COA Bulletin # 113 Summer 2016 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Summer / Été 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

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Prevention of DVT in Total Hip and Total Knee Arthroplasty See page 32 Prévention des thromboses veineuses profondes associées aux arthroplasties totales de la hanche et du genou Page 32

The 2015 North American Travelling Fellowship � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 Operation Walk Winnipeg: From Small Gifts to Big Effects � � � � � � � � � � � � � � � � � � � � � � � � � � 11 Un guichet unique pour tous les services de l’ACO � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 17 Comparing Outcomes for Simultaneous and Staged Bilateral Total Knee Replacement Surgeries � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 20

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Bulletin

CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 113 Summer / Été 2016

The COA has moved!

L’ACO a changé d’adresse!

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

Please remember to update your records with our new address:

N’oubliez pas de mettre vos dossiers à jour :

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

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

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

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

Thank you!

Merci de noter ces nouvelles coordonnées!

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

Resource Stewardship Robin R. Richards, M.D., FRCSC President, Canadian Orthopaedic Association

ost Canadian orthopaedic surgeons are independent health practitioners who practice in association with a publically-funded hospital. Canadian hospitals are challenged by chronic underfunding in relation to the demand for their services. Accordingly, resources are limited for the provision of orthopaedic surgical care. In my 11 years as Surgeon-in-Chief at Sunnybrook Health Sciences Centre I consistently maintained the position that individual surgeons needed to triage their own practices and that the hospital should take a hands-off approach to patient care decisions within individual surgical practices. In addition to their many other responsibilities, orthopaedic surgeons are stewards of the resources that devolve to them to provide surgical The Bulletin of the Canadian Orthopaedic Association is published Summer, 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 Été, 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

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care in our public health-care system. Stewardship is an ethic that embodies the responsible planning and management of resources. The concepts of stewardship can be applied to the environment and nature, economics, health, property and information. Choosing Wisely Canada is a campaign supported by the Canadian Orthopaedic Association to help physicians and patients engage in conversations about unnecessary tests, treatments and procedures and make smart and effective choices to ensure high-quality care. Unnecessary tests and treatments do not add value to care. In fact, they take away from care by potentially exposing patients to harm, leading to more testing to investigate false positives and contributing to stress for patients. Unnecessary tests and treatments put increased strain on the resources of our health-care system. The Executive has requested and received two reports from OrthoEvidence to identify orthopaedic interventions for which evidence of efficacy and cost-effectiveness is lacking. OrthoEvidence (access to OrthoEvidence is a COA membership benefit) was developed to provide an efficient and regularly updated resource for the best evidence in orthopaedics worldwide. Although not officially endorsed by the COA, I personally feel that these reports are well-written and provide food for thought. We need to individually and collectively embrace our roles as resource stewards and reports such as these, based on the scientific literature, are helpful for making informed decisions in this regard. Both of these reports are available to members (click here to access). They evaluate the strong evidence, randomized controlled trials and meta-analyses of RCTs in the orthopaedic literature to identify treatments currently in use that may be ineffective in comparison to conventional methods or have low levels of efficacy. With respect to the management of degenerative pathologies of the knee, the following interventions are discussed in “Identifying Musculoskeletal Interventions with Low Levels of Efficacy in the Knee”: • Arthroscopic debridement of degenerative meniscal tears • Patient-specific instrumentation and computer navigation in TKA • High flexion, mobile-bearing and posterior cruciate retaining TKA prostheses • Gender-specific instrumentation in TKA • Tourniquet use in TKA

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 19 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 41 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 45 The following interventions with respect to the shoulder and elbow are discussed in “Identifying Musculoskeletal Interventions with Limited Levels of Efficacy in the Shoulder & Elbow”: • Operative management of displaced humeral fractures in the elderly • Operative mangement of shoulder impingement syndrome • Platelet-rich plasma injections and acromioplasty in rotator cuff repair • Efficacy of treatment for adhesive capsulitis and lateral epicondylitis • Immobilization in external rotation following shoulder dislocation I wish to thank Mohit Bhandari, the Canada Research Chair in Evidence-based Orthopaedics at McMaster University in Hamilton, Ontario, for his leadership and assistance to the Executive in the development of the above reports. This is my last Bulletin message to you as your President. I wish to sincerely thank Meghan Corbeil, Trinity Wittman and Cynthia Vezina for their efforts over the past year. They are stellar individuals who provide strength and stability to our Association. I wish to thank Doug Thomson for his organizational skills and wise counsel, always delivered in a good-natured manner, often with wry and much appreciated humour. Finally, Barb and I wish to thank each and every member of the Association for allowing us to represent Canadian orthopaedics at home and abroad. It has been a singular honour and a privilege for which we will be forever grateful. The COA will be in good hands under the leadership of Dr. Peter MacDonald. Peter and Sherry will be superb ambassadors on our behalf.

Gérance des ressources Robin R. Richards, MD, FRCSC Président, Association Canadienne d’Orthopédie

a plupart des orthopédistes canadiens sont des professionnels de la santé indépendants qui œuvrent au sein d’un hôpital public. Le sous-financement chronique des

COA Bulletin ACO - Summer / Été 2016

hôpitaux canadiens nuit toutefois à leur capacité de répondre à la demande. Les ressources allouées aux chirurgies orthopédiques sont donc limitées. Durant les onze années où j’ai été chirurgien en chef du Sunnybrook Health Sciences Centre, je n’ai eu cesse de soutenir que chaque orthopédiste doit assurer le triage de ses cas et que l’hôpital doit déléguer aux chirurgiens les décisions en matière de soins. En plus de leurs

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nombreuses autres responsabilités, les orthopédistes assurent la gérance des ressources qui leur sont allouées pour offrir des soins chirurgicaux au sein du système de soins de santé. La gérance est une notion éthique qui a trait à la planification et à l’administration responsables des ressources. Le concept de gérance s’applique tant à l’environnement et aux milieux naturels qu’à l’économie, à la santé, aux biens mobiliers et à l’information. Choisir avec soin est une campagne nationale appuyée par l’ACO qui vise à aider les professionnels de la santé et les patients à engager un dialogue au sujet des examens et des traitements inutiles et à les aider à faire des choix judicieux et efficaces en vue d’assurer des soins de qualité. Les examens et traitements inutiles n’ajoutent aucune valeur aux soins. En fait, ils réduisent la qualité des soins, car ils exposent les patients à des risques potentiels, ce qui peut mener à un plus grand nombre de tests pour éliminer des faux positifs et contribuer au stress des patients. De plus, les examens et traitements inutiles mettent une pression accrue sur les ressources de notre système de soins de santé. La direction de l’ACO a demandé à OrthoEvidence de produire deux rapports afin d’établir les interventions orthopédiques dont l’efficacité et la rentabilité ne sont pas étayées par suffisamment de données probantes. OrthoEvidence (dont l’accès est un des avantages de l’adhésion à l’ACO) se veut une ressource efficace et régulièrement mise à jour en matière de pratiques exemplaires en orthopédie partout dans le monde. Bien que l’ACO n’approuve pas officiellement ces rapports, je suis d’avis qu’il s’agit de documents bien rédigés qui donnent matière à réflexion. Nous devons assumer notre rôle individuel et collectif dans la gérance des ressources; des rapports comme ceux d’OrthoEvidence, fondés sur la littérature scientifique, nous aident à prendre des décisions éclairées en ce sens. Les membres ont accès à ces deux rapports (cliquez ici). On y analyse les données probantes, des essais cliniques aléatoires et des méta-analyses d’essais cliniques aléatoires dans la littérature orthopédique afin de cerner les traitements utilisés à l’heure actuelle qui pourraient s’avérer inefficaces par rapport aux méthodes traditionnelles ou qui sont peu efficaces. En ce qui a trait à la gestion des pathologies dégénératives du genou, les interventions suivantes sont abordées dans le rapport Identifying Musculoskeletal Interventions with Low Levels of Efficacy in the Knee : • Débridement arthroscopique des lésions méniscales dégénératives • Arthroplastie totale du genou avec instrumentation personnalisée et navigation virtuelle • Prothèses totales du genou à grande amplitude de flexion, à plateau rotatoire et à conservation du ligament croisé postérieur • Arthroplastie totale du genou avec instrumentation sexospécifique • Arthroplastie totale du genou réalisée sous garrot Les interventions à l’épaule et au coude suivantes sont abordées dans le rapport Identifying Musculoskeletal Interventions with Limited Levels of Efficacy in the Shoulder & Elbow :

• Gestion opératoire des fractures déplacées de l’humérus chez les personnes âgées • Gestion opératoire du syndrome de conflit sous-acromial • Réparation de la coiffe des rotateurs par injections de plasma riche en plaquettes (PRP) et acromioplastie • Efficacité du traitement de la capsulite rétractile et de l’épicondylite latérale • Immobilisation de l’épaule en rotation externe après un épisode de luxation J’en profite pour remercier le Dr Mohit Bhandari, titulaire de la Chaire de recherche du Canada sur les traumatismes musculosquelettiques et les résultats chirurgicaux, à l’Université McMaster, à Hamilton, en Ontario, pour son leadership et l’aide qu’il a apportée à la direction dans l’élaboration des rapports susmentionnés. Il s’agit de ma dernière communication en tant que président de l’ACO. Je remercie sincèrement Meghan Corbeil, Trinity Wittman et Cynthia Vezina pour tous leurs efforts au cours de la dernière année. Ces personnes d’exception sont les piliers de notre association. Je salue également Doug Thomson, dont le sens de l’organisation et les conseils judicieux sont toujours prodigués avec bonhomie, et souvent avec un humour mordant fort apprécié. Enfin, Barb et moi souhaitons remercier chacun des membres de l’ACO de nous avoir donné l’occasion de représenter le milieu canadien de l’orthopédie au pays et à l’étranger. Ce fut un grand honneur et un privilège pour nous, et nous vous en serons éternellement reconnaissants. Je sais que, sous la houlette du Dr Peter MacDonald, l’ACO sera en de bonnes mains. Vous pouvez compter sur Peter et Sherry pour nous représenter avec brio.

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

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

COA Bulletin ACO - Summer / Été 2016

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The COA’s 2016 CFBS Fellows Drs. Danny Goel & Andrea Veljkovic

rs. Andrea Veljkovic and Danny Goel have been selected as the COA’s 2016 Canada-French-BelgianSwiss (CFBS) travelling fellows. Dr. Andrea Veljkovic is a foot and ankle orthopaedic surgeon recently appointed to the University of British Columbia. She is interested in alignment restoration, complex foot and ankle deformities, arthroplasty, and advanced arthroscopic reconstruction. After orthopaedic residency training in Halifax and Edmonton, she completed a Dr. Andrea Veljkovic, 2016 CFBS sports medicine fellowship at Fellow UBC, followed by training in foot and ankle and lower extremity reconstruction at the University of Iowa. During her second fellowship at the University of Iowa, she developed her skills for minimally-invasive foot and ankle surgery as it pertains to foot and ankle reconstruction and joint preservation. After completing her fellowship training, Dr. Veljkovic had a community orthopaedic practice in Nova Scotia before moving to the University Health Network at the University of Toronto, where she obtained a perfect teaching effectiveness score. Her research interests are in minimally-invasive reconstructive techniques, foot and ankle alignment, and joint preservation. She just completed her Masters of Public Health at Harvard University, and currently serves as the Research Director of both the Canadian Foot and Ankle Society and University of British Columbia’s residency program. Outside of orthopaedics, Dr. Veljkovic enjoys rock climbing, skiing, scuba diving, and photography. Dr. Andrea Veljkovic was also recently awarded the Austrian-Swiss-German (ASG) fellowship by the COA. She completed her ASG tour in April and will include a summary of her experience in an upcoming edition of the COA Bulletin.

COA Bulletin ACO - Summer / Été 2016

Dr. Danny Goel is a shoulder surgeon at Burnaby Hospital in Burnaby, BC. He is a Clinical Associate Professor at the University of British Columbia. His clinical practice includes arthroscopic and open shoulder reconstruction with an interest in tendon transfers for patients with brachial plexus injuries. Dr. Goel earned his MD and MSc degree from the University of Manitoba. He then pursued his orthopaedic surgery training at the University of Calgary. Dr. Danny Goel, 2016 CFBS Fellow

Following residency, Dr. Goel pursued two shoulder fellowships at Western and Harvard University. He has also had exposure to complex shoulder tendon transfers at the Mayo Clinic, Rochester, MN. His research interests are diverse and include studies of perception as they relate to shoulder arthroscopy, health economics and surgeon-driven shoulder ultrasound. Dr. Goel’s personal interests include golfing, hiking, snowboarding and spending time with his family. Both surgeons will tour centres in France, Belgium and Switzerland for four weeks beginning in October of this year and will attend the SOFCOT meeting in Paris. We wish them both safe travels and a most enjoyable tour! We would also like to thank our affiliates at the Société Française de Chirurgie Orthopédique et Traumatologique (SOFCOT), Société Royale Belge de Chirurgie Orthopédique et de Traumatologie (SORBCOT) and the Centre hôspitalier universitaire vaudois (CHUV) for hosting our Canadian fellows and supporting this exchange. Stay tuned for a summary of Drs. Veljkovic and Goel’s experience in an upcoming edition of the COA Bulletin.

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The 2015 North American Travelling Fellowship Bashar Alolabi, M.D., MSc, FRCSC McMaster University Hamilton, ON On behalf of the 2015 NATF Fellows: Jonathan Dickens, M.D., Xinning “Tiger” Li, M.D., Addisu Mesfin, M.D., Anna N. Miller, M.D.

he North American Traveling Fellowship (NATF) was initiated in 1970 after the American Orthopaedic Association (AOA) appointed a group to “further study exchange fellowships throughout the world” and “determine the feasibility of increasing exchange fellowships.” The goal of the fellowship is to promote clinical, scientific and social exchange among early-career academic orthopaedic surgeons. It aims to recognize young leaders for their early contributions to orthopaedics, develop leadership skills, allow interactions with world orthopaedic leaders and previous travelling fellows, prepare for the greater challenges of improving the specialty, and confront critical issues.

The 2015 tour focused specifically on leadership, in addition to the usual academics and networking. Throughout the tour, we had the opportunity to meet with departmental, hospital and medical school leaders, including world-wide leaders in orthopaedics. We also initiated a research project evaluating orthopaedic residents and fellows on factors that impact their residency and fellowship choices, understanding of the financial aspects of clinical practice as well as examining the prevalence of depression among orthopaedic residents and fellows. We brought each of our hosts a surgical mallet with “2015 North American Traveling Fellows” engraved on one side and our names on the other as a small gift to show our appreciation (Figure 1).

The four-week tour occurs every odd year in Canada and the United States. One surgeon is chosen from Canada on behalf of the Canadian Orthopaedic Association (COA), and four surgeons from the United States on behalf of the AOA. The 2015 NATF fellows were: Bashar Alolabi, M.D., MSc, FRCSC (Canadian Fellow) McMaster University. Hamilton. ON, Canada Trauma and Shoulder & Elbow Jonathan Dickens, M.D. Walter Reed National Military Medical Centre Bethesda, MD, USA Sports Medicine Xinning “Tiger” Li, M.D. Boston University Boston, MA, USA Sports Medicine and Shoulder & Elbow Addisu Mesfin, M.D. University of Rochester Rochester, NY, USA Spine Anna N. Miller, M.D. Wake Forest School of Medicine, Winston-Salem, NC, USA Trauma We had the privilege of visiting 14 academic institutions throughout the Midwest United States and Canada over a thirty-day period. I, personally, am grateful to the COA for granting me the opportunity to be their ambassador during this oncein-a-lifetime experience.

Figure 1

London, Ontario: Western University Our tour started in Canada in London, Ontario. We had our first mishap when Tiger’s connecting flight from Toronto to London got delayed. In order to avoid missing his first welcoming dinner of the tour, I drove to Toronto Pearson Airport to pick him up and started heading towards London, only to get caught in rush hour traffic in Toronto. Nevertheless, we made it right on time for our welcoming dinner in London, where all five fellows met for the first time. We were greeted by our host Dr. George Athwal (NATF 2007) as well as Drs. Steven MacDonald (Chairman), Mark MacLeod, Graham King (NATF 1993, ABC 1997), and Ken Faber (ABC 2005). The American fellows got to experience the Canadian health-care system for the first time. We had a “full-house” academic session in the morning, where the NATF fellows presented some of their research, and then spent some time in clinics and the operating room as well as visiting several of their hospitals. Dr. Athwal took a few of us on a tour of the shoulder and elbow research facility and gave us personal and career development advice stating that “personal sacrifice is important to help achieve future success.” We were also fortunate to attend a hockey game between the London Knights and Windsor Spitfires. This was a great experience especially for some of the American fellows that had never previously attended a hockey game (Figure 2).

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AOA President 2015), and Mr. Sabi Singh (Chief Operating Officer). Specifically, we discussed the importance of succession planning and choosing talented and brilliant successors, priorities of a chairman and the different models of running a hospital. We then had dinner with Drs. Buckwalter and Brian Wolf (ABC 2013) on the evening of homecoming in the heart of the college town centre. The next day after tailgating, we got to tour the Hawkeyes training facility and watched the Hawkeyes beat the Illinois Fighting Illini.

Figure 2

Winnipeg, Manitoba: University of Manitoba We then flew to Winnipeg, where we were hosted by Dr. Peter MacDonald (NATF 1992, Section Head). We toured the PanAm Clinic, where we listened to a number of interesting lectures regarding projects to improve timely patient care. The fellows also presented some of their research projects. While in Winnipeg, we had the opportunity to meet and learn from a number of faculty including Drs. Jason Old, Michael Johnson, Tod Clark, Jeff Leiter, Ted Tufescu, Michael Goytan and Eric Bohm (ABC 2009). We also visited the Concordia Hip and Knee Institute including implant retrieval and research facilities and were lucky to also tour the newly established Canadian Museum for Human Rights, a truly unique and impressive experience. Omaha, Nebraska: University of Nebraska Our tour then crossed the borders over to the United States, starting with the University of Nebraska hosted by Dr. Susan Scherl (ASG 2010). That evening we were invited to a pleasant dinner at Dr. Scherl’s house and were joined by Drs. Esposito and Jenson. The next morning, we visited clinics and operating rooms with our respective subspecialty hosts, followed by an interactive academic session with their faculty and residents led by Dr. Kevin Garvin (ABC 1995, Chair). Dr. Howard Liu, Assistant Vice Chancellor for Faculty Development, gave an entertaining lecture on leadership development and encouraged us “not to be afraid to take risks, especially early on. Have specific goals, expect the unexpected and be prepared to improvise. Find tough and honest mentors.” Presentations were also given by the NATF fellows and some of the University of Nebraska faculty. We also got to visit Dr. Hani Haider’s biomechanics research facility, including some of the new and fascinating technology that is being developed there with a special focus on knee arthroplasty. We were also fortunate to briefly experience the nationally renowned Omaha Zoo, but had to cut our visit short to make it to the airport for our flight to Iowa. Iowa City, Iowa: University of Iowa At the University of Iowa, Dr. Carolyn Hettrich (NATF 2013) was our host. We started our program in the morning with a large academic session at the University of Iowa Hospitals and Clinics. This was followed by a great leadership curriculum including discussions with Drs. Jody Buckwalter (ABC 1987, AOA President 2001, former Chair), Larry Marsh (current Chair, COA Bulletin ACO - Summer / Été 2016

Chicago, Illinois: Northwestern, University of Chicago, Loyola, and Rush The next stop of our tour was Chicago, where we had an intense and exhausting schedule visiting four programs in four days. We started with Northwestern and met for lunch with Dr. Terry Peabody (AOA President 2013, Chairman) and discussed his views on resident education and hospital compensation models. He advised us that one of the keys to success is to volunteer your time for positions and then get the job done well and on time. The next morning, we met with our host Dr. Wellington Hsu (NATF 2009) who gave us a tour of Northwestern Hospital followed by spending clinical time with our subspecialty hosts. We then got to experience the Chicago culture in the form of a Segway tour on Lakeshore Drive around Lake Michigan (Figure 3). This was followed by a well-attended academic session in the afternoon with lively discussions and presentations and concluded the day with a great steak dinner with Drs. Patel (ABC 2015), Peabody, Hsu and Kadakia.

Figure 3

At the University of Chicago, we were hosted by Dr. Rex Haydon (NATF 2005, ABC 2009) who took us on a tour of the Oriental Institute Museum. We then had an interactive academic session with presentations by Drs. Michael Lee, Lewis Shi, Jason Koh (NATF 2003), Aravind Athiviraham, Hue Luu (ABC 2015), Michael Simon (ABC 1983), and John Martell. This was followed by a nice dinner where Dr. Simon shared with us his experiences as previous Orthopaedic Chairman and current Dean of Graduate Medical Education. The next morning, we set out to to Loyola University Medical Centre, where we were greeted by our host Dr. William Hopkinson (Surgeon-in-Chief). We started with an academic session with presentations from the NATF fellows followed by discussions on hospital management, leadership

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and professionalism with Dr. Alex Ghanayem (incoming Chair), Dr. Karen Wu (Program Director), Mr. Larry Goldberg (President and CEO) as well as other hospital administrators. Mr. Goldberg taught us about the importance of long-term planning “Keep trying, even when the goal is beyond your lifetime.” That afternoon we experienced an informative tour of Frank Lloyd Wright’s first home organized by Dr. Terry Light (AOA President 2007), who is a board member responsible for the preservation and renovation of the Frank Lloyd Wright’s home in Chicago. That evening, we were hosted for dinner by the Rush faculty, including our host, Dr. Shane Nho (NATF 2011), as well as Drs. Howard An (NATF 1990), Steve Gitelis (NATF 1983), and Matt Colman. A number of residents were also present at the dinner. We learned from Dr. An that “surrounding yourself with great people is the foundation for achieving success.” We started the next morning very early with an academic session. After the fellows presented, we listened to presentations on hospital leadership, training leaders in sports medicine and running a successful practice by Drs. Gitelis, Bernie Bach Jr. and Bush-Joseph. Dr. Bach focused on setting high expectations for training in both academics and personal development and stated that “leaders should not be afraid to hire better and smarter people than themselves; this ideology is what builds a great department.” We finished our visit to Rush by observing a number of surgical cases in the operating room with each of our subspecialty hosts and rushed to the airport after grabbing some deep dish pizza for lunch. Ann Arbor, Michigan: University of Michigan We were greeted that evening in Ann Arbor by our host Dr. Jim Carpenter (Chair), who hosted us for a lovely dinner at his home along with Drs. Bruce Miller (ABC 2011), Jim Goulet, Brian Hallstrom, and John Grant (NATF 2013). The following morning, after presenting our talks, Dr. Hallstrom updated us on his work and leadership of a statewide arthroplasty registry initiative, and Dr. Sybil Biermann (Associate Dean for Graduate Medical Education) discussed leadership achievements and the importance of pursuing endeavours you are passionate about. We also got the opportunity to visit the original Ford plant at the Rouge and attended a historic Michigan vs. Michigan State football game (Figure 4).

Figure 4

St. Louis, Missouri: Washington University Our next stop was St. Louis where we were hosted by Drs. Regis O’Keefe (Chair, ABC 1999) and Robert Brophy (ABC 2015, NATF 2009). We had a full day of leadership talks with Drs. O’Keefe, Richard Gelberman (AAOS President 2001), Ken Yamaguchi (NATF 1997), Rick Wright and Bill Ricci (ABC 2007) (Figure 5). We also met with their CFO and head of their business plan. Dr. Yamaguchi shared with us pearls and lessons he had learned from business school, such as “success in academic medicine hinges on personal characteristics more than performance.” Dr. Gelberman stressed the idea of “hiring the right people, being patient until the right person comes and having the support of the hospital to build a great department”. Dr. O’Keefe taught us that the importance of the Chair supporting his/her staff with their professional development and putting his/her ego aside. Dr. Wright taught us how to successfully run a residency program and the importance of having “laser focus” in one’s career. We also toured the St. Louis Ram’s training facility and discussed leadership with the Ram’s head coach, Jeff Fischer, who also stated that leadership is about “surrounding yourself with great people”.

Figure 5

Columbia, Missouri: University of Missouri In the afternoon we left by ground to the University of Missouri in Columbia, where we were hosted by Dr. Greg Della Rocca (NATF 2009, ABC 2013). We had an educational session at the Missouri Orthopaedic Institute with lively discussions by Drs. Ted Choma, James Keeney and Jim Cook around the history and expansion of the Missouri Orthopaedic Institute, leadership and collaborative research in orthopaedics. Some of the fellows then went for some wine tasting at the Les Bourgeois Winery with Dr. Della Rocca. We also got to meet Dr. Jim Stennard (Chair, interim Dean of the medical school) who shared his experience with us and emphasized the importance of valuing every member of the team. Rochester, Minnesota: Mayo Clinic From Missouri we went to the Mayo Clinic in Rochester. We had a small glitch on the way due to a delayed flight, but our hosts Drs. Sanjeev Kakar (NATF 2013, ABC 2015) and Pete Rose (NATF 2011) were very accommodating. We had a number of leadership talks with chair Dr. Mark Pagnano and Dr. Bernard Morrey (ABC 1983, AOA President 2003, AAOS President 1994). Dr. Pagnano discussed pearls regardCOA Bulletin ACO - Summer / Été 2016

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ing career planning and the focus of one’s research career. Dr. Bernard Morrey explained the eight important qualities that he looked for when he recruited orthopaedic surgeons: knowledge, judgment, hands, humanity, energy, integrity, selflessness, and creativity. Tiger and I then got to spend a half-day in the OR with Drs. Bernard and Mark Morrey observing a revision elbow surgery. This was a unique and memorable day as it was Dr. Morrey’s last case at Mayo Clinic (Figure 6). Drs. Kakar and Rose then took us to visit the Mayo sports centre in Minneapolis followed by Minnesota Timberwolves game.

the outdoor ropes challenge course with the CFI wounded warrior patients (Figure 7). We finished the tour with a dinner at Dr. and Mrs. Dowd’s home with residents and other staff.

Figure 6

Memphis, Tennessee: Campbell Clinic In Memphis we were hosted by Dr. Bill Mihalko (NATF 2003, ABC 2009). We got to stay at the Peabody Hotel and experienced Memphis barbeque and live music on Beale Street. Some of the fellows also visited Graceland and the National Civil Rights Museum. We were given a tour of the clinic and saw the new edition of Campbell’s Operative Orthopaedics textbook in the works. While in Memphis, we had the opportunity to meet with Drs. James Beaty (ABC 1991, NATF 1984, AAOS President 2007), Terry Canale (AAOS President 2000) and Fred Azar (AAOS President 2014). Dr. Beaty encouraged us to be involved in our own hospital structure as a means to influence change. Dr. Azar stated that “managing people is the hardest thing to do in a leadership role.” Dr. Canale stressed the importance of spending time with our families and being involved in the local community. San Antonio, Texas: San Antonio Military Medical Centre Our final stop was Brook Army Medical Centre (San Antonio Military Medical Centre) in San Antonio, Texas, with Dr. Dan Stinner (NATF 2013) as our host. We started with an interactive journal club with the residents. We were fortunate to have a tour of the Centre for the Intrepid (CFI) and learned about the new advancements in prosthetic and physical therapy. Dr. Wenke showed us the US Army Institute for Surgical Research. We also got to test and try the firearms training facility. The most memorable part of this stop, if not the tour, was COA Bulletin ACO - Summer / Été 2016

Figure 7

The 2015 NATF tour was a once-in-a-lifetime experience. We had the privilege of meeting orthopaedic leaders and visionaries, hearing their advice, and learning from their successes and experiences. We learned a lot and we will definitely bring back to our own institutions and lives invaluable lessons to enhance our our care towards our patients, the way we educate residents and our contributions to the field. Above all, this fellowship brought together five strangers from different backgrounds and life paths and created bonds and memories that will last throughout our lives. We would like to thank our families for understanding and encouraging us despite us being away for 30 days; our colleagues for their trust in us and their support during our absence; the COA and AOA for granting us this incredible opportunity; Dr. John Kirkpatrick (NATF 1993), Dr. Pascal Vendittoli, Kathy Sinnen and Cynthia Vezina for all their organization and administrative assistance throughout the tour; and all hosts for their outstanding and kind hospitality and friendship.

Your COA / Votre association

Operation Walk Winnipeg: From Small Gifts to Big Effects Thomas Turgeon, M.D., MPH, FRCSC Medical Director, Operation Walk Winnipeg Winnipeg, MB

peration Walk Winnipeg is an orthopaedic medical mission team based out of Winnipeg, Manitoba that has been active in delivering joint replacement care in the developing world since 2012. The team is a branch of the Operation Walk organization that now has 15 teams across North America, with two based in Canada. Like the other teams, Operation Walk Winnipeg is dedicated to providing services to some of the most vulnerable and impoverished people in the Americas with debilitating end-stage arthritis. Our last four annual missions have been to the Roberto Calderon Hospital in the capital city of Managua, Nicaragua. The mission team is composed of members from every hospital in the city of Winnipeg and has involved orthopaedic surgeons and COA members from Manitoba, Saskatchewan, and British Columbia. As with most medical mission work, the team funds itself through donations and charitable giving of the team members themselves. We also rely heavily on the generosity of medical suppliers and vendors, who have kindly supported us with donations and supplies. For any given mission, we bring all of the required equipment and personnel from home in order to successfully complete the objectives. All told, 60 team members participating in all aspects of surgical, perioperative, and postoperative care provide the joint replacement surgeries which are desperately needed by local patients.

The socialist government of Nicaragua has severe limitations on the medical services it can provide to its people. For many years, Nicaragua has consistently been amongst the three poorest nations in the western hemisphere, along with Honduras and Haiti. While it is not clearly tracked, it is estimated that surgeons in Nicaragua perform between 700-800 joint replacements in total per year for a population of over six million people. Many of the patients whom we have met have measured their wait-time for surgery in decades. Nicaragua is a mountainous country, and, as is the case in most impoverished nations, the vast majority of employment opportunities are manual labour in nature. These patients live hand-to-mouth and when they are no longer able to work, they can neither provide for themselves nor for their families. Family relationships are strong in Nicaragua and family members support each other in any way that they can. This often means one family member having to take on additional jobs to be able to provide for the increasing dependence of their debilitated family member. In some cases, we have seen children dropping out of school to work in order to feed their parents and younger siblings. For these patients, there are really no good local options to acquire the care that they need. The Roberto Calderon Hospital in Managua is a governmentfunded facility with a mandate to provide service to the poor. Unfortunately, their funding is extremely limited. The facility is an academic hospital, training orthopaedic and anesthesia residents as well as nurses. The hospital and its staff do provide 90 joint replacements per year for impoverished patients. Last

Operation Walk Winnipeg team at the 2015 mission start

COA Bulletin ACO - Summer / Ă&#x2030;tĂŠ 2016

Your COA / Votre association

(continued from page 11)

year the Operation Walk Winnipeg team performed 69 joint replacement procedures during the 3-Â˝ days of surgery in Managua. To put that into perspective, this represents approximately 10% of the national annual total of joint replacement procedures done in the entire country of Nicaragua. The Operation Walk Winnipeg team works hard to be effective and efficient in the short one-week visit to Nicaragua. The first half-day is spent in a clinic reviewing all of the patients being considered for surgery for that mission. After a short planning meeting, the team kicks in to high gear and performs a halfday of operating on the first day and then continues in the OR and on the ward for the next three consecutive days. Following that, there is an opportunity for the team to visit the patients on the ward and to see their progress. This provides a wonderful opportunity for team members who would not normally get the chance back in Canada to interact with patients after their surgery and to see the impact of what their work really means to these people. There are goodbyes. There are tears of gratitude. There are smiles. And there is hope. In the end, the mission changes lives - pain and disability are eased, family structures are restored, communities are healed. But changes are not limited just to the patients and their families. All the team members who have been involved with these missions have, themselves, been changed. For many, it has been a first experience outside of the developed-world. It has opened their eyes to see the reality of life beyond our borders. It has brought greater understanding between groups within the same facility who rarely have the opportunity to interact at home. For many, it has restored faith in the basic reasons for which they went into orthopaedic health care in the first place - to help make people whole again after years of pain and suffering.

COA members of Operation Walk Winnipeg operating with a Nicaraguan orthopaedic resident

Once again, Operation Walk Winnipeg will be returning to Nicaragua this fall with a goal to continue the work that we have been so proud and privileged to be part of. It is an honour to work with the people of Managua and to share in the care of the patients of the Roberto Calderon Hospital. The planning, fundraising, preparation, and execution of the mission involve countless hours of work from a dedicated number of volunteers from the team, but ultimately we are all rewarded by the opportunity to work with such amazing patients in a fascinating and beautiful community. We would like to thank the Canadian Orthopaedic Association and the orthopaedic community for supporting this mission work as well as other important mission teams across our country. As Canadians, we are so blessed to have so much, and I take such great pride in the fact that so many of us in the Canadian orthopaedic community take the time and effort to support people in these vulnerable communities and continue to relieve suffering around the globe. To learn more about this project, please visit www.facebook.com/OperationWalkWinnipeg/ or www.concordiafoundation.ca/events/operation-walk-winnipeg/

Surgeons and nurses with a Nicaraguan patient

COA Bulletin ACO - Summer / Ă&#x2030;tĂŠ 2016

The COA Global Surgery (COAGS) Committee is pleased to feature Canadian global health organizations. If you are interested in profiling your organization, please contact Trinity Wittman at trinity@canorth.org.

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BIOLOX®delta Ceramics Reduce the Risk for PJI Revisions in THA Periprosthetic Joint Infection (PJI)

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1. Streicher RM, Porporati A. News on ceramics – beyond wear reduction. Hip Int 2014; 24 (5):515 2. Graves SE, Lorimer M, Bragdon C, Muratoglu O, Malchau H. Reduced risk of revision for infection when a ceramic bearing surface is used. Abstract ISTA 2015 3. Trampuz A, Maiolo EM, Winkler T, Perka C. Biofilm formation on ceramic, metal and polyethylene bearing components from hip joint replacement systems. Abstract ISTA 2015 4. Beraudi A, Stea S, Pasquale D, Bordini B, Catalani S, Apostoli P., Toni A. Metal ion release: also a concern for ceramic-onceramic couplings? Hip Int 2014: 24 (4): 321-326

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Introducing the Canadian Shoulder and Elbow Society (CSES) Darren Drosdowech, M.D., FRCSC President, Canadian Shoulder and Elbow Society London, ON, Richard Holtby, M.D., FRCSC Past-President, JOINTS Canada Toronto, ON

his year marks a new beginning for Canadian shoulder and elbow surgeons. We are pleased to introduce the newly minted Canadian Shoulder and Elbow Society (CSES), which will strive to offer a broad range of research, clinical and educational activities to the shoulder and elbow surgery community. Below is some background information on where we have been, where we are going, and how you can take part in CSES activities. Seventeen years ago, a group of Canadian shoulder surgeons convened with the unofficial title of “The Canadian Shoulder Research Group”, following the lead of Dr. Alexandra (Sandy) Kirkley from Western University, who nurtured the idea that Canada was uniquely positioned to perform multi-centered clinical trials around shoulder surgery. Tragically, Sandy died in a plane crash in September 2002, at which time Dr. Nick Mohtadi from Calgary assumed the leadership role of the association, with administrative assistance from Ms. Sharon Griffin. The group changed its name to Joint Orthopaedic Initiative for National Trials of the Shoulder (JOINTS Canada). In 2006, Dr. Richard Holtby was elected President. JOINTS research accomplishments include RCTs looking at thermal capsulorraphy vs. open capsular shift for MDI, cemented vs. uncemented humeral components for TSR, use of biological patches to enhance healing of rotator cuff tears and arthroscopic vs. open repair of rotator cuff tears. Several of these have been funded by CIHR. An increased focus on education initiated by the tireless work of Dr. Dominique Rouleau from Université de Montreal led to the inaugural JOINTS Canada Resident Shoulder Course in 2012. The course has typically taken place in Montreal or Ottawa, and

is now an annual focal point, bringing together shoulder surgeons, international invited guest teachers and residents from across the country. Take note that we are headed west for the 2016 course in Calgary! Recently, members and non-academic clinicians have expressed interest in a broader scope for the organization. In 2015, Dr. Darren Drosdowech from Western University was elected President of JOINTS and has led the recent evolution of JOINTS Canada into the newly named Canadian Shoulder and Elbow Society (CSES), which welcomes the inclusion of surgeons and researchers with an interest in elbow surgery. The CSES’ broader academic perspective will focus on research, clinical activities and education, enhancing its relevance to all Canadian shoulder and elbow subspecialists and giving Canada a louder voice among subspecialty societies worldwide. We believe that this transformation will continue to honour Sandy’s initial idea for a national group of upper extremity specialists. The CSES will next meet at the COA Annual Meeting in beautiful Québec City from June 16-19, 2016. The program includes shoulder and elbow ICLs, paper sessions and symposia throughout the meeting, followed by a CSES Clinical Half Day on the morning of Sunday, June 19. We are pleased to announce Dr. Richard Hawkins as our Guest Speaker, followed by a Distal Humeral Fractures Symposium. CLICK HERE for a summary of shoulder and elbow programming at the COA meeting. Joining the CSES is easy! If you consider shoulder and elbow to be part of your practice and you would like to become a CSES member, please visit http://coa-aco.org/cses/cses-membership/ to view membership criteria and instructions. All former JOINTS Canada members are still considered members of the CSES. For any inquiries, please contact cses@canorth.org. We look forward to a successful shoulder and elbow collaboration with our colleagues across Canada.

COA Bulletin ACO - Summer / Été 2016

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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 - Summer / Été 2016

Revision Redefined: Triathlon Tritanium Cone Augments ®

Stryker’s Triathlon Revision Knee System features Tritanium Cone Augments • Simplified preparation with reamer-based instrumentation1, 2, 3, 4 • Unique 3D printed Tritanium augments are designed to provide structural support and biologic fixation • Allows for metaphyseal fixation without constraining subsequent implant positioning1 • SOMA-designed to help meet reconstruction challenges and fit a broad range of patients5 References 1. Triathlon Revision Knee System Surgical Protocol (TRITS-SP-2 Rev-1) 2. Triathlon Tritanium Cone Augments Validation Report. Doc #A0004381. Project #195725 3. Femoral Bone Prep Tolerance Analysis. Doc #A0004384. Project #195725 4. Tibial Bone Prep Tolerance Analysis. Doc #A0004385. Project # 195725 5. Leibowitz E, Lipschutz D, Soliman M, Meneghini M. Virtual Bone Analysis Determines Metaphyseal Augment Fit. ORS 2015 Meeting Poster. 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. © 2016 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. TRITS-AD-2 Rev.2 03/16

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

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COA Bulletin ACO - Summer / Été 2016

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

Comparing Outcomes for Simultaneous and Staged Bilateral Total Knee Replacement Surgeries In April 2016, the Canadian Institute for Health Information (CIHI) released a Canadian Joint Replacement Registry (CJRR) report that examined outcomes for simultaneous versus staged bilateral total knee replacement surgeries. This brief article presents a summary of the main findings. Context otal knee replacement (TKR) is one of the most common and costly surgeries performed in Canada. Approximately 55,000 elective TKRs are performed annually, with an estimated acute care cost of nearly $400 million*. When patients need to have both knees replaced, one of the initial decisions is whether to have both knees surgically replaced with prosthetic joints during the same time surgery (simultaneous TKR) or during separate surgeries (staged TKR). Ultimately, the orthopaedic surgeon decides on the course of action after considering the patient’s demographic factors, disease progress and severity, and preferences and expectations of recovery. However, there are patient-related and hospital resource-related implications resulting from this decision, given that simultaneous bilateral TKR (BTKR) involves one hospitalization with one anesthetic administration to the patient.

The differences in outcomes between these two types of BTKR surgeries have been studied previously, with mixed findings1. The analysis presented here is the first pan-Canadian published study to date on this topic, examining data from CIHI’s Hospital Morbidity Database (HMDB). The HMDB captures demographic and clinical information on all discharges from acute care facilities in Canada, including all knee joint replacements and revisions, and is used for CJRR reporting. Methods and Findings The study cohort included all patients who underwent primary elective TKR surgery in Canadian acute care facilities between 2006–2007 and 2013–2014. Data for 2014–2015 was also used to identify post-discharge outcomes. Risks of adverse outcomes for simultaneous surgeries were compared with the cumulative risk over both stages of bilateral staged surgeries. Over the eight-year study period, 7,369 patients (19.6%) underwent simultaneous BTKRs and 30,188 (80.4%) underwent staged BTKRs (with 95% of them staged at least three months to a maximum of one year apart). There were statistically significant differences in the two BTKR groups’ characteristics: patients in the simultaneous group were younger, more likely male and had fewer comorbidities. Simultaneous BTKRs were also significantly more likely to be performed in facilities with the highest TKR volumes. All comparative analyses between the BTKR approaches were adjusted for patient age at time of surgery, sex, presence of comorbidity and facility TKR volume.

* excluding physician costs COA Bulletin ACO - Summer / Été 2016

The comparison of outcomes revealed a number of differences between the two BTKR approaches (Table 1); including some important differences regarding patient discharge pathways. Simultaneous BTKR patients were more likely discharged to inpatient rehabilitation (44.7%), whereas staged BTKR patients were more likely discharged home (88.4%). In terms of hospital stay, patients in the simultaneous BTKR group had a significantly shorter median length of stay and were significantly more likely to require a blood transfusion. As well, patients in the simultaneous BTKR group had a lower risk of readmission with a knee infection, compared to the staged BTKR group for the same period. The risk of having a cardiac complication or pulmonary embolism over the combined period of the inpatient stay and 90 days post-discharge was similar between the two BTKR approaches. There was no statistically significant difference identified between the two approaches for the risk of having a revision within three years of the primary BTKR. Based on available system cost estimates, the overall average costs of simultaneous and staged procedures were comparable, with total costs of $20,800 and $23,700, respectively (including acute care in-hospital and physician and inpatient rehab). Implications for the Canadian Health System Our analysis identified a number of differences in the outcomes of simultaneous and staged BTKRs, both during the hospital stay and after discharge. Although differences were found related to length of stay, blood transfusion rate and discharge pathway, it is important to keep in mind the relatively low observed rate of complications and revisions regardless of which approach was used. Many factors, related to the patient and to available resources, are involved in the decision to have simultaneous versus staged surgeries. Thus, it is important for surgeons to continue to have meaningful discussions with each patient to help determine the most appropriate treatment plan for each particular situation, including in-hospital and post-discharge stay options. By using the largest Canadian cohort of its kind, this study makes an important contribution to the body of knowledge comparing types of TKRs and their outcomes. Such findings have relevance for policy, health systems and patients. Improved data for monitoring TKRs and revisions is a key role of national registries related to joint replacements, such as the CJRR. For the full report, supplementary resources and for more information about CJRR, please visit www.cihi.ca/cjrr. CIHI would also like to thank Dr. Eric Bohm, Dr. Michael Dunbar, Dr. Bas Masri and Dr. Emil Schemitsch for their invaluable advice and support on the analysis and full report.

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

Table 1. Selected outcomes of simultaneous versus staged bilateral total knee replacements (BTKR)

Outcome* Median total inpatient length of stay (days)** Blood transfusion (%) Discharge disposition to level of care (%)‡‡ Transfer to general/special rehab Home or a home setting with support services from external agency§§ Home with no support services from external agency§§ Other pathways‡‡‡ Knee infection complication rate (90-day readmission) (%)*** Overall complication rate (inpatient and/or 90-day readmission)††† (%)*** Cardiac complications§§§ Pulmonary embolism Knee infection 3-year revision rate (% of TKRs)

Simultaneous BTKR 6 37.2

Staged BTKR‡ 8 17.3

p-Value§ <0.0001 <0.0001 <0.0001‡‡

44.7 21.5 28.6 5.2 0.4

8.5 32.5 55.9 3.0 0.9

0.0022

1.9 1.1 0.5 1.5

1.8 1.0 0.9 1.4

0.14 0.56 0.0045 0.59

Reference 1. Canadian Institute for Health Information. Outcomes for simultaneous and staged bilateral total knee replacement surgeries. 2016. URL: www.cihi.ca/cjrr.

Notes * Outcomes represent percentage of patients affected, except where otherwise noted. ‡ Outcomes were calculated over both stages and were counted if present at least once, except where otherwise noted. § Comparison between BTKR groups (simultaneous versus combined stages, unless otherwise noted). p-Value after adjusting for patient age at time of surgery, sex, presence of Charlson comorbidity and facility TKR volume. Significance level set at 0.05. ** Total length of stay for staged BTKR was first calculated for each patient and then combined over the two stages: there was a median of 4 days per hospital stay at each stage. ‡‡ For staged BTKRs, overall discharges after either stage of the staged BTKR (per number of knees replaced). p-Value represents comparison with the second surgery discharge. Includes only patients discharged alive. ‡‡‡ Includes: Transfer to acute care, Transfer to chronic care/nursing home/home for the aged, Transfer to other/unclassified care. §§ Support services are related to activities of daily living and not to rehabilitation care. *** Patients discharged before 2009–2010 were excluded due to coding differences (diagnosis cluster was not available). ††† If a patient experienced a complication (cardiac, pulmonary embolism or infection) in hospital and/or was readmitted with it within 90 days, 1 combined event was coded. §§§ Includes acute ischemia, infarction and arrhythmia. BTKR: Bilateral total knee replacement. Source: Hospital Morbidity Database, 2006–2007 to 2014–2015, Canadian Institute for Health Information.

Management of Isolated Medial-sided Knee OA in the Middle-aged Patient Introduction to this edition’s debate

50-year-old patient with moderate medial compartment osteoarthritis of the knee presents to your clinic for a definitive surgical opinion having failed all non-operative interventions. There are surgical options that range from joint preserving surgery to partial and complete reconstruction of the joint. The final choice on surgical intervention will depend on a multitude of factors including: patient values and preferences, clinical evidence in the literature and surgeon experience and skill. In this debate, experts from the University of Pittsburgh, Western University and McMaster University debate some important options for this scenario. Enjoy the debate! * excluding physician costs Femi Ayeni, M.D., MSc FRCSC, Dip Sport Med. Scientific Editor, COA Bulletin COA Bulletin ACO - Summer / Été 2016

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

High Tibial Osteotomy for Management of Isolated Medial-sided Knee OA in the Middle-aged Patient Michaela Kopka, M.D. Elmar Herbst, M.D. Volker Musahl, M.D. UPMC Centre for Sports Medicine, University of Pittsburgh Pittsburgh, PA

rthopaedic surgery has always been intimately linked with technology. Technological advances have driven orthopaedic research, been essential in developing surgical tools and techniques, and served to improve patient care. Yet despite the necessity and influence of technology, it is important not to let it obscure the fundamental surgical principles and procedures that have proved their merit over many years of practice. Unloading high tibial osteotomy (HTO) is one such technique. Used extensively to treat unicompartmental osteoarthritis (OA) in the 1980’s, HTO fell out of favour with the advent and success of total knee arthroplasty (TKA). However, a recent rise in arthroplasty failures in the young and active cohort has prompted a reconsideration of HTO as a viable treatment option1. In this text, we discuss why HTO should not only be considered in this scenario, but why it is likely the most appropriate choice. Consider this case scenario, a self-employed active person who presents with a ten-year history of progressive medial left knee pain not relieved by typical non-operative strategies. Pertinent physical examination findings include bilateral varus deformity of approximately 10˚, range of motion from 0-125˚, and a stable ligamentous exam. Radiographs (Figure 1) reveal isolated medial compartment OA with varus deformity. He was offered a TKA but presents for a second opinion due to his desire to remain active in his job and recreational activities. This patient represents the ideal candidate for an HTO. He is physiologically young and active, with isolated medial compartment OA, varus malalignment, preserved range of motion (>120˚), and no ligamentous instability2-4. The main advantage that HTO affords in this particular patient population is the ability to maintain an active lifestyle without the typical restrictions necessary following TKA. In fact, return to sport following HTO is as high as 93% – with 80% of patients returning to the same level of play. More importantly, up to 94% are able to return to work duties including heavy manual labour5. Activity restriction is not necessary because, unlike arthroplasty, HTO maintains the native knee joint and does not rely on prosthetic implants with a finite lifespan. It works instead by realigning the mechanical axis of the lower limb to transfer the load to the healthy lateral compartment. This can be accomplished on the tibial side by either an opening wedge medial or a closing wedge lateral osteotomy. In off-loading the medial compartment, HTO is also an important adjunct to meniscus and cartilage reconstruction techniques6,7. Furthermore, it can be used to supplement cruciate reconstruction by modifying the tibial slope to reduce anterior or posterior tibial translation8.

COA Bulletin ACO - Summer / Été 2016

Figure 1 Preoperative X-rays

One of the main criticisms of HTO is that the healthy lateral compartment will eventually wear out thereby necessitating conversion to TKA. Recent data reveals that this occurs much less frequently than once thought, with ten and 20 year survivorship reported as 98% and 85%, respectively9-11. Additionally, the conversion of HTO to TKA is much less involved than a revision arthroplasty procedure. Studies show no difference in outcomes between primary TKA and TKA following HTO12. In contrast, outcomes following revision TKA are significantly inferior to primary TKA with patient satisfaction dropping to 55% and the risk of complications rising up to 28%13,14. Critics of the HTO also cite prolonged surgical time, a need for additional procedures, and decreased postoperative range of motion as downsides of converting HTO to TKA. It is important to note that these issues relate primarily to lateral closing wedge osteotomy which has been shown to predispose to patella baja15. Medial opening wedge osteotomy acts instead to increase patellar height and is generally not associated with these concerns16. A recent systematic review has shown no difference in patient-reported outcomes or revision rates between primary

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

TKA and TKA following HTO, proving that osteotomy does not compromise a later TKA17-19. High tibial osteotomy has often been compared to unicompartmental knee arthroplasty (UKA). Despite some similarities in indications, UKA and HTO are distinctly different procedures that deviate in philosophy and should not be considered interchangeable. Unlike HTO, UKA is not indicated in active patients or those with significant varus malalignment (>10˚), and is more appropriate in low-demand patients with severe medial OA20. As with any arthroplasty procedure, activity restrictions are necessary following UKA. Furthermore, revision UKA to TKA has been shown to have inferior results compared to primary TKA21. In a direct comparison of 30 patients undergoing revision UKA to TKA and 30 patients undergoing conversion of HTO to TKA, bone grafting was required in 77% of UKAs compared to only 20% of HTOs. The HTO group also had significantly better functional scores22. These results support HTO over UKA as a superior and less invasive treatment for isolated medial OA. Finally, it is prudent to consider the societal costs associated with HTO, UKA, and TKA. A recent cost-analysis of all three procedures in various patient age groups showed that HTO is the most cost-effective in patients under the age of 60 years23. A similar study reported that HTO could save approximately $4,263 USD compared to UKA and TKA when considering complications, conversions, and revisions in a patient’s lifetime. Furthermore, based on a willingness-to-pay threshold of $50,000 USD, HTO was shown to be cost-effective 57% of the time, compared to 24% for TKA and only 19% for UKA24. In Canada’s publicly-funded health-care system, these cost considerations must be factored into the clinical decision-making process. In closing, in order to satisfy his goals of returning to an active lifestyle, we recommend a medial opening wedge HTO (Figure 2). Not only does HTO permit a higher level of activity than arthroplasty, it affords excellent patient satisfaction with long-term durability, decreased morbidity, and increased costeffectiveness. Accordingly, we believe that HTO is the most appropriate treatment option for isolated medial compartment OA in the young and active patient. Despite the lure of new technologies, it is critical to maintain a broad perspective and the skill set to apply fundamental surgical techniques which often provide more effective treatment options that better meet patient expectations and improve overall outcomes. References 1. Carr A.J., Robertsson O., Graves S., Price A.J., Arden N.K., Judge A., et al. Knee replacement. Lancet. 2012;379(9823):13311340. 2. Scordino L.E., DeBerardino T.M. Surgical treatment of osteoarthritis in the middle-aged athlete: new horizons in high tibial osteotomies. Sports Med Arthrosc. 2013;21(1):47-51. 3. Gomoll A.H. High tibial osteotomy for the treatment of unicompartmental knee osteoarthritis: a review of the literature, indications, and technique. Phys Sportsmed. 2011;39(3):45-54.

Figure 2 Postoperative X-rays

4. Gardiner A., Gutierrez Sevilla G.R., Steiner M.E., Richmond J.C. Osteotomies about the knee for tibiofemoral malalignment in the athletic patient. Am J Sports Med. 2010;38(5):1038-1047. 5. Faschingbauer M., Nelitz M., Urlaub S., Reichel H., Dornacher D. Return to work and sporting activities after high tibial osteotomy. Int Orthop. 2015;39(8):1527-1534. 6. Van Thiel G.S., Frank R.M., Gupta A., Ghodadra N., Shewman E.F., Wang V.M., et al. Biomechanical evaluation of a high tibial osteotomy with a meniscal transplant. J Knee Surg. 2011;24(1):45-53. 7. Harris J.D., Hussey K., Wilson H., Pilz K., Gupta A.K., Gomoll A., et al. Biological knee reconstruction for combined malalignment, meniscal deficiency, and articular cartilage disease. Arthroscopy. 2015;31(2):275-282. 8. Rossi R., Bonasia D.E., Amendola A. The role of high tibial osteotomy in the varus knee. J Am Acad Orthop Surg. 2011;19(10):590-599. 9. Gstottner M., Pedross F., Liebensteiner M., Bach C. Long-term outcome after high tibial osteotomy. Arch Orthop Trauma Surg. 2008;128(1):111-115. 10. Akizuki S., Shibakawa A., Takizawa T., Yamazaki I., Horiuchi H. The long-term outcome of high tibial osteotomy: a ten- to 20-year follow-up. J Bone Joint Surg Br. 2008;90(5):592-596. 11. Flecher X., Parratte S., Aubaniac J.M., Argenson J.N. A 12-28year followup study of closing wedge high tibial osteotomy. Clin Orthop Relat Res. 2006;452:91-96.

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

(continued from page 23)

12. Ramappa M., Anand S., Jennings A. Total knee replacement following high tibial osteotomy versus total knee replacement without high tibial osteotomy: a systematic review and meta analysis. Arch Orthop Trauma Surg. 2013;133(11):15871593. 13. Baier C., Luring C., Schaumburger J., Kock F., Beckmann J., Tingart M., et al. Assessing patient-oriented results after revision total knee arthroplasty. J Orthop Sci. 2013;18(6):955961. 14. Kallala R.F., Vanhegan I.S., Ibrahim M.S., Sarmah S., Haddad F.S. Financial analysis of revision knee surgery based on NHS tariffs and hospital costs: does it pay to provide a revision service? Bone Joint J. 2015;97-B(2):197-201. 15. Scuderi G.R., Windsor R.E., Insall J.N. Observations on patellar height after proximal tibial osteotomy. J Bone Joint Surg Am. 1989;71(2):245-248. 16. Wright J.M., Heavrin B., Begg M, Sakyrd G, Sterett W. Observations on patellar height following opening wedge proximal tibial osteotomy. Am J Knee Surg. 2001;14(3):163-173. 17. van Raaij T.M., Reijman M., Furlan A.D., Verhaar J.A. Total knee arthroplasty after high tibial osteotomy. A systematic review. BMC Musculoskelet Disord. 2009;10:88. 18. Amendola A., Rorabeck C.H., Bourne R.B., Apyan P.M. Total knee arthroplasty following high tibial osteotomy for osteoarthritis. J Arthroplasty. 1989;4 Suppl:S11-17.

19. Kazakos K.J., Chatzipapas C., Verettas D., Galanis V., Xarchas K.C., Psillakis I. Mid-term results of total knee arthroplasty after high tibial osteotomy. Arch Orthop Trauma Surg. 2008;128(2):167-173. 20. Dettoni F., Bonasia D.E., Castoldi F., Bruzzone M., Blonna D., Rossi R. High tibial osteotomy versus unicompartmental knee arthroplasty for medial compartment arthrosis of the knee: a review of the literature. Iowa Orthop J. 2010;30:131-140. 21. Springer B.D., Scott R.D., Thornhill T.S. Conversion of failed unicompartmental knee arthroplasty to TKA. Clin Orthop Relat Res. 2006;446:214-220. 22. Gill T., Schemitsch E.H., Brick G.W., Thornhill T.S. Revision total knee arthroplasty after failed unicompartmental knee arthroplasty or high tibial osteotomy. Clin Orthop Relat Res. 1995(321):10-18. 23. Smith W.B., 2nd, Steinberg J., Scholtes S., McNamara I.R. Medial compartment knee osteoarthritis: age-stratified costeffectiveness of total knee arthroplasty, unicompartmental knee arthroplasty, and high tibial osteotomy. Knee Surg Sports Traumatol Arthrosc. 2015. 24. Konopka J.F., Gomoll A.H., Thornhill T.S., Katz J.N., Losina E. The cost-effectiveness of surgical treatment of medial unicompartmental knee osteoarthritis in younger patients: a computer model-based evaluation. J Bone Joint Surg Am. 2015;97(10):807-817.

The Role of the Unicompartmental Knee Replacement in the Management of Isolated Medial-sided Knee OA in the Middle-aged Patient Brent A. Lanting, M.D., FRCSC, BESc, MSc Assistant Professor, Adult Reconstruction Division of Orthopaedic Surgery, Western University University Hospital London, ON

solated medial-sided knee osteoarthritis (OA) is a common entity resulting in presentation to an orthopaedic practice. The clinical manifestations, pertinent examinations and imaging are well documented in the literature. As with other forms of OA, non-operative modalities comprise the first line of treatment. When the patient no longer responds to nonoperative treatment, the decision to proceed with either hightibial osteotomy (HTO), partial knee replacement (UKR) or total knee replacement (TKR) is faced by the treating surgeon. At this juncture, the patient’s age is a key variable to consider when deciding on operative treatment.

COA Bulletin ACO - Summer / Été 2016

When considering a surgical treatment algorithm, it is imperative that UKR only be considered in the appropriate patient that has a full range of motion with isolated medial osteoarthritis, intact cruciate ligaments, and passively correctable varus malalignment of less than 15 degrees. An important question from the patient’s perspective is often the survivorship of the purposed intervention. The current literature demonstrates that TKR provides the greatest survivorship, as shown in a systematic review comparing the survivorship of TKR, UKR and HTO for unicompartmental osteoarthritis1. This review further suggested that HTO’s had shorter survivorship than UKRs1. Furthermore, survivorship is only one of the important variables to consider when deciding on treatment for this patient population. The majority of the contemporary literature examining TKR outcomes report patient satisfaction rates of approximately 80%2. These findings contrast with those of UKRs, which commonly have a higher rate of patient satisfaction3. The exact reasons for these differences in patient satisfaction are unclear,

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

although a number of possible reasons have been proposed. First, retention of both cruciate ligaments in UKR might result in additional proprioceptive feedback, allowing for a knee with a UKR to feel more like a native knee than one with a TKR. Second, contemporary UKR techniques often suggest leaving the mechanical axis of the leg slightly under-corrected. The retention of native alignment and both cruciate ligaments may allow the knee to function more similarly to the native state in comparison to TKRs and HTOs. These theories are perhaps supported by gait studies which demonstrate gait patterns closer to normal in patients with a UKR compared to a TKR4. Additionally, UKR patients more commonly return to the same level of sport than TKR patients, suggesting a difference in the intrinsic feelings of these postoperative knees5. Furthermore, a meta-analysis of comparative studies of UKR and HTO indicated an improved functional result in UKRs6. Perioperative complications are of significant concern for all surgical interventions. The most significant early complication for TKR is infection, at approximately 1-2%. Infections have substantial economic impact as well as a negative effect on the patient’s ultimate outcome. The infection risk of UKR is much lower, commonly shown to be half that of TKR7. Furthermore, TKR patients are twice as likely to have a DVT or myocardial infarction, and three times more likely to have a stroke7. In fact, registry data suggests that the 30-day mortality rate of TKR’s is 0.24%, while that of UKR’s is 0.06%, meaning TKR patients are four-times more likely to die in the first 30 days after surgery7. Unfortunately, literature directly comparing the complication rates of HTO’s to UKR’s is lacking. The most common reason for late re-operation for UKR is lateral compartment OA. When revising a UKR to TKR, the literature has demonstrated that TKR primary components can commonly be successfully utilized8. Unfortunately, revision TKRs following primary UKR have been shown to provide lower patient satisfaction than that of a primary TKR9. The outcomes of TKR following primary UKR are more similar to those of a revision TKR, with the exception that TKR revisions have higher rates of infection8. One of the advantages of a primary UKR is the lower perioperative cost of a UKR compared to a TKR. However, when including the cost of earlier revision, cost analysis does not support the use of UKRs for middle age patients. Registry data has suggested that UKR does not have a theoretical cost-benefit for middle-aged patients when compared to TKR10, and computer modelling indicates that HTO’s actually have the lowest cost per quality-adjusted life year11. Nevertheless, UKR’s have been demonstrated to be cost-effective in patients older than 65 years of age12. In conclusion, UKR should only be considered in the appropriate patient. The improved patient satisfaction and lower perioperative complication rates demonstrate advantages of UKR in comparison to TKRs and HTOs, with the recognition that survivorship does not reach that of a TKR and that UKR’s may not be economically beneficial in all patient populations.

Lateral and AP views of a left unicompartmental knee replacement in an active 52-year-old male

References 1. Griffin T., Rowden N., Morgan D., Atkinson R., Woodruff P., Maddern G. Unicompartmental knee arthroplasty for the treatment of unicompartmental osteoarthritis: a systematic study. ANZ journal of surgery. 2007;77(4):214-221. 2. Bourne R.B., Chesworth B.M., Davis A.M., Mahomed N.N., Charron K.D. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clinical orthopaedics and related research. 2010;468(1):57-63. 3. Von Keudell A., Sodha S., Collins J., Minas T., Fitz W., Gomoll A.H. Patient satisfaction after primary total and unicompartmental knee arthroplasty: an age-dependent analysis. The Knee. 2014;21(1):180-184. 4. Wiik A.V., Manning V., Strachan R.K., Amis A.A., Cobb J.P. Unicompartmental knee arthroplasty enables near normal gait at higher speeds, unlike total knee arthroplasty. The Journal of arthroplasty. 2013;28(9 Suppl):176-178. 5. Hopper G.P., Leach W.J. Participation in sporting activities following knee replacement: total versus unicompartmental. Knee surgery, sports traumatology, arthroscopy : official journal of the ESSKA. 2008;16(10):973-979. 6. Fu D., Li G., Chen K., Zhao Y., Hua Y., Cai Z. Comparison of high tibial osteotomy and unicompartmental knee arthroplasty in the treatment of unicompartmental osteoarthritis: a meta-analysis. The Journal of arthroplasty. 2013;28(5):759765.

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

7. Liddle A.D., Judge A., Pandit H., Murray D.W. Adverse outcomes after total and unicompartmental knee replacement in 101,330 matched patients: a study of data from the National Joint Registry for England and Wales. Lancet (London, England). 2014;384(9952):1437-1445. 8. Leta T.H., Lygre S.H., Skredderstuen A., et al. Outcomes of Unicompartmental Knee Arthroplasty After Aseptic Revision to Total Knee Arthroplasty: A Comparative Study of 768 TKAs and 578 UKAs Revised to TKAs from the Norwegian Arthroplasty Register (1994 to 2011). The Journal of bone and joint surgery. American volume. 2016;98(6):431-440. 9. Pearse A.J., Hooper G.J., Rothwell A., Frampton C. Survival and functional outcome after revision of a unicompartmental to a total knee replacement: the New Zealand National Joint Registry. The Journal of bone and joint surgery. British volume. 2010;92(4):508-512.

10. Koskinen E., Eskelinen A., Paavolainen P., Pulkkinen P., Remes V. Comparison of survival and cost-effectiveness between unicondylar arthroplasty and total knee arthroplasty in patients with primary osteoarthritis: a follow-up study of 50,493 knee replacements from the Finnish Arthroplasty Register. Acta orthopaedica. 2008;79(4):499-507. 11. Konopka J.F., Gomoll A.H., Thornhill T.S., Katz J.N., Losina E. The cost-effectiveness of surgical treatment of medial unicompartmental knee osteoarthritis in younger patients: a computer model-based evaluation. The Journal of bone and joint surgery. American volume. 2015;97(10):807-817. 12. Ghomrawi H.M., Eggman A.A., Pearle A.D. Effect of age on cost-effectiveness of unicompartmental knee arthroplasty compared with total knee arthroplasty in the U.S. The Journal of bone and joint surgery. American volume. 2015;97(5):396402.

Management of Isolated Medial-sided Knee OA in the Middle-aged Patient Argument for Total Knee Arthroplasty Dale S. Williams, M.D., FRCSC Adrian Z. Kurz, M.D. McMaster University, Department of Surgery, Division of Orthopaedics Hamilton, ON

Background he volume of total knee arthroplasty (TKA) is increasing in patients under the age of 55 at a higher rate than all other age groups. The use of classic operations, such as high tibial osteotomy (HTO) and unicompartmental knee arthroplasty (UKA), for isolated medial knee osteoarthritis (OA) in the middle-aged patient remains low, whereas TKA use continues to increase12,21–24. This clear difference regarding the application of surgical options for the middle-aged patient with isolated medial knee OA is multifactorial in nature but seems to be driven by patient experience and demands. For the average middle-aged patient with medial knee OA, the TKA provides the most consistent pain relief and function of the surgical options available, with the lowest revision rates22–24.

Indications Indications for the use of a TKA are broad and nearly all encompassing in the realm of medial knee OA, whereas the use of the UKA and HTO need to be limited to a subset of patients to minimize failures7,14,20. Middle-aged patients with medial knee OA that fall outside of the appropriate weight, deformity and range of motion parameters are necessarily excluded from receiving a HTO or UKA. In an average practice, at most there will be 10% of patients with knee OA that qualify for the HTO or UKA, severely limiting the options for the average middle-aged patient with medial knee OA.

COA Bulletin ACO - Summer / Été 2016

Reliability UKA and HTO are technically demanding operations that require experience and volume to ensure high patient satisfaction and low complication rates14,20. This complexity is reflected in the HTO complication rate, which has been reported to be as high as 30%13,20. Complications in UKA range from 5-10%, with TKA having a similar rate at around 5%6,8,9,17. Surgical tools and techniques for TKA have been refined over decades of highvolume use to allow consistent, reliable implant placement and function. Longevity Among the options for medial knee OA, the TKA is undoubtedly the option that provides the longevity required for the middle-aged patient10. The cumulative revision rate for patients under 55 with a TKA is 14.9% at 14 years, compared to 31.8% for UKA23. Other international joint registries confirm this finding22,24. A Canadian-based study showed the ten-year rate of conversion of a HTO to TKA is 33%, although patient selection may play a role in the high conversion rates shown7. To subject a full third of patients to a revision surgery at 10-14 years seems to be counterintuitive when a more robust option is readily available. The jury is still out on whether a UKA or HTO converted to a TKA gives the high satisfaction, low complication and low revisions rates that a primary TKA provides to patients with medial knee OA2 (Figures 1-2). However, literature from joint registries show a higher revision rate for UKA or HTO, compared to primary TKA11,15.

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

Satisfaction Patient satisfaction with a surgical procedure for medial knee OA relies on many factors including preoperative expectations, pain relief, and overall experience4. A TKA consistently results in persistently high patient satisfaction in over 80% of cases3,4. Reported mid-term satisfaction rates after UKA and HTO range widely but seem to approximate that of the TKA with around 80% of patients reporting satisfaction, but can be as low as 50% for HTO and 65% for UKA at 10-year follow-up1,3,5,16,18,19.

Figure 2 Loose UKA with deep tibial resection and cavitary defect requiring revision stem and augments for TKA

3. Dunbar M.J., Richardson G., Robertsson O. I can’t get no satisfaction after my total knee replacement: rhymes and reasons. Bone Jt. J. 2013 Nov;95-B(11 Suppl A):148–152. doi:10.1302/0301-620X.95B11.32767 4. Hamilton D.F., Lane J.V., Gaston P., Patton J.T., Macdonald D., Simpson A.H.R.W., et al. What determines patient satisfaction with surgery? A prospective cohort study of 4709 patients following total joint replacement. BMJ Open. 2013;3(4). doi:10.1136/bmjopen-2012-002525 Figure 1 Patella baja post HTO requiring tibial tubercle osteotomy for TKA exposure

Conclusion The satisfaction and longevity demands of the average middleage patient with medial knee OA drive the average orthopaedic surgeon to select the procedure with the highest satisfaction and lowest reoperation rate, which is the TKA. Long-term failure rates of all surgical options for medial knee OA remain unacceptably high in the under 55 age group but work continues on improving the bone-implant interface, bearing surfaces and surgical technique to continually increase the longevity of our most reliable solution, the TKA, for severe isolated medial knee OA. References 1. Chiang H., Hsu H.-C., Jiang C.-C. Dome-shaped high tibial osteotomy: a long-term follow-up study. J. Formos. Med. Assoc. Taiwan Yi Zhi. 2006 Mar;105(3):214–219. doi:10.1016/ S0929-6646(09)60308-9 2. Dettoni F., Bonasia D.E., Castoldi F., Bruzzone M., Blonna D., Rossi R. High tibial osteotomy versus unicompartmental knee arthroplasty for medial compartment arthrosis of the knee: a review of the literature. Iowa Orthop. J. 2010;30:131–140.

5. Hui C., Salmon L.J., Kok A., Williams H.A., Hockers N., van der Tempel W.M., et al. Long-term survival of high tibial osteotomy for medial compartment osteoarthritis of the knee. Am. J. Sports Med. 2011 Jan;39(1):64–70. doi:10.1177/0363546510377445 6. Ji J.H., Park S.E., Song I.S., Kang H., Ha J.Y., Jeong J.J. Complications of medial unicompartmental knee arthroplasty. Clin. Orthop. Surg. 2014 Dec;6(4):365–372. doi:10.4055/ cios.2014.6.4.365 7. Khoshbin A., Sheth U., Ogilvie-Harris D., Mahomed N., Jenkinson R., Gandhi R., et al. The effect of patient, provider and surgical factors on survivorship of high tibial osteotomy to total knee arthroplasty: a population-based study. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA. 2015 Nov 4;doi:10.1007/s00167-015-3849-4 8. Kim K.T., Lee S., Lee J.I., Kim J.W. Analysis and Treatment of Complications after Unicompartmental Knee Arthroplasty. Knee Surg. Relat. Res. 2016 Mar;28(1):46–54. doi:10.5792/ ksrr.2016.28.1.46 9. Maempel J.F., Riddoch F., Calleja N., Brenkel I.J. Longer hospital stay, more complications, and increased mortality but substantially improved function after knee replacement in older patients. Acta Orthop. 2015;86(4):451–456. doi:10.310 9/17453674.2015.1040304 COA Bulletin ACO - Summer / Été 2016

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

10. Niinimäki T., Eskelinen A., Mäkelä K., Ohtonen P., Puhto A.-P., Remes V. Unicompartmental knee arthroplasty survivorship is lower than TKA survivorship: a 27-year Finnish registry study. Clin. Orthop. 2014 May;472(5):1496–1501. doi:10.1007/ s11999-013-3347-2 11. Niinimäki T., Eskelinen A., Ohtonen P., Puhto A.-P., Mann B.S., Leppilahti J. Total knee arthroplasty after high tibial osteotomy: a registry-based case-control study of 1,036 knees. Arch. Orthop. Trauma Surg. 2014 Jan;134(1):73–77. doi:10.1007/s00402-013-1897-0 12. Nwachukwu B.U., McCormick F.M., Schairer W.W., Frank R.M., Provencher M.T., Roche M.W. Unicompartmental knee arthroplasty versus high tibial osteotomy: United States practice patterns for the surgical treatment of unicompartmental arthritis. J. Arthroplasty. 2014 Aug;29(8):1586–1589. doi:10.1016/j.arth.2014.04.002 13. Osti M., Gohm A., Schlick B., Benedetto K.P. Complication rate following high tibial open-wedge osteotomy with spacer plates for incipient osteoarthritis of the knee with varus malalignment. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA. 2015 Jul;23(7):1943–1948. doi:10.1007/s00167-0132757-8 14. Robertsson O., Knutson K., Lewold S., Lidgren L. The routine of surgical management reduces failure after unicompartmental knee arthroplasty. J. Bone Joint Surg. Br. 2001 Jan;83(1):45–49. 15. Robertsson O., W-Dahl A. The risk of revision after TKA is affected by previous HTO or UKA. Clin. Orthop. 2015 Jan;473(1):90–93. doi:10.1007/s11999-014-3712-9 16. Schallberger A., Jacobi M., Wahl P., Maestretti G., Jakob R.P. High tibial valgus osteotomy in unicompartmental medial osteoarthritis of the knee: a retrospective follow-up study over 13-21 years. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA. 2011 Jan;19(1):122–127. doi:10.1007/s00167-0101256-4 17. Schnaser E.A., Browne J.A., Padgett D.E., Figgie M.P., D’Apuzzo M.R. Perioperative Complications in Patients with Inflammatory Arthropathy Undergoing Total Knee Arthroplasty. J. Arthroplasty. 2015 Sep;30(9 Suppl):76–80. doi:10.1016/j.arth.2014.12.040

COA Bulletin ACO - Summer / Été 2016

18. Spahn G., Hofmann G.O., von Engelhardt L.V., Li M., Neubauer H., Klinger H.M. The impact of a high tibial valgus osteotomy and unicondylar medial arthroplasty on the treatment for knee osteoarthritis: a meta-analysis. Knee Surg. Sports Traumatol. Arthrosc. Off. J. ESSKA. 2013 Jan;21(1):96–112. doi:10.1007/ s00167-011-1751-2 19. Stukenborg-Colsman C., Wirth C.J., Lazovic D., Wefer A. High tibial osteotomy versus unicompartmental joint replacement in unicompartmental knee joint osteoarthritis: 7-10-year follow-up prospective randomised study. The Knee. 2001 Oct;8(3):187–194. 20. Woodacre T., Ricketts M., Evans J.T., Pavlou G., Schranz P., Hockings M., et al. Complications associated with opening wedge high tibial osteotomy - A review of the literature and of 15years of experience. The Knee. 2016 Mar;23(2):276–282. doi:10.1016/j.knee.2015.09.018 21. Canadian Institute for Health Information. Hip and Knee Replacements in Canada: Canadian Joint Replacement Registry 2015 Annual Report. Ottawa, ON: CIHI; 2015 [Internet]. [cited 2016 Apr 24];Available from: https://secure. cihi.ca/free_products/CJRR_2015_Annual_Report_EN.pdf 22. New Zealand Orthopaedic Association Joint Registry. Annual Report. Wellington:NZOA; 2015 [Internet]. [cited 2016 Apr 24];Available from: http://www.nzoa.org.nz/system/files/Web_DH7657_NZJR2014Report_v4_12Nov15.pdf 23. Australian Orthopaedic Association National Joint Replacement Registry. Annual Report. Adelaide:AOA; 2015 [Internet]. [cited 2016 Apr 24];Available from: https://aoanjrr.sahmri.com/documents/10180/217745/Hip%20and%20 Knee%20Arthroplasty 24. Swedish Knee Arthroplasty Register. Annual Report. Lund University; 2015. [Internet]. [cited 2016 Apr 24];Available from: http://www.myknee.se/pdf/SVK_2015_Eng_1.0.pdf

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

Bodycad HEADQUARTERS: Quebec 2035 rue du Haut-Bord Quebac, Quebec, Canada G1N 4R7 Chicago 111 West Illinois St. Chicago, IL USA 60654

WEBSITE: www.bodycad.com

K E Y C O N TA C T: Andrew McLeod Chief Commercial Officer info@bodycad.com

C O M PA N Y H I S T O R Y : • Bodycad Laboratories founded 2011 • Bodycad USA incorporated 2014 • First Bodycad OnCall patient June 2015

KEY EXECUTIVES: Jean Robichaud President and CEO Gabriel Robichaud Vice President Andrew McLeod Chief Commercial Officer Marc Bedard Chief Software Officer Marc Chaunet VP, Regulatory Affairs and Quality Geoffroy Rivet-Sabourin Research Director

FUNDING: • $20MM in angel funding • 2nd round anticipated

T H E P U R S U I T O F O R T H O PA E D I C P E R F E C T I O N Bodycad is transforming the current standard of orthopaedic care. Its personalized restorations offer a previously unavailable conformity to the patient’s anatomy, providing comfort, fit and durability that make the pursuit of orthopaedic perfection possible.

BODYCAD HISTORY AND MISSION Jean Robichaud founded Bodycad in 2011 because he wanted to change the paradigm of joint restoration. He believed that a direct relationship between the prosthesis designer and the orthopaedic surgeon needed to be established, and that mutual trust needed to be established to enable the development of the first truly personalized orthopedic restorations. Having helped to pioneer CAD/CAM technology as the standard of care in oral implantology, he knew the approach could improve orthopaedic outcomes. With technology advancing at an ever-increasing rate, the biomedical sector will continue to grow and change. Bodycad will be a pioneer in its evolution.

TECHNOLOGY Bodycad uses state-of-the-art additive manufacturing (3D printing). The process involves applying successive layers of material in a precise configuration guided by the model created with Bodycad Personalized Restoration Software. Bodycad maintains its own manufacturing facility, enabling it to control costs while continually upgrading its capabilities and optimizing mass customization.

S O F T WA R E Bodycad’s proprietary Personalized Restoration Software makes this level of personalization possible. This suite of software is comprised of 4 software platforms: • Bodycad Imager –Uses surgeon-provided imaging to produce an accurate 3D model of a patient’s anatomy. • Bodycad Planner – Enables surgical analysis and planning based on evidence-based anthropometric data and clinical landmarks/references. • Bodycad Designer – This CAD component has been optimized to rapidly produce an accurate personalized design for every patient. • Bodycad Maker – This workflow software improves the target shape of the final product and defines tool paths for more efficient CAM operations.

PROCESS The Personalized Restoration Evaluation Process (PREP) is guided by Bodycad PREP Techs, who collaborate with surgeons to achieve an anatomical fit for every patient. PREP Techs are trained in technology and have know-how of personalized restorations, we think of them as “master craftspeople.” PREP involves 3 steps: • Scan to plan: Patient images are sent to Bodycad to enable Bodycad PREP Techs to perform precision measurements of anatomical features. • Approve design: The surgeon receives a 3D rendering of the proposed solution for approval. • Restore: Bodycad manufactures the approved restoration for shipment to the hospital.

I N D I C AT I O N S Bodycad is pursuing two distinct product lines: • Bodycad OnCall is currently available and includes personalized complex restorations for oncology, osteotomies, revision, and other challenging or unique cases. • Bodycad Primary will include design and development for primary procedures such as unicompartmental knee, total hip, shoulder and other primary indications.

K E Y D I F F E R E N T I AT O R S Anthropometric data confirms that anatomical measurements can vary significantly from one patient to another. Off-the-shelf implants simply don’t address these unique features. Bodycad is developing a truly personalized experience to make the pursuit of precisely fitted orthopaedic restorations possible. Personalized restorations have the potential to improve economic quality metrics and achieve higher patient satisfaction. Bodycad’s suite of Personalized Restoration Software enables an efficient and accurate work flow. Bodycad’s know-how of mass customization drives the most efficient and economic design to production pathway. Bodycad substantially reduces the need for working capital and asset intensity that exists with traditional orthopaedics

PIPELINE Project

2016

2015 Q1

Bodycad Unicompartmental Knee System Bodycad Total Knee System Bodycad Big Toe Resurfacing Bodycad Acetabular Revision Bodycad Tumor Guided Resection System Bodycad Total Shoulder System FDA Submission HC and FDA Submission

2017 Q2

2019

2018 Q2

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

Update on DVT Prophylaxis After Joint Arthroplasty

t was a great pleasure to accept Dr. Femi Ayeni’s invitation to guest edit an update on deep vein thrombosis (DVT) prophylaxis after joint arthroplasty in this edition of the COA Bulletin. Over the past decade we all have been witness to a paradigm shift in the postoperative management of patients undergoing joint replacement surgery. While some healthy patients are going home on the same day of surgery, others have multiple co-morbidities such as morbid obesity. Consequently, one has to ask if all of these patients should be treated the same way for the prevention of DVT? More importantly, we are now faced with DVT prophylaxis medications that can be administered orally - further enhancing our options for their use. The authors in this feature bring expertise to the table from centres performing a high volume of joint replacement procedures, as well as having participated in large multi-centre trials examining new treatment modalities. I would like to thank all of the authors for taking the time from their busy practices to put together this contribution to our Bulletin. Paul E. Beaulé, M.D., FRCSC Guest Editor, COA Bulletin

Dr. Paul E. Beaulé is the Guest Editor of the DVT prophylaxis update feature in this edition of the COA Bulletin

Review of Current Agents and Pharmacokinetics in Thromboprophylaxis After Joint Replacement Surgery José M.H. Smolders, M.D., PhD Fellow, Adult Reconstruction, Department of Orthopaedic Surgery Marc A. Rodger, M.D., FRCPC, MSC Professor, Department of Hematology Paul E. Beaulé, M.D., FRCSC Professor, Department of Orthopaedic Surgery The Ottawa Hospital Ottawa, ON Based on the article ‘Overview of current venous thromboembolism protocols in hip reconstruction’1

enous thromboembolism (VTE), is a serious and frequent complication of orthopaedic surgery. It comprises two clinical entities: deep vein thrombosis (DVT) and pulmonary embolism (PE). The most widely disseminated guidelines to prevent VTE after total joint replacement are probably those proposed by the American College of Chest Physicians (ACCP). The most recent ACCP guidelines of 2012 recommend administering prophylaxis for at least 10 to 14 days and up to 35 days for patients undergoing total hip (THR) or knee (TKR) replacement2.The VTE risk is highest close to surgery and the median time of diagnosis for VTE is seven days after TKR and 17 days after THR3. The risk extends up to 35 days postoperatively and probably longer4. Several systematic reviews show a reduction COA Bulletin ACO - Summer / Été 2016

of DVT by more than one-half after extending low-molecularweight heparin (LMWH) up to 35 days (RR 0.46; 95%CI 0.260.82). A significant effect on major bleeding or total mortality could not be found. Extending thromboprophylaxis up to 35 days postoperatively compared to 10-14 days will result in nine fewer symptomatic VTE per 1,000 without an appreciable increase in major bleeding2. There is an occurrence of late symptomatic DVT and PE up to 3.1% and fatal PE rate up to 0.77% after completing a short-term course of prophylaxis (less than 15 days), according to several randomized studies with a 42-180 day follow-up1. On the other hand, one could also argue that because of the low frequency of symptomatic events, extended prophylaxis is not required5. The timing of initiation of thromboprophylaxis is also well researched. However, different studies define timing differently, but all suggest that dosing in closer proximity to surgery is more effective but also seems to be associated with higher bleeding rates6–8. Given the concern of epidural hematomas, immediate preoperative dosing is less commonly used in North America. The recommended agents for chemical thromboprophylaxis include LMWH, fondaparinux, direct anti-Xa inhibitors (e.g. apixaban and rivaroxaban), direct thrombin inhibitors (e.g. dabigatran), low-dose unfractionated heparin (LDUH), adjusted-dose vitamin K antagonist (VKA) and aspirin2. The different mechanisms of action in the coagulation cascade of the currently available chemical anticoagulants are shown in Figure 19.

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

Low-molecular-weight Heparin The most commonly used LMWH are enoxaparin (40 mg/day) and dalteparin (5000 U/day). One trial has directly compared two LMWHs and showed no difference in venographic thrombi10. A DVT treatment study comparing two LMWHs (dalteparin versus tinzaparin) showed no difference in efficacy or safety11. Patient preferences and risk stratification (e.g., very obese patients, very immobilized patients, patients with thrombophilia or previous thrombosis) may be useful in making individual patient decisions about use of extended LMWH prophylaxis. Vitamin K Antagonists For years, warfarin has been the only oral anticoagulant used for thromboprophylaxis. Although effective, warfarin has limitations including variable individual dose requirements, the need for laboratory monitoring, a long half-life, as well as drug–drug and drug–diet interactions12. Furthermore, patients must be on warfarin for at least five days before therapeutic anticoagulation is achieved13. Reversal of the anticoagulant effect could be obtained by vitamin K administration. In case of major bleeding or urgent surgery, another intervention should be added for a faster reversal, such as fresh frozen plasma, prothrombin complex concentrate (PCC), recombinant factor VIIa or activated PCC. Aspirin Aspirin is inexpensive, orally administered, and widely available. The PEP trial has created much discussion about the role of aspirin in VTE prophyalxis after THR14. This study examined 160mg of aspirin daily from preoperatively up to 35 days postoperative to THR and TKR. No statistically significant reduction was observed in 2648 subjects undergoing THR or TKR with 1.1% experiencing symptomatic VTE (at hospital discharge) in the aspirin group compared with 1.4% in the placebo group. Interestingly, over 40% of the subjects also got other forms of prophylaxis. Previous meta-analysis of venographic studies did not demonstrate a reduction in DVT and biologic data demonstrate that aspirin does not importantly reduce thrombin activity15,16. Therefore, aspirin should not be used alone for early (first 10-14 days postoperative) antithrombotic prophylaxis. The Canadian study of Anderson et al.17 showed that extended prophylaxis from the tenth postoperative day for another 28 days with 81mg of aspirin was noninferior to and as safe as dalteparin for the prevention of VTE after THR in patients who initially received dalteparin for ten days. Given its low cost and greater convenience, aspirin may be considered a reasonable alternative for extended thromboprophylaxis after THR.

Indirect Factor-Xa Inhibitor Fondaparinux is a synthetic analogous Xa inhibitor which binds to antithrombin with high specificity. After subcutaneous injection it has an almost complete bioavailability with a steady state after three to four daily doses. The half-life of 17h allows once-daily administration, because of the predictable anticoagulant effect, there is no need for laboratory monitoring. Turpie et al.8 have shown in a meta-analysis that fondaparinux in major orthopaedic surgery prophylaxis is superior to enoxaparin in preventing proximal (a)symptomatic DVT, but not symptomatic VTE. However, there was a 1% increase in major bleeds. In these studies, enoxaparin started 12-24h postoperatively and fondaparinux 6h postoperatively. Because of the narrow therapeutic window of vitamin K antagonists and the inconvenience of the parenteral route of administration of LMWH and fondaparinux, novel oral anticoagulants (NOAC’s) have been developed. The direct thrombin inhibitors and the direct inhibitors of the activated coagulation factor X (anti-Xa) can be easily administered, have an acceptable safety profile, and have a steady predictable response on the coagulation system, thus avoiding the need of frequent monitoring. Oral Direct Thrombin Inhibitors The first developed direct thrombin inhibitor was ximelagatran. The use of it resulted in less VTE events compared with LMWH after THR, it was also associated with a 3.33-fold increase in major bleeding1. Furthermore, unforeseen serious hepatic toxicity resulted in withdrawal from the market. A related compound, dabigatran etexilate (Pradax®) has been approved for VTE prophylaxis postoperative to orthopaedic surgery in Canada and other countries. In most patients, the dose of dabigatran is 220mg once-daily, with a lower dose (150mg once-daily) recommended in patients over 75 years, with moderate renal impairment, and receiving potent P-gp inhibitors2. The time of initiation postsurgery is 1-4h. It has been proven to COA Bulletin ACO - Summer / Été 2016

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

be at least equivalent to enoxaparin in large randomized trials and is not associated with liver toxicity18. One of the proposed disadvantages of NOAC’s used to be the lack of reversal agents in case of urgent surgery or major bleeding. However, since October 2015 the FDA approved a specific reversal agent for dabigatran, named idarucizumab (Praxbind®). It specifically binds to dabigatran and neutralizes its anticoagulant effect. Idarucizumab is administered intravenously and an immediate complete reversal of dabigatran-induced clotting time prolongation was observed, lasting at least 24h.

5. Warwick D., Williams M.H., Bannister G.C. Death and thromboembolic disease after total hip replacement. A series of 1162 cases with no routine chemical prophylaxis. J Bone Joint Surg Br 1995;77(1):6–10.

Oral Direct Anti-Xa Inhibitors Two drugs within the oral direct Anti-Xa inhibitor class who are approved for VTE prophylaxis after major orthopaedic surgery in Canada are apixiban and rivaroxaban. Phase III studies have suggested that this agent is likely more effective than LMWH for preventing VTE after THR with a safety profile similar to LMWH19. The dose of rivaroxaban dose is 10mg once-daily, and for apixaban 2.5mg - twice-daily. The time of initiation post surgery is 6–10h for rivaroxaban and 12–24h for apixaban. Compared with enoxaparin, the risk of VTE was lower with rivaroxaban (RR 0.70, 95%CI 0.60-0.81), the occurrence of bleeding complications with rivaroxaban were higher compared to enoxaparin (RR 1.52, 95%CI 1.14-2.02), and comparable between apixaban and enoxaparin (RR 0.88, 95%CI 0.73-1.05)20. The search for safe reversal agent for rivaroxaban and apixaban is ongoing, with a couple of promising agents which don’t have a FDA approval yet. In case of urgent surgery or life-threatening bleeding, PCC can be administered as both Anti-Xa drugs are too highly protein bound to use hemodialysis for clotting time prolongation reversal.

7. Strebel N., Prins M., Agnelli G., Büller H.R. Preoperative or Postoperative Start of Prophylaxis for Venous Thromboembolism With LMWH in Elective Hip Surgery? Arch Intern Med American Medical Association 2002;162(13):1451.

It seems probable that there will be a gradual shift to anticoagulants with easier routes of administration (than LMWH and fondaparinux) and more predictable anticoagulant effects requiring less frequent monitoring (than warfarin). It also seems likely that these NOACs will gradually be approved for the management of a wider variety of clinical conditions19. References 1. Lazo-Langner A., Rodger M.A. Overview of current venous thromboembolism protocols in hip reconstruction. Orthop Clin North Am 2009;40(3):427–436. 2. Falck-Ytter Y., Francis C.W., Johanson N.A., Curley C., Dahl O.E., Schulman S., et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: ACCP Evidence-Based Clinical Practice Guidelines. Chest 2012;141(2 Suppl):e278S–325S. 3. White R.H., Romano P.S., Zhou H., Rodrigo J., Bargar W. Incidence and time course of thromboembolic outcomes following total hip or knee arthroplasty. Arch Intern Med 1998;158(14):1525–1531. 4. Planes A., Vochelle N., Darmon J.Y., Fagola M., Bellaud M., Huet Y. Risk of deep-venous thrombosis after hospital discharge in patients having undergone total hip replacement: double-blind randomised comparison of enoxaparin versus placebo. Lancet 1996;348(9022):224–228.

COA Bulletin ACO - Summer / Été 2016

6. Hull R.D., Pineo G.F., Stein P.D., Mah A.F., MacIsaac S.M., Dahl O.E., et al. Timing of initial administration of LWH prophylaxis against deep vein thrombosis in patients following elective hip arthroplasty: a systematic review. Arch Intern Med 2001;161(16):1952–60.

8. Turpie A., Bauer K., Eriksson B., Lassen M. Efficacy and safety of fondaparinux in major orthopedic surgery according to the timing of its first administration. Thromb Haemost 2003;90(2):364–6. 9. Nutescu E.A. Oral anticoagulant therapies: balancing the risks. Am J Health Syst Pharm 2013;70(10 Suppl 1):S3–11. 10. Planès A., Samama M.M., Lensing A.W., Büller H.R., Barre J., Vochelle N., et al. Prevention of deep vein thrombosis after hip replacement--comparison between two LMWH, tinzaparin and enoxaparin. Thromb Haemost 1999;81(1):22–5. 11. Wells P.S., Anderson D.R., Rodger M.A., Forgie M.A., Florack P., Touchie D., et al. A randomized trial comparing 2 LMWHs for the outpatient treatment of deep vein thrombosis and pulmonary embolism. Arch Intern Med 2005;165(7):733–8. 12. Holbrook A.M., Pereira J.A., Labiris R., McDonald H., Douketis J.D., Crowther M., et al. Systematic overview of warfarin and its drug and food interactions. Arch Intern Med 2005;165(10):1095–106. 13. Whitlon D.S., Sadowski J.A., Suttie J.W. Mechanism of coumarin action: significance of vitamin K epoxide reductase inhibition. Biochemistry American Chemical Society 1978;17(8):1371–1377. 14. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000;355(9212):1295–302. 15. Imperiale T.F., Speroff T. A meta-analysis of methods to prevent venous thromboembolism following total hip replacement. JAMA 1994;271(22):1780–5. 16. Kessels H., Béguin S., Andree H., Hemker H.C. Measurement of thrombin generation in whole blood--the effect of heparin and aspirin. Thromb Haemost 1994;72(1):78–83. 17. Anderson D.R., Dunbar M.J., Bohm E.R., Belzile E., Kahn S.R., Zukor D., et al. Aspirin versus LMWH for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med 2013;158(11):800–6.

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

18. Tahir F., Riaz H., Riaz T., Badshah M.B., Riaz I.B., Hamza A., et al. The new oral anti-coagulants and the phase 3 clinical trials - a systematic review of the literature. Thromb J England, 2013;11(1):18. 19. Rachidi S., Aldin E.S., Greenberg C., Sachs B., Streiff M., Zeidan A.M. The use of novel oral anticoagulants for thromboprophylaxis after elective major orthopedic surgery. Expert Rev Hematol 2013;6(6):677–95.

20. Feng W., Wu K., Liu Z., Kong G., Deng Z., Chen S., et al. Oral direct factor Xa inhibitor versus enoxaparin for thromboprophylaxis after hip or knee arthroplasty: Systemic review, traditional meta-analysis, dose-response meta-analysis and network meta-analysis. Thromb Res 2015;136(6):1133–1144.

Risk Stratification for VTE Prophylaxis: What does it all mean? James L. Howard, M.D., MSc, FRCSC Program Director, Assistant Professor Division of Orthopaedic Surgery Western University London, ON

enous thromboembolism (VTE) following total hip (THA) and total knee (TKA) replacement continues to be a major concern for orthopaedic surgeons. There is currently no consensus recommendation presented in the literature as to the optimal strategy for prevention of VTE following total hip and total knee arthroplasty. The American College of Chest Physicians (ACCP) has evaluated the available literature and put forward guidelines that are intended to minimize the risk of VTE following THA and TKA1. However, despite these guidelines, many surgeons are unclear as to the best prophylaxis option for an individual patient. Risk stratification systems for VTE have been previously proposed in the literature2,3. The American College of Chest Physicians guidelines recommend that hospitals develop a strategy to help stratify risk of thromboembolism for surgical and nonsurgical patients. In order stratify patients, pertinent risk factors are arbitrarily assigned a risk score between 1 and 5. These risk factors can then be grouped according to severity and added to produce an overall risk factor score. Risk factor scores are then grouped into low (risk factor score 0-1), moderate (risk factor score 2), high (risk factor score 3-4), and very high (risk factor score 5+) groups. Unfortunately, stratification systems such as this do not help differentiate amongst arthroplasty patients. This is because simply having a hip or knee arthroplasty is assigned 5 points automatically, and therefore the risk factor system places all arthroplasty patients in the very high risk category. Patients in this category carry an estimated risk of calf DVT of 40-80% without prophylaxis, with clinical PE occurring in 4-10%, and fatal PE in 0.2-5%. With such high rates of VTE without prophylaxis, the question facing orthopaedic surgeons is not whether or not patients should be prophylaxed, but rather what method of prophylaxis one should employ.

The ACCP recommendations highlight the use of a number of chemotherapeutic agents as options for prophylaxis1. In the 2012 guidelines, low-molecular-weight heparin (LMWH), fondaparinux, apixaban, dabigatran, rivaroxaban, low-dose unfractionated heparin (LDUH), adjusted-dose vitamin K antagonist (VKA), and aspirin were given a grade 1B recommendation for a minimum of 10-14 days of use. However, the guidelines do not provide any direction as to when particular agents should or should not be employed. Other literature has demonstrated that some of the more potent agents have been associated with complications including postoperative wound problems, hematomas, and infection4-6. Furthermore, Sharrock et al.7 retrospectively reviewed 20 papers containing 15839 patients and demonstrated a higher all-cause mortality in patients managed with more potent anticoagulants (low-molecular-weight heparin, ximelagatran, fondaparinux, or rivaroxaban). This has led some authors to advocate for less potent options, such as aspirin, for DVT prophylaxis8. Unfortunately, the controversy surrounding prophylaxis options continues to persist. The result is that many arthroplasty surgeons are left to balance the risk of VTE following surgery with the risk of bleeding and associated complications without a useful risk stratification system to guide decision making. However, recent literature is beginning to address the topic of individualized risk stratification within the arthroplasty population. Parvizi et al.9 published a retrospective review of 26391 patients with primary and revision THA. The purpose of this study was to identify the preoperative comorbidities that were associated with an increased risk of symptomatic PE after joint arthroplasty in patients who were treated with either aspirin or warfarin. Elevated BMI, procedures on the knee (especially bilateral procedures), higher Charlson Comorbidity Index, chronic obstructive pulmonary disease, atrial fibrillation, anemia, depression, and presence of postoperative deep vein thrombosis were identified as independent risk factors for pulmonary embolus. This information was used to propose a risk stratification system for symptomatic PE that grouped COA Bulletin ACO - Summer / Été 2016

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

patients into low (0.35%), medium (1.4%), and high (9.3%) risk categories. Further work will be required to validate the risk stratification criteria. However, if shown to be useful, these criteria considered alongside bleeding risk may guide surgeons to appropriate VTE prophylaxis on an individualized basis for patients undergoing arthroplasty. Ultimately, when considering appropriate VTE prophylaxis for patients for today’s arthroplasty patient, one also has to consider the significant changes in arthroplasty practice that have occurred over time. Many patients have regional anesthetics to complete their arthroplasty. Surgical techniques have evolved to minimize tissue damage. Physiotherapy protocols begin much earlier in the postoperative period. Patients no longer remain in bed for many days with cautious mobilization in hospital. These changes in approach to anesthetic, surgery, and therapy regimes mean that today’s arthroplasty patient may not have the same VTE risk as historical ones. Therefore, as many aspects of our arthropalsty practice has changed over time, it stands to reason that our approach to VTE prophylaxis needs to evolve as well. It is likely that there is not one uniform approach to prophylaxis that works for all patients, but rather we will move towards a more individualized risk stratification system within the arthroplasty population. References 1. Falck-Ytter Y., Francis C.W., Johanson N.A., Curley C., Dahl O.E., Schulman S., et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012;141:e278S–325S. doi:10.1378/chest.11-2404. 2. Kearon C., Kahn S.R., Agnelli G., Goldhaber S., Raskob G.E., Comerota A.J., et al. Antithrombotic therapy for venous thromboembolic disease: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines (8th Edition). Chest 2008;133:454S–545S. doi:10.1378/chest.08-0658.

3. Caprini J.A., Arcelus J.I., Reyna J.J. Effective risk stratification of surgical and nonsurgical patients for venous thromboembolic disease. Semin Hematol 2001;38:12–9. 4. Sachs R.A., Smith J.H., Kuney M., Paxton L. Does anticoagulation do more harm than good?: A comparison of patients treated without prophylaxis and patients treated with lowdose warfarin after total knee arthroplasty. J Arthroplasty 2003;18:389–95. 5. Parvizi J., Ghanem E., Joshi A., Sharkey P.F., Hozack W.J., Rothman R.H. Does “excessive” anticoagulation predispose to periprosthetic infection? J Arthroplasty 2007;22:24–8. doi:10.1016/j.arth.2007.03.007. 6. Patel V.P., Walsh M., Sehgal B., Preston C., DeWal H., Di Cesare P.E. Factors associated with prolonged wound drainage after primary total hip and knee arthroplasty. J Bone Joint Surg Am 2007;89:33–8. doi:10.2106/JBJS.F.00163. 7. Sharrock N.E., Gonzalez Della Valle A., Go G., Lyman S., Salvati E.A. Potent anticoagulants are associated with a higher all-cause mortality rate after hip and knee arthroplasty. Clin Orthop Relat Res 2008;466:714–21. doi:10.1007/s11999007-0092-4. 8. Huang R.C., Parvizi J., Hozack W.J., Chen A.F., Austin M.S. Aspirin Is as Effective as and Safer Than Warfarin for Patients at Higher Risk of Venous Thromboembolism Undergoing Total Joint Arthroplasty. J Arthroplasty 2016. doi:10.1016/j. arth.2016.02.074. 9. Parvizi J., Huang R., Raphael I.J., Arnold W.V., Rothman R.H. Symptomatic pulmonary embolus after joint arthroplasty: stratification of risk factors. Clin Orthop Relat Res 2014;472:903–12. doi:10.1007/s11999-013-3358-z.

Is Aspirin the New Standard? Abdulaziz Almaawi, M.D., MSc, FRCSC Hôpital Maisonneuve-Rosemont Fellow, Université de Montréal Pascal-André Vendittoli M.D., MSc, FRCSC Professor of Surgery Université de Montréal Montréal, QC

enous thromboembolism (VTE) after orthopaedic procedures is a major concern for orthopaedic surgeons. The incidence of symptomatic VTE after total joint arthroplasty (TJA) was approximately 15-30% before introducing contemporary prophylactic strategies, which brought the incidence down to 1-2%1.

COA Bulletin ACO - Summer / Été 2016

The role of aspirin (ASA) in prevention of VTE after TJA has been reported with mixed evidence. Early clinical trials evaluating aspirin were limited by size and study design2,3. Modern clinical studies, including both randomized controlled trials and meta-analyses, have not consistently shown a benefit in the reduction of VTE in patients receiving ASA. Part of the controversy could be related to advanced perioperative protocols, which have helped to reduce the events of VTE (including early mobilization, less traumatic surgery through minimally-invasive techniques, use of regional anesthesia and intermittent pneumatic compression devices

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

(IPCD). These interventions have perhaps diminished the need for aggressive anticoagulation therapy, which is often prone to poor patient compliance. These factors combined have contributed to reducing the risk of VTE events while also making risk factors and preventative measures less discernible to clinical study2. The latest evidence has supported aspirin as an effective agent for the prevention of VTE, with an accompanying lower sideeffect profile when compared with other aggressive anticoagulant agents. These common complications include wound drainage, dehiscence, bleeding, increased incidence of readmission, reoperation rate, peri-prosthetic infection, and mortality4,5. In a recent study, Howard et al. compared the use of ASA, warfarin or low-molecular-weight heparin (LMWH) in patients undergoing elective primary total hip arthroplasty (THA) between 2000 and 2012. Mortality rate for LMWH was significantly higher (p < 0.05) than ASA. The 90-day mortality for these three groups was 0.38%, 1.09% and 0.43% respectively. There were six fatal PEs (0.08%), three of which occurred within 42 days, all within the LMWH group and three occurred between 42 and 90 days; one on warfarin, two on LMWH6. Historically, there have been contradictory consensuses among leading associations on prophylactic strategies for prevention of VTE after TJA. Recently, the American Association of Orthopaedic Surgeons (AAOS) and the American College of Chest Physicians (ACCP) have both recently issued relatively complimentary guidelines that can help reduce VTE events after TJA7,8. Both the AAOS and ACCP have reviewed the available evidence and advised that a surgeon’s choice of preventive strategy should be based on a balance between safety and efficacy of a particular anticoagulant, while keeping in mind individual patient risk at a standard level or at a high risk level of VTE or bleeding. The AAOS guidelines recommended any form of anticoagulation as acceptable after TJA without specifying any one in particular. This was mainly due to a lack of consistency in the available evidence. The ACCP, on the other hand, supported the use of ASA as a prophylactic agent with one member of the recommendation panel believing strongly that aspirin alone should not be included as an option. ASA has been recommended by both the AAOS and ACCP in case of a contraindication to other anticoagulation therapy; however, this must be always combined with IPCD. While the AAOS & ACCP have reviewed the available evidence to make their respective recommendations, they have used different outcome measures. The AAOS defined studies of interest as those including only critical outcomes defined as major bleeding, pulmonary emboli and mortality. The AAOS didn’t take any study with non-critical outcomes including symptomatic and asymptomatic, distal or proximal DVT into consideration; whereas the ACCP used patient-important outcomes such as PE and symptomatic DVT as critical outcomes.

Quality-based funding methods are gaining popularity to increase health-care efficacy and reduce costs. The prevention of hospital readmission, reoperation, and procedure-related complications (including VTE) have possibly placed physicians under pressure to incorporate a more aggressive approach in their choice of VTE prophylaxis. The use of preventive measures to reduce the rate VTE postoperatively should be a balance between VTE prevention and risk reduction. ASA can be a practical choice with similar preventive efficacy as other prophylactic strategies with reduced rates of bleeding and infection4,5. The importance of patient risk stratification should not be neglected when deciding on the use of a particular prophylactic agent. Pravizi’s et al. reviewed 26,000 patients, and found that obesity, chronic obstructive pulmonary disease, atrial fibrillation, anemia, depression, or history of postoperative DVT are at greater risk of having a postoperative PE9. Moreover, there are many variables in deciding the proper form of VTE prophylaxis. These include the time from surgery to start of therapy, the dose, duration, and the risk of administering other postoperative medications. The Surgical Care Improvement Project (SCIP) adoption of the ACCP guidelines accepting ASA as a VTE preventive measure is good step in the direction of optimizing patient-important outcomes, by preventing VTE while also limiting complications that can occur with administration of aggressive anticoagulants10. In Canada, The Ontario Quality-based procedures have pioneered these initiatives to encourage needed changes to health-care delivery that benefits patients and providers alike. Consideration of these guidelines, including needed standardization, can benefit and advance all health networks combined11. With current literature and the board recommendations, we think ASA use in VTE event prophylaxis can be resumed in the following situations: • In patients with high risk of bleeding, where the risks of using other anticoagulation therapy may overcome their benefit, ASA may be a good option. • For most patients without increased VTE risk, ASA could be the only prophylactic agent when used in combination with other measures like early mobilization, less traumatic surgery, use of regional anesthesia and IPCD. • Lastly, since most of the VTEs happen in the early perioperative period, another use for ASA could be for the extended prophylaxis in combination with LMWH or rivaroxaban (inhibitor of Factor Xa). Such combination was shown to be effective in EPCAT I study (Extended Prophylaxis Comparing LMWH to Aspirin in THA) where ASA had been used for 35 days for THA after an initial period of five days on LMWH12. ASA was as effective as a complete prophylaxis with LMWH, but with less bleeding events. Further scientific evidence will soon come from the EPCAT II study. In this second study, 3400 subjects (THA and TKA) were randomized by multiple Canadian centres to compare ASA extended prophylaxis with rivaroxaban. Results of this study may imply significant modification of current clinical practice.

COA Bulletin ACO - Summer / Été 2016

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

References 1. Stewart D.W., Freshour J.E.: Aspirin for the prophylaxis of venous thromboembolic events in orthopedic surgery patients: a comparison of the AAOS and ACCP guidelines with review of the evidence. Ann Pharmacother 2013, 47(1):63-74. 2. Borgdorff P., Tangelder G.J.: Arguments favoring low versus high dose aspirin in the prophylaxis of venous thromboembolism. Thromb Res 2016, 139:121-124. 3. Cohen A.T., Imfeld S., Markham J., Granziera S.: The use of aspirin for primary and secondary prevention in venous thromboembolism and other cardiovascular disorders. Thromb Res 2015, 135(2):217-225. 4. Drescher F.S., Sirovich B.E., Lee A., Morrison D.H., Chiang W.H., Larson R.J.: Aspirin versus anticoagulation for prevention of venous thromboembolism major lower extremity orthopedic surgery: a systematic review and meta-analysis. J Hosp Med 2014, 9(9):579-585. 5. Huang R., Buckley P.S., Scott B., Parvizi J., Purtill J.J.: Administration of Aspirin as a Prophylaxis Agent Against Venous Thromboembolism Results in Lower Incidence of Periprosthetic Joint Infection. J Arthroplasty 2015, 30(9 Suppl):39-41. 6. Bayley E., Brown S., Bhamber N.S., Howard P.W.: Fatal pulmonary embolism following elective total hip arthroplasty: a 12-year study. Bone Joint J 2016, 98-B(5):585-588. 7. American Academy of Orthopaedic Surgeons. Preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty. Evidence based guidelines and evidence report. [http://www.aaos.org/research/ guidelines/VTE/VTE_full_guideline.pdf] 8. Falck-Ytter Y., Francis C.W., Johanson N.A., Curley C., Dahl O.E., Schulman S., Ortel T.L., Pauker S.G., Colwell C.W., Jr., American College of Chest P.: Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012, 141(2 Suppl):e278S-325S. 9. Parvizi J., Huang R., Raphael I.J., Arnold W.V., Rothman R.H.: Symptomatic pulmonary embolus after joint arthroplasty: stratification of risk factors. Clin Orthop Relat Res 2014, 472(3):903-912.

COA Bulletin ACO - Summer / Été 2016

10. Mont M.A., Hozack W.J., Callaghan J.J., Krebs V., Parvizi J., Mason J.B.: Venous thromboemboli following total joint arthroplasty: SCIP measures move us closer to an agreement. J Arthroplasty 2014, 29(4):651-652. 11. Quality-Based Procedures Indicators. An Implementation Guidance Document. Ontario Ministry of Health and LongTerm Care [http://health.gov.on.ca/en/pro/programs/ecfa/ docs/qbp_indicator_guidance_en.pdf] 12. Anderson D.R., Dunbar M.J., Bohm E.R., Belzile E., Kahn S.R., Zukor D., Fisher W., Gofton W., Gross P., Pelet S. et al: Aspirin versus low-molecular-weight heparin for extended venous thromboembolism prophylaxis after total hip arthroplasty: a randomized trial. Ann Intern Med 2013, 158(11):800-806.

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ABOUT MEDEC

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

CANADA’S MEDICAL TECHNOLOGY INDUSTRY AT A GLANCE

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

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

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

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

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

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

OUR MISSION

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

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

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

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

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

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

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

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

Things Are Never So Bad That They Cannot Get Worse… Doug Thomson Chief Executive Officer Canadian Orthopaedic Association

he recent federal budget that Finance Minister Bill Morneau presented in the House of Commons has attracted attention for its devotion to big spending. This is a relatively new Ottawa phenomenon – but Canadians can hardly say that they weren’t warned. Although one may quibble with the sheer size of the deficit, at just a hair under $30 billion, PM Trudeau had clearly set the tone for a new love affair with activist big spending and big government during last Fall’s election campaign. He, of course, is not alone in this regard if we look at recent record deficit budgets in Alberta, Newfoundland & Labrador, and Ontario. Aside from the massive borrowing that governments across the country are going to be engaging in for the foreseeable future, the other similarity in these provincial budgets is how health care is being ignored, once again. In Ontario, Health Minister Dr. Eric Hoskins has recently ratcheted up his battle with Ontario doctors over fees (coincidentally calling his press conference on the eve of a public demonstration – the first time doctors have protested publicly since 1986). Dr. Hoskins’ theatre only serves to divert attention away from the very real issue of under-funding our health-care system. Ontario healthcare spending is budgeted to increase at approximately ½ the rate of population growth. Indeed, Ontario hospitals got their first increase in budgets in nine years – and the increase was 1.3%. As Konrad Yakabuski wrote in the Globe and Mail on March 28, 2016, the budget’s projections show that the Canada Health Transfer (CHT) will rise in line with the growth in GDP. The original CHT was pegged at a six percent annual multiplier for the past decade. The difference will be disastrous for provinces with aging populations unless a new deal is struck with Ottawa on a new Health Accord. Even under the much maligned Harper government deal, CHTs were guaranteed at 3% per year. Under the present scenario, provinces are on track to receive only 2.8% more than last year. The effect on already stretched provincial health-care budgets will be anything but good. Ottawa’s share of public health spending is currently 22% and is set to fall to 18% within a decade. The suggestion is that this will be particularly damaging to the state of affairs in Atlantic Canada and Québec. According to the Canadian Institute for Health Information (CIHI), population aging accounts for about 1% of the annual increases in health-care spending in the country since 2013. Consider that over 17% of Québecers and Newfoundlanders are older than 65, compared with 11.5% of Albertans and it is easy to imagine that some provinces are going to be forced to make difficult decisions about what new, costly treatments they will be able to pay for.

Health Minister Philpott has made the negotiation of a new health accord with the provinces a top priority for the government although no one knows how hard the negotiations are going to be. Finance Minister Morneau decided not to include the promised $3 billion for home care in the 2016 budget which may reflect provincial distaste for having Ottawa dictate how health dollars are spent. Québec has already made clear that any and all federal monies for health care flow exclusively through the CHT with its “no strings attached” history. This comes at a time when, I believe, Canadians increasingly understand the need for health-care reform based on the costs of our system and what is actually delivered. According to the Fraser Institute, Canada is one of the highest-cost providers of universal health care among industrialized countries. Unfortunately, Canada’s high spending ways are not delivering meaningful results. Compared to the OECD average country on an age-adjusted basis, Canada has fewer MDs, acute-care beds and diagnostic imaging technologies like MRIs and CT scanners. Worse, wait times have almost doubled since 1993 and we routinely rank at the bottom of the pack in terms of timeliness of care compared to other universal-health-care countries (Fraser Institute). Of all the issues that came up during last year’s election, none can rival health care for its persistence, endurance and tenacity. It ranks as a top-of-mind issue in campaign after campaign after campaign. It is curious how little effort is seemingly invested in meaningful reforms that employ some type of costsharing to encourage the efficient use of scarce health-care resources – a policy option that is effectively prohibited by the Canada Health Act (CHA). Reforms need not abandon universality, but before real reforms and innovation can be accomplished, Canadians need to have an adult conversation about reviewing the CHA. The CHA, as it is presently constituted, will not allow us to pursue policy options that other countries have implemented with the goal of delivering high quality and affordable health care while still maintaining a universal health-care system. The author of this article wishes to point out, in case it was not already embarrassingly, ridiculously obvious, that the opinions he expresses above are his own, and they do not represent in any way those of the Canadian Orthopaedic Association.

COA Bulletin ACO - Summer / Été 2016

Looking for a way to raise funds for your orthopaedic clinic or program?

Join us for the Hip Hip Hooray! Pedometer Challenge Monday, October 17 – Friday, October 21, 2016

Register a team of 5 or more. Collect pledges from friends, family, patients and colleagues. Count your steps for a week. Share the revenue; funds raised support the COF and your program or clinic. We provide everything you need: Use funds raised in your  Pedometers. program for:  An online pledge system.  A research assistant  Donation tax receipts.  An educational resource  Posters and sample donation request emails Add a friendly competition: challenge another clinic, hospital, or group to see who can:  Raise more money.  Log more steps.

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Foundation / Fondation

Canadian Orthopaedic Foundation Awards CORL Grant to Dr. Ivan Wong

he Canadian Orthopaedic Foundation (COF) is pleased to announce the recipient of the 2015 Canadian Orthopaedic Research Legacy (CORL) award: Dr. Ivan Wong, Dalhousie University and QE II Health Sciences Centre, Halifax, Nova Scotia. The CORL program was founded in 2006 to help ensure Canada’s world-class status in orthopaedic research, ensuring that orthopaedic patients reap the rewards of new techniques and treatments made possible through research grants. Dr. Wong’s project is entitled, “The Arthroscopic Treatment of Recurrent Anterior Shoulder Instability: A Randomized Controlled Trial.” Dr. Wong and Dr. Nathan Urquhart developed and published an all-arthroscopic anatomic glenoid technique using distal tibia allograft, which avoids damaging the subscapularis muscle, and allows for a repair of the anterior labrum and capsular tissues. This technique has all the advantages of both the European and American procedures and is based off the arthroscopic Bankart repair done in a lateral decubitus position. It requires only one additional medial portal that is created from an inside-out technique to avoid injuring neurovascular structures. Because it is an inside-out portal created parallel to the glenoid surface, it is reproducible for safe passage of the graft. In addition, since it is arthroscopic, it is more likely to be adopted by surgeons and

better accepted by patients. Fulfilling the principles of orthopaedic care, this technique recreates the bony and soft tissue anatomy while using minimally invasive methods. The primary objective of Dr. Wong’s CORL study, The Arthroscopic Treatment of Recurrent Anterior Shoulder Instability: A Randomized Controlled Trial (ATRASI), is to compare the clinical outcome of arthroscopic Bankart repair vs arthroscopic anatomic glenoid reconstruction using allograft bone and Bankart Dr. Ivan Wong, repair in recurrent shoulder instabil2015 CORL Recipient ity. To the researchers’ knowledge, ATRASI is the first randomized controlled trial to compare soft tissue repair to bony reconstruction in shoulder instability. The researchers hypothesize that the arthroscopic anatomic glenoid reconstruction using bone graft and Bankart repair will provide better functional outcomes and decrease the risk of recurrent dislocation/subluxation. The study will be completed in a year and the COF looks forward to learning and sharing the results.

La Fondation Canadienne d’Orthopédie décerne la Bourse de recherche du HROC au Dr Ivan Wong

a Fondation Canadienne d’Orthopédie est heureuse d’annoncer que le Dr Ivan Wong, de l’Université Dalhousie et du centre hospitalier Queen Elizabeth II Health Sciences (QEII), de Halifax, en Nouvelle-Écosse, est le lauréat 2015 de la Bourse de recherche du programme de l’Héritage de la recherche orthopédique au Canada (HROC). Le HROC a été créé en 2006 dans le but de renforcer la réputation en recherche orthopédique du Canada à l’échelle mondiale, permettant du même coup aux patients de bénéficier des nouvelles techniques et des nouveaux traitements qui en découlent. Le projet du Dr Wong s’intitule « The Arthroscopic Treatment of Recurrent Anterior Shoulder Instability: A Randomized Controlled Trial ». Les Drs Ivan Wong et Nathan Urquhart ont mis au point et présenté une technique de reconstruction glénoïdienne par allogreffe tibiale distale entièrement effectuée sous arthroscopie. Ainsi, on évite d’endommager le muscle sous-scapulaire et permet la réparation du bourrelet marginal et des tissus capsulaires. Cette technique combine les avantages des techniques européennes et américaines et est fondée sur les principes de la réparation de Bankart par arthroscopie chez un patient installé en décubitus latéral. Une voie médiale supplémentaire aménagée à l’aide d’une technique de « dedans en dehors »

(inside-out) permet d’éviter de blesser les structures neurovasculaires. Comme elle est parallèle à la surface glénoïdienne, on peut l’emprunter pour introduire la greffe en toute sécurité. De plus, cette technique étant arthroscopique, elle est plus susceptible d’être adoptée par les orthopédistes et mieux acceptée par les patients. En accord avec les principes des soins orthopédiques, cette technique reconstruit l’anatomie des os et tissus mous tout en étant minimalement effractive. Les travaux du Dr Wong, intitulés « The Arthroscopic Treatment of Recurrent Anterior Shoulder Instability: A Randomized Controlled Trial (ATRASI) », visent à comparer les résultats cliniques d’une réparation arthroscopique standard de Bankart à la reconstruction glénoïdienne par allogreffe osseuse effectuée sous arthroscopie dans les cas d’instabilité récurrente de l’épaule. D’après les renseignements dont disposent les chercheurs, cet essai clinique prospectif comparatif sur échantillon aléatoire ATRASI est le premier à comparer la réparation de tissus mous à la reconstruction osseuse dans les cas d’instabilité de l’épaule. Les chercheurs suggèrent que la technique de reconstruction glénoïdienne par allogreffe osseuse effectuée sous arthroscopie jumelée à la réparation de Bankart donnera de meilleurs résultats fonctionnels et réduira les risques de luxation ou de subluxation récurrente. Ces travaux seront terminés d’ici un an, et la Fondation a hâte d’en connaître les résultats pour les diffuser. COA Bulletin ACO - Summer / Été 2016

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

Incorporating Your Practice: Is It Right For You? Aaron Grinhaus Special to the COA Bulletin

your interests to incorporate sooner rather than later. We can help guide you through that analysis to see if incorporation is best for you.

What Is Tax Structuring? iven the relative high level of income, and lack of tax and business experience, doctors may end up paying a far greater amount of tax than would otherwise be necessary had they been structured properly. That’s where we come in.

What Are the Pros and Cons of Incorporating My Practice? The cons are a start-up cost of about $2,000-$3,000, which includes government fees, college/registration fees, taxes, other disbursements and legal fees. Other lawyers may charge more or less depending on the level of service you get and what is included. In addition, if you have been practicing for a few years, you may be required to execute a “rollover” of your “sole proprietorship” practice into the new MPC. A rollover is not always required, but when it is, there can be a substantial hike in the price, usually an additional $2,000-$4,000 or more. This is due to the additional legal and accounting work that is required.

Our job is to advise doctors and work with their accountants to create a tax-efficient structure. This allows for greater sums to be either used for personal purposes or retained in order to minimize the amount handed over to the Crown at the end of the year. Generally speaking, we use three strategies to meet this goal: deferral, splitting and rate minimization. Since an individual pays a higher rate of tax generally than a corporation, deferral is postponing the removal of funds from a corporation to a date where the doctor’s income is lower (such as during a sabbatical or at retirement). Income splitting is where you distribute funds, either through salaries or dividends, to other people (such as family members) based on the principle that two people making $50,000 a year pay less tax than one person making $100,000 per year. Finally, tax rate minimization is using entities, such as corporations, which pay a lower rate of tax in order to retain earnings and pay less tax to the Crown. How Do I Know if Incorporation is Right for Me? Each situation is unique, which is why it is important to consult with a qualified tax advisor before moving forward. The CPSO and other provincial regulators have strict requirements for compliance and so it is best to use a lawyer to help get you set up properly from the start. Before incorporating your medicine professional corporation (“MPC”) there are two important questions you need to consider: 1) for what activities do you intend to use the corporation, and 2) do you need all the income you are making in the practice to live? The CPSO mandates that you can only use the corporation for activities “related to or ancillary to the practice of medicine”, which means if you are thinking of using your retained earnings for anything other than that (such as real estate speculation), you should consult with a qualified tax advisor first. There are ways to structure such investments utilizing retained earnings in your professional corporation but it must be done properly. If you need everything you are earning to cover your living expenses, it may not be best to incorporate. The benefit in the lower corporate tax rate only applies to funds that are retained in (i.e. not paid out of) the corporation before the end of the tax year. That having been said, there are potential consequences to moving your practice into a corporation after you have been in practice, so if your financial need is temporary and you anticipate retained earnings in the near future, it may be in

As a caveat: make sure that your incorporation is done by a qualified lawyer. Accountants should not be creating corporations; their job is to administer the structure once created and their related fees are usually around $2,500. Be wary of accountants who charge discounted fees for setting up an MPC. The pros far outweigh the cons: substantial flexibility, liability protection and tax savings. Medical doctors are allowed to issue non-voting shares in their professional corporations to family members in order to split retained earnings and substantially reduce the tax burden. Although all doctors are required to maintain membership with the CMPA for professional negligence protection, doctors in private practice, who enter into agreements with employees, landlords and suppliers, enjoy the added benefit of commercial liability protection afforded by the corporation. In other words, the corporation would be liable if there were a commercial dispute, not the doctor personally. In addition, earnings retained in the corporation can be used in a variety of ways, among them for the purposes of investment and life insurance. There is also a lifetime capital gains exemption in the event that you wish to sell your practice upon retirement, which allows you to potentially take a substantial amount of the proceeds of sale tax free. This can only be done through the sale of shares of a qualifying corporation. Budget 2016 Changes In February, 2016, there were rumours that many of the benefits of MPCs would be curtailed. Thankfully these rumors did not materialize into reality and so the benefits remain. There were some other developments in the budget that are worth noting: 1) The Liberal Government DID NOT deliver on its promise to reduce the federal corporate tax rate by 0.5% per year over the next four years and instead stated that it will defer any decrease.

COA Bulletin ACO - Summer / Été 2016

Training & Practice Management / Formation et gestion d’une pratique (continued from page 45)

2) Up to $3,000 of the cost of incorporation can be deducted as a current expense against income making set-up costs tax deductible, which was not possible before. 3) We were all relieved that the rumours of an increase in the capital gains tax rate were false; there was no increase and it remains that 50% of any capital gain is taxable at graduated rates. This is good for the sale of a practice or real estate investment. 4) We were all very relieved to also learn that rumours of the application of the “active/passive business rules” were not applied to professional corporations, which could have doubled the tax rate for most MPCs.

The content of this article does not reflect the official opinion of the COA. Responsibility for the information and views expressed in the article lies entirely with the author. All of the information in this article is for informational purposes only and should not be relied upon as legal advice Aaron Grinhaus is an expert in Tax Law and the founder of Grinhaus Law Firm, a mid-town Toronto law firm specializing in, among other things, business, tax and estate planning for medical professionals. He may be contacted at: Aaron@grinhauslaw.ca or 647 497-6872 ext 231

Professionals Are Here To Help Tax structuring for any high income earner or high net worth individual, such as a skilled medical professional, is essential to protecting against superfluous income atrophy. You are entitled to structure your affairs in the most tax-efficient manner, and in our experience, that tends to be an objective exercise.

Calendar of Events / Calendrier des événements 2016 CORA Annual Meeting June 16 juin Ville de Québec, QC E-mail/Courriel : coraweb@canorth.org Web Site/Site Int. : www.coraweb.org South African Orthopaedic Association (SAOA) 62nd Annual Congress September 1-3 septembre Nombolo Mdhluli Conference Centre (situated at Skukuza camp in the Kruger National Park) South Africa Web Site/Site Int. : http://www.saoa.org.za/ 37th SICOT Orthopaedic World Congress September 8-10 septembre Rome, Italy E-mail/Courriel : congress@sicot.org Web Site/Site Int. : http://www.sicot.org/rome British Orthopaedic Association (BOA) Annual Scientific Congress September 13-16 septembre Belfast, UK Web Site/Site Int. : http://congress.boa.ac.uk/ European Orthopaedic Research Society (EORS) 24th Annual Meeting September 14-16 septembre Bologna, Italy Web Site/Site Int. : http://eors2016.org/

COA Bulletin ACO - Summer / Été 2016

2016 ICORS Meeting September 21-25 septembre Xi’an, China Web Site/Site Int. : www.2016icors.org Australian Orthopaedic Association (AUST.OA) & New Zealand Orthopaedic Association (NZOA) Combined Scientific Meeting Meeting October 9-13 octobre Cairns, Australia Web Site/Site Int. : http://asm.aoa.org.au/ 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 Canadian Orthopedic Foot and Ankle Society Foot & Ankle Symposium Februrary 2-4 février 2017 Fairmont Chateau Whistler Whistler, BC Web Site/Site Int. : http://ubccpd.ca/course/cofas2017

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

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

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