Fall 2015 COA Bulletin #110 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie Fall / Automne 2015 Publication Mail Envoi Poste-publication Convention #40026541

BULLETIN

MOVING FORWARD

4150 O. Ste-Catherine W., Suite 450 Westmount QC H3Z 2Y5

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

110

Moving Forward, Together – Dr. Robin R. Richards’ President Elect Address............................. p.5 Avancer, Ensemble – Allocution du Dr Robin R. Richards, président élu

AVANCER

Active Members – Your COA Membership Just Got a Whole Lot More Interesting! � � � � 8 Effect of Bearing Surface on Mid-term Survivorship of Total Hip Replacement – Results from the Canadian Joint Replacement Registry � � � � � � � � � � � � � � � � � � � � � � � � � � � � 25 The Role of the Orthopaedic Surgeon in Osteoporosis Management for Hip Fracture Patients � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 33 Remise de deux bourses d’études Bones and Phones � � � � � � � � � � � � � � � � � � � � � � � � � � � 45

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

Form e know rly n as JBJS ( Br)

Editor-in-Chief Mr Ben Ollivere

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

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

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Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 110 Fall / Automne 2015 COA / ACO Dr. Robin R. Richards President / Président Dr. John Antoniou Secretary / Secrétaire Mr. Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4150 Ouest, rue Sainte-Catherine West Suite 450, Westmount, QC H3Z 2Y5 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Dr. Marc Isler Editor-in-Chief / Rédacteur en chef Dr. Peter Lapner Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

Value for Your Membership Robin R. Richards, M.D., FRCSC President, Canadian Orthopaedic Association

Colleagues,

his is my first message to you as your 70th President. I accepted this role with humility and trepidation given the rich history of our Association and the many challenges we face in contemporary orthopaedic practice in Canada. Let me start my thanking the organizers of our most recent Annual Meeting in Vancouver. For those of you who were able to attend, I am sure you will agree that it was a terrific meeting! The venue, weather, program and social events were all perfect. Thanks to the Program Chairs, Dr. Kishore Mulpuri, Local Arrangements Chair, Dr. Bert Perey as well as Cynthia, Meghan, Trinity and Doug from the COA office. On a personal note, I would like to congratulate Drs. Bas and Rola Masri on a successful presidential year and thank them for their tutelage of Barb and myself as we take on the role. They will be a hard act to follow. Your Executive and Board wish to offer each of you value for your membership. As of next year, the new dues structure will include the cost of pre-registration at the Annual Meeting. For those of you attending once every three years, the cost will be neutral. For those who attend more frequently, you will be saving considerable fees. Membership provides access to our electronic communications (COA Bulletin, COA Dispatch, Community Portal), access to the OrthoEvidence web site, to the Bone & Joint Journal (formerly JBJS British edition) and Bone & Joint 360. Your Executive is actively working on an action plan that will include a COA Orthopaedic Human Resource Plan, a Position Statement on Access to Orthopaedic Care, Guidelines for Late Career Transition and an update of our Position Statement on Orthopaedic Unemployment with guidelines for locum positions and recruitment. I will continue to keep you informed on these initiatives as they develop. Our 2016 Annual Meeting in Québec City promises to be a great learning experience in a historic venue. As always, the Annual Meeting of our Association represents a chance to learn, network and meet friends old and new! The COA meeting is “right sized” for generalist and subspecialist orthopaedic surgeons alike. As previously mentioned, for the first time, the pre-registration fee is included in your membership dues if you are an Active member of the COA. Be sure to settle any outstanding membership dues prior to registering for the meeting to take full advantage of this member benefit. The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450, Westmount, Quebec, H3Z 2Y5. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: Canadian Orthopaedic Association, 4150 St. Catherine Street West, Suite 450 Westmount, Quebec, H3Z 2Y5

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

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

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

COA Bulletin ACO - Fall / Automne 2015

Your COA / Votre association

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We are very pleased to welcome Dave Williams, physician, astronaut and hospital CEO who will speak at the Annual Meeting’s Opening Ceremonies on Thursday, June 16. Marc Swiontkowski, accomplished orthopaedist and Editor of the Journal of Bone and Joint Surgery will be the R.I. Harris Lecturer and Kellie Leitch, orthopaedic surgeon, MP and Federal Cabinet Minister will be the Presidential Guest Speaker. The meeting will be held at the user-friendly Québec City Convention Centre facility conveniently adjacent to the Hilton and Delta hotels. The scientific program being developed by Program Chair, Dr. Etienne Belzile, and co-chair, Dr. Mélissa Laflamme will be relevant to orthopaedic practice in Canada. Local Arrangements Committee Chair, Dr. Michèle Angers, is putting together a social program which promises to be spectacular! Be sure not to miss what will be a most memorable meeting in one of Canada’s great cities. See you in Québec City!

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 25 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 41 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 43 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 46

I look forward to meeting as many of you as possible this year. You are welcome to communicate your thoughts directly with me (robin.richards@sunnybrook.ca) at any time. Thank you for the honour of serving as your President. For those of you who were not present at the Vancouver Annual Meeting, I invite you to read through the address I delivered as President Elect which follows this article.

Votre adhésion rapporte Robin R. Richards, MD, FRCSC Président, Association Canadienne d’Orthopédie

Chers collègues,

oici donc ma première communication en tant que soixante-dixième président de l’ACO. C’est avec humilité et exaltation que j’ai accepté d’assumer ce rôle, vu la riche histoire de notre association et les nombreux défis auxquels nous sommes confrontés dans notre exercice au Canada. Permettez-moi d’abord de remercier les organisateurs de notre dernière réunion annuelle, à Vancouver; je suis persuadé que tous ceux qui y étaient conviendront qu’elle était formidable! Le lieu, la météo, le programme et les activités sociales étaient tout simplement parfaits. Merci au Dr Kishore Mulpuri, président du Comité responsable du programme, et au Dr Bert Perey, président du Comité organisateur, de même qu’à Cynthia, Meghan, Trinity et Doug, des bureaux de l’ACO. Ensuite, j’aimerais personnellement féliciter les Drs Bas et Rola Masri pour leur excellente année à la présidence, et les remercier de nous encadrer, Barb et moi, alors que nous nous préparons à prendre le relais, ce qui n’est pas une mince affaire. La direction et le conseil de l’ACO souhaitent que l’adhésion rapporte à chacun de vous. La nouvelle structure tarifaire qui entrera en vigueur à compter de la prochaine année comprendra les droits d’inscription à la Réunion annuelle; ainsi, pour ceux d’entre vous qui assistez à la Réunion tous les trois ans, les coûts resteront les mêmes, tandis que ceux qui y assistent plus souvent réaliseront des économies considérables. L’adhésion donne accès à nos communications électroniques (le Bulletin, COA Bulletin ACO - Fall / Automne 2015

la Dépêche et le Portail communautaire de l’ACO), au site Web OrthoEvidence, au Bone & Joint Journal (anciennement le British Journal of Bone and Joint Surgery) et à Bone & Joint 360. La direction travaille activement à l’élaboration d’un plan d’action qui englobera un plan sur les ressources humaines en orthopédie, un énoncé de position sur l’accès aux soins orthopédiques, des lignes directrices sur la transition en fin de carrière, de même qu’une mise à jour de l’Énoncé de position de l’ACO sur le sous-emploi des diplômés en orthopédie, qui fournira des lignes directrices sur les suppléances et le recrutement. Je vous tiendrai au courant des développements à cet égard. La Réunion annuelle 2016 de l’ACO, à Québec, s’annonce une formidable expérience d’apprentissage dans un lieu historique. Comme d’habitude, elle constitue une occasion d’apprendre, de réseauter, de revoir de vieux amis et de faire de nouvelles rencontres! Et la Réunion annuelle convient à tous les orthopédistes, qu’ils soient généralistes ou spécialisés. Comme je vous l’ai déjà dit, pour la première fois, les droits d’inscription (les droits de pré-inscription) seront inclus dans la cotisation annuelle de tous les membres actifs de l’ACO. Par conséquent, assurez-vous de payer toute cotisation en souffrance avant de vous inscrire à la Réunion annuelle de sorte à pouvoir tirer pleinement profit de cet avantage offert aux membres. Nous aurons le grand plaisir d’accueillir Dave Williams, médecin, astronaute et président-directeur général d’un centre hospitalier, qui prononcera une allocution aux cérémonies d’ouverture de la Réunion annuelle, le jeudi 16 juin. Marc Swiontkowski, orthopédiste accompli et rédacteur en chef du Journal of Bone and Joint Surgery, sera le conférencier R.I. Harris, tandis que Kellie Leitch, orthopédiste, députée fédérale et ministre, sera

Your COA / Votre association

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la conférencière invitée par le président de l’ACO. La Réunion annuelle se tiendra au Centre des congrès de Québec, un établissement convivial relié aux hôtels Hilton et Delta. Le programme scientifique que nous préparent les Drs Etienne Belzile et Mélissa Laflamme, coprésidents du Comité responsable du programme, sera axé sur l’exercice de l’orthopédie au Canada. De son côté, la présidente du Comité organisateur, la Dre Michèle Angers, nous concocte un programme social qui promet d’être spectaculaire! Ne manquez pas cette réunion organisée dans l’une des plus belles villes canadiennes : elle sera assurément des plus mémorables. Au plaisir de vous voir à Québec!

J’espère rencontrer le plus grand nombre possible d’entre vous cette année. Et n’hésitez surtout pas à me transmettre directement vos idées (robin.richards@sunnybrook.ca). Je vous remercie pour le privilège que vous m’accordez en faisant de moi votre président. J’invite ceux et celles parmi vous qui n’ont pas assisté à la Réunion annuelle de Vancouver à lire l’allocution que j’y ai prononcée à titre de président élu, ci-après.

Moving Forward, Together Avancer, ensemble President Elect Address 2015 Delivered on June 19 in Vancouver during the 70th Annual Meeting of the Canadian Orthopaedic Association by Robin R. Richards, M.D., FRCSC Allocation du président élu, 2015 Prononcée le 19 juin, à Vancouver, à l’occasion de la 70e Réunion annuelle de l’Association Canadienne d’Orthopédie, par Robin R. Richards, MD, FRCSC Ladies and gentleman, members and guests, friends.

t is with trepidation and humility that I stand before you as your 70th president. The previous Presidents of this organization have provided truly exceptional leadership. Now that I have been selected to follow in their path, I will do whatever I can to confront our present reality and plan for our future. At the outset, I wish to offer you my sincere apologies for residing in Toronto, the source of most evil in this country. As you know, the Hockey Hall of Fame is located close to the Air Canada Centre in order to allow Toronto residents to view the Stanley Cup - the only possible way that they will ever see it. Perhaps it is of some comfort for you to know that my spiritual home is in Guelph, Ontario. Although I left Guelph in 1970 when it had a population of only 30,000, I still consider myself a small town person in spirit. The world at large seemed to be a very scary place as I was growing up in in the 50’s and 60’s. The Cold War and the Vietnam War were in the news daily. My father went away to learn how to build a nuclear bomb shelter for our backyard but when he came home, he didn’t follow through on the initiative. I was not certain how to interpret that. My childhood hero was John F. Kennedy and his assassination still seemed just as pointless then as the events we continue to watch on the news each night now.

Le Dr Robin Richards reçoit la médaille présidentielle du Dr Bas Masri, président sortant de l’ACO.

In the midst of this chaos, there was a beacon of stability. Our family home was located directly across from the Guelph General Hospital. Ambulances and hearses came and went on a regular basis and my first memory is my mother walking over there and my newborn younger brother being held up in the window a couple of hours later. What an amazing place! Unfortunately, he became a lawyer. Doctors were held in high regard in the community and some of the best shows on TV were medical. I decided to become a physician. Once in medical school it was quickly apparent to me that I was ill suited for most branches of medicine. My tutorial group at McMaster spent an entire week studying the molecular structure of the basement membrane of something called the glomerulus. Becoming desperately bored, I found a professor to give us a seminar. Thankfully he told us all we needed to know was that the kidney is a filter and a sponge. As the only person in the family who could change a tire, orthpaedics seemed the perfect fit for me. COA Bulletin ACO - Fall / Automne 2015

Your COA / Votre association

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After a 1976 elective with David Hastings originally from Vancouver, who eventually became President of this Association, I have never looked back. Orthopaedics has been a way of life, not a job, for me for the past 40 years. I still relish and enjoy the core business of orthopaedics which is helping individual patients. When the door closes, patients feel free to tell us their deepest secrets and concerns and it is an honour to have the responsibility that comes with their trust. We must cherish and preserve this trust. My practice as an orthopaedist has led me in many directions over the years including education, research, administration and leadership. The experiences have been rich and deep. It has been a particular joy to see former students such as Emil Schemitsch, Mike McKee, Graham King and Jim Wright become international academic superstars right here in Canada in the same environment we all experience. Orthopaedics has changed greatly in my lifetime. As a resident there was a new operation, a new joint replacement and a new fixation device every week. Now we are a mature specialty that is evidence-based. We have learned that things that are new are not necessarily better. We have gone from a specialty to a group of subspecialists and super subspecialists. As someone who used to perform all aspects of orthopaedic trauma including spinal and pelvic surgery and now reconstructs shoulders and elbows (only), I see this as a good thing for patient care. I first attended the Annual General Meeting of the COA in Vancouver in 1978. My research supervisor arranged for a group of us from the Mount Sinai Hospital, including Al Gross, to fly to the meeting in a private twin engine plane. We were forced to land for fuel in Regina in a strong cross wind preceding a thunderstorm. Notwithstanding this near-death experience, I have attended most meetings since. Although each one has been unique in some way, they have always been educational and, more importantly, a whole lot of fun. Where else would you see your professor Bob Salter roping a calf or your teacher Jim Waddell dressed up in aboriginal garb for a Klondike event? Although I have painted a rosy picture, we need to acknowledge our current challenges and figure out what to do about them. Our rich history has not prepared us for our present challenges – we need to move forward – together. Avancer, ensemble. We are a national association. Membership is voluntary and not all of our colleagues are members. The membership rate varies greatly according to the province. We need to do something about that. Orthopaedics is subspecialized, even in the community. We need to be inclusive of and offer value to all subspecialties. There are many meetings – we need to make ours competitive with the offering of industry and larger organizations. Although Canadians cherish their health-care system, orthopaedics is falling through the cracks. Who can argue with universal public care coast to coast to coast? There is no question COA Bulletin ACO - Fall / Automne 2015

that for catastrophic problems such as congenital disorders, heart disease, cancer and trauma - our system is amazing. No Canadian will ever be bankrupted by the cost of medically necessary care. Now go to the Government web site in Ontario and check out the wait times for forefoot surgery – 477 days at one of the downtown hospitals in Toronto with a subspecialist! On December 19, 2014 I received a message from hospital administration that the handful of us who do upper extremity at our hospital would be allowed to do a grand total of 50 shoulder arthroplasties per annum for budgetary reasons – a bitter pill to swallow since I personally perform almost that number annually myself. A few weeks later, Darren Drosdowech and I were sitting together at the residency review course in Mississauga. Our phones went off and we were informed that Ontario’s Government no longer does negotiations or agreements with physicians and our services were now worth almost three percent less than they were previously. Furthermore, if utilization increased they could be further devalued. So now we have the surgeons with hospital resources capped, cut and clawed back. Let’s talk about our colleagues without resources. Yes that’s right, the 150 – 200 underemployed or unemployed orthopaedists we have trained. They are young, keen, ready, willing and able to use their state-of-the-art skills to care for patients. They are relegated to working at night without daytime resources, performing serial fellowships or packing their bags for other jurisdictions where there is some hope of resource access. I have been at meetings where politicians state that there is more than enough resource for health care in the system. In Ontario, we are told, 1.9% annually is more than enough to cover new hospital construction, population increases, aging, new technology and union wage increases. There is “more than enough money in the system”. Why 1.9%? Because they say so. Sure. So what are we going to do about this mess? First note the word “we”. One thing I learned back in Guelph where I was a union card carrying steelworker for three summers is “stick together”. Our Association has done a good job of keeping the Canadian orthopaedic fleet together. We have many brother and sister societies that meet in association with us. We have the Foundation, the Trauma, Foot and Ankle, Research and Arthroplasty groups, and the Residents’ Association as well as others. We must maintain and enhance unity. Membership is available at no cost for those who do not have resource access. The goal of our Membership Committee, led by Mark Glazebrook is to have every orthopaedist in Canada as a member - 100% membership. We need to work together with Mark and his Committee to achieve this goal. We need to expand our concept of inclusiveness far beyond orthopaedics. The relative lack of resources for musculoskeletal care is political – when is the last time you read a newspaper story about someone waiting for orthopaedic care? Politicians respond to one thing only – voters. We need to build bridges

Your COA / Votre association

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to citizens groups, senior’s groups, patient care groups and political organizations to advocate for better access to care. Each one of us, when we see a patient, advocates for that individual. See more rather than less patients. No one has any control over that. If surgery would help, explain the situation. If there are resource constraints or roadblocks, explain that situation too. One of my colleagues is on a quota system for hip replacements. When he runs out of resources he fills out the Ministry form for care in the United States – if that is what the patient wishes - rather than waiting. When the Ministry gets the bill they give him resources for another 30 or 40 joint replacements. I have been at meetings where a former Premier, after assuring himself that there were no reporters in the room, admitted that his Government’s method of dealing with new medical technology was delay, delay, delay! Have we accomplished anything in the past? Yes we have. A Position Paper with respect to access to hip and knee replacement was developed in 1997 when I was Chair of the Special Committee on Public Relations. I remember the skepticism expressed by some when the document was discussed initially. There was gradual acceptance by many of the issue and eventually funding flowed from the Federal Government. If we have made a mistake in the past, is has been from not aiming high enough – the current resource shortfall affects musculoskeletal care broadly. There is less leadership from the federal government. More layers of bureaucracy have been introduced and/or the layers have changed, sometime in a serial fashion, in the provinces. We need to go to the source of funding – Canadians in general, our patients, friends, neighbours, relatives (anyone who will listen) and tell them about the problems that are going to impact them or their family at some point in their life if something does not change. Politicians should be asked to comment on the adequacy, or lack thereof, of orthopaedic resource access in their jurisdiction. I have not forgotten the employment issue. The COA leadership has met with the Royal College and other stakeholders. The problem relates to the lack of a coordinated physician human resource plan in this country. We are developing such a plan for orthopaedics and a great deal of effort has gone into this. At the end of the day we must recognize that if there was more resource, there would be more positions – hopefully this will change in the long-term with concerted political action by all of us. Our position as an Association is clear – it has been articulated with clarity by my predecessors. There should be a significant reduction in the number of training positions at least on a temporary basis. Quebec has taken action – the number of positions has been reduced by 50% - we need to recognize the leadership of our colleagues from La Belle Province in this regard. Other programs have also reduced their training positions.

Orthopaedists taking call should have access to scheduled resources. Where will this resource come from? Good question. Two sources – the resources we may receive in the future and the resources we have now. We will not get increased resource in the future unless we make much more noise through our patients to elected officials – at the end of the day, resource allocation in public health care is a societal decision. With respect to the present resource, we need to look at two things – equity and what I am going to call, late career transition, (a phenomenon that used to be referred to as retirement). At my Institution, if everyone had an equitable amount of resource, there would be resources for several new positions. Do the exercise at your Institution. If resources are equitably distributed, consider lowering the mean allocation to allow recruitment. When people are away, give their resource to those taking call in recognition of their contribution to your Institution rather than someone with resource who “needs” extra time. Who needs the resource more?? What is a late career transition surgeon? You are looking at one. There are many others is in the room. We are individuals in our late 50’s, their 60’s and their 70’s. I am going to be 63 this year. Like many people my age, I have no plans to retire. I love what I do. Nothing is sweeter that tapping a new glenoid component into place or restoring motion to a pseudoparalysis shoulder with a reverse arthroplasty. Having said that, I did 178 cases last year versus 190 cases the year before. This volume of surgery is much less than many of my colleagues who are same age or older. As time goes on, I will do less surgery rather than more. There are other things in life – for me fishing, biking, ecotourism, gardening, cottaging, grandchildren. There are also other ways to pay bills – administration, consulting, teaching, investing, writing reports and seeing patients in the office. In fact, on a time-spent basis these activities are equally or far more remunerative that operating. Have you read any epitaphs that state the deceased would have been a better person if they had done another 200 cases? It makes me feel good to know that I am using less rather than more resource at this stage of my life. Hopefully that is going to help a young person. I do not feel diminished as an orthopaedist by doing less surgery than I did 20 years ago. I mentioned John Kennedy earlier. When I am in Washington, I try to get out to his beautiful gravesite in Arlington, Virginia overlooking the Mall in the distance. He is buried there along with Jackie, Bobbie and some of their children. Some of his words are inscribed in the stone plaza that surrounds an eternal flame including the famous words from his inauguration, “Ask not what your country can do for you – Ask what you can do for your country.” It is said that there is nothing new under the sun. The Roman orator Cicero used similar words, as did Oliver Wendell Holmes in 1884, Warren Harding in 1916 and a poet writing in Arabic in 1925. The poet stated that those who give back are like “an oasis in the desert.”

COA Bulletin ACO - Fall / Automne 2015

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At the end of the day we have the recording of Mr. Kennedy and he seems to have said it best. We need to adopt the same concept for the future of our Association – Avancer, Ensemble – Moving Forward, Together. Our Association needs each and every one of you to be engaged! Your future and the future of our Association depends on it. I have many individuals to thank. Thank you to Rick and Mary, my parents who grew up on family farms, their ashes now interred in Toronto close to my home much to their chagrin I am sure. Thank you to my friends and family for putting up with me. Thank you to the orthopaedic industry for supporting our Association and for the rich symbiotic constructive relationship we share with you. Thanks to my teachers and students for inspiring me. Thank you to my patients for their trust. Thanks to my colleagues for helping me with patient care over the years.

A special thanks to the COA staff made up of Meghan Corbeil, Trinity Wittman, Cynthia Vezina and Doug Thomson. In the fall of 2000, I was Secretary of the COA and Cecil Rorabeck was President. The preceding Executive had decided that we needed a new CEO so we did not have one. There were very dark days as we searched for a CEO. Cecil and I relied completely on Cynthia to keep the Association’s lights on and we lived in mortal fear that she would quietly leave and send us the office key in the mail. Fortunately for all of us, Cynthia stayed and Doug was appointed. Thank you for all your contributions and the stability that has allowed our Association to grow in so many ways. Thank you to our hard-working Committee Chairs and Committee Members. I thank each and every one or you for attending this meeting and for your contributions to our Association now and in the future. And finally, last but not least, I thank Barb McArthur.

Active Members – Your COA Membership Just Got a Whole Lot More Interesting! Cynthia Vezina Manager, Membership Services & Communications Canadian Orthopaedic Association

n a direct response to your request for added value, Active membership within the COA will soon include additional advantages beginning with easier access to our premier educational event. Under the new membership dues structure being introduced in 2016; Active members will no longer be required to pay pre-registration fees when attending a COA Annual Meeting. How will this work? In order to be eligible for the waived registration fees, you must first pay your 2016 Active membership dues invoice as well as any other outstanding past invoices in your account. Upon receipt of your dues payment, your pre-registration fees for the 2016 Annual Meeting will be automatically waived when you register for the Québec City Annual Meeting. Remember that you will also need to register for the Annual Meeting prior to the pre-registration cut-off date. Fees for later registration or onsite registration for all membership categories still apply regardless if you have already paid your membership dues or not. The only additional charges you will incur during the preregistration period are through purchasing optional ICL tickets, workshops and social event tickets offered at an additional fee.

COA Bulletin ACO - Fall / Automne 2015

When will this take effect? In early January after the holiday break, we will send you an e-mail notification that includes a link to your 2016 invoice. You can go ahead and pay your membership dues upon receipt of this notice. Annual Meeting pre-registration will also open earlier than usual next year and will be available in early January at www.coaannualmeeting.ca. If you try to register for the Annual Meeting without first paying your membership dues, the system will alert you and redirect you to the COA’s Membership Portal where you can pay your dues invoice online. Once your payment has been processed, you can follow the links back to the registration system and complete your meeting registration. The next edition of the COA Bulletin will include a detailed ‘how to’ article outlining the various steps you should follow from log in, to payment of your dues, through to completion of your meeting registration. But wait! I don’t go to the COA Meeting every year! Even if you attend an Annual Meeting once every three years, you are still gaining value. Early bird registration fees for Active members were previously $550, while the regular registration rates were $700. Your $985 membership dues payment will now cover your pre-registration fee for the given year’s meeting. We hope that the inclusion of your pre-registration fees within your annual dues will encourage you to attend the COA Annual Meeting more often.

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Here is how you can get ready for the upcoming changes: 1) Make sure any outstanding dues invoices are paid in full before the New Year. Log in to your account on the COA web site: www.coa-aco.org to verify your invoice’s payment status or to pay your 2015 invoice. This will allow you to start off the 2016 fiscal year in good standing without any additional balances to settle when you receive your 2016 invoice. 2) Start making your plans to attend the 2016 COA Annual Meeting in Québec City. You can visit www.coaannualmeeting.org to view the preliminary schedule, featured guest speakers and book your hotel accommodations. Pre-registration will open early in the New Year.

3) Stay tuned for an e-mail notification in early January including a link to your 2016 membership dues invoice. Members are invited to contact me at cynthia@canorth.org or 514 874-9003 x 3 or our CEO, Doug Thomson: doug@canorth.org / 514 874-9003 x 5 with any questions you may have about the upcoming changes. There has never been a better time to be a member of the COA.

Oyez membres actifs! Votre adhésion à l’ACO vient de prendre une tournure encore plus avantageuse! Cynthia Vezina Gestionnaire, Communications et services aux membres Association Canadienne d’Orthopédie

ous nous avez demandé une adhésion à valeur ajoutée; afin de répondre à ce souhait, nous allons bonifier sous peu les avantages que nous offrons à nos membres actifs, en commençant par faciliter l’accès à notre principale activité de formation. En effet, selon la nouvelle structure tarifaire, qui entrera en vigueur en 2016, les membres actifs n’auront plus à payer de droits s’ils s’inscrivent à la Réunion annuelle de l’ACO pendant la période de préinscription. Comment cela fonctionnera-t-il? Afin d’assister à la Réunion annuelle sans payer de droits d’inscription, vous devrez d’abord payer votre cotisation de membre actif pour 2016, de même que toute facture en souffrance à votre dossier, et ensuite vous inscrire pendant la période de préinscription. Sur réception de votre paiement, vos droits d’inscription à la Réunion annuelle 2016 seront automatiquement considérés comme réglés lorsque vous vous inscrirez à la Réunion annuelle de Québec. Cependant, n’oubliez pas que vous devrez vous inscrire avant la fin de la période de préinscription, car les droits demeurent applicables en cas d’inscription tardive ou sur place, et ce, pour toutes les catégories de membres, que votre compte soit en règle ou non. Par conséquent, les seuls frais que vous encourrez pendant la période de préinscription seront pour la participation à des conférences d’enseignement et à des ateliers de même que l’achat de billets pour les activités sociales payantes, qui sont tous facultatifs. Quand la nouvelle structure entrera-t-elle en vigueur? Début janvier, après le congé des Fêtes, nous vous ferons parvenir un courriel comprenant un lien vers la facture de votre cotisa-

tion pour 2016. Vous pourrez payer votre cotisation annuelle sur réception de cet avis. La période de préinscription à la Réunion annuelle commencera en outre plus tôt que d’habitude, soit dès le début du mois de janvier, à www.coaannualmeeting.ca. Si vous tentez de vous inscrire à la Réunion annuelle avant d’avoir payé votre cotisation, vous recevrez un avis automatique et serez dirigé vers le Portail communautaire de l’ACO, où vous pourrez la régler en ligne. Une fois votre paiement traité, vous pourrez cliquer sur les liens proposés pour retourner dans le système d’inscription et procéder à votre inscription. Le prochain numéro du Bulletin de l’ACO comprendra un article détaillant les étapes à suivre afin d’ouvrir une session, de payer votre cotisation, puis de vous inscrire. Mais un moment s’il vous plaît! Je n’assiste pas à la Réunion annuelle de l’ACO tous les ans! Même si vous assistez à la Réunion annuelle seulement une fois tous les trois ans, cette nouvelle offre reste avantageuse. Les droits d’inscription pour les membres actifs qui s’inscrivent tôt étaient de 550 $, tandis qu’ils étaient de 700 $ pour les autres membres. Votre nouvelle cotisation de 985 $ comprendra désormais vos droits d’inscription à la Réunion annuelle – pourvu que vous vous inscriviez pendant la période de préinscription. Nous espérons que l’inclusion de vos droits d’inscription dans votre cotisation annuelle vous incitera à assister plus souvent à la Réunion annuelle de l’ACO. Pour vous préparer à ces changements, vous pouvez faire ce qui suit : Assurez-vous de régler toute facture en souffrance avant le Nouvel An. Ouvrez une session sur le site Web de l’ACO, à www.coa-aco.org/fr, vérifiez si des factures sont en souffrance et réglez votre cotisation pour 2015, le cas échéant; vous débuterez ainsi la nouvelle année du bon pied, sans solde à payer lorsque vous recevrez votre avis de cotisation pour 2016. COA Bulletin ACO - Fall / Automne 2015

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Commencez à planifier votre participation à la Réunion annuelle 2016 de l’ACO, à Québec. Pour ce faire, vous pouvez vous rendre à www.coaannualmeeting.org afin de consulter le programme provisoire, de prendre connaissance des conférenciers invités et de réserver votre chambre. Vous pourrez vous inscrire dès le début de 2016.

Début janvier, vous recevrez un courriel comprenant un lien vers la facture de votre cotisation pour 2016.

Québec City Accommodations Remember to book early!

Hébergement à Québec : N’oubliez pas de réserver tôt!

ur 2016 host city is a very popular summer destination so we encourage our members to book their hotel rooms early. The COA’s room blocks at the two conference hotels were sold out by early March for last June’s Vancouver Annual Meeting, and we are also expecting increased attendance at the 2016 meeting given that the registration fees will be included with your Active membership dues. The COA has room blocks in the Hilton Québec and Delta Québec properties – both of which are connected to the Québec City Convention Centre where the meeting will be held. Don’t wait for registration to open – go ahead and book your accommodations now! To reserve a room at either of these two hotels, please visit www.coaannualmeeting.ca and click on the Travel and Hotel tab at the top of the page. A preliminary meeting schedule can be found in the Attend > Schedule at-a-glance section. Inquiries? Contact meetings@canorth.org

Si vous avez des questions sur les changements à venir, vous pouvez communiquer avec moi, à cynthia@canorth.org ou au 514-874-9003, poste 3, ou avec Doug Thomson, notre directeur, à doug@canorth.org ou au 514-874-9003, poste 5. Être membre de l’ACO n’a jamais été aussi avantageux!

omme la ville hôte de la Réunion annuelle 2016 est une destination vacances très prisée en été, nous invitons nos membres à réserver leur chambre tôt. De plus, les blocs de chambres réservés par l’ACO dans les deux établissements associés à la Réunion annuelle de Vancouver, en juin dernier, étaient complets dès le début du mois de mars, et nous nous attendons à une hausse de la participation à la Réunion annuelle 2016, puisque les droits d’inscription seront inclus dans la cotisation annuelle des membres actifs. L’ACO a déjà réservé un bloc de chambres au Hilton Québec de même qu’au Delta Québec (ces deux établissements communiquent avec le Centre des congrès de Québec, où la Réunion aura lieu). Alors n’attendez pas que la période d’inscription soit commencée : réservez votre chambre dès aujourd’hui! Pour réserver une chambre dans l’un ou l’autre de ces établissements, rendez-vous à www.coaannualmeeting.ca, puis cliquez sur l’onglet « Destination », dans le haut de la page. Vous pouvez également consulter le programme provisoire de la Réunion annuelle en cliquant sur l’onglet « Participez », puis sur « Aperçu du programme ». Vous avez des questions? Écrivez à meetings@canorth.org.

COA Bulletin ACO - Fall / Automne 2015

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Awards of Distinction

The 2015 Recipients of the COA Award of Merit and Presidential Award for Excellence Bas Masri, M.D., FRCSC Immediate Past President Canadian Orthopaedic Association

non-operative and medicolegal practice. He is one of the most respected experts in the Supreme Court of British Columbia.

lease join us in congratulating this year’s recipients of the COA’s awards of distinction. Recipients were presented with their awards during the Opening Ceremonies of the COA Annual Meeting held this past June in Vancouver.

Dr. McGraw is the founder of the Department of Orthopaedics at the University of British Columbia, and served as Department Head for 11 years. He is currently Professor Emeritus at UBC. He also served the COA as President in 1990. For his past, present, and future contributions, he has been selected as this year’s recipient of the COA Award of Merit.

The Canadian Orthopaedic Association’s Award of Merit is presented for excellence in at least two of the following areas:

The COA Presidential Award for Excellence is presented for excellence in at least two of the following areas:

• Service to the profession in the field of medical organization as it relates to orthopaedic surgery specifically; • Service to the people of Canada in raising the standards of orthopaedic care in Canada; • Personal contributions to the advancement of orthopaedic research, orthopaedic education, health-care organization or orthopaedic education of the public.

• Service to the profession in the field of orthopaedic surgery; • Service to the people of Canada in raising the standards of orthopaedic care in Canada; • Personal contributions to the advancement of the art and science of orthopaedic surgery.

It was a great pleasure for me to present the 2015 COA Award of Merit to Dr. Robert W. McGraw. Dr. Robert W. McGraw has been an icon in Canadian Orthopaedics for the past four decades. He was a Canadian pioneer in joint replacement having been one of the first introducers of total hip replacement to British Columbia. He became an expert in arthritis surgery, dedicating the majority of his career to the comprehensive care of the arthritic patient, especially patients afflicted with rheumatoid arthritis, when surgery was the only partial cure for this disabling disease. As his career progressed, he still focussed on the rheumatoid patient, but narrowed his focus to hip and knee replacement. He retired from surgical practice 15 years ago, yet maintained a busy

Dr. Robert W. McGraw receives the 2015 COA Award of Merit from Dr. Bas Masri during the Opening Ceremonies at the COA Annual Meeting in Vancouver

I was honoured to present this year’s Award for Excellence to Dr. Donald Garbuz. Dr. Garbuz is Professor of Orthopaedics, and Head of the Division of Lower Limb Reconstruction and Oncology in the Department of Orthopaedics at UBC. He is a skilled hip and knee replacement surgeon, and a talented researcher. He is a two-time recipient of the Charnley Award and winner of the Frank Stinchfield Award - two of the most prestigious award from the Hip Society. He has published numerous peerreviewed publications and has been a regular and trusted contributor to the academic mission of the COA. He is an excellent colleague and a family man. For his numerous contributions to orthopaedic care in Canada, he has been awarded the COA’s 2015 Presidential Award for Excellence.

Dr. Donald Garbuz is presented with the COA’s 2015 Presidential Award for Excellence by Dr. Bas Masri

COA Bulletin ACO - Fall / Automne 2015

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CORA 2015 Top Paper Awards

ongratulations are extended to the recipients of the top paper awards that were presented at the 2015 CORA Annual Meeting held on June 17 in Vancouver. The meeting’s podium presentations were adjudicated by Drs. Kelly Apostle and Gerard Slobogean who both previously served as CORA Co-Chairs together in 2009. The 2015 top paper award recipients are: • Top Paper Award - J.A. Nutter Award Sponsored by Smith & Nephew Dr. Jerry G. Xing (University of Toronto) • 2nd Prize - Alexandra Kirkley Award Daniel Banaszek (Queen’s University) • 3rd Prize – COA Award Shandy Fox (University of Saskatchewan) The abstracts for these top papers follow this article.

We would like to thank the session moderators and abstract reviewers for their time and commitment to resident education. We would also like to acknowledge Drs. Graham King, Brian Kwon and Ross Leighton for participating in the CORA symposium as guest speakers. Their contribution to the residents’ program was extremely valuable and enriching. The 2015 CORA event was hosted by Drs. Tym Frank and Lauren Roberts from the University of British Columbia. The 2016 CORA meeting will be held on June 16 in Québec City. We would like to welcome Drs. Pierre-Luc Blouin and Simon Corriveau-Durand from Université Laval as the new co-chairs. Mark your calendars for next year’s CORA meeting; call for abstracts is open until January 31. www.coraweb.org

Top Paper Award - J.A. Nutter Award Sponsored by Smith & Nephew Preoperative Femoral Nerve Block for Hip Arthroscopy: A Randomized Triple-masked Controlled Trial Jerry G. Xing, University of Toronto F.W. Abdallah, S. Oldfield, A. Dold, M.L. Murnaghan, R. Brull, D.B. Whelan Introduction: Arthroscopy has become a standard method of treatment for a variety of intra-articular hip pathologies. While most arthroscopic hip procedures are performed as day-surgeries, patients can still experience significant postoperative pain and opioid-associated side-effects. The potential benefits of a preoperative femoral nerve block (FNB) in hip arthroscopy were explored in a previous retrospective review. It was our objective to confirm these findings in a prospective randomized study. Methods: Fifty patients undergoing hip arthroscopy were included in this prospective, single-centre, patient, operator and assessor blinded, randomized controlled trial. Patients received either a preoperative ultrasound-guided FNB with 20 mL of 0.5% bupivacaine (FNB group) or normal saline (Control group). Nerve blockade was confirmed via standardized sensory testing prior to the induction of general anaesthesia. The primary endpoint was cumulative oral morphine equivalent consumption at 24 hours after discharge. Secondary endpoints included opioid use at various time-points, pain scores, Quality of Recovery (QoR-27) score, incidence of nausea

COA Bulletin ACO - Fall / Automne 2015

Dr. Jerry Xing is presented with the top paper award by Drs. Kelly Apostle and Gerard Slobogean.

and vomiting, time to discharge, block-related complications, falls at 24 hours, and patient satisfaction. Results: Fifty patients completed the study, including 27 in the FNB group, and 23 in the Control group. Most patient characteristics were statistically similar between groups except for operative time, which was longer in the Control group. Cumulative oral morphine consumption was lower in the

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FNB group at 48 hours. There was no difference at 24 hours or seven days postoperatively. Pain scores were significantly lower at six hours postoperatively in the FNB group, compared to Control; however, rebound pain was observed at 24 hours after discharge in patients who received FNB. There was no difference in most secondary outcomes. Importantly, a total of six patients in the FNB group reported falls (without injury) within the first 24 hours postoperatively compared to none in the

Control group. Patient satisfaction with pain control was high in both groups at all time-points. Conclusions: Preoperative FNB may improve early pain control following hip arthroscopy. However, given the observed risk of falls, we cannot recommend the routine use of FNB for outpatient hip arthroscopy.

CORA session in progress

2nd Prize - Alexandra Kirkley Award Virtual Reality versus Bench Top Simulation in the Acquisition of Arthroscopic Skill: A Randomized Control Trial Daniel Banaszek, Queenâ&#x20AC;&#x2122;s University D. You, M. Pickell, D. Hesse, D. Borschneck, D. Bardana Purpose: With modern restrictions in resident work hours, attempts have been made to incorporate virtual reality (VR) simulators and benchtop trainers (BT) to accelerate surgical skill acquisition. Prior research has established the benefit of these modalities in operative skill. To our knowledge, no studies have compared skill acquisition between virtual and benchtop simulators concurrently. We hereby aim to directly compare two surgical simulation set-ups in a randomized control study, and assess efficiency in skill from the lab into the operating room. Materials/Methods: Thirty-nine surgical novices (medical clerks) were given an orientation to basic arthroscopy. Each participant performed a baseline 10-minute diagnostic exam on both VR and BT simulators. Participants were randomized to train in either of t modality for six to eight hours over a fiveweek period. Post-testing consisted of: 1) repeat arthroscopy

CORA Co-Chairs, Drs. Tym Frank and Lauren Roberts

on both modalities, 2) arthroscopy in a cadaveric knee, and 3) a surprise task assessing skill transfer. A single expert blinded observer was used for all evaluations. Primary outcomes COA Bulletin ACO - Fall / Automne 2015

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included total Global Rating Scale, Arthroscopic Checklist, and procedural time. Secondary outcomes included ArthroVR Motion analysis data, as well as Benchtop analysis data. SPSS was used for statistical evaluation. Results: Data reflects the first 17 subjects. There were no differences in baseline objective measures (GRS, checklist, procedure time) between the VR and BT groups. After training, both VR and BT groups demonstrated improvements in arthroscopy skill. In the BT group, mean GRS scores were higher on both simulators (VR and BT p=0.01). Although participants in the BT group were only able to complete significantly more tasks on the BT model, the group was showed significant improvement in mean procedure time in both simulators (BT: p=0.01; VR: p=0.02). Similarly in the VR group, mean GRS scores were higher post-test (BT: p=0.01; VR: p=0.01), participants were able to complete more tasks on both simulators post-test (BT:p=0.01; VR:p=0.01) and procedural times decreased significantly (BT: p=0.01; VR: p=0.01). Post-test cross-over analysis showed increased improvement in all three primary outcomes for the VR group (GRS, Checklist, time; p=0.01). There were no differences in improvement posttest between groups on their respective modalities. There were no differences in between the VR and BT groups for primary outcomes in the cadaveric knee. However, mean VR group GRS scores and procedure time were improved in the skill transfer evaluation (p=0.01). Motion analysis showed significant decreases in camera distance (p=0.001) and probe distance (p=0.004). Mean camera roughness and probe roughness differences were not significant.

Dr. Ross Leighton presents at the CORA symposium

Conclusion/Future Directions: Surgical simulation training is a powerful tool in the efficient training of surgical residents. In our randomized trial, we aimed to identify potential strengths of two different set-ups in the design of an arthroscopic curriculum for our institution. Preliminary data from our study suggests that both BT and VR arthroscopic simulators are effective training modalities to accelerate surgical skills acquisition.

3rd Prize â&#x20AC;&#x201C; COA Award Spinal Instability Neoplastic Score: An Analysis of Reliability among Spine Fellows and Resident Physicians in Orthopaedic Surgery and Neurosurgery Shandy Fox, University of Saskatchewan M. Spiess, L. Hnenny, D. Fourney Purpose: Spine surgical trainees are involved in the assessment and management of patients with spinal neoplasia and the determination of tumour-related instability. The Spinal Instability Neoplastic Score (SINS) was devised by the Spine Oncology Study Group (SOSG) in 2010 as a tool to facilitate the diagnosis of neoplastic instability and enhance timely management. It assesses six variables: location of lesion, characterization of pain, type of bony lesion, radiographic spinal alignment, degree of vertebral body destruction, and involvement of posterolateral spinal elements. The scores for each variable are added, and a final score obtained (zero to 18). A score of zero to six denotes stability, seven to 12 denotes indeterminate (possibly impending) instability, and 13 to 18 denotes instability. A surgical consultation is recommended for scores greater than seven. Face and content validity, reliability, and COA Bulletin ACO - Fall / Automne 2015

Dr. Shandy Fox receives the COA Award for her presentation

predictive validity have previously been evaluated among practicing spine surgeons. The purpose of this study was to determine the inter- and intra-observer reliability of SINS

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among Spine Fellows and Resident Physicians in Orthopaedic & Neurosurgery. Methods: Twenty-three residents (orthopaedics=18; neurosurgery=5) and two spine fellows were recruited and instructed on the use of SINS. Thirty de-identified cases were independently scored on two occasions at least six weeks apart. The scores from each of six SINS criteria were combined to obtain a final score. Intraclass correlation coefficient (ICC) was used to measure both inter- and intra-observer agreement for total SINS scores. For each of the components, Fleiss’s Kappa was used to evaluate inter-observer agreement, and Cohen’s Kappa for intra-observer agreement.

Results: (A) Inter-observer agreement: The ICC for total SINS score was 0.990, representing near perfect agreement. The Kappa statistics were 0.948, 0.739, 0.382, 0.427, 0.550, and 0.435 for the fields of location, pain, bone quality, alignment, body collapse, and posterolateral involvement, respectively. The level of agreement was near perfect for location, substantial for pain, moderate for alignment, body collapse, and posterolateral involvement, and fair for bone quality. (B) Intra-observer agreement: The ICC for total SINS score was 0.907, representing near perfect agreement. The Kappa statistics were 0.954, 0.814, 0.576, 0.610, 0.671, and 0.561 for the same respective fields. The level of agreement was near perfect for location and pain, substantial for alignment and body collapse, and moderate for bone quality and posterolateral involvement. Conclusion: Amongst spine fellows and orthopaedic and neurosurgery residents, SINS results in highly reliable assessments of stability in neoplastic spinal disease.

The COA’s 2016 ASG Fellow Dr. Andrea Veljkovic

Pascal-André Vendittoli, M.D., FRCSC Chair, COA Exchange Fellowships Committee Montréal, QC

e are pleased to announce that Dr. Andrea Veljkovic of Vancouver, British Columbia will represent the COA on the 2016 Austrian-Swiss-German (ASG) Travelling Fellowship Tour. Although it was previously announced that Dr. Andrew Howard (University of Toronto) was selected as the 2016 fellow, Dr. Howard was unable to fulfill the role due to other commitments. The COA’s Exchange Fellowships Committee reconvened and unanimously agreed that the fellowship opportunity be awarded to Dr. Veljkovic who also ranked very highly in the candidate review. We would like to thank Dr. Veljkovic for accepting the fellowship and congratulate her on being the first Canadian ASG fellow in over a decade. She will tour centres in Austria, Switzerland and Germany in the spring of next year with two American fellows selected by the American Orthopaedic Association. Andrea Veljkovic is a foot and ankle orthopaedic surgeon recently appointed to the University of British Columbia. She is interested in alignment restoration in complex foot and ankle deformities, arthroplasty, and advanced arthroscopic reconstruction. After orthopaedic residency training in Halifax and Edmonton, she completed a sports medicine fellowship at 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. Please join us in congratulating Dr. Veljkovic on this achievement.

COA Bulletin ACO - Fall / Automne 2015

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Lifelong Learning and Supporting Communities Getting to Know your COA Global Surgery Committee: Part II

he COA Global Surgery (COAGS) initiative brings Canadian orthopaedic surgeons together to share ideas and promote opportunities for providing humanitarian care to vulnerable populations. COAGS invites you to get to know the committee and some of the projects they are proud to support. The spotlight in this issue is on four COAGS Executive members, Drs. Neil White, Norgrove Penny, Andrew Furey and Andrea Chan. Dr. Neil White has been practicing surgery since 2012 at the new South Health Campus in Calgary with a combined upper extremity and trauma academic appointment. He is proud to be a part of the combined orthopaedic and plastic surgery hand program, and is in the second year of a grant-funded research program, with a special interest in scaphoid fractures and scapholunate ligament injuries. He enjoys training fellows and sharing his overseas experiences with colleagues. Motivated by an innate desire to help people and the lessons learned while working in refugee camps in Albania, Neil’s interest in low- and middle-income countries (LMIC) was core to his initial draw into medicine. He admits to a fleeting concern that pursuing orthopaedics would limit his global health options, but then quickly realized the vast possibilities for a surgeon to answer the call abroad, and joined missions to Ecuador and Haiti as a resident and fellow. After completion of his training (and by virtue of being unemployed), he set up his own project, organized through SIGN Fracture Care and funded through the Osteosynthesis & Trauma Care Foundation (OTC), doing orthopaedic trauma surgery and post-traumatic deformity This young Ethiopian boy sustained an open supracondylar elbow fracture in a tussle with another child, resulting in a feud between the two families over the hospital bills. The village elder eventually came to a decision after three weeks, by which time the bone was infected. After debridement by Dr. Neil White and his team, the elbow was reduced and splinted with a window to allow for repeat washouts. Four additional washouts in the OR finally allowed for formation of a bed of granulation tissue, and the wound healed by secondary intention.

COA Bulletin ACO - Fall / Automne 2015

High five! Dr. Neil White with a young patient, three days after surgical treatment of chronic elbow dislocation.

correction in chronically injured patients in Ethiopia, Kenya and Tanzania, while sourcing donated equipment for each site. Since beginning his practice in Calgary, White has volunteered throughout Africa with SIGN, in Haiti with Team Broken Earth, and in the Dominican Republic with the Foundation for Orthopedic Trauma. SIGN Fracture Care supports local health care teams in multiple LMIC countries by providing orthopaedic instruments and sustainable training. White described in 2013 the ‘agony and ecstasy’ (expression courtesy of Lew Zirkle, SIGN founder) of making a small contribution to helping local people return to productive lives, coupled with profound frustration with the system, such as when elective surgeries are repeatedly delayed, sometimes due simply to unavailability of oxygen or other basic resources. To learn about SIGN or to read about Dr. White’s missions abroad, please visit https://signfracturecare.org/blog/dr-neil-white-adventures-abroad/. From the minute he describes his early experiences, Neil’s appreciation and excitement for helping those in need feels contagious: “The more you do, the more you want to do. Global health is less about fixing bones and more about human equality. Trips to the developing world make one realize how extreme the equality gap is, yet building friendships in those places show us how similar people are in their needs, desires, intelligence, and humour.” White’s advice to any surgeon looking to take the plunge into global health is simply ‘Just do it!’. The first trip is the most difficult to organize, between logistics, visas, work permits, licensing, vaccinations, malaria prophylaxis, effective packing and safety, but is also the most eye-opening and rewarding. There are many barriers to global missions, but the more Canadian surgeons take part, the more commonplace it becomes for others to jump on board. Talk to

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colleagues about their experiences, get involved with medical missions early in your training and study each region carefully to determine its unique challenges. Dr. Norgrove Penny is a paediatric and sports orthopaedic surgeon from Victoria and Clinical Assistant Professor at University of British Columbia. He has served as the surgeon for Team Canada in the 1992 Olympic Games, Chief Medical Officer in the 1994 Commonwealth Games, Senior Advisor for Physical Impairment for CBM International, Disability and Rehabilitation Team Advisor for World Health Organization and Chief of Paediatric Surgery for the Vancouver Island Health Authority. His longstanding commitment to global paediatric care has been recognized with numerous awards, including the Order of Canada in 2007 and the 2013 COA Presidential Award for Excellence. Born in Africa to a missionary doctor, passion for global health is in his DNA. Motivated by the plight of children suffering from physical disabilities in LMIC, Penny moved his young family to rural Uganda for six years, where he started a small orthopaedic rehabilitation facility, which later became CoRSU hospital (http://corsu-uganda.org/), where 5000 surgeries are now done annually in six well-equipped operating rooms. With the expanding middle class population in Uganda, Penny hopes to build local capacity in arthroplasty and arthroscopy, with the assistance of Rebalance Legacy Society, a charitable organization in which he plays a leadership role. This group does work both locally and internationally, advocating for improvements to children’s orthopaedic health in local communities (through prevention of ACL injuries, among others) as well as regularly sending multidisciplinary teams to Uganda to build surgical and administrative self-sufficiency in paediatric settings: “Teaching young African surgeons to perform surgery that is common in the western world is one way to counteract the brain drain and keep surgeons in their home country”. To learn more about this society, please visit http://rebalancemd.com/ news/2013/rebalance-legacy-society/. Penny is also currently on the Board of Directors of the Canadian Network for International Surgery (CNIS), a surgical NGO with which he has been associated for many years. Most recently, Penny developed a unique two-day certificate course

Dr. Will Moores and Dr. Andrew Furey instructing on fixation of a fracture of the acetabulum in Port-au-Prince, Haiti, in 2015.

In Ethiopia’s Soddo Christian Hospital, there is no lab to identify the causative organism in infection. This sheep is routinely phlebotomized to make agar and grow organisms. Using this low-tech, yet effective method, the medical team directs antibiotic therapy by killing the bug, despite never confirming its identity.

for surgeons in LMIC for the CNIS, teaching surgical management of osteomyelitis using low-fidelity limb models as surgical simulators. Global development work is the most rewarding part of Penny’s practice: “Many of us went into medicine to help people, and global work brings that idealism into sharp focus. I love the way that physical examination and logical thinking have the largest impact, rather than reliance on fancy operating equipment. Africa is so young in its medical development that mentoring young surgeons makes a huge contribution to the future leadership of the continent”. No matter the stage in your career, the global surgery community could use your help! Senior surgeons are an asset because many LMIC techniques recall previous training and technology that is now outdated in Canada, and most LMIC cultures profoundly value elders as mentors. Junior surgeons are energetic and may get an early taste for the rewards of outreach work. Finding the time to get away from practice is difficult, so residency may also be a prime time to “catch the wave”, so to speak. The recent Lancet Commission on Global Surgery, World Bank publication on Essential Surgery, and 68th World Health Assembly resolution on Strengthening Emergency and Essential Surgical Care and Anaesthesia, are groundbreaking initiatives that will pave the way to addressing glaring disparities in surgical care. Penny warns novices not to expect to “save the world”, but instead to travel as an orthopaedic tourist first, study the local context, and identify a need that can be filled on a future trip. Stay loyal to one project - returning volunteers are worth their weight in gold! Dr. Andrew Furey is an orthopaedic trauma surgeon, Assistant Professor of Surgery, and Resident Training Research Director at Memorial University in St. John’s, NL, where he was born and raised. He has a Master of Clinical Epidemiology degree and is currently completing a Diploma in Organizational Leadership at Oxford School of Business. As early as residency, Furey was highly involved with the COA as the CORA co-chair, and continues to represent his province on a number of committees since starting his practice in 2007. He is currently the President of the Newfoundland Orthopaedic Association. Well-known for his leadership and philanthropic contributions to global orthopaedics, Furey’s recent accolades include the Rotary COA Bulletin ACO - Fall / Automne 2015

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Emerging Professionals Award, Queen’s Diamond Jubilee Medal, Memorial University Alumnus of the Year Award, COA Award of Merit and being named one of Atlantic Business Magazine’s top 50 CEO’s in 2015. During his first trip to Port-au–Prince in June 2010 following the earthquake that immediately killed more than 250,000 Haitians, Furey and his small medical team were taken aback by the devastation, realizing that “this was a journey about people, who by accident of birth, were suffering untold hardships”. Unable to shake the profound loss suffered by families, and driven by the need to provide sustained medical assistance to the community, Furey co-founded Team Broken Earth, a task force of more than 400 hard-working doctors, nurses, physiotherapists and other health-care workers from across Canada who volunteer on the ground in Haiti, providing acute care and education to patients, as well as skilled training to local healthcare teams. With each trip, the partnership with the local Haitian staff at Medishare’s Bernard Mev Hospital (one of the only trauma centres serving Port-au-Prince’s two million people, and where Furey is now Director of Orthopaedic Surgery) grows stronger, as does the overwhelming support from Canadian health-care professionals and supporters. Team Broken Earth was involved in the first Haiti Fracture Summit in Port-au-Prince in 2011 and has partnered with the Society of Haitian Orthopaedic Trauma surgeons (SHOT) to further develop staff training. They helped to successfully establish a third operating room in 2014, dedicated to orthopaedic surgery, and completed a new building at the hospital in 2015. They are hoping to create a Travelling Fellowship which will fund Haitian residents to receive training in Canadian operating rooms. Team Broken Earth is successful, according to its Founder, due to the dedication of volunteers, and the perseverance and spirit of the Haitian people. If you would like more information, please visit http://www.brokenearth.ca/ or e-mail andrew@brokenearth.ca. Dr. Andrea Chan is a fourth-year resident at the University of Toronto and the most recent addition to the COAGS committee, having been awarded the Resident Liaison position from a pool of very strong applicants. In addition to representing her program on the Canadian Orthopaedic Residents’ Association (CORA) Board, she sits on multiple committees at the University of Toronto on a broad range of topics including resident education, curriculum and matching. Chan has been a global health advocate since her Masters in Forensic Anthropology. In 2007, she was a researcher for a Canadian film crew that travelled across Malawi documenting the faith-based response to HIV/AIDS. This experience helped to shed light on the impact of poverty, religion and foreign fiscal policy on health and illness in that country. In another Malawi project, she worked with health-care providers, policy makers, funding agencies, and community and faith leaders, facilitating dialogue which led to creation of novel partnerships between otherwise disconnected stakeholders, a common understanding of HIV/AIDS issues, and the capacity to develop more effective programs on the ground. Later, Chan worked with medical anthropologist Dr. Dennis Willms as a researcher/grant writer/program developer through his NGO, COA Bulletin ACO - Fall / Automne 2015

If the shoe fits, use it as a traction boot. The Surgical team in Kijabe, Kenya frequently turned to an old box of running shoes in the OR, and the Canadian surgeons were again surprised by how well this worked.

Salama SHIELD Foundation, where she was able to pragmatically implement social theories learned in anthropology, again with a focus on HIV/AIDS work in Sub-Saharan Africa. During her fourth year in medical school, Chan completed an elective at Mulago Hospital’s Infectious Disease Institute, rotating through HIV, urgent care, tuberculosis, women’s/reproductive health and adolescent clinics, all with a focus on medical care for patients living with HIV and associated illnesses. Dr. Chan is eager to inspire junior trainees and foster resident awareness in current global health-care issues and initiatives. There are numerous ways to get involved with COAGS. If you are interested in starting a local initiative and would like to speak with a committee member, if you have a suggestion for the COA Bulletin, or if you would like the COA to highlight your upcoming global health event, please contact Trinity Wittman at trinity@canorth.org or 514-874-9003 x 2. We encourage you to follow the COA on Twitter @CdnOrthoAssoc and look out for #COAGlobalSx announcements.

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

Your COA / Votre association

James Floyd McMillan

February 6, 1945 to March 27, 2015

r. Jim McMillan, husband, father, brother, grandpa, uncle, orthopaedic surgeon, golfer, and world traveller, died peacefully in his sleep of a heart attack on Friday March 27, 2015. Raised in Lac La Biche, Alberta, he married his sweetheart Jan McMillan also from Lac La Biche, 46 years ago. They both attended the University of Alberta where Jim studied medicine and began working as an orthopaedic surgeon at the Charles Camsell General Hospital. The rest of his long career was spent working at various hospitals in the Edmonton area and with the Worker’s Compensation Board. As well as performing thousands of surgeries, he brought smiles to the faces of colleagues and friends with his sharp wit and shenanigans. Jim was part of a close, supportive family. He will be greatly missed by his wife, Jan, sister Marilyn (John) Fedun, brother Allan McMillan, sister-in-law Donna Hamar, brother-in-law Bill Hamar (Stephen White), three children David McMillan (Audrey Inouye), Cathy McMillan (Stuart Copeland) and Jill McMillan, and three nephews Kevin Fedun, Scott McMillan and Jeff McMillan.

Jim took great joy in spending time with his “troops”: his five grandsons (Taro, Kiyoshi, Olin, Kaito, Sterling), and two grandnephews (Connor, Matthew). He had a lifelong affair with golf and played hundreds of courses around the world. He was happiest walking on the golf course, rarely playing holes in numerical order, collecting golf balls along the way. In lieu of flowers, please make a donation to the charity of your choice or to Edmonton Community Foundation (9910103 Street Edmonton T5K 2V7) for a fund being set up in Jim’s memory. Published in The Edmonton Journal from Apr. 1 to Apr. 2, 2015

What’s coming up in the next edition of the COA Bulletin? Que vous réserve le prochain numéro du Bulletin de l’ACO? Canadian Orthopaedic Association Association Canadienne d’Orthopédie Winter / Hiver 2015 Publication Mail Envoi Poste-publication Convention #40026541 4150 O. Ste-Catherine W., Suite 450 Westmount QC H3Z 2Y5

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

BULLETIN

111

Stay tuned for the Winter edition #111 of the COA Bulletin before the end of this year which will include a debate on the accelerated treatment of hip fractures, information about the guest lecturers participating in the upcoming COA Annual Meeting, step-by-step instructions outlining how to pay your membership dues and in turn, pre-register for the Annual Meeting at no cost, as well as a clinical feature on complications and pitfalls of distal radius fracture treatment. Keep your eye on your inbox for a link to the Winter 2015 edition when it’s posted online. Ne manquez pas le numéro 111 du Bulletin de l’ACO, qui paraîtra à l’hiver! Vous y trouverez entre autres une discussion sur le traitement rapide des fractures de la hanche, des renseignements sur les conférenciers invités à la prochaine réunion annuelle de l’ACO, des directives détaillées pour le paiement de votre cotisation et, ensuite, pour votre préinscription gratuite à la Réunion annuelle, de même qu’un article clinique sur les complications et difficultés associées au traitement des fractures du radius distal. Surveillez votre boîte de réception : vous devriez recevoir le lien vers ce numéro hivernal dès qu’il sera accessible en ligne.

COA Bulletin ACO - Fall / Automne 2015

Your COA / Votre association

The 2015 COA & CORS Annual Meeting A review in photos

n behalf of the 2015 program and planning committees, we would like to thank all COA members who attended the 2015 Annual Meeting in Vancouver this past June. We value your participation and support and look forward to seeing you in Québec City next year for the 2016 COA and CORS Annual Meeting from June 16-19. We hope you enjoy these fantastic photos taken by COA member, Dr. Paul Wright, and invite you to review the entire Annual Meeting photo gallery at www.wrightmoment.com. Click on “Client Folders” and scroll down to the COA A-F files. These folders are password protected. To obtain your password to access the photo site, contact: cynthia@canorth.org

Réunion annuelle 2015 de l’ACO et de la SROC Un aperçu en photos

u nom des comités organisateur et responsable du programme, nous remercions tous les membres de l’ACO qui ont assisté à la Réunion annuelle 2015, à Vancouver, en juin dernier. Votre participation et votre soutien sont importants pour nous, et nous avons hâte de vous retrouver, du 16 au 19 juin 2016, à Québec, à l’occasion de la Réunion annuelle de l’ACO et de la SROC. Nous espérons que vous aimerez les magnifiques photos prises par le Dr Paul Wright, membre de l’ACO. Consultez la galerie de toutes les photos prises à la Réunion annuelle, à www.wrightmoment.com. Cliquez sur « Client Galleries », puis faites défiler la liste jusqu’aux dossiers COA2015 A à F. Pour obtenir le mot de passe nécessaire pour accéder aux dossiers, communiquez avec cynthia@canorth.org.

Deputy Minister of Health and Long-term Care, Dr. Robert Bell, delivers his guest speaker address during the Opening Ceremonies / Le Dr Robert S. Bell, sous-ministre de la Santé et des Soins de longue durée de l’Ontario, prononce son allocution aux cérémonies d’ouverture

The COA’s Executive Committee / Le Comité de direction de l’ACO

Presidential Guest Speaker, Dr. Brian Day, with Local Arrangements Chair, Dr. Bert Perey / Le Dr Brian Day, conférencier invité par le président de l’ACO, en compagnie du Dr Bert Perey, président du Comité organisateur COA Bulletin ACO - Fall / Automne 2015

Your COA / Votre association

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Dr. Bas Masri received the Past President’s pin from newly-minted COA President, Dr. Robin Richards / Le Dr Bas Masri reçoit l’épinglette du président sortant des mains du Dr Robin Richards, notre tout nouveau président élu

Dr. Kishore Mulpuri, Program Chair, attends the Soirée Under the Sea social event at the Vancouver Aquarium with his beautiful family / Le Dr Kishore Mulpuri, président du Comité responsable du programme, assiste à la Soirée sous la mer à l’Aquarium de Vancouver, accompagné de sa magnifique famille

Foundation Chairman, Dr. Geoffrey Johnston, presents Dr. Paul E. Beaulé with the J.E. Samson Award / Le Dr Geoffrey Johnston, président du conseil d’administration de la Fondation Canadienne d’Orthopédie, remet le Prix J.-Édouard-Samson au Dr Paul E. Beaulé

The orthopaedic graduating class of 2015 along with the COA Executive and Program Directors. Congratulations on the completion of your residency training! / La cohorte de diplômés en orthopédie de 2015, avec les directeurs de programme et la direction de l’ACO. Félicitations! Votre résidence est maintenant terminée! COA Bulletin ACO - Fall / Automne 2015

Your COA / Votre association

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Carousel Presidents from the international orthopaedic associations / Les présidents du groupe Carousel, issus de diverses associations orthopédiques dans le monde

Dr. Bas Masri with the ASG, CFBS and Anica Bitenc Travelling Fellows / Le Dr Bas Masri en compagnie des lauréats de la Bourse de voyage autrichienne-suisseallemande (ASA), de la Bourse de voyage canado-franco-belge-suisse (CFBS) et de la Bourse de voyage Anica Bitenc

COA Bulletin ACO - Fall / Automne 2015

Dr. Robert B. Bourne, Past President of the COA (2006) presenting ‘Life Lessons’ during his R.I. Harris Lecture. / Le Dr Robert B. Bourne, ancien président de l’ACO (2006), pendant son allocution à titre de conférencier R.I. Harris, intitulée « Leçons de vie »

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

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

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

Effect of Bearing Surface on Mid-term Survivorship of Total Hip Replacement – Results from the Canadian Joint Replacement Registry David H. Ames, M.D., FRCSC Eric Bohm, BEng, MSc, M.D., FRCSC Michael Dunbar, PhD, M.D., FRCSC Bas Masri, M.D., FRCSC Emil Schemitsch, M.D., FRCSC Naisu Zhu, M.D., DPH Jing Gu, M.D. CJRR Team* *Nicole de Guia, MHSc Cassandra Linton, MSc Tammy Anderson, MSc David Paton, MSc Vivian Poon, MSc Shirley Chen, MSc Michael Terner, MSc

he number of THAs performed in Canada has increased each year over the past decade with now more than 40,000 performed annually1. A key measure of success is implant survivorship. Early revisions have significant ramifications in terms of decreased health status for patients2 and increased costs to the health-care system. A significant determinant in the survivorship of THAs is the type of bearing surface that is selected by the surgeon.

gery on the femoral side. The selection of a particular bearing surface is primarily dependent on patient factors such as age, bone quality, and activity level. Other contributing factors are typically the surgeon’s familiarity with a given implant, the implant’s availability and cost, and the expected long-term performance5. Using data from the Canadian Joint Replacement Registry (CJRR), we investigated the effect of bearing surface material, implant design (resurfacing vs. standard THA), and patient characteristics on the mid-term survivorship of THAs implanted between 2003 and 2011. We sought to answer two questions: 1) Are there differences in mid-term (five-year) THA revision risk according to bearing surface and implant type? and 2) Does patient age, gender, and/or comorbidities affect the risk of mid-term revision? Data was extracted from the CJRR for patients who had undergone a primary THA between years April 2003 and November 2010. The study cohort consisted of 72,331 patients. This data was submitted to the CJRR voluntarily by institutions in all provinces and territories excluding Quebec, Prince Edward Island, Yukon, and Nunavut and during that time, captured approximately 40% of all THR procedures in Canada. This cohort was further limited to those patients with osteoarthritis as the primary diagnosis, reducing the sample to 61,768 (85% of initial). Revision status was ascertained using the hospital discharge abstract database (DAD) in which a 92% linkage rate was attained, resulting in a final cohort of 56,942 patients. The

The development of new THA bearings has generally focused on increasing the hardness of the materials while not compromising strength and durability. Alternative bearings have included modification of polyethylene (UHMWPE) through cross-linking (XLPE). This crosslinking has reduced wear rates and particulate debris that was associated with osteolysis and synovitis3. It has also allowed for larger head sizes, which has improved stability via increased head diameter by expanding the “jump distance”4. This has then been paired with metal (MoP) and ceramic (CoP) femoral heads. New bearing couples such as ceramic-on-ceramic (CoC) and metal-on-metal (MoM) in standard diameter, large-diameter (LD) >40mm with monoblock acetabular components, and resurfacing styles have also been utilized. Hip resurfacing offered theoretical benefits such as bone preservation on the femoral side, large head bearing surface for a reduced dislocation rate, Figure 1 and ease of future revision sur- Kaplan Meier Revision Curves by Bearing Surface and Implant Type

COA Bulletin ACO - Fall / Automne 2015

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

DAD captures all in-patient stays, and thus, a determination of revision status does not depend upon capture of the revision procedure in CJRR. A total of 1,438 first revision procedures within five years of the primary surgery (defined as an early revision event) were identified. Subsequent revisions were ignored for the purposes of this study. Figure 1 demonstrates the cumulative revision curves within the first five years for each bearing surface and implant design. Most bearing surfaces had similar revision rates up to the twoyear mark, after which LD MoM modular designs showed a jump in revision rate. By the five-year mark, LD MoM had the highest cumulative percentage revision among all groups (5.9%), which was more than double that of the most common bearing surface subgroup, metal-on-cross-linked polyethylene (2.7%) Table 1). Interestingly, there was not an increased rate Table 1 Cumulative Percent Revision by Bearing Surface Group

Table 2 Cox Proportional Hazards Model for Revision Within Five Years After THA

COA Bulletin ACO - Fall / Automne 2015

of revision in the resurfacing group. Male gender, younger age, and the presence of one or more comorbidities increased the risk of revision (Table 2). When controlling for these factors, patients who underwent a large-diameter modular metalon-metal THA were 60% more likely to have a revision within five years compared to patients who had a THA with the most common bearing surface, metal-on-cross-linked polyethylene (hazard ratio = 1.61, p<0.01). Using data from the Canadian Joint Replacement registry, we found that large-diameter metal-on-metal THA had significantly increased risk of mid-term revision. Revision risk was also increased in males, younger patients and those with medical comorbidities. Further national participation in the registry will provide a more complete picture of emerging trends and outcomes in Canadian arthroplasty.

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

References 1. Hip and Knee Replacements in Canada: Canadian Joint Replacement Registry 2014 Annual Report. 2014. www.cihi.ca/cjrr 2. Davis A.M., Agnidis Z., Badley E., Kiss A., Waddell J.P., Gross A.E. Predictors of functional outcome two years following revision hip arthroplasty. J Bone Joint Surg Am 2006 ; 88 : 685-691

4. Lombardi A.V. Jr, Skeels M.D., Berend K.R., Adams J.B., Franchi O.J. Do Large Heads Enhance Stability and Restore Native Anatomy in Primary THA? Clin Orthop Relat Res. 2011;(469):1547-53 5. Sharkey P.F., Sethuraman V., Hozack W.J., Rothman R.H., Stiehl J.B. Factors influencing choice of implants in total hip arthroplasty and total knee arthroplasty: perspectives of surgeons and patients. J Arthroplasty. 1999;14(3):281-287

3. Willert H.G., Bertram H., Buchhorn G.H. Osteolysis in alloarthroplasty of the hip. The role of ultra-high molecular weight polyethylene wear particles. Clin Orthop Relat Res. 1990;(258):95-107

Critical Appraisal of Studies of a Diagnostic Test Harman Chaudhry, M.D. Olufemi R. Ayeni, M.D., MSc, FRCSC Division of Orthopaedic Surgery, McMaster University Hamilton, ON

iagnostic tests are common in orthopaedic practice. These include physical examination maneuvers (e.g., O’Brien’s test for SLAP tears1), imaging studies (e.g., ultrasound for rotator cuff pathology2), and quantitative tests of blood or synovial aspirates (e.g., leukocyte esterase or alphadefensin tests for periprosthetic joint infection3,4). Each diagnostic test differs in its ability to detect and exclude orthopaedic pathology, with some tests being invaluable while others merely passed down through eminence-based – rather than evidence-based methods. Increasingly, we are seeing published studies evaluating the accuracy of diagnostic tests used commonly in day-to-day practice. These studies have enormous potential to positively impact the practice of orthopaedic surgery. Therefore, developing an approach to understanding and critically appraising diagnostic test studies is imperative for the contemporary orthopaedic surgeon. A diagnostic test study is a study which attempts to determine how well a diagnostic test (which we will refer to as the ‘index’ test) functions to predict the presence of a pathologic condition. A comprehensive approach to critical appraisal was initially described by Guyatt and colleagues in their ‘users’ guides to the medical literature’ series5, and this has subsequently been modified, abbreviated, and expanded, but the essence remains the same6,7. It is upon this framework that we will base our approach. There are five key questions the orthopaedic surgeon must ask him- or herself when appraising a diagnostic test study.

First, are the results of the index test consistently compared to an appropriate reference test in all cases? A reference test is a test that confirms the presence of a disease or pathologic condition. Ideally, it is the ‘gold standard’ for that condition. However, often the gold standard cannot be employed as the reference test. This may be the case if the gold standard is unethical or impractical given the clinical circumstance. For instance, when evaluating the accuracy of shoulder ultrasound to determine whether patients have rotator cuff tears, a diagnostic arthroscopy is both impractical and unethical, especially for those with no detected tears on ultrasound. In this case, MRI may be an appropriate substitute. Alternatively, a gold standard may not even exist. For instance, a diagnostic study to determine whether a rapid leukocyte esterase test of synovial fluid can accurately diagnose periprosthetic joint infection may not have a true ‘gold’ standard3. Rather, commonly accepted criteria, such as those proposed by the Musculoskeletal Infection Society (MSIS)8, may be the only practical alternative. Therefore, it is often incumbent on the reader to use his or her clinical expertise to make a judgement regarding the adequacy (and limitations) of the reference test. The key to the reference test is that it should be conducted on all patients that have the index test. Only in this way can the results of the two be adequately compared to determine the accuracy of the diagnostic index test being studied. If only some patients receive the reference test, then this will bias the study results in some way. For instance, if only those with a positive alphadefensin test for periprosthetic joint infection undergo surgery and tissue culture (as part of the MSIS criteria for infection), then it is plausible that a high number may be positive, leading to the conclusion that the alpha-defensin test is very accurate in diagnosing infection. However, we would know nothing about those with negative tests - in other words, perhaps the majority of patients with negative tests also had infection, but these infections were not detected because tissue cultures were never obtained. This is referred to as verification bias, and is an important diagnostic study shortcoming to recognize. Therefore, all patients must undergo both the index and reference tests for a diagnostic test study to be robust in its methodology. COA Bulletin ACO - Fall / Automne 2015

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

Second, is the comparison between the index and reference tests appropriately blinded? If the same radiologist reads both the ultrasound (index test) and MRI (reference test) of a shoulder to determine how both compare in detecting rotator cuff tears, then that radiologist’s opinion may be influenced by the test he/she reads first. Therefore, it is important that both tests are read in a blinded fashion (i.e., anonymized). Ideally, two independent and blinded radiologists who are not directly involved in the care of the patient should read each test result to effectively minimize any bias. The importance of blinding becomes increasingly important with the degree of subjectivity of the outcome measure. For example, the importance of blinding would be paramount in a study assessing a physical examination maneuver. In contrast, quantitative blood tests are more objective and unlikely to be influenced by the individual reading them; therefore, blinding would be less important in these scenarios. Third, does the study include a diversity of patients with a broad spectrum of disease severity? In clinical practice, cases at the extreme ends of a spectrum rarely require a diagnostic test to make the definitive diagnosis. For instance, diagnostic test for periprosthetic joint infection would provide minimal additional information in a post-knee arthroplasty patient who presents with overlying cellulitis, restricted range-of-motion, and purulent aspirate. Rather, diagnostic tests are most important for the ‘middleof-the-spectrum’ cases, where the diagnosis is ambiguous. Therefore, it is crucial that readers ensure that diagnostic test studies include a broad spectrum of clinical presentations, with a large number resembling the ‘middle-of-the-spectrum’ cases. The synovial fluid alpha-defensin test for periprosthetic joint infection would likely appear extremely effective if all included patients resembled the aforementioned patient with purulent aspirate. Including patients with chronic knee pain, aseptic loosening, and intra-articular effusions of unknown etiology would serve to strengthen such as study. Fourth, were the index test results consistent in more than one cohort of patients? The reproducibility of the accuracy (or lack thereof) of a diagnostic test in multiple different patient populations serves to consolidate the findings of a diagnostic test study. This often requires multiple different studies in varying patient populations. However, consistency may also be demonstrated in a single, large multi-centre study. As a general rule, the results of a single small study on a single cohort of patients should rarely serve to change the standard of clinical practice. Fifth (and finally), were clinically applicable results presented? Diagnostic test studies are only useful to the clinician insofar as they present results in a manner that can be applied to clinical practice. Therefore, results should give the reader some idea regarding how good the studied diagnostic test is at both detecting and excluding a disease or pathologic condition. COA Bulletin ACO - Fall / Automne 2015

Typically, this information is presented in the form of sensitivity and specificity. Sensitivity refers to the ability of a negative test result to exclude (or rule out) a condition; specificity refers to the ability of a positive test result to detect (or rule in) a condition. A detailed discussion of sensitivity and specificity is beyond the scope of this article, and we refer readers to more detailed sources9. Better still, positive and negative likelihood ratios (LRs) may be presented, and these are both more intuitive to understand and apply in day-to-day clinical practice. If these measures are not presented, then they can be calculated (using sensitivity and specificity values) with a relative easy formula9. A LR = 1 means that a diagnostic test does not alter the likelihood of a diagnosis compared to the pre-test probability. A positive LR (>1) gives the likelihood of a patient with the disease having a positive test. For example, assume an MRI with arthrogram (MRA) has a positive LR of approximately five for detecting any rotator cuff tear2. That means if an MRA shows a rotator cuff tear in a patient, this increases the orthopaedic surgeon’s pre-test suspicion by five times. If the surgeon did not suspect this patient had a rotator cuff tear to begin with (e.g., his/her pre-test probability was <10-20%), a tear can now be suspected in this patient. If the surgeon already felt that the patient had a rotator cuff tear based on clinical examination (e.g., his/her pre-test probability was >70-80%), a positive MRA now solidifies the diagnosis. Similarly, a negative LR (<1) gives the likelihood of a patient without the disease having a negative test. Continuing with the above example, assume that an MRA has a negative LR of approximately 0.22. This means if an MRA does not detect a rotator cuff tear on a patient, then that decreases the pre-test suspicion by five times (i.e., 0.2 or one-fifth). More objective methods to determine the impact of positive and negative LRs on pre-test probabilities exist (e.g., formulaic or nomogram methods), and we refer interested readers to other resources for a discussion of these7,9. Conclusion Diagnostic tests are common in orthopaedics, although studies of diagnostic tests are less frequent than therapeutic studies and more difficult to critically appraise. This article has presented a simple, five-step framework to approach the critical appraisal of these studies. We hope that this framework serves to better inform your day-to-day orthopaedic practice. References 1. Stetson W.B., Templin K. The crank test, the O’Brien test, and routine magnetic resonance imaging scans in the diagnosis of labral tears. Am J Sports Med. 2002;30:806-809. 2. Dinnes J., Loveman E., McIntyre L., Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health Technol Assess. 2003;7:iii, 1-166.

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3. Tischler E.H., Cavanaugh P.K., Parvizi J. Leukocyte esterase strip test: matched for musculoskeletal infection society criteria. J Bone Joint Surg Am. 2014;96:1917-1920.

7. Scales C.D. Jr, Dahm P., Sultan S., Campbell-Scherer D., Devereaux P.J. How to use an article about a diagnostic test. J Urol. 2008;180:469-476.

4. Deirmengian C., Kardos K., Kilmartin P., Cameron A., Schiller K., Booth R.E. Jr, Parvizi J. The alpha-defensin test for periprosthetic joint infection outperforms the leukocyte esterase test strip. Clin Orthop Relat Res. 2015;473:198-203.

8. Parvizi J., Zmistowski B., Berbari EF., Bauer T.W., Springer B.D., Della Valle C.J., Garvin K.L., Mont M.A., Wongworawat M.D., Zalavras C.G. New definition for periprosthetic joint infection: from the Workgroup of the Musculoskeletal Infection Society. Clin Orthop Relat Res. 2011;469:2992-2994.

5. Jaeschke R., Guyatt G.H., Sackett D.L. Users’ guides to the medical literature. III. How to use an article about a diagnostic test. B. What are the results and will they help me in caring for my patients? The Evidence-Based Medicine Working Group. JAMA. 1994;271:703-707.

9. Furukawa T.A, Strauss S., Bucher H.C., Guyatt G. Diagnostic Tests. In: Users’ guides to the medical literature: essential of evidence-based clinical practice (2nd ed). Guyatt G, Rennie Dr, Cook D (Eds.);2008:195-222.

6. Diagnostic test studies: assessment and critical appraisal. BMJ Clinical Evidence. URL: http://clinicalevidence.bmj. com/x/set/static/ebm/toolbox/665061.html. Accessed on: October 4, 2015.

Call for Nominations for the ICORS International College of Fellows

s an active and participating country in the International Combined Orthopaedic Research Society (ICORS; i-cors.org), members of CORS are eligible to apply for the honorary status of “Fellow of International Orthopaedic Research (FIOR)”. This is a new program within the ICORS group intended to provide international public recognition of individuals who have gained a status of excellent professional standing and high achievements in the field of orthopaedic research.

The CORS Executive is therefore soliciting nominations for this honour (self-nominations are allowed). We would appreciate a cover letter and a CV outlining the member’s contributions to the field over the past 15 years no later than November 20, 2015, e-mailed to CORS President, Dr. Janie Wilson: Janie.Wilson@Dal.Ca. Complete information can be found here.

Acromioplasty in 2015 – Introduction to this edition’s debate

cromioplasty has traditionally been a component of rotator cuff repair and stems from Dr. Neer’s theories of external impingement. Acromial curvature is acquired and has been demonstrated to become more pronounced with age. In some cases, a spur may develop on the anterior edge of the acromion; this has led to the hypothesis that “impingement” of the rotator cuff occurs between the greater tuberosity and the coracoacromial arch, and upon the curved anterior edge of the acromion in particular. It is interesting that this debate has been ongoing since the 1980s. Dr. Uhthoff has published evidence that rotator cuff pathology is, in fact, an intrinsic

phenomenon and occurs secondary to tendon degeneration with advancing age, and not due to external compression. In 2015, acromioplasty remains a component of rotator cuff repair for many surgeons and new evidence is now available. I hope that you enjoy this debate. I would like to thank Drs. Mark Sommerfeldt and Matt MacEwan for their contribution to this interesting topic. Peter Lapner, M.D., FRCSC Scientific Editor, COA Bulletin

COA Bulletin ACO - Fall / Automne 2015

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

Acromioplasty is a Necessary Component of Cuff Repair Mark Sommerfeldt, M.D., FRCSC Clinical Research Fellow Division of Orthopaedic Surgery University of Alberta Edmonton, AB

he surgical management of rotator cuff problems is a topic of considerable debate and acromioplasty in conjunction with rotator cuff repair has come under much scrutiny. Much of the recent literature investigating this issue suggests that performing acromioplasty with a rotator cuff repair does not improve short-term clinical outcomes compared to performing a rotator cuff repair alone1-3. Most shoulder surgeons likely disagree with the statement, “acromioplasty is a necessary component of all cuff repair,” and yet data suggests acromioplasty remains an over-utilized procedure4,5. The purpose of this article is to challenge the assumption that acromioplasty is never a beneficial adjunct to rotator cuff repair. At the very least, the suggestion will be made that acromioplasty may be appropriate in certain rotator cuff tears, but evidence in this regard is lacking. To highlight the controversy in this area, consider the clinical practice guidelines compiled in 2010 by the American Academy of Orthopedic Surgeons regarding the management of rotator cuff pathology6. Recommendations were made in 14 key areas but the majority of their recommendations were graded as inconclusive or limited, which is a reflection of the quality and strength of the available evidence. The recommendation on acromioplasty was based largely on two randomized studies and received a moderate grade. It stated: We suggest that routine acromioplasty is not required at the time of rotator cuff repair6. The use of the word “routine” is noteworthy as it does not exclude the possibility that there may be an occasional role for acromioplasty. Recent high-level evidence suggests that clinical outcomes after rotator cuff repair are not improved by performing an acromioplasty. Two systematic reviews of four randomized controlled trials (RCTs) have demonstrated that performing a formal subacromial decompression in conjunction with a rotator cuff repair does not result in improved clinical outcomes after two years1-3, 7-9. When studies of this quality are conducted in our field, serious consideration should be and has been given to their findings. However, high-quality studies and especially expert guidelines are not without limitation. For example, average follow-up in each of these studies was two years or less. Additionally, two of these studies made no mention of healing rates7,9. The other two studies reported higher reoperation rates in the group that did not undergo acromioplasty, although this was not found in the pooled analysis3,8. The authors of the meta-analysis acknowledged that “long-term follow-up with stratification by acromion type…is required.”2 One RCT (not included in either of the systematic reviews) explicitly excluded patients with a subacromial spur and the AAOS guidelines acknowledged that “acquired acromial spurs…are beyond the scope of the curCOA Bulletin ACO - Fall / Automne 2015

rent guideline.”6,10 Recommendations made based upon data obtained from patients without a subacromial spur should not be generalized to patients with a subacromial spur. Our understanding of the pathology of rotator cuff disease has changed significantly over the years, as has our approach to its management. It is now known that most cases of rotator cuff disease are not caused by external impingement, but rather intratendinous degeneration, and it follows that an acromioplasty would not provide benefit in the latter case5. However, on occasion overt signs of external impingement (attrition of the coracoacromial (CA) ligament and subacromial spur formation) are seen, and it is in these cases that minimal acromioplasty may be justified and beneficial. The valid question has been asked, “if there is attrition of the CA ligament in the presence of a spur and evidence of bursal-sided fraying of the rotator cuff, once you repair the cuff, wouldn’t you want to remove the rubbing spur?”11 As stated in a letter responding to a critique of their meta-analysis, Chahal et al. suggested that “it may be possible that certain groups do benefit from acromioplasty (e.g., acquired type 3, lateral downslope)... (L)arger well-designed trials… will allow investigators to perform the appropriate subgroup analyses to address these issues.”12 Another scenario in which acromioplasty may be useful is when it allows improved visualization and easier repair of the rotator cuff. In patients who have very narrow sub-acromial space, repairing the rotator cuff may be made easier by first performing a subacromial decompression. An interesting finding of the recent well-designed acromioplasty studies is that complication rates were not different between the groups1-3, 7-10. The theoretical complications of acromioplasty (detachment of the deltoid, superior escape), can potentially be mitigated by performing a minimal acromioplasty, or smoothing procedure; an approach carried out at the authors’ institution when deemed necessary. This approach involves removing the subacromial spur if present, and a small amount of acromial bone if necessary (i.e. type 3 or lateral down-sloping acromion with evidence of external impingement). In conclusion, high-level evidence suggests that there is no short-term clinical benefit afforded by adding routine acromioplasty to a rotator cuff repair. However, if a subacromial spur is present with signs of external impingement, there may be a benefit in performing an acromioplasty in conjunction with rotator cuff repair, although evidence is lacking. Large, long-term studies of this particular subgroup with a focus on patient-centered functional outcomes and healing rates are required to clarify this issue. References 1. Familiari, F., et al., Is acromioplasty necessary in the setting of full-thickness rotator cuff tears? A systematic review. J Orthop Traumatol, 2015.

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

2. Chahal, J., et al., The role of subacromial decompression in patients undergoing arthroscopic repair of full-thickness tears of the rotator cuff: a systematic review and meta-analysis. Arthroscopy, 2012. 28(5): p. 720-7. 3. Abrams, G.D., et al., Arthroscopic Repair of Full-Thickness Rotator Cuff Tears With and Without Acromioplasty: Randomized Prospective Trial With 2-Year Follow-up. Am J Sports Med, 2014. 42(6): p. 1296-303. 4. Yu, E., et al., Arthroscopy and the dramatic increase in frequency of anterior acromioplasty from 1980 to 2005: an epidemiologic study. Arthroscopy, 2010. 26(9 Suppl): p. S142-7. 5. Frank, J.M., et al., The role of acromioplasty for rotator cuff problems. Orthop Clin North Am, 2014. 45(2): p. 219-24. 6. American Academy of Orthopaedic Surgeons Clinical Practice Guideline on optimizing the management of rotator cuff problems. Rosemont (IL): American Academy of Orthopaedic Surgeons (AAOS); 2010

7. Gartsman, G.M. and D.P. O’Connor, Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes. Journal of Shoulder and Elbow Surgery, 2004. 13(4): p. 424426. 8. MacDonald, P., et al., Arthroscopic Rotator Cuff Repair with and without Acromioplasty in the Treatment of Full-Thickness Rotator Cuff Tears. A Multicenter, Randomized Controlled Trial, 2011. 93(21): p. 1953-1960. 9. Milano, G., et al., Arthroscopic Rotator Cuff Repair With and Without Subacromial Decompression: A Prospective Randomized Study. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 2007. 23(1): p. 81-88. 10. Shin, S.J., et al., The efficacy of acromioplasty in the arthroscopic repair of small- to medium-sized rotator cuff tears without acromial spur: prospective comparative study. Arthroscopy, 2012. 28(5): p. 628-35. 11. Bishop, J., Personal correspondence, 2015. 12. Chahal, J., et al., Author’s Reply. Arthroscopy. 28(8): p. 10481049.

Acromioplasty is Not Necessary During Arthroscopic Cuff Repair Matt MacEwan, M.D., FRCSC, MBA Fellow, Upper Extremity Surgery Division of Orthopedics, University of Ottawa Peter L. C. Lapner M.D., FRCSC Division of Orthopedics, The Ottawa Hospital Associate Professor, University of Ottawa Ottawa, ON

of age-related degeneration, and that changes in acromial morphology result from a chronic superior migration of the humerus and reactive change in the acromion3. Bigliani’s data4 demonstrated changes in the anterior acromion in only 7% of patients under the age of 50 compared to 30% over the age of 50. The case against acromioplasty in the setting of rotator cuff repair has four main tenets:

eer first coined the term “impingement” to describe the contact between the supraspinatus tendon beneath the coracoacromial ligament and anterolateral acromion leading to tendon degeneration and eventual rupture1. He further advanced the notion that changes in the morphology of the anterolateral acromion are responsible for the development of rotator cuff tears and therefore require treatment by way of “acromioplasty”. Neer described this procedure by open technique to be carried out during cuff repair surgery. Later, Ellman described an acromioplasty by an arthroscopic approach2.

1. Acromioplasty is not cost-effective

However, what if Neer was wrong and mistakenly attributed association for causation? Is it possible that changes in acromial morphology may occur secondary to a chronic rotator cuff tear, or as an age-related change, and not as a cause of rotator cuff disease? Proponents of the “intrinsic theory” suggest that rotator cuff tears occur as a function of overuse in the setting

2. We are not very skilled at acromioplasty

Although a cost-effectiveness analysis has not been formally conducted, in a publicly-funded health-care system such as what exists in Canada, it is imperative that the surgeon consider whether carrying out a given procedure adds value given the additional cost. Foregoing acromioplasty in the setting of cuff repair would almost certainly result in shorter case times, a decrease in instrument use, and a reduction in case costs. It behooves us as surgeons and taxpayers to consider these factors when evaluating the utility of a treatment.

Koh et al.5 in 2012 found that in greater than one in three acromioplasty/rotator cuff repair cases, either the hooked acromial morphology was not addressed, or the procedure actually resulted in the creation a hooked acromion despite COA Bulletin ACO - Fall / Automne 2015

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

previous normal morphology. The data indicates that in 36% of cases, surgeons either failed to address the “abnormal” morphology, or in fact, made it worse. The authors reported on 100 consecutive patients who underwent arthroscopic rotator cuff repair and acromioplasty with a cutting block technique. Of these 100 patients, only 29 had a hooked (type 3) acromion preoperatively. On postoperative MRI, three had a residual hooked acromion; thus indicating that surgeons carried out an “inadequate acromioplasty” in 10.3% (3 of 29). In addition, they identified 23 “new” hooked acromia postoperatively, 20 of which were flat (type I) preoperatively. This indicates that in 77 patients with a normal acromion, 20 cases (26%) now had a hooked acromion subsequent to an acromioplasty. One might assume that this result is technique-dependent (i.e. portal placement, angle of the shaver, etc.). However, any procedure carried out incorrectly 36.3% of the time is worrisome indeed. Interestingly, the authors did not find any clinical differences in patients three years postoperatively when accounting for acromial morphology.

These results have been reproduced with a high-level of evidence Canadian trial. MacDonald et al. 13 conducted a multicentre, randomized controlled trial comparing arthroscopic rotator cuff repair with or without acromioplasty. In this study, patients with all acromial morphology were included. In addition, they used a disease-specific outcome instrument to evaluate treatment effect. This study showed significant improvement in both groups postoperatively, with no additional benefit in the group who underwent acromioplasty with cuff repair compared with those treated with cuff repair alone.

3. Acromioplasty alters the anatomy of the shoulder

1. C. S. Neer. Anterior acromioplasty for the chronic impingement syndrome in the shoulder: a preliminary report, The Journal of Bone & Joint Surgery A, vol. 54, no. 1, pp. 41–50, 1972

The preservation of anatomy in the shoulder is important during rotator cuff repair. Acromioplasty can lead to injury or complete excision of the coracoacromial ligament (CAL). Once injured or resected, Codman’s classic article6 revealed that anterosuperior escape of the humeral head may occur should the cuff repair fail in the long-term; an occurrence further supported by Su et al.7 Green et al.8 found that a 4 mm resection of the acromion results in resection of 56% of the deltoid origin, a figure that rises to 77% with a 5.5 mm acromial resection. 4. The best evidence indicates that acromioplasty does not change outcomes Ketola et al.9 showed in a randomized controlled trial that there is no difference in outcomes between supervised therapy alone vs. subacromial decompression and acromioplasty in addition to supervised therapy for patients with rotator cuff impingement syndrome. The current AAOS practice recommendations10 published in 2012 suggest that acromioplasty is not necessary at time of rotator cuff repair. This evidence was graded as “moderate”, the second-from-highest recommendation grade; a moderate grade is issued when good evidence exists to show no benefit with the intervention. Furthermore, the AAOS suggests that practitioners follow moderate recommendations while remaining open to new evidence. The AAOS recommendations were based in part on two prospective, randomized controlled trials by Milano et al.11 in 2007 and Gartsman et al.12 in 2004. Both trials investigated acromioplasty for type 2 or 3 acromia during repair of full thickness tears. The study by Milano et al. had 89% follow-up at two years and did not demonstrate any differences as measured by the Constant or DASH scores. Gartsman et al. studied 93 patients with full thickness tears and type 2 acromia. With 15 months follow-up in 100% of the patients, no statistical difference was seen between groups.

COA Bulletin ACO - Fall / Automne 2015

In summary, acromioplasty is an intervention which is more costly, adds additional operating room time, produces inconsistent anatomical results, alters anatomy, and is not supported by the best available evidence. We respectfully submit that acromioplasty is not necessary during rotator cuff repair. References

2. H. Ellman. Arthroscopic subacromial decompression: analysis of 1-3 yr results. Arthroscopy. Vol. 3, No. 3, 173-81. 1987. 3. C. Milgrom, M. Schaffler, S. Gilbert, and M. van Holsbeeck. Rotator-cuff changes in asymptomatic adults. The effect of age, hand dominance and gender, The Journal of Bone & Joint Surgery B, vol. 77, no. 2, pp. 296–298, 1995. 4. G. P. Nicholson, D. A. Goodman, E. L. Flatow, and L. U. Bigliani. The acromion: morphologic condition and age-related changes. A study of 420 scapulas, Journal of Shoulder and Elbow Surgery, vol. 5, no. 1, pp. 1–11, 1996 5. K. Koh, M. Laddha, T. Lim, J. Lee, J. You. A magnetic resonance imaging study of 100 cases of Arthroscopic Acromioplasty. Am J Sports Med 2012. 40: 352-7 6. E.A. Codman. The Shoulder. Rupture of the Supraspinatus Tendon and other lesions in or about the subacromial bursa. Thomas Todd, Boston MA, 1934. 7. W. R. Su, J. E. Budoff, and Z. P. Luo. The effect of coracoacromial ligament excision and acromioplasty on superior and anterosuperior glenohumeral stability, Arthroscopy, vol. 25, no. 1, pp. 13–18, 2009. 8. A. Green, S. Griggs, D. Labrador. Anterior Acromial Anatomy: relevance to arthroscopic acromioplasty. Arthroscopy. Vol. 20, no. 10, 1050-54, 2004. 9. S. Ketola, J. Lehtinen, I. Arnala. Does arthroscopic acromioplasty provide any additional value in the treatment of shoulder impingement syndrome? A two-year randomized controlled trial. Journal of Bone & Joint Surgery Br. Vol. 91. No 10. 1326-34. 2009.

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10. R.A Pedowitz., K. Yamaguchi, C.S. Ahmad, et al. American Academy of Orthopaedic Surgeons. Optimizing the management of rotator cuff problems: Guideline and evidence report. J Bone Joint Surg Am 2012;94:163-167 11. G. Milano, A. Grasso, M. Salvatore, D. Zarelli, L. Deriu, and C. Fabbriciani Arthroscopic rotator cuff repair with and without subacromial decompression: a prospective randomized study, Arthroscopy, vol. 23, no. 1, pp. 81–88, 2007

12. G. M. Gartsman and D. P. O’Connor. Arthroscopic rotator cuff repair with and without arthroscopic subacromial decompression: a prospective, randomized study of one-year outcomes. Journal of Shoulder and Elbow Surgery, vol. 13, no. 4, pp. 424–426, 2004. 13. P. MacDonald, S. McRae, J Leiter, R. Mascarenhas, P. Lapner. Arthroscopic Rotator Cuff Repair with and without Acromioplasty in Full-Thickness Rotator Cuff Tears. J Bone Joint Surg Am 2011:93, 1954-60

The Role of the Orthopaedic Surgeon in Osteoporosis Management for Hip Fracture Patients Ted Tufescu, M.D., FRCSC Orthopaedic Surgeon, University of Manitoba Winnipeg, MB Mohit Bhandari, M.D., FRCSC Orthopaedic Surgeon, McMaster University Hamilton, ON La-Toya Williamson Senior Manager, Fracture Liaison Services Monica Menencola Regional Integration Lead, York Region, Ontario Osteoporosis Strategy The Osteoporosis Canada Scientific Advisory Council, Knowledge Translation Committee, Orthopedic Specialist Subgroup

he BBC recently reported that Australian Paul Royle passed away after a simple fall1. While you may not be familiar with Royle, you may have heard of the 1963 film “The Great Escape” starring Steve McQueen. It is the story of 76 airmen who escaped from the notorious Nazi Stalag Luft III camp in Nazi Germany in 1944. Royle was one of only three who survived the escape. After a full life, his demise came in hospital after a fall resulting in a hip fracture. The facts and the myths of osteoporosis treatment in hip fracture patients As orthopaedic surgeons we pay a great deal of attention to timely and appropriate care of elderly patients with an osteoporotic hip fracture. However, once the patient’s fracture is treated, we generally fail to treat the underlying cause of the fracture, the osteoporosis. This leads to one in three of our patients suffering re-fracture within a year. These secondary fractures contribute to the 30,000 strong yearly hip fracture patient burden on Canadian health care2. Each patient represents an additional and preventable, $21,285 expenditure for our health-care system3. As a COA member, you may be one of 130 Canadian surgeons who recently had their knowledge tested in a survey on behalf of Osteoporosis Canada. Here are some of the facts and the myths about preventing a second osteoporotic hip fracture, as they were highlighted by the survey:

• 90% of us treat hip fractures, of whom 89% feel there is a benefit in initiating osteoporosis care to prevent subsequent fragility fractures. • 25% of us incorrectly feel a bone mineral density scan is required prior to osteoporosis management. In fact, individuals over age 50 with a fragility fracture of the hip or vertebra, or multiple fragility fractures, are at high risk for future fractures, and should be offered pharmacologic therapy4. • 42% of us opt to ask the patients’ general practitioner to initiate medical management. In fact, this generally does not translate in patients receiving medical management. Admittedly, this gap in care needs to be addressed, however it is also known that when treatment is initiated while in hospital, it tends to be continued out of hospital. • 41% of us did not feel up to date on osteoporosis guidelines, and 35% of us do not have a pathway in our institution for the medical care of osteoporotic patients. • 38% of us felt unsure of the concept of a fracture liaison service (FLS). When educated about the function of the FLS, 80% of us felt this was the key to helping close the care gap in osteoporotic hip fractures. • 43% of us were not aware of a fall prevention program in our area. Better care through partnerships: Fracture Liaison Service Should orthopaedic surgeons bear the full brunt of closing the post-hip fracture care gap? Certainly not. While timely surgery and provision of sturdy hip fracture fixation to withstand full weight-bearing is an obligation for the surgeon, initiating osteoporotic medical management is more so an important opportunity. While it is up to us to recognize this opportunity, for meaningful action, support is ideal. The FLS program is one means of support for orthopaedic surgeons and our patients, whenever available. The FLS is a specific model of care where a coordinator proactively identifies fracture patients, on a system-wide basis, and determines their fracture risk with the express purpose of facilitating effective osteoporosis treatment for high-risk patients. The FLS is, by far, the most effective secondary fracture prevention method to ensure fracture patients receive the osteoporosis care they need to prevent additional fractures. COA Bulletin ACO - Fall / Automne 2015

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

The FLS is appropriate for post hip fracture patients, as well as patients with any fragility fracture. The FLS can function independently of orthopaedic services, or in parallel by screening fracture clinic patients and those admitted to hospital with a fragility fracture. The main FLS objectives are as follows: • Identification: All men and women over 50 years who present with fragility fractures will be assessed for risk factors for osteoporosis and future fractures. • Investigation: Those at risk will undergo bone mineral density testing as per the 2010 Osteoporosis Canada Guidelines4. • Initiation: Where appropriate, osteoporosis treatment will be initiated by the FLS. In the context of low-energy hip fracture patients, the task of “identification” is simple enough, as the vast majority of these patients will be hospitalized under the care of an orthopaedic surgeon as they await fracture fixation. Further “investigation” for these patients is unnecessary, as the 2010 Osteoporosis Canada Guidelines universally rank these individuals into the high-risk category, and do not indicate additional tests4. The final piece is the “initiation” of management. This is ideally done at the time of admission, so as not to be forgotten, but does require follow-up. Here the orthopaedic surgeon has a choice to make, to either initiate medical management and secure appropriate follow-up for the patient, or to seek support from an FLS or alternative service for both initiation and monitoring. The FLS is slowly growing in presence across Canada. It currently accepts patients from coast-to-coast, but to provide care for all patients in need, much more dedicated funding is required. The FLS initiative is distinct from orthopaedic surgical services, both in the expertise provided and the funding to support it. As orthopaedic surgeons we can advance this initiative by being aware of its role and providing a champion’s voice whenever and wherever possible. To learn more about the FLS, one can refer to the Osteoporosis Canada Fracture Liaison Service web page: www.osteoporosis.ca/fls5. Preventing the next fall Fall prevention programs and interventions are available in all provinces. There are different types of professionals and programs that our patients can turn to for help: • They should talk to their doctor about medical problems, especially dizziness. • A physical therapist can help with walking and balance. • An occupational therapist can improve home safety and identify the best assistive devices for patients. • Patients should have their vision and hearing checked once a year. To learn more about fall prevention programs in your area, contact your public health department or seek a local or regional Fall Prevention Coalition. November is Fall Prevention Month in Alberta, Saskatchewan and Ontario. Be on the look-out for the many activities and resources available to the public and health-care professionals.

COA Bulletin ACO - Fall / Automne 2015

The take home message Canada spends $6.2 billion per year addressing fall-related injuries, despite the fact that falls in older adults are predictable and preventable6. Over one third of fall-related hospitalizations among seniors are associated with a hip fracture6. In turn, the gatekeepers for hip fracture patient care are orthopaedic surgeons. It is important to recognize that all low-energy hip fracture patients are high risk for further fragility fractures, and all can benefit from a referral to an FLS or equivalent, and a fall prevention program. It is up to us to make the referral, and whenever possible, to advocate for additional resources. References 1. British Broadcasting Company: http://www.bbc.com/news/world-australia-34082333 2. Leslie W.D., O’Donnell S., Lagace C., et al. Population-based Canadian hip fracture rates with international comparisons. Osteoporos Int. Aug 2010;21(8):1317-1322. 3. Tarride J.E., Hopkins R.B., Leslie W.D., et al. The burden of illness of osteoporosis in Canada. Osteoporos Int. Nov 2012;23(11):2591-2600. 4. Papaioannou A., Morin S., Cheung A.M., et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ. Nov 23 2010;182(17):1864-1873. 5. Osteoporosis Canada web site: www.osteoporosis.ca 6. Public Health Agency of Canada. Seniors’ Falls in Canada: Second Report. Ottawa: Public Health Agency of Canada; 2014.

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Every patient is different, and individual results will vary. There are risks associated with surgery. Pritchett JW. Patients prefer a bi-cruciate-retaining or the medial-pivot total knee prosthesis. J Arthroplasty. 2011;26(2):224-8. Trademarks and Registered marks of MicroPort Orthopedics. ©2015 MicroPort Orthopedics Inc. All rights reserved. 010687

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

Office-based Shoulder Ultrasound for the Canadian Orthopaedic Surgeon Tym Frank, M.D. Orthopaedic Resident, UBC Department of Orthopaedic Surgery Vancouver, BC Jeffrey M. Pike, M.D., MPH, FRCSC Clinical Assistant Professor UBC Department of Orthopaedic Surgery Division of Distal Extremities Vancouver, BC Danny P. Goel, M.D., MSc, FRCSC Clinical Assistant Professor UBC Department of Orthopaedic Surgery Division of Arthroscopic, Reconstructive Surgery and Joint Preservation Burnaby, BC

houlder pain is a common presentation to the family physiciansâ&#x20AC;&#x2122; office. With a yearly incidence of 15 new episodes per 1,000, it constitutes 16% of all musculoskeletal visits1,2. The etiology, although multifactorial, commonly affects the rotator cuff3,4. Therefore, establishing a treatment algorithm is reliant on the integrity of these tendons. Physicians will typically confirm their clinical impression with advanced imaging in the form of magnetic resonance imaging (MRI) or ultrasound (US). Magnetic resonance imaging is the most commonly utilized modality for diagnosing rotator cuff disorders5. Its advantages include detailed characterization of the tear with respect to extent, retraction, and muscle atrophy/ fatty infiltration. These factors assist the clinician in establishing an appropriate patient-specific treatment plan4. The disadvantages however include cost, access, false positive findings, and reduced patient tolerance with the occasional need for sedation; these factors support the need for a less invasive option6. Although MRI is the historical reference standard, the literature supports US as a less resource-intensive modality in identifying rotator cuff pathology5,7. This is highly relevant where excessive cost and wait times for MRI studies continue to burden the existing health-care system8. Delays in access pose clinical and economic implications for orthopaedic surgery and other specialities9. The utilization of ultrasound as an alternate imaging modality for rotator cuff tears is well documented10-14. Shoulder US is an evolving, cost-effective alternative to MRI15. Ultrasound is a portable modality which permits dynamic and contralateral limb assessment. The lack of radiation and need for sedation results in greater patient tolerance and satisfaction16 while enabling the physician to reliably visualize the softtissue structures17. When compared with MRI, US has equivalent reliability for the detection of full thickness18,19 and partial thickness rotator cuff tears, both of which are highly operator dependant20. Ultrasound is also capable of quantifying rotator cuff muscle atrophy21. In the post-surgical setting, US reveals superior resolution compared to MRI5,22,23 and is also valuable in identifying pathology related to the long head of biceps 24. A meta-analysis by Roy et al highlights the implications of US for the diagnosis and treatment of rotator cuff tears as an acceptCOA Bulletin ACO - Fall / Automne 2015

able alternative to MRI25. The basic cost savings of US compared to MR have also been demonstrated15. Point-of-Care Shoulder Ultrasound by the Orthopaedic Surgeon Given the cost and wait times associated with three-dimensional imaging, a major advantage to US is the added benefit of officebased utilization by the orthopaedic surgeon. Imaging the shoulder at the time of visit, termed point-of-care (POC), reveals a tremendous added advantage of this modality over MRI for both patients and the clinician26. Point-of-care US has been successfully demonstrated in several other areas of medicine27-32,33 where an introduction of this concept at the undergraduate and graduate level with trainees is also gaining interest34, 35. With improved access, POC shoulder US may significantly mitigate the need for outsourced imaging and reduce MRI utilization15,36. The latest technological advances in US include equipment size with newer units weighing less than five kilograms. The ultrasound unit, complete with transducer, battery charger and gel; fits into a carrying case for easy transportation between examination rooms and office locations37. The initial technical and anatomical training can be completed in a four-hour session and has shown considerable promise when combined with history and physical examination38. In a recent study, when combined with clinical examination and radiographs, the orthopaedic surgeon was more accurate in diagnosing rotator cuff tears when compared to a trained ultrasonographer39. Interestingly, the ultrasonagrapher in this study trained the surgeon on the utility of the US in diagnosing rotator cuff tears. This paper emphasizes the benefit of correlating the history and physical examination with immediate POC US by the treating orthopaedic surgeon. Other surgeon-driven applications include the management of calcific tendinopathy, long head biceps pathology and both intra and extra-articular injections around the shoulder. Image-guided injections are better tolerated by patients and result in higher accuracy when compared to palpation-based procedures40. Given the harmful effects of misplaced injections41, several clinical studies have demonstrated US-guided injections to be more accurate42-44 with outcomes reporting clinical improvement and a reduction of adverse events when compared to blind injection45. The opportunity to include US as an extension of the physical examination directly addresses the wait times of radiologybased imaging studies. More importantly, it improves patient care and the potential morbidity associated with delays in imaging. The value of US in this scenario given the wait times for imaging in Canada cannot be underestimated. Although clinically and economically relevant from a population perspective, POC shoulder US has seen limited use in Canada. The cost of a portable US machine ($30-40,000 CAD) combined with absent fee codes limit its use. The cost-effectiveness of POC US is currently under investigation by the senior author (DPG). Early pilot data suggests, as expected, a significant cost savings when compared to radiology-based imaging.

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

Without further investigation, imaging wait times and delay in patient-focused care will likely persist. Given the high incidence of rotator cuff disease and the similar utility of US and MRI, POC US necessitates further research. Although unlikely to eliminate the need for shoulder MRI, the potential overall impact of this modality for orthopaedic patients necessitates an ongoing critical evaluation given the current state. References 1. Burbank K.M., Stevenson J.H., Czarnecki G.R., Dorfman J. Chronic shoulder pain: part I. Evaluation and diagnosis. American Family Physician. 2008;77(4):453-60. PubMed PMID: 18326164. 2. Urwin M., Symmons D., Allison T., Brammah T., Busby H., Roxby M., et al. Estimating the burden of musculoskeletal disorders in the community: the comparative prevalence of symptoms at different anatomical sites, and the relation to social deprivation. Annals of the Rheumatic Diseases. 1998;57(11):649-55. PubMed PMID: PMC1752494. 3. van der Windt D.A., Koes B.W., Boeke A.J., Deville W., De Jong B.A., Bouter L.M. Shoulder disorders in general practice: prognostic indicators of outcome. The British journal of general practice : the journal of the Royal College of General Practitioners. 1996 Sep;46(410):519-23. PubMed PMID: 8917870. Pubmed Central PMCID: 1239746. 4. Tashjian R.Z. Epidemiology, natural history, and indications for treatment of rotator cuff tears. Clinics in sports medicine. 2012 Oct;31(4):589-604. PubMed PMID: 23040548. 5. Dinnes J., Loveman E., McIntyre L., Waugh N. The effectiveness of diagnostic tests for the assessment of shoulder pain due to soft tissue disorders: a systematic review. Health technology assessment. 2003;7(29):iii, 1-166. PubMed PMID: 14567906. 6. Jbara M., Chen Q., Marten P., Morcos M., Beltran J. Shoulder MR arthrography: how, why, when. Radiologic clinics of North America. 2005 Jul;43(4):683-92, viii. PubMed PMID: 15893531. 7. Brenneke S.L., Morgan C.J. Evaluation of ultrasonography as a diagnostic technique in the assessment of rotator cuff tendon tears. The American journal of sports medicine. 1992 May-Jun;20(3):287-9. PubMed PMID: 1636859. 8. Emery D.J., Forster A.J., Shojania K.G., Magnan S., Tubman M., Feasby T.E. Management of MRI Wait Lists in Canada. Healthcare Policy. 2009;4(3):76-86. PubMed PMID: PMC2653696. 9. Association CM, Economics CfS, Stokes E, Somerville R. The Economic Cost of Wait Times in Canada: Centre for Spatial Economics; 2008. 10. Park I., Lee H.J., Kim S.E., Bae S.H., Lee K.Y., Park K.S., et al. Evaluation of the Effusion within Biceps Long Head Tendon Sheath Using Ultrasonography. Clinics in orthopedic surgery. 2015 Sep;7(3):351-8. PubMed PMID: 26330958. Pubmed Central PMCID: 4553284.

11. Teefey S.A., Hasan S.A., Middleton W.D., Patel M., Wright R.W., Yamaguchi K. Ultrasonography of the rotator cuff. A comparison of ultrasonographic and arthroscopic findings in one hundred consecutive cases. The Journal of bone and joint surgery American volume. 2000 Apr;82(4):498-504. PubMed PMID: 10761940. 12. Middleton W.D., Teefey S.A., Yamaguchi K. Sonography of the rotator cuff: analysis of interobserver variability. AJR American journal of roentgenology. 2004 Nov;183(5):14658. PubMed PMID: 15505321. 13. Nazarian L.N., Jacobson J.A., Benson C.B., Bancroft L.W., Bedi A., McShane J.M., et al. Imaging algorithms for evaluating suspected rotator cuff disease: Society of Radiologists in Ultrasound consensus conference statement. Radiology. 2013 May;267(2):589-95. PubMed PMID: 23401583. Pubmed Central PMCID: 3632808. 14. Fischer C.A., Weber M.A., Neubecker C., Bruckner T., Tanner M., Zeifang F. Ultrasound vs. MRI in the assessment of rotator cuff structure prior to shoulder arthroplasty. Journal of orthopaedics. 2015 Mar;12(1):23-30. PubMed PMID: 25829757. Pubmed Central PMCID: 4354568. 15. Adelman S, Fishman P. Use of portable ultrasound machine for outpatient orthopedic diagnosis: an implementation study. The Permanente journal. 2013 Summer;17(3):18-22. PubMed PMID: 24355886. Pubmed Central PMCID: 3783087. 16. Middleton W.D., Payne W.T., Teefey S.A., Hildebolt C.F., Rubin D.A., Yamaguchi K. Sonography and MRI of the shoulder: comparison of patient satisfaction. AJR American journal of roentgenology. 2004 Nov;183(5):1449-52. PubMed PMID: 15505319. 17. Smith J., Finnoff J.T. Diagnostic and interventional musculoskeletal ultrasound: part 2. Clinical applications. PM & R : the journal of injury, function, and rehabilitation. 2009 Feb;1(2):162-77. PubMed PMID: 19627890. Epub 2009/07/25. eng. 18. de Jesus J.O., Parker L., Frangos A.J., Nazarian L.N. Accuracy of MRI, MR Arthrography, and Ultrasound in the Diagnosis of Rotator Cuff Tears: A Meta-Analysis. American Journal of Roentgenology. 2009 2009/06/01;192(6):1701-7. 19. Lenza M., Buchbinder R., Takwoingi Y., Johnston R.V., Hanchard N.C., Faloppa F. Magnetic resonance imaging, magnetic resonance arthrography and ultrasonography for assessing rotator cuff tears in people with shoulder pain for whom surgery is being considered. Cochrane Database of Systematic Reviews.9:CD009020. PubMed PMID: 24065456. 20. Sonnabend D.H., Hughes J.S., Giuffre B.M., Farrell R. The clinical role of shoulder ultrasound. The Australian and New Zealand journal of surgery. 1997 Sep;67(9):630-3. PubMed PMID: 9322701. Epub 1997/10/10. eng. 21. Wall L.B., Teefey S.A., Middleton W.D., Dahiya N., Steger-May K., Kim H.M., et al. Diagnostic performance and reliability of ultrasonography for fatty degeneration of the rotator cuff muscles. The Journal of bone and joint surgery American volume. 2012 Jun 20;94(12):e83. PubMed PMID: 22717835. Pubmed Central PMCID: 3368496. COA Bulletin ACO - Fall / Automne 2015

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

22. Muir J.J., Curtiss H.M., Hollman J., Smith J., Finnoff J.T. The accuracy of ultrasound-guided and palpation-guided peroneal tendon sheath injections. American journal of physical medicine & rehabilitation / Association of Academic Physiatrists. 2011 Jul;90(7):564-71. PubMed PMID: 21765275. Epub 2011/07/19. eng. 23. Collin P., Yoshida M., Delarue A., Lucas C., Jossaume T., Ladermann A., et al. Evaluating postoperative rotator cuff healing: Prospective comparison of MRI and ultrasound. Orthopaedics & traumatology, surgery & research : OTSR. 2015 Aug 14. PubMed PMID: 26283053. 24. Armstrong A., Teefey S.A., Wu T., Clark A.M., Middleton W.D., Yamaguchi K., et al. The efficacy of ultrasound in the diagnosis of long head of the biceps tendon pathology. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 2006 Jan-Feb;15(1):7-11. PubMed PMID: 16414462. 25. Roy J.S., Braen C., Leblond J., Desmeules F., Dionne C.E., MacDermid J.C., et al. Diagnostic accuracy of ultrasonography, MRI and MR arthrography in the characterisation of rotator cuff disorders: a meta-analysis. British journal of sports medicine. 2015 Feb 11. PubMed PMID: 25677796. 26. Sahlani L., Thompson L., Vira A., Panchal A.R. Bedside ultrasound procedures: musculoskeletal and non-musculoskeletal. European journal of trauma and emergency surgery : official publication of the European Trauma Society. 2015 Jun 10. PubMed PMID: 26059560.

34. Kotagal M., Quiroga E., Ruffatto B.J., Adedipe A.A., Backlund B.H., Nathan R., et al. Impact of point-of-care ultrasound training on surgical residentsâ&#x20AC;&#x2122; confidence. Journal of surgical education. 2015 Jul-Aug;72(4):e82-7. PubMed PMID: 25911457. 35. Counselman F..L, Sanders A., Slovis C.M., Danzl D., Binder L.S., Perina D.G. The status of bedside ultrasonography training in emergency medicine residency programs. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2003 Jan;10(1):37-42. PubMed PMID: 12511313. 36. Adelman S., Fishman P. Use of Portable Ultrasound Machine for Outpatient Orthopedic Diagnosis: An Implementation Study. The Permanente Journal. 2013 Summer;17(3):18-22. PubMed PMID: PMC3783087. 37. Churchill R.S., Fehringer E.V., Dubinsky T.J., Matsen F.A. Rotator Cuff Ultrasonography: Diagnostic Capabilities. Journal of the American Academy of Orthopaedic Surgeons. 2004 January 1, 2004;12(1):6-11. 38. Gupta H., Robinson P. Normal shoulder ultrasound: anatomy and technique. Seminars in musculoskeletal radiology. 2015 Jul;19(3):203-11. PubMed PMID: 26021582. 39. Iannotti J.P., Ciccone J., Buss D.D., Visotsky J.L., Mascha E., Cotman K., et al. Accuracy of Office-Based Ultrasonography of the Shoulder for the Diagnosis of Rotator Cuff Tears 2005 2005-06-01 00:00:00. 1305-11 p.

27. Lee S., Hayward A., Bellamkonda V.R. Traumatic lens dislocation. International journal of emergency medicine. 2015;8:16. PubMed PMID: 26069473. Pubmed Central PMCID: 4456605.

40. Park K.D., Kim T.K., Lee J., Lee W.Y., Ahn J.K., Park Y. Palpation Versus Ultrasound-Guided Acromioclavicular Joint Intra-articular Corticosteroid Injections: A Retrospective Comparative Clinical Study. Pain physician. 2015 JulAug;18(4):333-41. PubMed PMID: 26218936.

28. Mallin M., Craven P., Ockerse P., Steenblik J., Forbes B., Boehm K., et al. Diagnosis of appendicitis by bedside ultrasound in the ED. The American journal of emergency medicine. 2015 Mar;33(3):430-2. PubMed PMID: 25559314.

41. Partington P.F., Broome G.H. Diagnostic injection around the shoulder: hit and miss? A cadaveric study of injection accuracy. Journal of shoulder and elbow surgery / American Shoulder and Elbow Surgeons [et al]. 1998 Mar-Apr;7(2):147-50. PubMed PMID: 9593094. Epub 1998/05/21. eng.

29. Marin J.R., Lewiss R.E. Point-of-Care Ultrasonography by Pediatric Emergency Medicine Physicians. Pediatric emergency care. 2015 Jul;31(7):525. PubMed PMID: 26148103. 30. McCormick T., Chilstrom M., Childs J., McGarry R., Seif D., Mailhot T., et al. Point-of-Care Ultrasound for the Detection of Traumatic Intracranial Hemorrhage in Infants: A Pilot Study. Pediatric emergency care. 2015 Aug 21. PubMed PMID: 26308609. 31. Mehta M., Kaul S. Reply: Handheld Ultrasound is a Valuble Bedside Tool Which Can Supplement the Bedside Cardiac Exam but not Replace It. JACC Cardiovascular imaging. 2015 May;8(5):622. PubMed PMID: 25937202. 32. Zieleskiewicz L., Muller L., Lakhal K., Meresse Z., Arbelot C., Bertrand P.M., et al. Point-of-care ultrasound in intensive care units: assessment of 1073 procedures in a multicentric, prospective, observational study. Intensive care medicine. 2015 Sep;41(9):1638-47. PubMed PMID: 26160727. 33. Hand-held ultrasound serving three EDs. ED management : the monthly update on emergency department management. 2007 Feb;19(2):18-20. PubMed PMID: 17361586. COA Bulletin ACO - Fall / Automne 2015

42. Hoeber S., Aly A.-R., Ashworth N., Rajasekaran S. Ultrasoundguided hip joint injections are more accurate than landmarkguided injections: a systematic review and meta-analysis. British journal of sports medicine. English. 43. Sethi P.M., El Attrache N. Accuracy of intra-articular injection of the glenohumeral joint: a cadaveric study. Orthopedics. 2006 Feb;29(2):149-52. PubMed PMID: 16485459. Epub 2006/02/21. eng. 44. Ucuncu F., Capkin E., Karkucak M., Ozden G., Cakirbay H., Tosun M., et al. A comparison of the effectiveness of landmark-guided injections and ultrasonography guided injections for shoulder pain. The Clinical journal of pain. 2009 Nov-Dec;25(9):786-9. PubMed PMID: 19851159. 45. Soh E., Li W, Ong K.O., Chen W., Bautista D. Image-guided versus blind corticosteroid injections in adults with shoulder pain: a systematic review. BMC Musculoskeletal Disorders.12:137. PubMed PMID: 21702969.

Mobile Bearing Hip System Addressing a real concern Three Dimensional Posterior Dislocation Distance at 26° of Pelvic Tilt* 20

• ADM offers more than 88% greater jump distance than a competitive dual mobility bearing.1,2 • MDM also surpasses the jump distance of a traditional fixed and competitive dual mobility bearing.1,2

19.8

15 10

11.1

10.5

9.7

5 Note: Jump Distance (mm) measured with a 54mm shell at 45° of inclination and 20° of anteversion based upon three dimensional digital simulations.

A m m 48

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cin

A system that not only defines

Sta·bil·i·ty but has the data to back it.

ADM X3 TM

Anatomic Dual Mobility

MDM X3 TM

Modular Dual Mobility

Stryker Hips. Implant with confidence. www.mobilebearinghip.com * Three dimensional digital simulations of posterior horizontal dislocation demonstrate that for a given cup size the MDM and ADM designs surpass the jump height of a traditional fixed bearing and a competitive hard-on-hard device.1,3 Although resurfacing type shells have lower jump heights, they have the greatest ROM which is needed when the native femoral neck is retained.1,3 References 1. Heffernan, C., Bhimji, S., Macintyre, J., et al. (2011). Development and Validation of a Novel Modular Dual Mobility Hip Bearing. ORS: Poster #1165. 2. Stryker Test Report RD-10-072. 3. Stryker Test Report RD-10-073. A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery.The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any Stryker product. Products may not be available in all markets because product availability is subject to the regulatory and/or medical practices in individual markets. Please contact your Stryker representative if you have questions about the availability of Stryker products in your area. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: ADM, MDM, Mobile Bearing Hip, Stryker, X3. All other trademarks are trademarks of their respective owners or holders. NL11-AD-HP-1792 Copyright ©2011 Stryker. All rights reserved. Printed in the USA.

Right from the Start. We knew scapular notching was a design problem—but it didn’t have to be. That’s why we developed the Equinoxe® system. An eight center study found a notching rate of just 13.2%, with 0 notches with grades >2, using the Equinoxe reverse shoulder prosthesis.1

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

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

The Equinoxe system showed a

of rotation reverse

NOTCHING

n STABILITY / ROTATION n COMPONENT LOOSENING

68.2%

low notching rate (medialized center

n SCAPULAR

Reported Scapular Notching Rate for Grammont-Style Reverse Shoulder Prosthesis

shoulder with two years minimum follow-up).

20.9% 13.2% 0% Scapular Notching Rate

Notch > Grade 2

Grammont-Style Prosthesis, weighted average of 8 studies, n=8682 Equinoxe Reverse, 8 center radiographic study (minimum follow-up of 2 years), n=1511

n REVISABILITY

Go towww.exac.com/equinoxestudies to view the research. 1. Roche C. et al. Scapular Notching and Osteophyte Formation after Reverse Shoulder Replacement. Bone Joint J 2013;95-B:530–5. 2. JBJS, Sirveaux (2004); JBJS, Werner (2005); JSES, Boileau (2006); JBJS, Simovitch (2007); JSES, Karelse (2008); Clin Orthop Relat Res, Levigne (2010); Acta Orthop, Stechel (2010); JSES, Kempton (2011).

www.exac.com 905-765-1117

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

COA Bulletin ACO - Fall / Automne 2015

To the gracious corporate citizens who supported the event, Thank You.

The 4th Annual Bad to the Bone charity golf tournament reveals a successful 2015 event.

Surgeons and community citizens celebrated the gift of mobility by participating in the 2015 Sherry Bassin Charity Golf Classic in support of the Canadian Orthopaedic Foundation. It was a day filled with philanthropy, fun, food, and entertainment as players hit the links at the beautiful Wooden Sticks Golf Club in Uxbridge, Ontario. The event attracted more than 100 golfers, including NHL VIP guests. Many special features were incorporated into the day including a $1-Million dollar hole-in-one.

The evening entertainment was hosted by Sherry Bassin, an orthopaedic patient himself. Celebrated in the NHL, Bassin has led the Canadian World Junior Team to two gold medals, was the Assistant General Manager of the Quebec Nordiques (now the Colorado Avalanche), and served as a color commentator for CBC Sports in the late 1980's for their World Junior Championship coverage.

The event generated more than $86,000 with proceeds being invested into the Foundation’s programs of research, education and patient care. Thank you to our gracious corporate sponsors and to everyone who volunteered, golfed and participated. We hope to see you again next year.

www.whenithurtstomove.org 1-‐800-‐461-‐3639

Foundation / Fondation

Two Bones and Phones Legacy Scholarships Awarded

he Canadian Orthopaedic Foundation awarded two scholarships through its Bones and Phones program in June 2015. The program recognizes orthopaedic residents who have demonstrated commitment and contribution to enhancing musculoskeletal heath in their community or abroad, beyond that which would be expected during their residency training period. Dr. Michael MacKechnie from the University of Toronto received the award for his project entitled Development of a contextually appropriate orthopaedic surgery training program in Botswana. Recognizing that this low-middle income country has a shortage of orthopaedic surgeons, Dr. MacKechnie and his team worked with partners in the public and private health systems in Gaborone, Botswana’s capital city, to use a validated curriculum tool to assess the current practice of orthopaedics. The team met with local stakeholders and analysed operative log book data from 2008 to 2013, and clinical log book data from 1995 to 2012, from the department of orthopaedic surgery at Princess Marina Hospital, the largest tertiary care centre in the country and teaching hospital for the University of Botswana. Much of this work was done in conjunction with local medical students and surgeons, furthering the goal of international cooperation. The collected data was analysed and compared to published guidelines for orthopaedic surgery trainees. Abstracts, with both Botswana and Canadian authors, were presented at the Association for Surgical Education, European Federation of Orthopaedics and Trauma, and America and Canadian Orthopaedic Association meetings in 2014. The results of the data provide a framework with which to develop an orthopaedic training program in Botswana. Dr. Thierry Pauyo from McGill University received his award for a project entitled Evaluating Google Glass in peri-operative orthopaedic consultations: Linking Haiti to Canada. Dr. Pauyo’s team recognized the exponential growth of applications of information and communication technologies in low-income countries to aid in delivering health care. They looked at Google Glass, a new low-profile wearable technology that allows physicians to record hand free video and pictures and to directly video link and communicate with other wearers of the device. The aim of this study was to describe and analyze the use of Google Glass by Haitian and Canadian orthopaedic surgeons for live discussion of intra-operative cases and clinical consultations. The study takes place at the University Hospital of Mirebalais in the plateau central of Haiti. Two Google Glass devices are used, linking Canadian trauma orthopaedic surgeons at McGill University with a Haitian orthopaedic surgeon at the Mirebalais Hospital. For a month, during a bi-weekly four-hour time period, the surgeons are available to communicate for live discussion. Data collected will be: types of surgery discussed, number of intra and clinical consultations, length of consultations, number of videos and pictures shared. A survey will measure the experiences of both surgeons using the devices and to assess the patient’s perspective.

Founded by Dr. Veronica Wadey and Mr. Henry Chow, the Bones and Phones Legacy Scholarship recognizes and honours the vital role surgeons play in the lives of others. The scholarship fund celebrates exceptional residents by honouring their dedication to community spirit and/or giving back for the benefit of others. One scholarship is awarded annually, after all applications are assessed by a review committee. Committee members were impressed with the quality of applications this year and thanks to a generous additional donation to the Fund, two awards were possible in 2015. Dr. Wadey says, “The whole purpose of the Bones and Phones Legacy Scholarship Fund was to increase awareness of the Canadian Orthopaedic Association and Foundation to our resident colleagues so that we might encourage early membership to foster future participation and collaboration with our colleagues. Henry and I are thrilled with the quality of applications to the Bones and Phones program. Our incoming orthopaedic surgeons are certainly dedicated to enhancing orthopaedic health. The work that both Drs. Pauyo and MacKechnie are doing is innovative and exciting. We look forward to hearing about their progress. In addition, we encourage future applications in all the areas of contributions in society and beyond towards MSK health outside of residency.” For more information about the Bones and Phones Legacy Scholarship visit www.whenithurtstomove.org.

COA Bulletin ACO - Fall / Automne 2015

À toutes les entreprises qui ont soutenu la classique : Merci!

Une classique de golf de bienfaisance Bad to the Bone réussie en 2014 Des personnes de partout au pays ont célébré la mobilité en compagnie d’orthopédistes à la

troisième classique de golf de bienfaisance Sherry Bassin, au profit de la Fondation Canadienne d’Orthopédie. Les golfeurs ont eu droit à une journée marquée par la philanthropie, le plaisir, les divertissements et la bonne chère au magnifique Wooden Sticks Golf Club, situé à Uxbridge, en Ontario. Chaque golfeur a eu l’occasion de jouer avec l’un des quelque 15 invités de la LNH présents. La journée comportait nombre d’activités spéciales, dont le trou d’un coup à un million de dollars.

La soirée qui a suivi était animée par Sherry Bassin, lui-même un ancien patient en orthopédie. Bassin, fort apprécié au sein de la LNH, a remporté deux médailles d’or avec l’équipe canadienne au Championnat du monde junior, en plus d’avoir été directeur général adjoint des Nordiques de Québec (aujourd’hui l’Avalanche du Colorado) et analyste à CBC Sports à la fin des années 1980, pendant le Championnat du monde junior de hockey.

La classique a permis de recueillir près de 85 000 $, qui seront investis dans le financement de la recherche et le programme de soutien par les pairs Connexion Ortho. Nous remercions donc nos généreux commanditaires et tous les bénévoles, golfeurs et autres participants à cette manifestation. Au plaisir de vous revoir l’an prochain!

www.whenithurtstomove.org 1-‐800-‐461-‐3639

Foundation / Fondation

Remise de deux bourses d’études Bones and Phones

a Fondation Canadienne d’Orthopédie a remis deux bourses d’études Bones and Phones en juin 2015. La Bourse d’études Bones and Phones vise à reconnaître des résidents en orthopédie dont la contribution et l’engagement exceptionnels pendant leur résidence ont permis d’améliorer la santé de l’appareil locomoteur dans leur collectivité ou ailleurs. Le Dr Michael MacKechnie (Université de Toronto) a reçu cette bourse pour son rôle dans l’établissement d’un programme de formation en orthopédie adapté au contexte du Botswana (projet intitulé Development of a contextually appropriate orthopaedic surgery training program in Botswana). Constatant la pénurie d’orthopédistes dans ce pays à revenu faible et moyen, le Dr MacKechnie et son équipe ont collaboré avec des partenaires des systèmes de santé public et privé à Gaborone, capitale du Botswana, à l’évaluation de l’enseignement en orthopédie à l’aide d’un outil approuvé. L’équipe a donc rencontré des intervenants locaux et analysé les données des registres opératoires de 2008 à 2013, de même que les données des registres cliniques de 1995 à 2012, du service de chirurgie orthopédique de l’hôpital Princess Marina, plus grand centre de soins tertiaires au pays et hôpital d’enseignement de l’université du Botswana. Une bonne part du travail a été fait en collaboration avec des étudiants en médecine et des chirurgiens locaux, ce qui contribue à la concrétisation de l’objectif de coopération internationale. On a analysé et comparé les données recueillies aux lignes directrices publiées pour les stagiaires en orthopédie. Des précis ont été soumis par des auteurs botswanais et canadiens à l’Association for Surgical Education, à l’European Federation of National Associations of Orthopaedics and Traumatology et à la réunion annuelle 2014 de l’American Orthopaedic Association et de l’Association Canadienne d’Orthopédie. Les résultats de ce projet fournissent un cadre de travail pour l’élaboration d’un programme de formation en orthopédie au Botswana. Le Dr Thierry Pauyo (Université McGill) a reçu cette bourse pour son rôle dans l’évaluation de Google Glass dans les consultations périopératoires en orthopédie, d’Haïti au Canada (projet intitulé Evaluating Google Glass in peri-operative orthopaedic consultations: Linking Haiti to Canada). L’équipe du Dr Pauyo a misé sur la croissance exponentielle des applications de technologie de l’information et de communication dans les pays à faible revenu pour faciliter la prestation des soins de santé. L’équipe s’est intéressée à Google Glass, une nouvelle technologie portable et compacte qui permet aux médecins d’enregistrer des vidéos et des photos en mode mains libres et de communiquer directement avec d’autres utilisateurs du dispositif pour leur envoyer des liens vidéo. Le but de l’étude était de décrire et d’analyser l’utilisation de Google Glass par les orthopédistes haïtien et canadiens pour discuter en direct de cas périopératoires et de consultations cliniques. Cette étude s’est déroulée à l’hôpital universitaire de Mirebalais, dans le plateau central d’Haïti. On a utilisé deux paires de lunettes Google Glass afin d’établir la communication entre les orthopédistes-traumatologues canadiens, à l’Université McGill, et un orthopédiste haïtien, à l’hôpital de Mirebalais. Pendant un mois, à raison de séances bihebdomadaires de quatre heures, les orthopédistes pouvaient communiquer en direct. Les

données ainsi recueillies ont trait au type de chirurgie abordé, au nombre de consultations périopératoires et cliniques, à la durée des consultations, ainsi qu’au nombre de vidéos et de photos échangées. Un sondage permettra enfin d’évaluer l’expérience des orthopédistes qui ont utilisé le dispositif et le point de vue des patients. Créé par la Dre Veronica Wadey et M. Henry Chow, le Fonds de la Bourse d’études Bones and Phones rend hommage au rôle central des orthopédistes dans la vie des gens. Il souligne en effet la contribution exceptionnelle de résidents en célébrant leur esprit communautaire ou leur don de soi. Une bourse est accordée chaque année, d’après l’évaluation des candidatures reçues par un comité. Les membres du comité d’évaluation ont été impressionnés par la qualité des candidatures reçues cette année et, grâce à un généreux don, le comité a pu accorder deux bourses en 2015. Selon la Dre Wadey : « Le Fonds de bourses d’études Bones and Phones vise avant tout à faire connaître davantage l’Association Canadienne d’Orthopédie et la Fondation Canadienne d’Orthopédie aux résidents afin de les inciter à y adhérer rapidement, et ainsi favoriser les occasions de participation et de collaboration. Henry et moi sommes ravis de constater la qualité des candidatures soumises pour la Bourse d’études Bones and Phones. Nos orthopédistes en devenir ont assurément à cœur d’améliorer la santé de l’appareil locomoteur. Le travail des Drs Pauyo et MacKechnie est aussi novateur que passionnant. Nous serons à l’affût de leurs progrès. Aussi, nous sommes ouverts à toutes les formes de contribution à la société en général en vue d’améliorer la santé de l’appareil locomoteur hors du cadre de la résidence. » Pour de plus amples renseignements sur la Bourse d’études Bones and Phones, consultez www.whenithurtstomove.org/fr.

COA Bulletin ACO - Fall / Automne 2015

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

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COA Bulletin ACO - Fall / Automne 2015

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

Transition Planning: Financial Planning In a Changing Environment Adam O’Neill, Bsc, MBA, CHS adam.oneill@sunlife.com Conor Pollock, BComm, CFP, CHS conor.pollock@sunlife.com

Introduction e were very honoured to have the opportunity to present an ICL at the COA Annual Meeting in Vancouver this past spring and are very pleased with the positive response we received from the participants. We have been working with the COA over these past three years, helping individual surgeons and the organization respond to the maelstrom of changing need with regards to financial planning. These changes are affecting all Canadians, but their effects on orthopaedic surgeons in particular have been greatly amplified, which when considered in concert with the changes affecting the orthopaedic specialty in Canada, necessitates a specific response. In part because of this, our most recent ICL at the Vancouver Annual Meeting generated extremely high registration, an enthusiastic response, and numerous requests for more specific information. This article is the first of several initiatives, leading up to the 2016 COA Annual Meeting, all aimed at helping Canadian surgeons adapt their financial strategy to thrive in an new environment of adversity.

Changing Environment The past decade has seen significant macro change to the investing and economic landscape globally, nationally and regionally. Rapidly increasing globalization and integration has led to a riskier investment landscape, and increased market volatility. The remnants of the 2008 financial crisis, coupled with historically low interest rates are also being profoundly felt. All of these have led to an increasing focus on maximizing the value investors are getting and efficiency in investing, particularly with regards to minimizing fees, increasing education and offer additional value added through the integration of relevant professional services. At the same time, Canadians continue to see increasing longevity and a trend of what were previously fatal health conditions towards chronic, controllable ones. Governmental response (predictably) has been slow, and is increasingly focused on cost containment with regards to medical care and entitlements. Adjusting financial strategies for these new factors (longevity, care, limited governmental support, etc.) has been a major development of the financial planning industry. One bright spot in this shifting environment has been the regulatory changes in Canada, specifically with regards to medical (professional services) corporations, trust and life insurance structures and other planning tools applicable to doctors. Many of the strategies with these new tools have created significant ability to better reach planning goals and minimize overall tax exposure.

At the same time, Canadian orthopaedics has been facing increasing issues with availability of resources, producing profound strain on patient care, incomes, and available fulltime positions. The effects of this has been a rapidly changing career path, with on average, a lengthened and more costly educational phase, locum work, delayed attainment of peak earnings, an increasing diversity of income mix, and increasing pressure on more established surgeons to share work. One key indication of these changes is in the rapid increase in the diversity and complexity of orthopaedic income mix, along with the introduction of alternative payment and funding plans. The end result of these factors is increased uncertainty around income, income mix, stability, compensation, and a host of other issues. These changes affect all surgeons to a degree, and require a planning strategy that emphasizes flexibility, adaptability, and the use of some of these more progressive planning strategies. Transition Planning The move to a transition-based planning model is a direct response to the evolving life and career paths of Canadians. The nuclear family, working for 45 years in one role for a single employer, followed by a uniform retirement is no longer representative of the vast majority of Canadians, even more so for surgeons. Delayed marriage and children, increased prevalence of non-traditional and blended families, dual income households, and a shift towards multiple career phases, each with their own income mix and tax implications, have necessitated changes in the best practices of financial strategy. The response to these changes; transition planning, focuses on integrated, centralized planning, ensuring all the related and interacting pieces of a plan are aligned and working together. More focus is now aimed at maintaining flexibility, and achieving a higher level of efficiency, especially with regards to fees and taxation. The goal of transition planning is to ensure individuals and families are as well positioned as possible to react to a new career phase, life phase, regulatory or market change, all while anticipating and accommodating for a longer and more intricate “retirement” phase than has historically been expected. 3. Estate and Legacy One area of financial planning which has experienced a sea of change in best practices has been estate and legacy planning. The ever-increasing estate needs resulting from a much greater diversity in family situation (especially blended families), combined with the changes to tax, investment and estate regulation, have necessitated these changes.

COA Bulletin ACO - Fall / Automne 2015

Training & Practice Management / Formation et gestion d’une pratique (continued from page 47)

Technically speaking, estate planning is the documenting of your final intentions with respect to possessions and its focus is on how you will transfer assets. Legacy planning, on the other hand, is a value-based approach determining the impact your estate will have on heirs, relationships, and causes. This is more of a focus on how you will impact others. Generally when passing on wealth, people negotiate three different considerations; how the succession of this wealth will affect existing relationships, does the intention of this wealth transfer align with their values and does the passing of this wealth provide fulfillment for the benefactor and recipient. To best meet these needs, new tools have facilitated the advent of a wider range of possible strategies and outcomes, allowing greater control and specificity with regards to the division and allocation of estates. Concepts such as family corporations, estate freezes and the use of trusts have all added opportunity and potential benefit to your estate strategy. How a wealth transfer affects existing relationships is an important topic. A common discussion that comes out of this is the concept of fairness versus equality. It is difficult to transfer wealth to children equally when the circumstances of children most often are not equal. The last thing any parent wants is to have a succession of wealth negatively affect the relationships of their children. A good approach to this is to have a family meeting where you can have an open discussion about estate planning and integrate your children into the process. Typically most people want to provide the most appropriate succession structure (benefit size, being fair versus being equal, charitable giving, etc.), while minimizing their estate’s tax exposure. This leads to providing fulfillment of the estate proceeds process, while minimizing estate risk in terms of relationship breakdown, misalignment of intention and unnecessary tax exposure. Finally, with greater longevity and advances in medical treatment, estate planning has been forced to adopt new perspectives in a number of areas. With parents living longer, many are planning to pass on wealth and assistance to children prior to death. Issues such as ensuring for the care and comfort of a surviving spouse are also becoming increasingly important. The ability to adapt to evolving realities should be a central part of every surgeon’s overall financial plan. Conclusion This article is a brief summary of the ICL on Transition Planning: An Evolution in Financial Planning Best Practices in Response to a Changing Landscape presented during the Vancouver meeting. Due to the volume of interest we received both during and after the presentation (and the correspondence since), we will be presenting the material for doctors in the Toronto area in November and February. We are happy to provide professionals in other provinces webinars of the presentation upon request.

Next Steps & Engagement The two main areas of improvement for most individuals tend to be in the shift to a more integrated, transitional approach, and the creation of a proper estate and legacy plan. If you have any specific questions or would like a review of your current plan, please feel free to reach out to us. Our contact information can be found just under the article title. If you would like to provide us with any feedback, we welcome your engagement. Disclaimer: The information provided in the article has been provided to the COA by Sun Life Assurance Company of Canada and is for informational purposes only. It may not reflect all current rules, regulations, or laws for your province of residence and it may not pertain to your situation. Because every person’s situation is unique, it is important to consult a professional to obtain advice that relates to your particular circumstances.

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 - Fall / Automne 2015

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

Events of Interest / Activités d’intérêt 90e Congrès SOFCOT November 9-12 novembre Palais des congrès, Paris, France Web Site/Site Int. : http://www.sofcot-congres.fr/fr Registration/Inscription: http://www.sofcot-congres.fr/fr/sinscrire Programme : http://www.sofcot-congres.fr/fr/synopsis CAS 4th Annual Meeting November 26-27 novembre Ottawa, ON E-mail/Courriel : cas@canorth.org Web Site/Site Int. : http://www.coa-aco.org/cas/cas/

2016 Canadian Shoulder & Elbow Society (CSES - formerly JOINTS Canada) Annual Shoulder Course January 28-29 janvier Ottawa, ON E-mail/Courriel : cpd@toh.on.ca Web Site/Site Int. : http://www.coa-aco.org/joints/joints-meetings/

13th Meeting of the Combined Orthopaedic Associations April 11-15 avril Cape Town, South Africa Registration/Inscription : http://www.comoc2016.org/registration Hotel : http://www.comoc2016.org/accommodation Web Site/Site Int. : www.comoc2016.org

AAOS 2016 Annual Meeting March 1-5 mars COA RECEPTION = THURSDAY, MARCH 3 @ 18:00 RECEPTION DE L’ACO = LE JEUDI 3 MARS @ 18 H Orange County Convention Centre, Orlando, FL Web Site/Site Int. : www.aaos.org 12th Biennial Canadian Orthopaedic Foot & Ankle (COFAS) Symposium April 14-16 avril Wet lab on April 14 Eaton Centre Marriott Toronto, ON E-mail/Courriel : cofas@canorth.org Web Site/Site : http://www.canadafoot.com/

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

2016 June 16-19 juin Québec City, QC

2017 June 16-18 juin Ottawa, ON

2018 June 21-23 juin Victoria, BC

COA Bulletin ACO - Fall / Automne 2015

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

EXTEND YOUR

KNOWLEDGE

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

coa.sclivelearningcenter.com THE CANADIAN ORTHOPAEDIC ASSOCIATION “ACHIEVE EXCELLENCE IN ORTHOPAEDIC CARE FOR CANADIANS”

COA Bulletin ACO - Fall / Automne 2015

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Access For All COA Attendees

Canada’s Orthopaedic Community Gathers to Celebrate La communauté orthopédique canadienne se réunit pour célébrer la The largest professional gathering of Canada’s Orthopaedic Community will take place in Quebec City from June 16-19, 2016 at the COA/CORS/CORA Annual Meeting. We will celebrate orthopaedic medicine’s contribution to improving the quality of life by sharing the latest research, showcasing the latest technologies and by re-defining the limits of orthopaedic medicine and care.

Joie de Vivre is our passion, and our profession. Le plus grand rassemblement de la communauté orthopédique canadienne se tiendra à Québec du 16 au 19 juin 2016 dans le cadre de la réunion annuelle de l’ACO, de la SROC et de l’ACRO. Nous célèbrerons la contribution de la médecine orthopédique à l’amélioration de la qualité de vie en diffusant les plus récentes études, en présentant les toutes dernières technologies et en redéfinissant les limites de la médecine et des soins orthopédiques.

La Joie de vivre c’est notre passion et notre profession. Visit/Visitez www.coaannualmeeting.ca

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