linear one. Its fibers lengthen and straighten in response to tension20. To our knowledge, no previous studies have been conducted to investigate how this translates to resistance of shear force, but the ATenâ&#x20AC;&#x2122;s ability to change alignment does suggest that the tendon may respond to more than longitudinal tension alone. Based on histological composition, the LMA and ATen thus appear to be highly suitable to tolerate physiologic loads. Hemiarthroplasty with Anterior Capsule (ACap) or Fascia Lata (FL) Allograft Burkhead and Hutton treated 14 patients under the age of 55 with hemiarthroplasty and either FL or ACap resurfacing12. The outcomes of BGR in these cases were promising at two years follow-up. In 2007, Krishnan et al. added 22 patients to this original series and presented follow-up from two to fifteen years, with a 97% (35/36) success rate (Table 1)8. Of the patients treated with FL, there was only one failure, and this was secondary to infection rather than persistent pain or decreased function. Of the group treated with ACap, four of seven patients required reoperation. Though the sample size was small, the authors concluded that use of ACap as the resurfacing graft was associated with unsatisfactory results, compared to FL with only a single failure. Hemiarthroplasty with Lateral Meniscal Allograft (LMA) Wirth et al. treated 30 patients with LMA and hemiarthroplasty10. In this report, 27 patients 55 years old or younger were followed for two to five years (Table 1). Visual analog score, ASES, and range of motion improved in all patients. Preoperatively, 15 patients were unable to participate in sports. Postoperatively, 53% had returned to sports. Radiographic follow-up at two to five years revealed mild joint-space narrowing which was not clinically significant. Longer-term follow-up over a mean period of 8.3 years demonstrated preserved shoulder function with no significant increased glenoid erosion9. Only 10% (3/30) of patients required revision to TSA for persistent pain and loss of function.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 44)

Nicholson et al. also obtained initially promising results with LMA (Table 1)7. However, a follow-up study at a mean of 2.8 years demonstrated a failure rate of 45%5. In this series of patients, the LMA was secured utilizing six or seven sutures around the circumference of the glenoid with an anchor or transosseus suture if necessary5,7. In contrast, Wirth’s series

used nine sutures and had only one early failure due to displacement of the LMA, as well as substantially better outcomes at mean 8.3 years postoperative9. It is possible that this small difference in securing the graft led to improved outcomes in Wirth’s series.

Table 1

Author

Graft Material

Burkhead et • Fascia lata (11) al. 1995 (Short • Anterior capsule (7) Term) • Achilles Tendon (18) • Total: 36 shoulders Krishnan et al. 2007 (Intermediate) Elhassan et al. 2009

• Fascia lata (1) • Anterior Capsule (1) • Achilles Tendon (11)

Puskas et al. 2015

• GraftJacket (6) • Meniscus (5) • Anterior Capsule (6)

Wirth 2009 • Meniscus (30) (Short Term) Bois et al. 2015 (Intermediate)

Nicholson et • Meniscus (31) al. 2007 • Human acellular (Short Term) dermal tissue (10) Strauss et al. 2014 (Intermediate)

Graft Thickness

Technical Considerations/ Anchoring • FL: 2x4cm section taken, • FL: Sutures into the posterior folds/thickness unstated and anterior labrum • AC: Half thickness of anterior (Ethibond) capsule • AC: Anatomic anterior • AT: Three layers if possible, attachment; sutures into the two at least. 5-8mm posterior labrum (Ethibond) • AT: Four bioabsorable anchors and transosseus suture with Ethibond • FL: 4x8cm, folded over once • FL/AC: Bioabsorbable anchors • AC: Reflected capsule in glenoid surface and then • AT: Two layers thick sutures into the labrum • AT: FiberWire sutures around perimeter of glenoid into labrum; four anchors into glenoid face. • GJ: 2mm • GJ: 4-6 polydioxanone suture • Meniscus: Thickness of anchors around rim meniscus, horns sutured • Meniscus: 5-7 suture anchors together to form oval • AC: 3-4 suture anchors • AC: Reflected capsule • Hardware from previous operations left in place in some cases, if not in contact with glenoid surface or new biologic surface • Nonabsorable anchors (metallic) used. • Thickness of meniscus, horns • Nine equilateral anchoring sutured together to form sites around perimeter of oval glenoid using Cottony Dacron suture. • If labrum deficient, bioabsorbable anchor placed with Durabraid suture. • Meniscus: Thickness of meniscus; horns sutured together to form oval • HADTM: 0.8mm

Outcome • Mean ASES improved from 39 to 91 • Pain relief good or excellent for 86% of shoulders • 29 patients returned to premorbid activity • Glenoid erosion at 7.2mm at most recent follow up, stabilized at five years • 3 AC patients revised to TSA • 1 AC patient required I&D for infection • 1 FL patient had infection, no surgery • No difference in VAS pain scores • No difference in Constant scores • 11 of 13 patients had persistent severe pain • 10 patients under went total shoulder arthroplasty within 36 months • GJ: Persistent pain and poor function in all patients. 5 required TSA or rTSA within 22 months. At time of TSA, GJ gone and metallosis present • Meniscus: 3 required revision at 22 months (TSAx1, debridex1, arthrodesisx1). No statistically significant improvement in Constant score • AC: 4 revised to TSA within 34 months. No statistically significant improvement in Constant score.

• 26 patients available for minimum five year follow up • ASES, STT, VAS (average), VAS (strenuous activity), VAS (at rest) – statistically significant improvement • Increased glenoid erosion from immediate post-op XR to latest follow up (mean 2.8mm to 4.1mm) but not significant • 3 infections, one requiring I&D, another resection arthroplasty, and last antibiotic spacer • 6 persistent pain/loss of function – 3 revised to TSA, 2 for debridement, 1 revision meniscus allograft • Meniscus: 6 to 7 points • At 12-48 month follow up (all menisci), significant of fixation around the improvement in ASES and VAS circumference; anchors • 4 early failures – infection, allograft tearing, progressive painx2 or transosseus sutures as • Two revised to TSA, one allograft excised, one infection required necessary for deficient labrum I&D, one debridement • Non-absorbable suture • At intermediate follow up (mean 2.8 years), 45.2% meniscal utilized failure rate (converted to TSA/rTSA, recommended conversion, • HADTM: As above revision for graft removal or disabling pain/loss of function) • 70% HADTM failure rate • 8 patients required rTSA or TSA, 5 recommended for conversion, 1 had infection, 5 had ASES < 50, 2 reported disabling pain. • Overall, ASES,STT, VAS still showed significant improvemenet from pre-op to post-op in both “successful” and “failed” groups.

COA Bulletin ACO - Fall / Automne 2016

Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 45)

Clinical Indications and Recommendations Selecting the ideal candidate for biologic resurfacing must be considered carefully after weighing the available evidence. While documented case series in the literature have yielded mixed outcomes in support of BGR, the basic science and clinical literature support the use of ATen or LMA as the best available graft materials, given their intrinsic composition and subsequent biomechanical properties. Krishnan et al. have obtained the most promising results with ATen; however, other studies have yet been unable to reproduce their findings. Given the different technical approaches, it may be that a significant etiology for the failures observed by Elhassan et al. included graft preparation and subsequent fixation.

Figure 1 Arthritic glenoid prior to resurfacing. Image courtesy of Dr. S. Krishnan (Baylor University Medical Centre)

Hemiarthroplasty with Achilles Tendon (ATen) Allograft In the series by Krishnan et al., the authors utilized ATen in 18 shoulders (Table 1)8. Overall, return to function, stabilization of glenoid erosion, and avoidance of early arthroplasty were achieved (Figure 1). The authors reported no failures in the 18 shoulders treated with ATen (Figure 2). Failures, as noted above, were observed in patients treated with ACap and FL. The authors concluded ATen to be superior to ACap and FL for BGR. Elhassan et al. attempted unsuccessfully to reproduce these findings in 13 patients, utilizing ATen, ACap, or autogenous FL4. In this series, 11 out of 13 patients were treated with ATen. Unlike Krishnan et al., 91% (10/11) were revised to total shoulder arthroplasty at 14 months. It should be noted that Krishnan et al. preferred folding their grafts three times and securing the graft via transosseus sutures, whereas Elhassan et al. describe folding the graft twice and securing it to the remaining labrum4,8. This suggests that a thicker, more securely fixed graft may be a critical technical aspect of this procedure. Hemiarthroplasty with Graft Jacket Puskas et al. utilized GraftJacket secured with metal anchors6. Multiple patients in this series were revisions who had undergone from one to as many as six prior surgeries. In the setting of early failure, the authors of that study did not investigate nor comment on the possibility of infection as a reason for failure. It is possible that indolent infection, the use of a thin graft secured with metal anchors, and/or retained hardware contributed to the high failure rate. This certainly supports the hypothesis that thinner, more weakly secured grafts may be more susceptible to failure.

COA Bulletin ACO - Fall / Automne 2016

While Wirth et al. have observed promising long-term outcomes utilizing LMA, the subsequent study by Nicholson et al. was unable to reproduce such findings. However, it is possible that graft security may have contributed to the high failure rate observed in their series as well, indicating that LMA is not necessarily a poor choice for BGR. In summary, the evidence in favour of BGR continues to evolve, with graft selection and security as major technical considerations. Further studies are needed, including comparisons of surgical techniques and details. Biological resurfacing may be a viable option in the younger active patient with end-stage glenohumeral arthritis. In several studies, resurfacing has not only improved function and pain, but has allowed patients to return to activity. There are certainly concerns regarding this procedure, including durability and reproducibility4â&#x20AC;&#x201C;6. However, a correctly indicated patient may benefit from BGR, provided that careful consideration is given to type of graft and security of attachment to the glenoid, insuring the biologic bearing surface remains in its intended location.

Figure 2 Glenoid after resurfacing with Achilles tendon. Image courtesy of Dr. S. Krishnan (Baylor University Medical Centre)

Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 46)

References 1. Sperling J.W., Cofield R.H., Rowland C.M. Minimum fifteenyear follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. J Shoulder Elb Surg. 2004;13(6):604-613. doi:10.1016/j.jse.2004.03.013. 2. Bartelt R., Sperling J.W., Schleck C.D., Cofield R.H. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elb Surg. 2011;20(1):123-130. doi:10.1016/j.jse.2010.05.006. 3. Krishnan S.G., Reineck J.R., Nowinski R.J., Harrison D., Burkhead W.Z. Humeral Hemiarthroplasty with Biologic Resurfacing of the Glenoid for Glenohumeral Arthritis: Surgical Technique. JBJS Essent Surg Tech. 2008;os90(Supplement_2_Part_1):9-19. doi:10.2106/JBJS.G.01220. 4. Elhassan B., Ozbaydar M., Diller D., Higgins L.D., Warner J.J.P. Soft-tissue resurfacing of the glenoid in the treatment of glenohumeral arthritis in active patients less than fifty years old. J Bone Joint Surg Am. 2009;91(2):419-424. doi:10.2106/ JBJS.H.00318. 5. Strauss E.J., Verma N.N., Salata M.J., et al. The high failure rate of biologic resurfacing of the glenoid in young patients with glenohumeral arthritis. J Shoulder Elb Surg. 2014;23(3):409419. doi:10.1016/j.jse.2013.06.001. 6. Puskas G.J., Meyer D.C., Lebschi J.A., Gerber C. Unacceptable failure of hemiarthroplasty combined with biological glenoid resurfacing in the treatment of glenohumeral arthritis in the young. J Shoulder Elb Surg. 2015;24(12):1900-1907. doi:10.1016/j.jse.2015.05.037. 7. Nicholson G.P., Goldstein J.L., Romeo A.A., et al. Lateral meniscus allograft biologic glenoid arthroplasty in total shoulder arthroplasty for young shoulders with degenerative joint disease. J Shoulder Elb Surg. 2007;16(5):S261-S266. doi:10.1016/j.jse.2007.03.003. 8. Krishnan S.G., Nowinski R.J., Harrison D., Burkhead W.Z. Humeral Hemiarthroplasty with Biologic Resurfacing of the Glenoid for Glenohumeral Arthritis: Two to Fifteen-Year Outcomes. J Bone Jt Surg. 2007;89-A(4):727-734. 9. Bois A.J., Whitney I.J., Somerson J.S., Wirth M.A. Humeral Head Arthroplasty and Meniscal Allograft Resurfacing of the Glenoid: A Concise Follow-up of a Previous Report and Survivorship Analysis. J Bone Jt Surg. 2015;97(19):1571-1577. doi:10.2106/JBJS.N.01079.

11. Lollino N., Pellegrini A., Paladini P., Campi F., Porcellini G. Gleno-Humeral arthritis in young patients: clinical and radiographic analysis of humerus resurfacing prosthesis and meniscus interposition. Musculoskelet Surg. 2011;95(S1):5963. doi:10.1007/s12306-011-0122-y. 12. Burkhead W.Z., Hutton K.S. Biologic resurfacing of the glenoid with hemiarthroplasty of the shoulder. J Shoulder Elbow Surg. 1995;4(4):263-270. http://www.ncbi.nlm.nih.gov/pubmed/8542369. Accessed July 30, 2016. 13. Poppen N.K., Walker P.S. Forces at the glenohumeral joint in abduction. Clin Orthop Relat Res. 1978;(135):165-170. http:// www.ncbi.nlm.nih.gov/pubmed/709928. Accessed August 8, 2016. 14. Lee S.B., Kim K.J., Oâ&#x20AC;&#x2122;Driscoll S.W., Morrey B.F., An K.N. Dynamic glenohumeral stability provided by the rotator cuff muscles in the mid-range and end-range of motion. A study in cadavera. J Bone Joint Surg Am. 2000;82(6):849-857. http://www.ncbi. nlm.nih.gov/pubmed/10859105. Accessed August 13, 2016. 15. Gohlke F., Essigkrug B., Schmitz F. The pattern of the collagen fiber bundles of the capsule of the glenohumeral joint. J Shoulder Elb Surg. 1994;3(3):111-128. doi:10.1016/S10582746(09)80090-6. 16. Kumka M., Bonar J. Fascia: a morphological description and classification system based on a literature review. J Can Chiropr Assoc. 2012;56(3):179-191. http://www.ncbi.nlm. nih.gov/pubmed/22997468. Accessed August 8, 2016. 17. Barber F.A., Aziz-Jacobo J. Biomechanical Testing of Commercially Available Soft-Tissue Augmentation Materials. Arthrosc J Arthrosc Relat Surg. 2009;25(11):1233-1239. doi:10.1016/j.arthro.2009.05.012. 18. Greis P.E., Bardana D.D., Holmstrom M.C., Burks R.T. Meniscal injury: I. Basic science and evaluation. J Am Acad Orthop Surg. 2002;10:168-176. doi:10.5435/00124635-20020500000003. 19. Fox A.J.S., Bedi A., Rodeo S.A. The basic science of human knee menisci: structure, composition, and function. Sports Health. 2012;4(4):340-351. doi:10.1177/1941738111429419. 20. Doral M.N., Alam M., Bozkurt M., et al. Functional anatomy of the Achilles tendon. Knee Surgery, Sport Traumatol Arthrosc. 2010;18(5):638-643. doi:10.1007/s00167-010-1083-7.

10. Wirth M.A. Humeral Head Arthroplasty and Meniscal Allograft Resurfacing of the Glenoid. J Bone Jt Surg. 2009;91(5):1109. doi:10.2106/JBJS.H.00677.

COA Bulletin ACO - Fall / Automne 2016

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

Hemiarthroplasty for Osteoarthritis in the Young Patient Michael Carroll, M.D., FRCSC Justin LeBlanc, M.D., FRCSC Section of Orthopaedic Surgery University of Calgary Calgary, AB

urgical management of symptomatic glenohumeral arthritis is indicated when nonoperative strategies fail to satisfactorily improve patient function. The ‘young’ patient with glenohumeral arthritis, arbitrarily defined as less than 45-50 years of age, represents a unique subset of patients for which a consensus of optimized operative management has not been reached. In general, several surgical options exist - among them are isolated humeral head replacement (HHR) in the form of stemmed or stemless hemiarthroplasty, and resurfacing. The young patient with glenohumeral arthritis differs from the older population in several ways. First, younger patients tend to be more active with heavier functional demands and have higher expectations postoperatively. Second, in comparison to the older cohort, young patients generally present with considerably different degenerative etiologies (sequela of trauma, post-instability arthropathy, avascular necrosis, post-infection arthropathy, chondrolysis, as well as inflammatory conditions). Lastly, shoulder arthroplasty in the young patient is relatively uncommon accounting for less than 15% of arthroplasty performed in large volume referral centres1,3. As a result of these factors, the available literature is limited consisting of smaller sample sizes and heterogeneous groups of patients with mixed etiologies making clear evidence-based treatment recommendations difficult. Sperling et al. initiated one of the earlier studies on the young patient with advanced glenohumeral arthritis7. Using a stemmed monoblock design, a cohort of 62 patients less than 50 years old were followed for a minimum of 15 years or until a revision procedure was performed. Despite significant improvements in range of motion and pain at long-term follow-up, 60% had an unsatisfactory outcome based on the modified Neer result rating system. Glenoid erosion was present in 72% of patients, and the overall revision rate was 22% compared to 14% in the total shoulder arthroplasty (TSA) group, where the most common reason for revision was symptomatic glenoid arthrosis for HHR. The estimated revision-free survival at five and ten years was 91% and 82% respectively (versus 97% for both five- and ten-year survival in the TSA group). The authors found that previous surgery and trauma were risk factors for revision. Twenty-year follow-up of the same group was recently reported where the dissatisfaction rate increased to 73%6. In another study, Bartelt et al. reviewed 20 patients aged 55 years or younger at an average of 9.3 years following hemiarthroplasty for primary or secondary arthritis2. The decision to proceed with hemiarthroplasty or TSA was determined preoperatively based on the patient’s wish for more complete assurance of pain relief, desired activity level, status of the glenoid, and ability to balance the joint with or without glenoid resurfacing. The hemiarthroplasty cohort demonstrated significant COA Bulletin ACO - Fall / Automne 2016

improvements in pain scores as well as range of motion, with 65% of the patients being subjectively satisfied. Comparatively, improvement in pain, final forward elevation and satisfaction were significantly better in the TSA group at final follow-up. Similar to the study by Sperling et al.7, the overall revision rate was 30%, with five of six revisions being conducted due to painful glenoid arthritis. The revision-free survival in this study was 85% and 72% at five and ten years, respectively. The comparative TSA group fared better with a revision free survival of 100% and 92% at the five and ten years postoperatively. The most recent literature, provided by Eichinger et al., includes a review of 27 patients less than 50 years old who underwent hemiarthroplasty using a modular implant for a variety of indications3. In this study the decision to undergo hemiarthroplasty (with or without additional glenoid treatment) versus total shoulder arthroplasty was based on the status of the glenoid and degree of humeral head subluxation. At an average of 5.2 years post-operatively the clinical failure rate was 22% (pain being the primary reason) and overall revision rate was 11%. The authors highlight the disparity between clinical failure and revision rates, indicating that revision rates may underestimate the subjective dissatisfaction with the procedure. Humeral resurfacing arthroplasty has been reviewed in several studies. In 2008, Bailie et al. reported on a cohort of 36 patients less than 55 years old who had a cementless humeral resurfacing procedure for a variety of indications1. Only Walch8 type A and B1 glenoids and those with minimum two-year follow-up (mean 3.2 years) were included. The satisfaction rate was high (97%) and patients showed significant improvements in visual analog pain score, single assessment numeric evaluation scale, and American Shoulder and Elbow Surgeons score. There were no signs of radiographic loosening of the implant and only one patient (3%) underwent a revision procedure. Note should be made that patients underwent a variety of glenoid procedures (meniscal or dermal allograft, microfracture, curettage, non-structural bone graft) at the discretion of the operating surgeon. More recently, Levy et al. published outcomes at minimum of ten years on a cohort of patients 50 years of age or less (mean 38.9 years) with mixed etiologies5. In 37 humeral resurfacings for osteoarthritis, rheumatoid arthritis, avascular necrosis, and post-infection arthropathy, there was a statistically significant improvement in pain scores. Range of motion as well as age and sex-adjusted Constant scores also trended towards improvement. In this group the overall revision rate was 13.5% and estimated five- and 11-year survival was 97%. The available literature on humeral head replacement for symptomatic glenoid arthritis in the young patient is limited, difficult to consolidate and apply in clinical decision-making. The small sample sizes, inclusion of cohorts with mixed etiologies, and variable glenoid treatment makes it challenging to apply the data to any one of the groups in this diverse patient population. While the majority of studies demonstrate improvement for pain and range of motion, the question remains over its longer-term durability. Humeral head replacement alone may be theoretically appealing in that it preserves native glenoid bone and obviates complications associated with glenoid resurfacing. However, when overall revision rates

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are considered, the literature would favour prosthetic resurfacing of the glenoid (i.e. TSA). It is likely that there are certain subgroups within the patient population who would be successfully treated with HHR rather than TSA. Because of the limitations in existing data, exactly which subgroups may benefit from HHR remains unclear. The young patient with symptomatic glenoid arthritis is a diverse and challenging patient population with limited outcome data on which a rigorous evidence-based treatment algorithm cannot be derived. In those with adequate rotator cuff function, we feel that patients more likely to be successfully treated with HHR alone demonstrate little or no glenoid derangement (i.e. early avascular necrosis), a concentric wear pattern (i.e. Walch type A), and/or have correctable mild posterior subluxation with little to no glenoid degenerative change (i.e. Walch type B1). This is in keeping with a recent review which also cited the patient’s function (high or low demand) as an important consideration when evaluating the suitability of a young patient for HHR4. Preoperative discussions should include this information and an individualized treatment plan should be derived through a shared decision-making process between the patient and surgeon. References 1. Bailie D.S., Llinas P.J., Ellenbecker T.S. Cementless humeral resurfacing arthroplasty in active patients less than fifty-five years of age. The Journal of Bone and Joint Surgery. 2008 Jan;90(1):110–117. doi:10.2106/JBJS.F.01552 2. Bartelt R., Sperling J.W., Schleck C.D., Cofield R.H. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. Journal of Shoulder and Elbow Surgery. 2011 Nov 1;20(1):123–130. doi:10.1016/j.jse.2010.05.006

3. Eichinger J.K., Miller L.R., Hartshorn T., Li X., Warner J.J.P., Higgins L.D. Evaluation of satisfaction and durability after hemiarthroplasty and total shoulder arthroplasty in a cohort of patients aged 50 years or younger: an analysis of discordance of patient satisfaction and implant survival. Journal of Shoulder and Elbow Surgery. 2015 Dec 14;:1–9. doi:10.1016/j.jse.2015.09.028 4. Johnson M.H., Paxton E.S., Green A. Shoulder arthroplasty options in young (<50 years old) patients: review of current concepts. Journal of Shoulder and Elbow Surgery. 2015 Jan 1;24(2):317–325. doi:10.1016/j.jse.2014.09.029 5. Levy O., Tsvieli O., Merchant J., Young L., Trimarchi A., Dattani R., et al. Surface replacement arthroplasty for glenohumeral arthropathy in patients aged younger than fifty years: results after a minimum ten-year follow-up. Journal of Shoulder and Elbow Surgery. 2015 Jul 1;24(7):1049–1060. doi:10.1016/j.jse.2014.11.035 6. Schoch B., Schleck C., Cofield R.H., Sperling J.W. Shoulder arthroplasty in patients younger than 50 years: minimum 20-year follow-up. Journal of Shoulder and Elbow Surgery. 2015 May 1;24(5):705–710. doi:10.1016/j.jse.2014.07.016 7. Sperling J.W., Cofield R.H., Rowland C.M. Minimum fifteenyear follow-up of Neer hemiarthroplasty and total shoulder arthroplasty in patients aged fifty years or younger. Journal of shoulder and elbow …. 2004;doi:10.1016/j.jse.2004.03.013 8. Walch G., Badet R., Boulahia A., Khoury A. Morphologic study of the glenoid in primary glenohumeral osteoarthritis. Journal of Arthroplasty. 1999 Sep;14(6):756–760.

Total Shoulder Arthroplasty for Arthritis in Young Patients Jonah Davies, M.D., FRCSC Shoulder & Elbow and Trauma Surgery Specialist Hôpital Sacré-Coeur Université de Montréal Montréal, QC

reatment of end-stage shoulder arthritis in young patients is challenging. These patients tend to have higher expectations and demands than older patients. Total shoulder arthroplasty (TSA) is the treatment of choice for symptomatic glenohumeral osteoarthritis that has failed nonoperative management. Many other treatment options exist for these young patients including hemiarthroplasty with or without glenoid

resurfacing and shoulder fusion. Several studies have shown that TSA is the most reliable and cost-effective treatment, however, there are justifiable concerns about durability in younger patients. The success of TSA in treating primary OA in the elderly has encouraged more surgeons to treat younger patients similarly. Proper patient selection and counselling is essential in order to limit complications and maximize outcomes. Results Shoulder arthroplasty for patients under 55 years old only account for a small fraction of all TSAs, reaching only 5% in one large cohort1. Despite this, several case series have reported medium- to long-term outcomes. A recent study by Padegimas et al. has projected the demand for arthroplasty in

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young patients to increase by 333% over the next 20 years2. This underlines the need for both increasing durability and limiting complications in order to maximize outcomes for these young, active patients. Although there is still some debate as to whether optimal treatment includes glenoid replacement, there is a definite trend for favouring TSA. The previously mentioned study projects the percentage of hemiarthroplasties (HA) performed will decrease in this patient population from 34% to 23%2. Excellent outcomes for TSA in older patients have been welldocumented, however very few studies have published outcomes for young patients. Raiss et al. looked specifically at results for TSA in patients under 60 years old from a single centre cohort. They reported results of 21 patients at a mean of seven years follow-up with no revisions3. They found significant improvement in function, with Constant scores increasing from 24 points preoperatively to 64 points postoperatively. Interestingly, they found that 52% of patients were able to participate in sports such as tennis more than twice a week. A more recent multicentre study looked at outcomes for TSA in young patients with a keeled glenoid. Overall, a total of 52 patients had great improvements in range of motion and Constant scores, improving from 37% to 73%. Survival of the glenoid component was 98% at five years, but dropped to 62.5% at ten years4. The authors warned that while initial outcomes were excellent, the need for revision should force surgeons to properly counsel patients preoperatively. Several studies have directly compared outcomes between TSA and HA for young patients. Sperling et al. published the initial Mayo clinic cohort and found unsuccessful results in 51% of hemiarthroplasties vs. 50% of anatomic shoulder arthroplasty5. Survival of implants at 15 years favoured TSA with 84% vs. 73% of hemiarthroplasties still being in place. This trend was confirmed in a more recent cohort reported by the same group that found 92% survival at ten years vs. 72% for hemiarthroplasty1. Subjective patient satisfaction was 87% for TSA compared to 65% for HA. More recently, they reported minimum 20-year follow-up of a single surgeon cohort from the same institution using a Neer implant and HA6. Overall survival rates remained flat at 76% for HA and 83% for TSA, indicating most revisions take place prior to 15 years. A similar review of all shoulder arthroplasties performed in a large hospital system in the United States also showed a higher revision rate for HA and humeral head resurfacing (5%) compared to 1% for shoulder arthroplasty. The reason for revision among these patients was glenoid wear in 70% of the patients7. Eichinger et al. reported outcomes in 71 patients treated with either TSA or HA. They looked specifically at implant survival and patient satisfaction, more specifically asking patients whether they would elect to undergo the procedure again. The overall five-year revisionfree rate was 89% for HA and 95% for TSA. However, the fiveyear patient satisfaction “survival-rate” was only 72% for HA compared to 95% for TSA8. These outcomes for TSA also translate to an economic benefit favouring TSA over HA. A recent study from Bhat et al. created an economic decision model for treating 30-50 year olds with end-stage shoulder arthritis. Their model found a decreased number of revisions, an increased quality-adjusted life-years (QALY) and an increase in savings of $2000 per patient favourCOA Bulletin ACO - Fall / Automne 2016

ing TSA over the cohort’s lifetime. They concluded that on a population level, TSA is the cost-effective way to treat young patients with glenohumeral arthritis9. Reverse Shoulder Arthroplasty Although most young patients with end-stage arthritis will benefit from shoulder arthroplasty, certain patients will not. These include patients with irreparable rotator cuff tears with or without humeral head migration. In these cases, reverse shoulder arthroplasty might be the best option, although they should be reserved for patients that meet specific indication. Muh et al. reported medium-term results of primary reverse shoulder arthroplasty in patients 60 years and younger. They found excellent outcomes with 81% of patients satisfied with the procedure10. However, there was a 15% complication rate and up to 43% of notching - highlighting the importance of proper patient counselling with regards to the durability of these implants in an active population. Treating younger patients with glenohureal arthritis is complex. Total shoulder arthroplasty is effective for pain relief and restoring function, is cost-effective and provides excellent results with few complications. Mid-term results show increased outcomes compared to hemiarthroplasty, however long-term results show decreased survivorship. More studies are needed to evaluate survivorship of newer glenoid implants. Regardless of improvements in longevity, careful patient selection and counselling remain of utmost importance to ensure good outcomes. References 1. Bartelt R., Sperling J.W., Schleck C.D., Cofield R.H. Shoulder arthroplasty in patients aged fifty-five years or younger with osteoarthritis. J Shoulder Elbow Surg. 2011 Jan;20(1):123– 30. 2. Padegimas E.M., Maltenfort M., Lazarus M.D., Ramsey M.L., Williams G.R., Namdari S. Future patient demand for shoulder arthroplasty by younger patients: national projections. - PubMed - NCBI. Clin Orthop Relat Res. 2015 Mar 11;473(6):1860–7. 3. Raiss P., Aldinger P.R., Kasten P., Rickert M., Loew M. Total shoulder replacement in young and middle-aged patients with glenohumeral osteoarthritis. Bone Joint J. Bone and Joint Journal; 2008 Jun 1;90-B(6):764–9. 4. Denard P.J., Raiss P., Sowa B., Walch G. Mid- to long-term follow-up of total shoulder arthroplasty using a keeled glenoid in young adults with primary glenohumeral arthritis. J Shoulder Elbow Surg. 2013 Jul;22(7):894–900. 5. Sperling J.W., Cofield R.H., Rowland C.M. Neer hemiarthroplasty and Neer total shoulder arthroplasty in patients fifty years old or less. Long-term results. The Journal of Bone and Joint Surgery. 1998 Apr;80(4):464–73.

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6. Schoch B., Schleck C., Cofield R.H., Sperling J.W. Shoulder arthroplasty in patients younger than 50 years: minimum 20-year follow-up. - PubMed - NCBI. Journal of Shoulder and Elbow Surgery. 2015 May;24(5):705–10.

9. Bhat S.B., Lazarus M., Getz C., Williams G.R., Namdari S. Economic Decision Model Suggests Total Shoulder Arthroplasty is Superior to Hemiarthroplasty in Young Patients with Endstage Shoulder Arthritis. Clin Orthop Relat Res. 2016 Jul 25.

7. Dillon M.T., Inacio M.C.S, Burke M.F., Navarro R.A., Yian E.H. Shoulder arthroplasty in patients 59 years of age and younger. J Shoulder Elbow Surg. 2013 Oct;22(10):1338–44.

10. Muh S.J., Streit J.J., Wanner J.P., Lenarz C.J., Shishani Y., Rowland D.Y., et al. Early Follow-up of Reverse Total Shoulder Arthroplasty in Patients Sixty Years of Age or Younger. The Journal of Bone and Joint Surgery. The American Orthopedic Association; 2013 Oct 16;95(20):1877–83.

8. Eichinger J.K., Miller L.R., Hartshorn T., Li X., Warner J.J.P., Higgins L.D. Evaluation of satisfaction and durability after hemiarthroplasty and total shoulder arthroplasty in a cohort of patients aged 50 years or younger: an analysis of discordance of patient satisfaction and implant survival. Journal of Shoulder and Elbow Surgery. 2016 May;25(5):772–80.

Is Shoulder Fusion Still an Option? Jason Strelzow, M.D., FRCSC George S. Athwal, M.D., FRCSC St. Joseph’s Health Care Western University, Roth | McFarlane Hand and Upper Limb Centre London, ON

he current success of modern shoulder arthroplasty implants, rotator cuff repair and advances in peripheral nerve surgery has led to a re-evaluation of the role for glenohumeral arthrodesis in modern shoulder surgery. Despite advances in surgical techniques and procedures, glenohumeral fusion remains a useful tool in modern orthopaedics. It provides an effective salvage option for painful end-stage shoulder pathology that cannot be managed with available reconstructive options. Functional motion through the scapulothoracic articulation, with preserved trapezius, levator scapulae, rhomboids and serratus anterior function, provides abduction, forward elevation and rotation of the arm through scapular motion, rather than glenohumeral. Indications Surgical indications for glenohumeral arthrodesis include; failed total joint arthroplasty, failed shoulder instability surgery, post-infectious sequelae, brachial plexus injury, reconstruction post-tumour resection, end stage osteoarthritis, post-traumatic arthritis, deltoid and/or rotator cuff deficient shoulder1–8. A number of relative contraindications exist including; poor scapulothoracic joint function, contralateral shoulder fusion, neurogenic arthropathy, progressive neurologic disease, advanced age, and peri-scapular muscle or nerve injury6,9. Prior to proceeding with glenohumeral fusion, an understanding of the patient’s prior pathology, treatment and dysfunction are critical. Once the decision has been reached, appropriate preoperative investigations include radiographs and a CT scan to assess glenohumeral bony anatomy and bone loss. If there are questions regarding patient neurological function or periscapular muscle function, additional investigations can include electromyography and nerve conduction studies and MRI to assess peri-scapular muscle viability/function.

Techniques Surgical techniques for glenohumeral fusion are grouped as intra or extra-articular6,12. Intra-articular fusion techniques (anatomic) establish fusion between the glenoid and humerus, while extra-articular techniques (non-anatomic) fuse the lateral scapular spine, clavicle and undersurface of the acromion with the humeral head. Arthroscopic techniques have also been described7,8. The authors’ preferred technique is an intraarticular technique to maximize bony surface area for fusion and to maintain glenohumeral alignment for potential future conversion to arthroplasty (Figure 1). Figure 1 Authors’ preferred technique using an intra-articular method to optimize bony surface contact for fusion and to maintain glenohumeral alignment for potential future conversion to arthroplasty

Arthrodesis position is selected based on patient functional demands and body habitus. Throughout the literature, a range of fusion positions are described; abduction 15-30º, flexion 10-30º and internal rotation 30-50º with no clear consensus6,8,14. The ability to reach the hand to mouth and midline for hygiene purposes is paramount. Additionally, excessive abduction (>50º), as historically suggested, potentially causes periscapular winging and pain10 , while increased flexion improves function above waist level at the cost of increased periscapular pain8. Our preferred position is that described by Iannotti COA Bulletin ACO - Fall / Automne 2016

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(2006) with 20º abduction, 20º flexion and 40º internal rotation in mesomorphic patients, allowing for the performance of most daily activities11. Increased abduction may be required in obese patients. The patient is positioned in the beach chair with the operative arm in an articulated arm positioner. The ipsilateral iliac crest is prepped and draped. An S-shaped incision beginning along the scapular spine, curving anteriorly at the anterolateral acromion and continuing into the deltopectoral approach is made (Figure 2).

erative or intra-operative findings suggest limited bone stock or poor bone quality. Plain films and CT scan can be used to assess fusion at follow-up. Results Over 60% of patients obtain a satisfactory outcome; however, most patients are unable to perform tasks above shoulder height. Early studies reported a limited number of pain free patients (four of 16), but modern series have reported improved pain relief3,7,12,14,16,17. In one of the largest series, Cofield and Briggs noted 38% of patients were pain free, 59% had mild or moderate pain and 3% had severe pain. Series reporting fusions for rheumatoid arthritis and brachial plexus pathology reported excellent overall pain relief12,14. In most series, patients demonstrate functional abilities to perform ADLs and work below shoulder level3,7,12,13,18. Overhead and shoulder level activities, however, are generally not possible4.

Figure 2 Standard patient set-up, positioning, and the planned incision

If prior incisions are present, they are incorporated, or an adequate tissue bridge is created. The anterior deltoid is released from the distal clavicle and acromion, a biceps tenodesis is performed and a subscapularis peel arthrotomy allows access to the glenohumeral joint. Care is taken to preserve the joint capsule of the acromoclavicular joint. The supraspinatous and the upper half of the infraspinatus tendons are excised and the joint surfaces are prepared. Bony surfaces including the glenohumeral joint and undersurface of the acromion are denuded. The glenohumeral joint is then reduced into the pre-determined position and provisionally secured with two or three 3.0mm Steinmann pins. Motion of the upper extremity is then examined to ensure hand to mouth and appropriate fusion positioning. Bony compression at the glenohumeral fusion site is obtained by switching the Steinmann pins with trans-articular 6.5 mm cancellous screws inserted with a washer. A 4.5mm LC-DCP plate is then positioned along the scapular spine and down the lateral aspect of the humeral shaft providing neutralization and additional fixation for the fusion. Rarely, in cases of severe osteopenia, a locking plate is used. Additionally, the literature has demonstrated that a 4.5mm reconstruction type plate is sufficient, however, the authors prefer an LC-DCP2,3,10. Iliac crest bone autograft or allograft is placed at the fusion site, and a structural allograft is positioned between the undersurface of the acromion and humeral head. The released anterior and middle deltoids are repaired to the acromion and distal clavicle utilizing a transosseous technique with #2 non-absorbable braided sutures. Closure is performed in a layered fashion ensuring adequate hardware coverage with viable muscular and soft tissues. Postoperatively, patients are managed in an abduction sling for six to eight weeks or a spica cast if compliance is questionable. Extended periods of immobilization are considered if preopCOA Bulletin ACO - Fall / Automne 2016

Complications include: non-union, infection, fracture, fusion malposition, and hardware prominence (Figure 3). Modifications to surgical technique and fixation strategies have reduced the non-union rate to below 10% while historically higher numbers have been reported3–5,8,14–16,19,20. Periarthrodesis fractures have been reported in up to 11% of patients with glenohumeral arthrodesis3,5. These typically occur at either end of the fusion mass, and can be managed based on stability and displacement either operatively or nonoperatively. The subcutaneous location of the fusion plate makes painful or prominent hardware problematic in some patients. Some studies have reported hardware removal rates as high at 26-57%3–5,12,13,20. Figure 3 Non-union with failed hardware

Conclusion Glenohumeral arthrodesis provides predictable outcomes in the appropriately selected patient population. When the narrow indications are met, outcomes are satisfactory for the majority of patients. It remains critical, however, to ensure expectations are carefully discussed with patients regarding functional outcomes and surgical goals. As a salvage procedure for complex shoulder pathology, glenohumeral fusion provides an important option, particularly in the younger patient.

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References 1. Arntz C.T., Matsen F.A., Jackins S. Surgical management of complex irreparable rotator cuff deficiency. The Journal of Arthroplasty [Internet]. 1991 Dec 1;6(4):363–370. Available from: http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi? dbfrom=pubmed&id=1770374&retmode=ref&cmd=prlinks 2. Chun J.M., Byeon H.K. Shoulder arthrodesis with a reconstruction plate. International Orthopaedics [Internet]. 2008 Aug 21;33(4):1025–1030. Available from: http://link.springer. com/10.1007/s00264-008-0599-7doi:10.1007/s00264-0080599-7 3. Cofield R.H., Briggs B.T. Glenohumeral arthrodesis. Operative and long-term functional results. The Journal of bone and joint surgery American volume [Internet]. 1979 Jan 1;Available from: http://jbjs.org/content/61/5/668.abstract 4. Diaz J.A., Cohen S.B., Warren R.F., Craig E.V. Arthrodesis as a salvage procedure for recurrent instability of the shoulder. Journal of Shoulder and Elbow Surgery [Internet]. 2003 Jan 1;Available from: http://www.sciencedirect.com/science/ article/pii/S1058274602868835 5. Dimmen S., Madsen J.E. Long-term outcome of shoulder arthrodesis performed with plate fixation: 18 patients examined after 3–15 years. Acta Orthopaedica [Internet]. 2009 Jul 8;78(6):827–833. Available from: http://www. tandfonline.com/doi/full/10.1080/17453670710014626d oi:10.1080/1745 3670710014626 6. Ebeid W.A., Ghoneimy A.N., Amin S.N. Functional outcome of proximal humeral reconstruction following tumour resection: endoprosthesis versus shoulder arthrodesis using vascularised autograft. Bone & Joint Journal Orthopaedic Proceedings Supplement [Internet]. 2012 Apr 1;94-B:33. Available from: http://www.bjjprocs.boneandjoint.org.uk.ezproxy.library. ubc.ca/content/94- B/SUPP_XIV/33.abstract 7. Gonzalez-Diaz R., Rodriguez-Merchan E.C. The role of shoulder fusion in the era of arthroplasty. International Orthopaedics [Internet]. 1997 Jan 1;21(3):204–209. Available from: http:// link.springer.com/10.1007/s002640050151doi:10.1007/ s002640050151 8. Hawkins R.J., Neer C.S.I. A Functional Analysis of Shoulder Fusions. Clinical Orthopaedics and Related Research® [Internet]. 1987 Oct 1;223:65. Available from: http://journals.lww.com/corr/Fulltext/1987/10000/A_Functional_ Analysis_of_Shoulde r_Fusions_.9.aspx

11. Porcellini G., Savoie F.H. III, Campi F., Merolla G., Paladini P. Arthroscopically Assisted Shoulder Arthrodesis: Is It an Effective Technique? Arthroscopy: The Journal of Arthroscopic and Related Surgery [Internet]. 2014 Dec 1;30(12):1550–1556. Available from: http://linkinghub.elsevier.com/retrieve/pii/ S0749806314005696doi:10.1016/j.arthro.2014.06.026 12. Richards R.R., Sherman R.M., Hudson A.R., Waddell J.P. Shoulder arthrodesis using a pelvic- reconstruction plate. A report of eleven cases. The Journal of bone and joint surgery American volume [Internet]. 1988 Mar 1;70(3):416–421. Available from: http:// jbjs.org.ezproxy.library.ubc.ca/content/70/3/416.abstract 13. Richards R.R., Waddell J.P., Hudson A.R. Shoulder Arthrodesis for the Treatment of Brachial Plexus Palsy. Clinical Orthopaedics and Related Research® [Internet]. 1985 Sep 1;198:250. Available from: http://journals.lww.com/corr/ Fulltext/1985/09000/Shoulder_Arthrodesis_for_the_Trea tment_of_Brachial.37.aspx 14. 14.Rouholamin E., Wootton J.R., Jamieson A.M. Arthrodesis of the shoulder following brachial plexus injury. Injury [Internet]. 1991 Jan 1;Available from: http://www.sciencedirect.com/ science/article/pii/002013839190004X 15. Rowe C.R. Arthrodesis of the Shoulder Used in Treating Painful Conditions. Clinical Orthopaedics and Related Research® [Internet]. 1983 Mar 1;173:92. Available from: http://journals.lww.com/corr/Fulltext/1983/03000/Arthrodesis_of_ the_Shoulder_Used _in_Treating.12.aspx 16. Rühmann O., Clare D.J., Wirth M.A., Groh G.I., Rockwood C.A. Pseudarthrosis After Shoulder Arthrodesis. The Journal of bone and joint surgery American volume [Internet]. 2002 May 1;84(5):874–876. Available from: http://linkinghub.elsevier. com/retrieve/pii/S0883540306801890doi:10.1016/S08835403(06)80189-0 17. Rybka V., Raunio P., Vainio K. Arthrodesis of the shoulder in rheumatoid arthritis: a review of forty-one cases. The Journal of bone and joint surgery British volume [Internet]. 1979 May 1;61-B(2):155–158. Available from: http://eutils.ncbi. nlm.nih.gov/entrez/eutils/elink.fcgi? dbfrom=pubmed&id= 438265&retmode=ref&cmd=prlinks 18. Safran O., Iannotti J.P. Arthrodesis of the shoulder. The Journal of the American Academy of Orthopaedic Surgeons [Internet]. 2006 Mar 1;14(3):145–153. Available from: http:// eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi? dbfrom=pu bmed&id=16520365&retmode=ref&cmd=prlinks

9. Morgan C.D., Casscells C.D. Arthroscopic-assisted glenohumeral arthrodesis. YJARS [Internet]. 1992 Jun 1;8(2):262– 266. Available from: http://linkinghub.elsevier.com/retrieve/ pii/074980639290048Gdoi:10.1016/0749- 8063(92)90048-G

19. Scalise J.J., Iannotti J.P. Glenohumeral Arthrodesis After Failed Prosthetic Shoulder Arthroplasty. The Journal of bone and joint surgery American volume [Internet]. 2008 Jan 1;90(1):70–77. Available from: http://jbjs.org/cgi/ doi/10.2106/JBJS.G.00203doi:10.2106/JBJS.G.00203

10. Nagy L., Koch P.P., Gerber C. Functional analysis of shoulder arthrodesis. Journal of Shoulder and Elbow Surgery [Internet]. 2004 Jul 1;13(4):386–395. Available from: http://linkinghub.elsevier.com/retrieve/pii/ S1058274604000412doi:10.1016/j.jse.200 4.01.024

20. Stark D.M., Bennett J.B., Tullos H.S. Rigid internal fixation for shoulder arthrodesis. Orthopedics [Internet]. 1991 Aug 1;14(8):849–855. Available from: http://eutils.ncbi.nlm.nih. gov/entrez/eutils/elink.fcgi? dbfrom=pubmed&id=192396 6&retmode=ref&cmd=prlinks COA Bulletin ACO - Fall / Automne 2016

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 53)

21. Wick M., Müller E.J., Ambacher T., Hebler U., Muhr G., KutschaLissberg F. Arthrodesis of the shoulder after septic arthritis. Long-term results. The Journal of bone and joint surgery British volume [Internet]. 2003 Jul 1;85(5):666–670. Available from: http://www.bjj.boneandjoint.org.uk/content/85B/5/666.abstractdoi:10.1302/0301- 620X.85B5.13915

22. Wilde A.H., Brems J.J., Boumphrey F.R. Arthrodesis of the shoulder. Current indications and operative technique. The Orthopedic clinics of North America [Internet]. 1987 Jul 1;18(3):463–472. Available from: http://www.ncbi.nlm.nih. gov/pubmed/3441366

GLA:D™Canada: Reducing the Symptoms of OA Aileen Davis, PhD Senior Scientist, Division of Health Care and Outcomes Krembil Research Institute and Professor, University of Toronto Rhona McGlasson, PT, MBA Executive Director Bone and Joint Canada

xtensive research over the last few years has changed the thinking about osteoarthritis (OA). Until recently, OA has been thought of as a disease of the cartilage with a diagnosis made if there were structural changes in the cartilage within the joint that could be seen on an X-ray. Now, given that symptoms can occur without X-ray change and vice versa, an OA diagnosis is often made based on symptoms. The initial symptoms of OA include some mild joint pain and/or swelling and/or stiffness with some individuals progressing to changes within all the structures of the joint. Many people respond to education and exercise as the first line of treatment, with medication, assistive devices (e.g. ambulatory aids, orthotics, braces) added as second line therapy for those who need it. For a small number of people, the condition becomes gradually more severe causing significant pain and disability and leading to the need for surgical intervention, such as arthoplasty. Although symptoms and disease state are not related, for many as the disease progresses, physical activity becomes reduced due to pain and disability. The result is a negative effect on overall health, including increased risk for other comorbidities such as diabetes or heart disease. 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 function and physical activity. GLA:D® is a six-week program that includes two education sessions and 12 neuromuscular exercise sessions conducted in a group format. The exercises focus on stability and control of the knee and hip joint. Individuals are taught strategies and exercises to control the movement of the joint. These exercises reflect every day activities so that they can be used on a daily basis, thereby reducing the abnormal stresses through the joint structures. The program has been effective for individuals who have mild, occasional knee and hip pain, (suggestive of early OA symptoms or “pre OA”), as well as for those with moderate and even severe symptoms, including individuals waiting to undergo joint replacement surgery. Training on the GLA:D program has been provided COA Bulletin ACO - Fall / Automne 2016

BONE and JOINT CANADA to almost 600 physiotherapists across Denmark and outcome data are collected from participants at baseline, and three and 12 months post program. Almost 10,000 individuals have received the standardized program and show that the program has effectively reduced symptoms by up to 32% sustained over one year. Working with the researchers from Denmark, Bone and Joint Canada (BJC), a knowledge translation division of the Canadian Orthopaedic Foundation (COF), has brought the program to Canada. The program is licensed to the COF and is functioning under the title “GLA:D™Canada”. The program has been piloted at the Holland Orthopaedic and Arthritic Centre, Sunnybrook Health Sciences Centre in Toronto where it has been offered to individuals who are being assessed for hip and knee replacement surgery and who wish to access conservative management. The program content remains the same including the education, exercise and data collected at baseline, three months and one year; however materials have been modified to reflect the Canadian context of geography and culture. Through a grant received from the Ontario Trillium Foundation in 2016, the program is being launched in a number of sites across Ontario with training provided to physiotherapists, chiropractors and kinesiologists. The group design of the program ensures that it is affordable for participants. GLAD™Canada has also been launched in Alberta with sites accepting patients into the program in the fall this year. Training is being organized for BC in February 2017 and for New Brunswick and Newfoundland later in the year. Information about the program, a map of the trained sites and program results are available on the web site http:\\gladcanada.ca. As we learn more about the needs of the participants, we will also be modifying the program to make it available in wellness centres, such as recreation centres and gyms, thereby addressing the needs of individuals who are very early in their disease states. If you have any questions about the GLA:D™Canada program, please contact Rhona McGlasson at Rhonaamcglasson@gmail.com

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Resident Scholarship Opportunity – Call for Applications The Canadian Orthopaedic Foundation is pleased to announce that applications are now being accepted for the 2017 Bones and Phones Legacy Scholarship Award. One thousand dollars is awarded on an annual basis to an orthopaedic resident in his or her year prior to their final year of clinical training who is a member of the Canadian Orthopaedic Association (COA) and who meets the criteria as outlined in the guidelines and application documentation. More information, including eligibility criteria, application forms and guidelines, is available at www.whenithurtstomove.org: click on ‘Bones and Phones Scholarship’ under ‘Research & Awards’.

Bourses offertes aux résidents — Soumission des candidatures La Fondation Canadienne d’Orthopédie est heureuse d’annoncer qu’il est maintenant possible de soumettre sa candidature pour la Bourse d’études Bones and Phones 2017 : Chaque année, 1 000 $ seront remis à un résident en orthopédie membre de l’Association Canadienne d’Orthopédie effectuant son avant-dernière année de formation clinique et respectant tous les critères établis dans les directives et le formulaire de demande. Pour accéder à de plus amples renseignements, y compris les critères d'admissibilité, le formulaire et les lignes directrices, rendez-vous à www.whenithurtstomove.org/fr et cliquez sur « Fonds de bourses d'études Bones and Phones », dans le menu « Prix, bourses et subventions ».

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

Mapping a Strategy for Access to Orthopaedic Care in Canada Peter B. MacDonald, M.D., FRCSC COA President Winnipeg, MB

Dr. Geoffrey Johnston, M.D., FRCSC COA Past President Saskatoon, SK

n January 2016, the COA Board ratified a Position Statement on Access to Orthopaedic Care in Canada. The statement, “calls on provincial governments to partner with the Association so that patients can access appropriate orthopaedic care in a safe, timely, fair and transparent manner.” It cites the COA’s support for evidence-based practice, the responsible and strategic use of health resources, and the concern that appropriately-referred patients are not being seen by an orthopaedist or an orthopaedic delegate in a timely way, thereby threatening to worsen the situation even further. Read the full statement HERE. The Access to Care Steering Committee struck by the Board proposed that the COA should develop a strategy to demonstrate how its members are leading the way with innovative and efficient pathways to improve patient access to MSK care. Though the barriers to access are numerous and complex, the common threads between effective models of care can serve as examples to governments and decision-makers. These underscore the commitment of COA members to maximizing efficient use of scarce health resources and seeking improvements to patient care.

Kevin Orrell, M.D., FRCSC COA President Elect Sydney, NS

The Steering Committee enlisted member support in developing an inventory of successful approaches to improving access to timely, appropriate orthopaedic care, and was pleased to receive responses from project leaders across the country, highlighting improved outcomes resulting from a change in care delivery. Through your responses, the Committee is gaining an understanding of the constructive solutions that you believe would positively impact orthopaedic patients and systems. On behalf of the Association, members of the COA Executive will be meeting with government representatives in the coming months to discuss collaboratively the best path forward for improving access to MSK care for all Canadians. We are committed to pursuing an open dialogue, both with members and other stakeholders, on issues around access to MSK care, so that the Association can remain a trusted source of information and advice for decision-makers at all levels. If you would like to share a novel innovation with the COA Executive, please contact policy@canorth.org.

Établir une stratégie pour l’accès aux soins orthopédiques au Canada Peter B. MacDonald, MD, FRCSC Président de l’ACO Winnipeg (Manitoba)

Geoffrey Johnston, MD, FRCSC Président sortant de l’ACO Saskatoon (Saskatchewan)

n janvier 2016, le conseil d’administration de l’ACO a adopté un énoncé de position sur l’accès aux soins orthopédiques au Canada, dans lequel l’ACO demande aux gouvernements provinciaux de collaborer avec elle afin de veiller à ce que les patients aient accès aux soins orthopédiques appropriés de manière sécuritaire, juste et transparente, en temps opportun. Il précise en outre que l’ACO appuie les principes de l’exercice fondé sur des données probantes et de l’utilisation responsable et stratégique des ressources en santé, et qu’elle est préoccupée par l’incapacité de patients justement aiguillés de voir un orthopédiste ou un autre professionnel du domaine en temps opportun, ce qui risque d’aggraver leur état. Cliquez ICI pour lire l’énoncé. Le conseil a donc créé le comité directeur de l’ACO sur l’accès aux soins orthopédiques, qui propose d’élaborer une stratégie illustrant la façon dont les membres de l’ACO montrent l’exemple en matière de plans de soins novateurs et efficaces qui améliorent l’accès aux soins musculosquelettiques. Les obstacles à l’accès sont certes nombreux et complexes, mais les gouvernements et décideurs peuvent s’inspirer des points communs des différents modèles de soins efficaces. Ces plans de soins viennent souligner l’engagement des membres de l’ACO à maximiser les ressources restreintes en santé et à améliorer les soins.

Kevin Orrell, MD, FRCSC Président élu de l’ACO Sydney (Nouvelle-Écosse)

Le comité directeur a invité les membres à lui faire part des modèles ou plans de soins novateurs qu’ils connaissent ou appliquent pour améliorer l’accès en temps opportun aux soins orthopédiques pertinents, et a eu la satisfaction de recevoir des réponses de chefs de projets de partout au pays qui ont fait ressortir les résultats concluants obtenus à la suite de changements apportés à la prestation des soins. Grâce à leurs réponses, le comité directeur peut mieux comprendre les solutions constructives qui pourraient avoir une incidence positive sur les patients et systèmes en orthopédie. Au nom de l’ACO, le Comité de direction rencontrera des représentants gouvernementaux au cours des prochains mois pour discuter de la meilleure façon d’améliorer l’accès aux soins musculosquelettiques pour l’ensemble de la population canadienne. Nous nous sommes engagés à dialoguer ouvertement avec les membres et d’autres intervenants sur les questions liées à l’accès aux soins, de sorte à demeurer une source fiable de renseignements et de conseils pour les décideurs à tous les échelons. Si vous souhaitez nous communiquer une innovation pertinente à cet égard, écrivez-nous à policy@canorth.org.

COA Bulletin ACO - Fall / Automne 2016

Foundation / Fondation

J. Édouard Samson Award: Promoting Valuable Orthopaedic Research

ach year the Canadian Orthopaedic Foundation (COF) presents the J. Édouard Samson Award to an orthopaedic researcher for work over a five year period. The intent of the award is to promote further research. This intent has most definitely been met, as evidenced by two researchers who recently submitted final reports on their research, with funding through the Samson Award.

this spring. Dr. Kwon’s research was entitled “Bench to Bedside and Back: Translational Research in Acute Spinal Cord Injury.” Dr. Kwon explains:

Dr. Nadr Jomha from the University of Alberta received the award in 2012 for his research project, “Vitrification of intact human articular cartilage.” Dr. Jomha’s research focused on the biologic restoration of joint surfaces to prevent the development of osteoarthritis. He explains:

“Translational research invokes the bidirectional flow of investigation and knowledge generation from bench to bedside and bedside back to bench. We began with a clinical trial in acute spinal cord injured patients in which cerebrospinal fluid (CSF) samples were analyzed for biomarker discovery. Ongoing work in this led to the expansion of our clinical trial of CSF pressure monitoring and sampling to other Canadian sites. Taking these insights “from bedside back to bench”, we established a large animal model in which we could evaluate changes in CSF pressure around the injured spinal cord. This animal model enabled parallel investigations of CSF samples for biomarker discovery. Such animal models were utilized to evaluate novel therapies, and we led the development of a neuroprotective agent that entered into clinical trials in acute SCI patients, thus completing the ‘bench to bedside’ loop.”

“Our moveable joints are lined with articular cartilage that provides almost frictionless range of motion and decades of function. When a portion of the joint surface is damaged, the joint is likely to deteriorate over time resulting in osteoarthritis (OA). Once OA begins, there is no treatment that can reverse the process. There are methods that can regenerate a type of cartilage that provides some function but does not regenerate the complex properties of articular cartilage. One alternative is to take articular cartilage from another joint. As we do not have spare cartilage to take in significant quantities, it must be taken from deceased donors. This is in practice but there are limitations because the storage time after harvest is 28 days. This short time frame makes it difficult to assemble the surgical team, match for size and location and test for infectious diseases, resulting in suboptimal transplantation conditions and the wastage of tissue that is harvested but not transplanted within 28 days. My research has investigated ways to allow storage of articular cartilage for prolonged periods of time without tissue deterioration. To accomplish this, we have focused on a method of cold preservation called vitrification, which is the formation of a solid from a water solution without the formation of ice crystals.” Dr. Jomha and his research team have been able to cryopreserve joint cartilage and the researchers have been working with the Comprehensive Tissue Centre in Edmonton to optimize the protocol to make the process clinically applicable. They continue to progress toward being able to bank human articular cartilage for prolonged periods of time to enable transplantation for joint defects. The Samson award has made a difference to the team’s work. Dr. Jomha points to difficult economic times, with researchers seeing cutbacks in funding. As well, his research does not fit with other funding streams which focus on new knowledge; his research focuses on optimization of previously determined knowledge. The COF was able to provide funding to fill in gaps where other funding was not available. Dr. Brian Kwon, Professor and Canada Research Chair in Spinal Cord Injury at the University of British Columbia, received the J. Édouard Samson award in 2013 and submitted his final report COA Bulletin ACO - Fall / Automne 2016

The funds received through the Samson award were used to support two initiatives: identifying biomarkers of spinal cord injury in human cerebrospinal fluid (CSF) samples; and a comparison between norepinephrene and phenylephrine in the management of acute SCI. In the first initiative, researchers analyzed 50 patients, using proteins within the CSF to predict outcome after SCI. The team found that the analysis of CSF can provide valuable biological information about injury severity and recovery potential after acute SCI, and that such biological markers may be valuable tools for stratifying individuals in acute clinical trials. In the second initiative, the research team used a pig model of SCI to evaluate how these commonly used vasopressors influence intraparenchymal physiology. The team’s results in this initiative suggest that norepinephrine would be the vasopressor of choice in the early treatment after traumatic SCI. Dr. Kwon reported that the work carried out under the Samson award was leveraged to help generate data that was used in successfully applying to Brain Canada for a $3M MultiInvestigator Research Initiative entitled “Biomarkers for crossing the translational divide in acute spinal cord injury.” Says Dr. Kwon, “This ‘future direction’ from the Samson Award is now taking us into doing proteomics, genomics, and metabolomics on our human SCI patients.”

Foundation / Fondation

(continued from page 58)

Dr. Marvin Tile, Patron of the Canadian Orthopaedic Foundation, notes the importance of funding from the COF in these two projects. He says, “Research funding from the COF fills a definite niche: we help to fund research that other funding bodies simply do not fund; and the research we do fund is used as a springboard to larger, innovative projects. The COF plays an important role in making these projects possible.” As a charitable organization, the COF relies on generous donors to fund its research program; and a large and committed portion of the donor database is orthopaedic surgeons.

As evidenced by Dr. Jomha’s and Dr Kwon’s research, says Dr. Tile, “Canada has some of the best and brightest orthopaedic researchers in the world – researchers whose ideas can lead to innovations in orthopaedic surgery, treatment and care. As orthopaedic surgeons, we must invest in this research.” The COF is grateful to the individuals and corporations that support its programs.

Prix J.-Édouard-Samson : Promotion de la recherche en orthopédie

haque année, la Fondation Canadienne d’Orthopédie remet le Prix J.-Édouard-Samson à un chercheur en orthopédie pour récompenser ses travaux des cinq années précédentes. Elle souhaite ainsi promouvoir la recherche. Et, comme le prouvent les rapports de recherche finaux déposés récemment par deux lauréats, elle y parvient avec brio. Le Dr Nadr Jomha, de l’Université de l’Alberta, a reçu le Prix J.-Édouard-Samson en 2012 pour son projet de recherche intitulé Vitrification of intact human articular cartilage, axé sur la restauration biologique de la surface articulaire afin de prévenir l’arthrose. « Nos articulations sont couvertes de cartilage qui élimine presque entièrement la friction provoquée par le mouvement et en assure le bon fonctionnement pendant des dizaines d’années. Quand une partie de sa surface est endommagée, l’articulation est plus susceptible de se dégrader et de montrer des signes d’arthrose, explique le Dr Jomha. Malheureusement, quand l’arthrose s’attaque à une articulation, aucun traitement ne permet d’en venir à bout. Certaines méthodes permettent de régénérer un certain type de cartilage, et donc de remédier en partie au problème, sans pour autant restaurer les propriétés complexes du cartilage articulaire. L’utilisation de cartilage d’une autre articulation est possible, mais comme nous n’avons pas suffisamment de cartilage pour en prélever une grande quantité, il faut recourir à des donneurs décédés. Cette méthode a toutefois ses limites, le cartilage ne pouvant être conservé que 28 jours après son prélèvement. Vu ce court délai, il est difficile de réunir l’équipe chirurgicale, d’utiliser la greffe sur une articulation compatible de même taille et de vérifier la présence de maladies infectieuses, ce qui entraîne des conditions de transplantation non optimales et la perte de tout tissu prélevé qui n’est pas utilisé dans les 28 jours. Mes recherches portent sur les façons d’entreposer du cartilage pendant de longues périodes sans qu’il y ait détérioration tissulaire. Pour ce faire, nous nous sommes concentrés sur la vitrification, une méthode de conservation par le froid; on crée ainsi un solide exempt de cristaux de glace à partir d’une solution aqueuse. »

Le Dr Jomha et son équipe ont réussi à cryoconserver du cartilage articulaire, et collaborent avec le Comprehensive Tissue Centre d’Edmonton pour optimiser le protocole et rendre ce processus viable en clinique. Leurs travaux progressent; ils visent à créer une banque de cartilage articulaire humain permettant sa conservation pendant de longues périodes à des fins de transplantation chez des patients atteints de troubles articulaires. Le Prix J.-Édouard-Samson a eu une incidence positive sur ces travaux. Le Dr Jomha souligne que la morosité économique a réduit les fonds consentis aux chercheurs. En outre, ses travaux ne correspondent à aucune des catégories de financement courantes, axées sur le développement du savoir, puisqu’ils portent sur l’optimisation des connaissances actuelles. Le financement offert par la Fondation est venu combler ce manque. Le Dr Brian Kwon, professeur au département d’orthopédie de l’Université de la Colombie-Britannique et titulaire de la Chaire de recherche du Canada sur les lésions médullaires, a reçu le Prix J.-Édouard-Samson en 2013. Le printemps dernier, il a déposé son rapport final sur ses recherches, intitulées Bench to Bedside and Back: Translational Research in Acute Spinal Cord Injury.

COA Bulletin ACO - Fall / Automne 2016

Foundation / Fondation

(continued from page 59)

« La recherche translationnelle fait référence à la boucle de rétroaction itérative entre la recherche fondamentale et la recherche clinique, c’est-à-dire des laboratoires aux patients et inversement, explique-t-il. Nous avons commencé par un essai clinique auprès de patients atteints d’une lésion médullaire traumatique en analysant des échantillons de liquide céphalorachidien (LCR) pour en établir les biomarqueurs. Les travaux en cours ont permis d’étendre notre essai clinique de suivi de la pression et d’échantillonnage à d’autres sites au pays. Nous avons ensuite appliqué le principe « du patient au laboratoire » à nos résultats : nous avons conçu un grand modèle animal pour évaluer les variations de la pression du LCR dans la moelle épinière endommagée. Le modèle animal a permis d’étudier en parallèle des échantillons de LCR pour en établir les biomarqueurs. De tels modèles ont servi à l’évaluation de traitements novateurs; nous avons aussi chapeauté l’élaboration d’un agent neuroprotecteur utilisé lors d’essais cliniques auprès de patients atteints d’une lésion médullaire traumatique, ce qui est venu, en quelque sorte, boucler la boucle. » Les fonds associés au Prix J.-Édouard-Samson ont servi au financement de deux initiatives, soit l’établissement des biomarqueurs des lésions médullaires dans des échantillons de LCR humain et la comparaison de la norépinéphrine et de la phényléphrine dans le traitement de lésions médullaires traumatiques. Dans la première initiative, les chercheurs ont analysé 50 patients à l’aide de protéines du LCR pour prévoir les résultats après une lésion médullaire. L’équipe a constaté que l’analyse du LCR peut fournir des renseignements biologiques utiles sur la gravité de la lésion et le rétablissement potentiel après une lésion médullaire traumatique, et que de tels biomarqueurs peuvent servir à la stratification des cas dans les essais cliniques auprès de blessés médullaires traumatiques. Dans la deuxième initiative, l’équipe de recherche a utilisé un modèle porcin de lésion médullaire pour évaluer la façon dont ces vasopresseurs d’usage courant influent sur la physiologie intraparenchymateuse. Les résultats indiquent que la norépinéphrine serait le vasopresseur à privilégier pour le traitement précoce d’une lésion médullaire.

Selon le Dr Kwon, les travaux effectués grâce au Prix J.-ÉdouardSamson l’ont aidé à obtenir les données nécessaires à la présentation de sa demande au concours Initiative de recherche regroupant plusieurs chercheurs (MIRI) de la Fondation Brain Canada et, ainsi, à l’obtention d’une subvention de 3 millions de dollars pour ses travaux intitulés Biomarkers for crossing the translational divide in acute spinal cord injury. « L’investissement dans l’avenir que représente le Prix J.-Édouard-Samson nous permet aujourd’hui d’étudier la protéomique, la génomique et la métabolique chez des personnes ayant subi une lésion médullaire traumatique. » Le Dr Marvin Tile, champion de la Fondation, souligne l’importance du financement qu’elle a accordé à ces deux projets : « Le financement offert par la Fondation comble un besoin bien précis en recherche, car il contribue à financer des travaux que d’autres organismes n’appuient tout simplement pas; et les recherches financées servent ensuite de tremplin à des projets novateurs de plus grande envergure. La Fondation joue un rôle important dans la concrétisation de ces projets. » À titre d’organisme de bienfaisance, la Fondation dépend de la générosité de ses donateurs, dont la majeure partie sont des orthopédistes, pour doter ses programmes de financement de la recherche. Le Dr Tile estime que, comme en témoignent les travaux des Drs Jomha et Kwon, on trouve au Canada certains des chercheurs les plus brillants et accomplis dans le monde, des chercheurs dont les idées peuvent permettre de grandes innovations en chirurgie de même que dans les soins en orthopédie. « En tant qu’orthopédistes, nous avons le devoir d’investir dans la recherche », affirme-t-il. La Fondation remercie les particuliers et les entreprises qui soutiennent ses programmes.

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 - Fall / Automne 2016

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

Introducing COAplan™

Financial planning and advice available at no cost to COA & CORA members Adam O’Neill, B.Sc., MBA, CHS™, CLU® Conor Pollock, BComm, CHS™, CFP®

e are very pleased to announce the creation of COAplan™ for all COA and CORA members. This program will ensure that every member and their family will have access to the best financial planning and advice at no cost, along with exclusive access, pricing and discounting on financial and insurance solutions on the Canadian market. We encourage you all to investigate further at COAplan.ca. Goal The goal of this program is to ensure that COA and CORA membership is financially secure, efficient and empowered. We want the membership to receive the best possible advice, at no cost, from the best possible sources. We wanted to make sure that the complexities of professional corporation management, tax minimization, protection and estate planning are made as clear as possible, and that members have access to the best solutions and fee reductions, and discounting available. Planning, Assessment and Advice We believe that every member should have the opportunity to work with the best planners in Canada to create a comprehensive financial plan, or get an expert second opinion on their current plan. The COA has negotiated exclusive access to Sun Life Financial’s Estate and Financial Planning Services (EFPS), for all COA and CORA members at no cost. This team of salaried professionals is happy to provide a comprehensive financial plan upon request, as well as assess, or design plans for any of the following topics: • • • • • • •

Corporate structure Estate, trusts and legacy planning Investment strategy Retirement and de-accumulation strategy Tax management Corporate wind down Debt management

The EFPS team is non-commissioned, non-selling, impartial planners, who do not receive any compensation on the sale of financial products or services. Their job is to provide our members with impartial advice and comprehensive planning. In addition to the EFPS service, we have created a team of advisors, accountants, corporate tax lawyers, and other specialists. These professionals are vetted, all work in the Canadian medical professional space, and have a strong commitment to orthopaedic health in Canada. COA Bulletin ACO - Fall / Automne 2016

Investments COA and CORA members now have preferential access to Sun Life Global Investment’s Private Client service, including aggressive fee discounting, access to multiple top tier fund companies, and enhanced reporting. There is full fee transparency, no locking in (DSC), or additional charges of any kind. Protection COA and CORA members now receive 25% discounting on RBC Disability premiums. This can be applied to existing coverage as well as new coverage. Proper disability coverage is essential to your financial protection plan, and policies are especially complex. We have disability specialists on hand to ensure your coverage plan is tailored to your specific needs, with the industry leader, at exclusive discounts. Tailored We are happy to work with you at whatever level you desire. If you have a team and plan in place, we are happy to review it for you. If there is one specific area in which you need help, we are happy to focus on that. And, if you are starting with a clean slate and need a comprehensive plan, we can guide you through the process. We understand the needs facing both new and established surgeons, and will make sure that your plan is efficient, precise and tailored to your specific needs. Support and Education All of the professionals and corporate partners involved in this program have made a commitment to the Association, and orthopaedic health in general. We are happy to speak at grand rounds, provide educational seminars, respond to specific questions, or write on topics for this publication. We have also all agreed to commit a portion of all revenues to the Canadian Orthopaedic Foundation. We look forward to helping you in whatever way you might need, and to enhancing the above benefits moving forward. Please visit our web site at COAplan.ca, or click on the Planning & Benefits Program option under the Member Services tab at www.coa-aco.org. The information in the article has been provided to the COA by Sun Life Assurance Company of Canada. It is recommended to seek independent advice related to your particular circumstances as necessary.

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

Why a Physician’s Online Presence Matters

You’ll never get a second chance to make a first impression. Optimizing your online presence is more important now than ever

one are the days of taking a doctor’s referral with no questions asked. Now, the average individual simply opens up their iPad or clicks through their mobile app to find a highly-rated professional to treat their sore knee or torn tendon - and it is also this same digital space where patient and employers read reviews and evaluate a doctor or clinic’s web site before choosing whether or not to book an appointment, interview them, or consider them for medicolegal, IME, consulting, or Expert Witness work. The ever-present digital landscape and the rise of social engagement are increasingly relevant to potential patients, colleagues and collaborators. You can’t stop the growth of digital, but there are many ways to use it to your advantage. Representing yourself professionally and credibly online has become integral to maintaining and building professional relationships with both colleagues and externally. Detailing the Digital Takeover The numbers speak for themselves. Eighty percent of all online searches in Canada occur on Google and more than 30 percent of those are health-care related. If your site doesn’t have relevant information or a contemporary design, it won’t be easy to stay at the top of the search results in your industry. And you can’t forget the power of social media. Studies show that the use of social media has greatly enhanced the branding and visibility of medical clinics and subsequently their medical professionals. It’s not just millennials who are accessing information online - the number of adults using social media has increased from eight percent to 72 percent in the past ten years. Not only is a strong digital presence important for retaining current patients but in a health-care setting, many doctors are now successfully attracting new career opportunities through these avenues. A digital presence is important for health-care professionals when it comes to building opportunities such as speaking engagements, working with product development firms, attracting unique patient cases, government or corporate opportunities or finding partners in future business endeavours. But how can you harness the power of the World Wide Web to create a strong, trustworthy digital presence? Building an Online Brand With an increasing demand for digitally-focused information, come new challenges for entrepreneurial professionals. Take the story of one orthopaedic surgeon in Toronto. While he had years of experience under his belt and a strong reputation through word-of-mouth, he seemed to be losing out on opportunities to his colleague for engagements in the medical legal business as well as with new patients. He sought out professional expertise to help guide his online reputation. The doctor chose a service called My Industry Brand (http://www.myindustrybrand.com/), which focuses specifically on optimizing online brand images for doctors. Armed with the right tools, the surgeon was able to create an engaging web site and ultimately get his business into

the top search results. The improvement of his digital presence translated into more clients and overall more success in his practice. After transforming his online reputation, he also worked to create a long-term strategy for improving his presence. Because the doctor also worked within a larger clinical setting on occasion, he also helped to build the clinic’s brand by creating a proactive online presence. Similarly, an outdated web site, negative and low reviews, or questionable online information can have the opposite effect. A poor online presence can diminish or eliminate the positive impact of a word-of-mouth referral quickly. It’s not just about marketing, but more so about appropriately representing your professional presence. Creating Professional Prospects Building future professional opportunities outside of a patient base is important for medical experts. Toronto orthopaedic surgeon Dr. Fielden was still practicing medicine but he wasn’t getting the opportunities he once had when it came to consulting engagements, despite his many years of expertise. He joined an online network that promotes experts such as doctors, dentists and lawyers to connect them with professional consulting services, called OpinionEx (https://www.opinionex.com/). He wanted to enhance his current web site and create more connections when it came to consulting. Optimizing his online image was one way for him to properly promote his many years of knowledge in a professional and polished way. Utilizing the Best Resources for Professional Development Everyone searches online before making a decision, and a profile on a university or hospital page will just not do when it comes to sharing your extensive resume and presenting yourself in an appealing way for various audiences and opportunities. Creating a personal brand is important to remaining relevant so how does a physician create the right message and still remain professional? If you’re not web-savvy, work with a professional service to create a custom web site to keep on top of the all-too-important aspect of online reputation management. Having a strong online presence is not a bonus these days; it’s a must when building both a global and local profile, and especially when being part of a professional community. An investment in your digital presence won’t go unnoticed. For answers to questions and more information please contact: (647) 494 – 0489 info@myindustrybrand.com The information provided in this article has been provided to the COA by Opinionex.com and is for the information of our members. The COA does not warrant or endorse the information in this article and has received no compensation for its inclusion in the COA Bulletin

COA Bulletin ACO - Fall / Automne 2016

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

Calendar of Events / Calendrier des événements Le 91ème Congrès de la SOFCOT November 8-11 novembre Paris, France Web Site/Site Int. : www.sofcot-congres.fr CAS 5th Annual Meeting November 24-25 novembre Toronto, ON E-mail/Courriel : cas@canorth.org Web Site/Site Int. : http://www.coa-aco.org/cas/cas/

2017

COA Mid Winter Meeting (Board & Committee Meetings) January 13-14 janvier Toronto, ON E-mail/Courriel : meetings@canorth.org CSES Annual Shoulder & Elbow Course February 1-3 février Calgary, AB E-mail/Courriel : cses@canorth.org Web Site/Site Int. : http://coa-aco.org/cses/cses-meetings/ Canadian Orthopedic Foot and Ankle Society Foot & Ankle Symposium Februrary 2-4 février Fairmont Chateau Whistler Whistler, BC Web Site/Site Int. : http://ubccpd.ca/course/cofas2017

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COA Bulletin ACO - Fall / Automne 2016

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COA Bulletin ACO - Fall / Automne 2016

Some things get

better with age… 1976 First implantation of the Oxford Partial Knee 1982 Indicated for and used in the treatment of anteromedial osteoarthritis 2003 Oxford Cementless Partial Knee Replacement* launched 2011 Study demonstrates survivorship with 91.0% of implants still in place at 20 years1 2011 Launch of Microplasty® Instrumentation To learn more, visit oxfordpartialknee.com

* Not approved for sale in the USA 1. Price, A., Svard, U. A Second Decade Lifetable Survival Analysis of the Oxford Unicompartmental Knee Arthroplasty. Clinical Orthopedics and Related Research. 469(1): 174-9, 2011. In the United States (US), the medial Oxford® Partial Knee is intended for use in individuals with osteoarthritis or avascular necrosis limited to the medial compartment of the knee and is intended to be implanted with bone cement; it is not indicated for use in the lateral compartment or patients with ligament deficiency. Various countries outside of the US offer Oxford Partial Knees intended for lateral use and indicated for uncemented application; these devices are not available for sale in the US. Potential risks of knee replacement surgery include, but are not limited to, loosening, dislocation, bone or implant fracture, wear, and infection, any of which can require additional surgery. ©2016 Zimmer Biomet. All content herein is protected by copyright, trademarks and other intellectual property rights owned by or licensed to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or in part, without the express written consent of Zimmer Biomet. This material is intended for healthcare professionals. Zimmer Biomet does not practice medicine. The treating surgeon is responsible for determining the appropriate treatment, technique(s), and product(s) for each individual patient. For product information, including indications, contraindications, warnings, precautions, potential adverse effects and patient counseling information see the package insert and www.zimmerbiomet.com. Not intended for surgeons practicing medicine in France.