COA Bulletin #118 - Fall/Winter 2017 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Fall / Winter Automne / Hiver 2017 Publication Mail Envoi Poste-publication Convention #40026541 4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3

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

BULLETIN

118

Evolution of Orthopaedic Trauma Care in Canada . . . . . . . . . . . . . . . . . . . Page 31 Évolution de l’orthopédie traumatologique au Canada

Read Dr. Kevin Orrell’s President Elect Address - We Are Our Own Best Friends Lisez l’allocution du Dr Kevin Orrell à titre de président élu - Nous sommes nos meilleurs allies �� 7 Voici ce que VOUS aviez à dire sur la Réunion annuelle 2017 �� 12 COA Global Surgery Committee Announces the First Norman Bethune Scholar �� 28 Debate: Treatment Options for High-grade AC Separations �� 35

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Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 118 - Fall/Winter / Automne/Hiver 2017 COA / ACO Kevin Orrell President / Président Kishore Mulpuri Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Femi Ayeni Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

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

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Celebrating Friendship and Cooperation Kevin Orrell, M.D., FRCSC President, Canadian Orthopaedic Association

n the occasion of Canada’s 150th birthday, the COA was privileged to host its Annual Meeting in our nation’s capital. The festive atmosphere, venue and cooperative weather helped to make our time in Ottawa a true celebration of our cultural and orthopaedic heritage. We are indebted to the Local Arrangements Committee Chair, Dr. J Pollack and Program Chair, Dr. Peter Lapner, and their committees; for their time and effort in making this The Bulletin of the Canadian Orthopaedic Association is published Spring, Summer, Fall, Winter by the Canadian Orthopaedic Association, 4060 St. Catherine Street West, Suite 620, Westmount, Quebec, H3Z 2Z3. It is distributed to COA members, Allied Health Professionals, Orthopaedic Industry, Government, universities and hospitals. Please send address changes to the Bulletin at the: cynthia@canorth.org

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

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

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

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Your COA / Votre association

(continued from page 3)

and outstanding event. Waiving the pre-registration fees for Active and Associate members continues to encourage large attendance and participation at our meeting. Congratulations are extended to Presidential Award winners, Drs. Bill Rennie, Bob McCormack and Kishore Mulpuri. Learn more about these distinguished gentlemen and their enormous contributions to our organization and to Canadian orthopaedics by reading the article on page 19 of this edition. Well done! We were privileged to have Dr. James Wright return from Oxford, England to deliver the R.I. Harris Lecture. Dr. Hani Awad from the University of Rochester was this year’s Macnab Lecturer and we were very fortunate to have Professor Fares Haddad, editor in chief of the Bone and Joint Journal, as part of our faculty. Special thanks are extended to our outgoing President, Dr. Peter MacDonald. Peter has led us in a very positive direction and has worked hard to address the significant issues we face as an organization. Peter and Sherry are highly respected and have represented us well on the international stage. It is a great privilege to serve as the 72nd President of the Association. In my President Elect Address, I referred to the friendship and cooperation we enjoy as Canadian orthopaedic surgeons. I believe this to be the envy of many of our colleagues in other disciplines. Personally, I experienced a true sense of this friendship with the attendance of my orthopaedic colleagues from Sydney, Nova Scotia at the Transfer of Office ceremony. I am deeply grateful for their support and encouragement during my term as President. Also in attendance were the residents with whom I trained at Dalhousie University. Ed Abraham and his wife Sarah joined us from Saint John, New Brunswick, John and Janet Ready drove through the early morning from Boston to be present for the 11:30 AM ceremony. It is the strength of such relationships that I refer to in my Presidential Address, “We Are Our Own Best Friends” that immediately follows this article. Four of our five children were also with Anne and I, and enjoyed the day and the fun night that followed at the Canada Aviation and Space Museum. The band from Montreal, Squidjigger, had those with Celtic dance abilities demonstrating their talent throughout the evening.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 30 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 41 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 50 To date, Anne and I have attended several of the Carousel meetings. All Carousel associations have identified significant issues that orthopaedic surgeons must address in their respective countries. Canadian orthopaedics is held in high esteem around the world. We must work hard as an organization to improve access to care, reduce unemployment of young talented orthopaedic surgeons, and support each other in order to retain this respect. There is much to do. Once again, thank you for the privilege of serving you. Please be assured of my ongoing commitment to the betterment of Canadian orthopaedics. I would like to hear from as many of you as possible with comments, concerns and suggestions. Please feel free to reach me any time at: korrell@eastlink.ca.

In my address, I referred to the need for all members to become active in the Association. As a community surgeon with university affiliation, I feel well placed to encourage everyone, especially our younger members, to take an active role. This will strengthen our organization and foster the rich friendships with colleagues across the country. Drs. Ed Abraham, Kevin Orrell and John Ready COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Your COA / Votre association

Célébrer l’amitié et la coopération Kevin Orrell, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

l’occasion du cent-cinquantième anniversaire du Canada, l’ACO a eu le privilège de tenir sa réunion annuelle dans la capitale nationale. L’ambiance festive, les lieux et le beau temps ont contribué à faire de notre réunion à Ottawa une véritable célébration de nos patrimoines culturel et orthopédique. Un grand merci au président du Comité organisateur, le Dr J. Pollack, au président du Comité responsable du programme, le Dr Peter Lapner, et à leurs collaborateurs, dont le temps et les efforts nous ont permis de profiter d’une manifestation exceptionnelle. L’annulation des droits d’inscription des membres actifs et associés continue de favoriser une grande participation à notre réunion. Toutes nos félicitations aux Drs Bill Rennie, Bob McCormack et Kishore Mulpuri, lauréats du Prix d’excellence du président. Pour en savoir plus sur ces brillants messieurs et leur énorme contribution à notre organisme et au milieu canadien de l’orthopédie, lisez l’article à la page 19 du présent numéro. Bravo! Nous avons eu le privilège de recevoir le Dr James Wright, directement d’Oxford, en Angleterre, qui a donné la conférence R.I. Harris. Le Dr Hani Awad, de l’université de Rochester, était quant à lui le conférencier Macnab de cette année. Et, parmi les autres conférenciers présents, nous avions la chance de recevoir le Pr Fares Haddad, rédacteur en chef du Bone and Joint Journal. Je tiens à remercier tout particulièrement notre président sortant, le Dr Peter MacDonald. Sous sa houlette, nous avons progressé de façon très positive; il a travaillé dur sur les dossiers importants pour notre organisme. Peter et Sherry sont très respectés et nous ont bien représentés à l’étranger.

ont accompagnés, Anne et moi, et ont passé une belle journée, puis une amusante soirée au Musée de l’aviation et de l’espace du Canada. Le groupe Squidjigger, de Montréal, a permis aux amateurs de danse celtique de montrer l’étendue de leur talent durant toute la soirée. Dans mon allocution, je parlais de la nécessité pour tous les membres d’être actifs au sein de l’ACO. En tant qu’orthopédiste en milieu communautaire affilié à une université, j’estime être bien placé pour inciter tout le monde, et plus particulièrement nos membres les plus jeunes, à jouer un rôle actif. C’est ainsi que nous pourrons renforcer l’ACO et nourrir des amitiés fécondes entre collègues d’un bout à l’autre du pays. À ce jour, Anne et moi avons assisté aux congrès de l’American Orthopaedic Association et de la South African Orthopaedic Association. Tous les présidents du groupe Carousel ont cerné des dossiers importants que les orthopédistes doivent aborder dans leur pays. Le milieu canadien de l’orthopédie est tenu en grande estime partout dans le monde. À l’ACO, nous devons travailler dur pour améliorer l’accès aux soins, réduire le chômage chez nos jeunes orthopédistes de talent et nous soutenir les uns les autres pour demeurer dignes de tout ce respect. Il a tant à faire! Encore une fois, je vous remercie de m’accorder le privilège de vous servir. Soyez assurés de mon engagement indéfectible envers l’amélioration de l’orthopédie au Canada. J’espère que beaucoup d’entre vous me transmettrez vos commentaires, préoccupations et suggestions. N’hésitez pas à communiquer avec moi n’importe quand, à korrell@eastlink.ca.

C’est un grand honneur pour moi d’être votre soixante-douzième président. Dans mon allocution de président élu, j’ai fait référence à l’amitié et à la coopération dont nous bénéficions à titre d’orthopédistes canadiens. Je crois que nous faisons l’envie de nombre de nos collègues dans d’autres disciplines. Personnellement, j’ai vécu cette amitié de façon très profonde avec mes collègues de Sydney, en Nouvelle-Écosse, qui étaient présents à la cérémonie de transfert des charges. Je suis très reconnaissant de leur soutien au cours de mon mandat à la présidence. Les résidents que j’ai formés à l’Université Dalhousie étaient également présents. Ed Abraham et Sarah, son épouse, étaient venus de Saint John, au Nouveau-Brunswick, tandis que John Ready et sa femme, Janet, avaient pris la route tôt le matin à Boston pour être des nôtres à la cérémonie, à 11 h 30. C’est à la force de telles amitiés que je faisais référence dans mon allocution, « Nous sommes nos meilleurs alliés », qui est retranscrite Le Dr Kevin Orrell et ses partenaires et collègues orthopédistes de Sydney, après cet article. Quatre de nos cinq enfants nous en Nouvelle-Écosse COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Over double the number of Level 1, 2 and 3 clinical studies than all competitors combined.1

No other bone stimulator comes close. *

* LEVEL

LEVEL

Controlled Clinical Studies2-17

15 fresh fracture studies2-16

LEVEL

16 Randomized

3 Cohort Studies

12 Case Controlled

2 fresh fracture studies18,19

1 fresh fracture study21

1 nonunion study20

11 nonunion studies22-32

18-20

1 nonunion study17

Studies21-32

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Summary of Indications for Use: EXOGEN is indicated for the non-invasive treatment of all osseous defects (excluding vertebra and skull), including the treatment of delayed unions, nonunions,† stress fractures and joint fusion. EXOGEN is also indicated for the acceleration of fresh fracture heal time, repair following osteotomy, repair in bone transport procedures and repair in distraction osteogenesis procedures. There are no known contraindications for the EXOGEN device. Safety and effectiveness have not been established for individuals lacking skeletal maturity, pregnant or nursing women, patients with cardiac pacemakers, on fractures due to bone cancer, or on patients with poor blood circulation or clotting problems. Some patients may be sensitive to the ultrasound gel. Full prescribing information can be found in product labeling, at www.exogen.com, or by calling customer service at 1-855-771-0606 (toll free). * These studies, which reflect the body of evidence of the bone stimulator EXOGEN, include evaluations of applications outside the approved label. Assignment of evidence levels was based on the updated level of evidence rating system in the Journal of Bone & Joint Surgery. 2015;97(1):1-2. †

Active Healing Through Orthobiologics

A nonunion is considered to be established when the fracture site shows no visibly progressive signs of healing.

References: 1. Bioventus, LLC. EXOGEN studies and competitor studies analysis literature search, United States. Data on File, RPT-000557: 2016. 2. Dudda M, Hauser J, Muhr G, Esenwein SA. J Trauma. 2011;71:1376-80. PMID: 22071933. 3. El-Mowafi H, Mohsen M. Int Orthop. 2005;29(2):121-4. PMID: 15685456. 4. Emami A, Petrén-Mallmin M, Larsson S. J Orthop Trauma. 1999;13(4):252-57. PMID: 10342350. 5. Handolin L, Kiljunen V, Arnala l, at el. J Orthrop Sci. 2005;10(4):391-5. PMID: 16075172. 6. Handolin L, Kiljunen V, Arnala I, et al. Arch Orthop Trauma Surg. 2005; 125(5):317-21. PMID: 15821899. 7. Heckman JD, Ryaby JP, McCabe J, Frey JJ, Kilcoyne RF. J Bone Joint Surg Am. 1994;76(1):26-34. PMID: 8288661. 8. Kristiansen TK, Ryaby JP, McCabe J, Frey JJ, Roe LR. J Bone Joint Surg Am. 1997;79(7):961-73. PMID: 9234872. 9. Leung KS, Lee WS, Tsui HF, Liu PP, Cheung WH. Ultrasound Med Biol. 2004;30(3):389-95. PMID: 15063521. 10. Lubbert PH, van der Rijt RH, Hoorntje LE, van der Werken C. Injury. 2008;39(12):1444-52. PMID: 18656872. 11. Mayr E. Rudzki MM, Rudzki M, et al. Handchir Mikrochir Plast Chir. 2000;32(2):115-22. PMID: 10857066. 12. Rue JP, Armstrong DW 3rd, Frassica FJ, Deafenbaugh M, Wilckens JH. Orthopedics. 2004;27(11):1192-5. PMID: 15566133. 13. Salem KH, Schemlz A. Int Orthop. 2014;38(7):1477-82. PMID: 24390009. 14. Strauss E, Ryaby JP, McCabe J. J Ortho Trauma. 1999;13(4):310-21. http://journals.lww.com/jorthotrauma/Citation/1999/05000/Treatment_of_Jones__fractures_of_the_foot_with.76.aspx. 15. Tsumaki N, Kakiuchi M, Sasaki J, Ochi T, Yoshikawa H. J Bone Joint Surg Am. 2004;86-A(11):2399-405. PMID: 15523009. 16. Zacherl M, Gruber G, Radl R, Rehak PH, Windhager R. Ultrasound Med Biol. 2009;35(8):1290-7. PMID: 19540659. 17. Schofer MD, Block JE, Aigner J, Schmelz A. BMC Musculoskelet Disord. 2010; 11:229. PMID: 20932272. 18. Couglin MJ, Smith BW, Traughber P. Foot Ankle Int. 2008;29(1):970-7. PMID: 18851812. 19. Gold SM, Wasserman R. J Orthop Trauma. 2005;19(1):10-6. PMID: 15668578. 20. Romano C, Messina J, Meani E. Guarderni di infezione osteoarticolari. 1999;83–93. 21. Kinami Y, Noda T, Ozaki T. J Orthop Sci. 2013;18(3):410-8. PMID: 23463120. 22. Farkash U, Bain O, Gam A, Nyska M, Sagiv P. J Orthop Surg Res. 2015;10:72. PMID: 25986554. 23. Gebauer D, Mayr E, Orthner E, Ryaby JP. Ultrasound Med Biol. 2005;31(10):1291-402. PMID: 16223643. 24. Jingushi S, Mizuno K, Matsushita T, Itoman M. J Orthop Sci. 2007;12(1):35-41. PMID: 17260115. 25. Lerner A, Stein H, Soudry M. Ultrasonics. 2004;42(1-9):915-7. PMID: 15047406. 26. Mayr E, Mockl C, Lenich A, Ecker M, Rüter A. Unfallchirurg. 2002;105(2):108-15. PMID: 11968536. 27. Nolte PA, van der Krans A, Patka P et al. J Trauma. 2001;51(4):693-702. PMID: 11586161. 28. Pigozzi F, Moneta MR, Giombini A et al. J Sports Med Phys Fitness. 2004;44(2):173-8. PMID: 15470315. 29. Roussignol X, Currey C, Duparc F, Dujardin F. Orthop Traumatol Surg Res. 2012;98(2):206-13. PMID: 22424956. 30. Rutten S, Nolte PA, Guit GL, Bouman DE, Albers GH. J Trauma. 2007;62(4):902-8. PMID: 17426546. 31. Watanabe Y, Arai Y, Takenaka N, Kobayashi M, Matsushita T. J Orthop Sci. 2013;18(5):803-10. PMID: 23775464. 32. Zura R, Della Rocca GJ, Mehta S, et al. Injury. 2015;46(10):2036-41. PMID: 26052056. EXOGEN, Bioventus and the Bioventus logo are registered trademarks of Bioventus LLC.

SMK-002250

09/17

Your COA / Votre association

We are pleased to share the President Elect Address delivered by Dr. Kevin Orrell on Saturday, June 17 during the COA Annual Meeting held in Ottawa with our members.

C’est avec grand plaisir que nous vous transmettons ci-après l’allocution prononcée par le Dr Kevin Orrell à titre de président élu à la Réunion annuelle d’Ottawa, le samedi 17 juin.

We Are Our Own Best Friends Nous sommes nos meilleurs alliés

r. Chairman, members and partners of the COA, special guests, ladies and gentlemen, Mesdames et Messieurs,

It goes without saying that it is a great privilege for me to serve as the 72nd President of the Canadian Orthopaedic Association. This honour is magnified even more, occurring on the occasion of the 150th birthday of Canada, in our nation’s capital. In preparing this address, I have had the opportunity to review several of the presidential addresses of the past. These contain a great deal of wisdom and scholarly advice from impressive members of our organization. I am happy to say that I recall many of these Past Presidents and consider them my mentors and dear friends. C’est un privilège pour moi de servir comme 72e président de l’Association Canadienne d’Orthopédie. En tant que chirurgien communautaire, travaillant de près avec l’Université, je me sens bien placé pour reconnaître plusieurs des soucis importants qu’éprouvent les chirurgiens orthopédistes partout au Canada. Je suis fier des liens que j’ai noués avec de nombreux collègues dans chaque province du pays. Ces amitiés et contacts m’ont servi d’appui tout au long de ma carrière. Aujourd’hui, ces amitiés servent de thème à ma présentation. For my part, as we continue to grow as an organization, I would like to reference the importance of the friendship we have come to enjoy as Canadian orthopaedic surgeons. We have taken full advantage of this collegial relationship to create a very significant orthopaedic presence in the health-care system in this country. Relatively speaking, we are a small number and we are spread across an enormous geographical area. Yet, unlike many other specialties, the bonds of friendship we share has empowered us and strengthened our impact on Canadian health care. Thomas Aquinas stated, “… there is nothing on earth more prized than true friendship”. As Canadian orthopaedic surgeons, I believe we truly understand what this means. As a young surgeon, I was surprised by how much time and effort was necessary to deal with policy makers and administrators to speak on behalf of the rights of our patients for timely care. In Nova Scotia, when I began to practice, surgeons had to lobby for protected beds, adequate OR time, appropriate prosthetic budget, sufficient manpower, committed trauma time etc.

Regrettably, we must remain actively involved and continue to lobby on behalf of our patients and fellow Canadians. We are still dealing with many of these same issues. Currently, I live in a province where 80,000 people do not have a family doctor. In some parts of Nova Scotia, patients wait three years for joint replacement surgery. In those early years, there was an impression that the richer Immediate Past President, provinces in Canada Dr. Peter MacDonald presenting did not have the same Dr. Kevin Orrell with the medal of office concerns. Now, of course, there are fewer richer provinces. Later in my career, as I established friendships with other Canadian orthopaedic surgeons, I was astonished to discover that our problems in Nova Scotia were mirrored by colleagues across the entire country. There were very diverse initiatives for resolution of these problems. In many parts of Canada there were very important champions among the ranks of orthopaedic surgeons who worked very diligently on behalf of all of us. I am certain you will agree with me that two notable examples are Jim Waddell and the late Cy Frank, whose work with Bone and Joint Canada has improved our ability to care for our patients. In every region of the country, leaders among our ranks stepped forward to influence change. The Atlantic region had no shortage of such individuals. Orthopaedic surgeons understood what was necessary to practice our specialty and the bonds of friendship we enjoyed helped us to move forward as a united front. There was, and regrettably still are, very different levels of interest and cooperation by provincial governments in addressing the problems that are well known to us. I came to appreciate that the shared experiences of friends and colleagues contributed significantly to the efforts that I could make as an individual. This united appeal helped to strengthen our voice in Canada. We understood each other and the task was to assist COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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(continued from page 7)

our departments of health and decision makers to understand us. Over time, the success achieved in one province established a standard of care that other provincial authorities could not ignore. The shared knowledge and cooperation among orthopaedic colleagues assists all of us in improving our local situations.

Canada, we must work together to resolve this issue. Permanent employment for these young surgeons is critical.

Internally, we must become more aware of the transition from late career to retirement creating opportunities for newly-trained surgeons. The COA and others have provided some guidance in this regard but we As an alumnus of the orthocan and will do more. A central paedic training program at registry should be created idenDalhousie University, I have tifying job opportunities across fond memories of the leaderthe country. As these young ship of my chief, Dr. Reg Yabsley. surgeons work in alternate In his presidential address in positions awaiting permanent 1991, Dr. Yabsley makes refer- Dr. Kevin Orrell presents Dr. Peter MacDonald with the jobs, we must establish guideence to the establishment of Past President’s Pin lines concerning their work the residency training program conditions. Ultimately, we need in Halifax. He explained, “Medical students became orthoto assist and encourage these young surgeons to remain in paedic residents for the first time at Dalhousie, and residents Canada. became orthopaedic surgeons, and they have all become close friends.” This, of course, is not unique to Dalhousie. I believe it Secondly, I would like to articulate the recent efforts this is reflective of all our training programs and lays the foundation organization has made and continues to make for both our for the close relationships we enjoy as Canadian orthopaedic membership and the Canadian public. Under the leadership surgeons. of our Past President, Dr. Robin Richards, a position paper on Access to Care has been formalized. We have a consensus Dr. Yabsley went on to state, “Medicine has been good to me statement for patients with total joint replacements requiring and for me, and I want the President of the COA in 25 years to dental procedures put forward by our Standards Committee be able to stand before you and say the same…” in collaboration with the Canadian Dental Association and the Association of Medical Microbiology and Infectious Disease. Twenty-six years later I am proud to be able to say the same Under Dr. MacDonald’s term of office, the COA has addressed thing. I believe this is true because we are able to make a late career transitioning, intimate partner violence, unemsignificant difference to the lives of our patients with musculoployed graduates and we have made statements on freedom skeletal disease in Canada. Importantly, the fraternal manner in to travel. The COA has also finalized a report on podiatry which we work together to improve how we deliver this care, in Ontario in partnership with the Ontario Orthopaedic contributes significantly to our job satisfaction. So, in the same Association. Currently we are addressing issues of opioid enthusiastic manner as Dr. Yabsley, it is my hope that the COA usage through our Standards Committee under the leaderPresident 25 years from today will enjoy the same contentship of Dr. Jeff Gollish. The COA is also participating in the ment. Choosing Wisely movement which seeks to identify tests and treatments commonly used that are not supported by eviAs a community-based orthopaedic surgeon with university dence and may expose patients to harm. affiliation, I feel well placed to articulate some of the ways in which the COA promotes friendship among all Canadian orthoLastly, I would like to encourage all of our members, espepaedic surgeons. In this address, I wish to do the following: cially our young surgeons, to become involved in the work of the COA. This organization provides a venue for you to Firstly, I would like to provide the younger members and those meet and work with colleagues from across this country and in doubt more about the role that the COA plays in their profesmake the friendships to which I have referred. These friendsional lives. ships will empower us as a profession to continue to make a difference on behalf of the Canadian public. Citizens of this Sadly, we are all aware of the irony in this country, which country are aware that the system does not adequately prois among the worst in the developed world for wait times vide for their needs. No one understands better what has to be for surgery; yet, there are still 160 unemployed well-trained done to improve orthopaedic care than orthopaedic surgeons. orthopaedic surgeons looking for permanent jobs. The lack of Therefore, it is our responsibility now, as it has been in the past, vision of our policy makers has never been more apparent. As to take every opportunity to identify and change the obstacles an organization, the COA must continue its efforts to correct that hinder our profession. To do so as a united group of friends this. Externally, we must lobby our governments for appropriand colleagues has much more impact than anyone of us could ate access to care for the citizens of Canada. This can only be make individually. Wayne Gretsky stated “you miss 100% of the done by increasing patient access to orthopaedic surgeons. shots you don’t take.” He spoke these words in reference to a As friends who understand this current employment crisis in team sport recognizing that everyone on the ice contributes. COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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If we are the players on the orthopaedic team in our healthcare system, then the COA can serve as the club franchise. We must take every opportunity available to us to improve our organization. This pattern of involvement may commit you for a long time but you come to enjoy its rewards. Interestingly, in 1991 I was the President of the Canadian Orthopaedic Residents’ Association (CORA) to be succeeded by Dr. Peter MacDonald the following year. Now, in reverse order, we will serve as President of the COA. In between, we have become good friends. Near and dear to me is the Canadian Orthopaedic Foundation (COF), an organization with which you can also become involved. Following my tenure as Chair, the COF’s leadership passed to the capable hands of Dr. Jim Waddell and now Dr. Geoffrey Johnston, both Past Presidents of this organization. It has a proven record of support for orthopaedic surgeons and our patients. Une partie importante du travail que nous accomplissons comme chirurgiens orthopédistes, c’est d’agir comme porteparole pour ceux et celles qui ne sont pas en état de se prononcer eux-mêmes. Nous devons tenir responsables aussi bien les administrateurs que les politiciens de nous permettre d’offrir un niveau normalisé de soins appropriés. C’est en œuvrant ensemble comme amis et collègues que nous pouvons le mieux accomplir cette tâche. En s’appuyant l’un l’autre, cela rend l’effort de chaque chirurgien moins exigeant. De plus, cela rend davantage possible un accès équivalent aux services dans chaque province du Canada. L’Association Canadienne d’Orthopédie joue un rôle clé dans la promotion de ces relations collégiales dans notre communauté orthopédique au Canada. Before closing, I would like to gratefully recognize Doug Thomson, our CEO, and our staff, Cynthia, Trinity and Meghan. They are a small but mighty group who work very hard on our behalf. I will always be indebted to Drs. Ed Abraham and John Ready, with whom I trained during my residency. We became and have remained the best of friends throughout our careers. I am also indebted to my orthopaedic colleagues and friends in Sydney: Don Brien, James Collicut, Horacio Yeppes, Faith Dodd and Michele O’Neill. We are a small group and I am grateful

Sherry and Peter MacDonald with Anne and Kevin Orrell.

for their support during this year as President. It has been the relationships with such people that have served as inspiration for my address today. Finally, I would like to acknowledge the tremendous love and support of my wife and best friend; Anne, and our family; four of whom are here today. For someone who has enjoyed as busy a career and as wonderful a family as I, I must acknowledge the tremendous effort Anne has made in keeping everything in focus. I am very grateful for your encouragement and tolerance of all of my adventures. Our five children have been our greatest joy and are now mature adults who encourage and celebrate our success. As they proceed along their career paths, three in medical professions, I am hopeful they will be surrounded by the supportive friendships we have enjoyed through the years. William Penn said, “A true friend advises justly, assists easily, adventures boldly, takes all patiently and defends outrageously.” I have been fortunate to have been surrounded by such people within the orthopaedic community in Canada, and I am very grateful. Thank you. Merci.

Article submissions to the COA Bulletin are always welcome!

Les contributions au Bulletin de l’ACO sont toujours les bienvenues!

Contact: Cynthia Vezina Tel: (514) 874-9003 ext. 3 E-mail: cynthia@canorth.org

Contacter : Cynthia Vezina Tél. : 514-874-9003, poste 3 Courriel : cynthia@canorth.org COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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Here’s What YOU Said About the 2017 Annual Meeting

he 2017 COA, CORS and CORA Annual Meeting was held in Ottawa this past June during Canada’s 150th birthday celebrations. Over 480 surgeons, 225 residents and fellows and 130 allied health professionals attended the meeting in our nation’s capital where the Program Committee, chaired by Dr. Peter Lapner, offered a high quality and diverse educational program.

Here is some of the feedback we received directly from members and participants and how we’ll be using your suggestions to make further improvements to next year’s Annual Meeting.

of respondents were satisfied with the 2017 Annual Meeting from an educational perspective

were VERY SATISFIED with the ICLs

were VERY SATISFIED with the symposia

were VERY SATISFIED with the paper and poster sessions

were satisfied or very satisfied with the Guest Lecturers

were satisfied or very satisfied with the Fireside Chat sessions

Milt Stegall, former CFL and NFL player, speaking at the Opening Ceremonies

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Dr. James Wright (formerly of Sick Kids, University of Toronto – now at University of Oxford, UK) delivers the Presidential Guest Lecture

Dr. J Pollock, Local Arrangements Committee Chair opens the meeting in Ottawa

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Although most of the respondents enjoy the meeting program as it is, the recommendations that we also received were heard loud and clear! Here is how we’ll be applying your requests to next year’s Annual Meeting:

Add more symposia

(requested by 28% of participants)

You got it! The 2018 Annual Meeting will include more symposia sessions. Important discussions on pain management and opioids, transition to retirement, resident-specific issues, along with additional subspecialty symposia are just some of the sessions that will be available in the program.

More HAND & WRIST content

Look for more hand and wrist sessions in next year’s program.

Expand the SUBSPECIALTY sessions

A full specialty day will be offered on Saturday, June 23 with sessions offered from all of the orthopaedic subspecialties.

More SPINE content More PAPER SESSIONS Spine will be highlighted throughout the Annual Meeting program as the featured subspecialty at next year’s event. Look for featured paper and poster sessions (we received 400% more spine abstract submissions for next year’s event) along with sessions that bridge spine with other subspecialties.

The leadership of the COA have reviewed all your comments and feedback provided through the evaluation forms. We will also be exploring ways to make improvements to: • The AV services offered during our events; • The location of the poster presentations; • The timing and scheduling of sessions and breaks; • The on site registration hours on the opening day to better accommodate those arriving later in the evening.

We will be adding paper sessions to the program, allowing us to consider more abstracts for presentation.

Plans are already well underway for next year’s Annual Meeting being held in Victoria from June 20-23. The Program Committee is putting together an exciting and dynamic educational program that we look forward to sharing with you in the New Year. Make regular visits to the 2018 Annual Meeting web page that can be found at: http://coa-aco.org/annual-meeting-2018/ for updated information about next year’s event. Make your plans to join us in Victoria now!

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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Voici ce que VOUS aviez à dire sur la Réunion annuelle 2017

a Réunion annuelle 2017 de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO) avait lieu à Ottawa en juin dernier, en pleines célébrations du sesquicentenaire du Canada. Plus de 480 orthopédistes, 225 résidents et boursiers et 130 professionnels des soins de santé connexes ont assisté à cette réunion dans notre capitale nationale; le Comité responsable du programme, présidé par le Dr Peter Lapner, leur avait concocté un programme scientifique très diversifié et de grande qualité.

Voici une partie de la rétroaction que nous avons reçue des membres et des participants, de même que la façon dont nous appliquerons vos suggestions de sorte à améliorer la prochaine Réunion annuelle.

Du point de vue de la formation, des répondants étaient satisfaits de la Réunion annuelle 2017.

étaient TRÈS SATISFAITS des conférences d’enseignement.

étaient TRÈS SATISFAITS des symposiums.

étaient TRÈS SATISFAITS des séances de présentation de précis.

étaient satisfaits ou très satisfaits des conférenciers invités.

étaient satisfaits ou très satisfaits des « Discussions au coin du feu ».

Le Dr Hani Awad, conférencier Macnab

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Le Dr Peter Lapner, président du Comité responsable du programme 2017

Le Dr Richard Hawkins, conférencier R.I. Harris

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Même si la plupart des répondants ont aimé le programme offert, nous avons aussi très bien entendu leurs recommandations! Voici donc la façon dont nous appliquerons vos suggestions pour la prochaine réunion annuelle :

Ajout de SYMPOSIUMS (28 % des répondants)

C’est fait! La Réunion annuelle 2018 comprendra plus de symposiums, dont des discussions importantes sur la gestion de la douleur et les opioïdes, la transition vers la retraite et des questions touchant les résidents, en plus des symposiums des sous-spécialités.

Ajout de contenu sur la MAIN et le POIGNET

Attendez-vous à plus de séances sur la main et le poignet à la prochaine réunion.

Augmentation du temps consacré aux SOUS-SPÉCIALITÉS Une journée complète des sous-spécialités sera offerte le samedi 23 juin; toutes les sous-spécialités de l’orthopédie seront représentées.

Ajout de contenu sur le RACHIS

Le rachis sera la sous-spécialité en vedette à la prochaine réunion. Il y aura des séances de présentation de précis sur le rachis (nous avons reçu 400 % plus de précis sur le rachis pour la prochaine réunion) ainsi que des séances qui feront le pont entre le rachis et d’autres sous-spécialités.

La direction de l’ACO a pris connaissance de toute la rétroaction formulée dans les formulaires d’évaluation. Nous chercherons en outre à améliorer : • les services audiovisuels pendant les activités; • l’emplacement des affiches; • le moment choisi pour les séances et les pauses, et l’horaire en général; • les heures d’inscription sur place pendant la soirée d’ouverture, de sorte à mieux accommoder les participants qui arrivent tard.

Ajout de SÉANCES DE PRÉSENTATION DE PRÉCIS

Nous ajouterons des séances de présentation de précis au programme, ce qui nous permettra d’accepter plus de précis.

La planification de la prochaine réunion annuelle, qui aura lieu à Victoria du 20 au 23 juin, va déjà bon train. Le Comité responsable du programme prépare un programme de formation emballant et dynamique que nous vous communiquerons avec empressement en début d’année. Consultez régulièrement la page Web de la Réunion annuelle 2018, à http://coa-aco.org/fr/reunion-annuelle-2018, pour des renseignements à jour. Planifiez dès maintenant votre participation à la Réunion annuelle de Victoria! COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

INTRODUCING

TRIATHLON TRITANIUM ®

Orthopaedics

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

FONT: Helvetica with bell curve

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

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Resident Research and Career Advice at CORA 2017 Annual Meeting

anadian residents met in Ottawa on June 15 for the CORA 2017 Annual Meeting. Co-chairs Drs. Lisa Lovse and Bogdan Matache from the University of Ottawa were pleased to host colleagues from coast to coast for a morning of resident research presentations and posters, followed by an afternoon symposium on what it takes to have a successful and satisfying career. A sincere thank you to abstract reviewers, as well as paper session moderators Drs. Alberto Carli and Kevin Smit, and symposium speakers Drs. Geoff Wilkin, Kevin Smit, Darren Drosdowech and Don Johnson, for their outstanding contribution to resident education. The day was capped off with a well-attended social event at Blue Cactus Bar and Grill. Congratulations are extended to the recipients of the top paper awards presented on site: • First Prize CORA Paper - J.A. Nutter Award, Sponsored by Sanofi Canada Adam Hart, McGill University • Second Prize CORA Paper - Alexandra Kirkley Award Troy Bornes, University of Alberta • Third Prize CORA Paper – COA Award Andrew Bodrogi, University of Ottawa • CORA First Prize Poster Award Naser AlNusif, McGill University The abstracts for these top papers follow this article.

Drs. Lisa Lovse and Bogdan Matache, CORA Co-chairs, introducing Dr. Geoff Johnston, Chair of the Canadian Orthopaedic Foundation

The CORA Board, consisting of resident representatives from each of the 17 orthopaedic programs, held its annual face-toface meeting on June 16, and had a lively discussion about surgeon employment, the COA Job Board, job sharing models and resident morale. CORA Board members would like to encourage all COA members to take advantage of the free job posting service offered by the COA when new positions arise. Resident liaisons to the COA committees reported on their respective committees’ ongoing projects, and new liaison members were elected from the Board. The full COA committee slate can be seen by clicking here, and we would like to extend a warm welcome to all newly appointed CORA committee liaisons. Mark your calendar! The 2018 CORA meeting will be held on June 20 in Victoria, BC, hosted by co-chairs Drs. Amar Cheema and David Stockton. This year’s meeting will begin later in the morning to accommodate same-day travel from certain cities. The CORA call for abstracts is open until January 31, 2018. For more info, visit http://coa-aco.org/residents-cora/coraannual-meeting/. For any questions about CORA, please contact Trinity Wittman at coraweb@canorth.org

Dr. Geoffrey Wilkin addresses residents during the CORA Symposium

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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First Prize CORA Paper - J.A. Nutter Award, Sponsored by Sanofi Canada Anatomic Anterior Cruciate Ligament Reconstruction: A Prospective Evaluation Using Three-Dimensional Magnetic Resonance Imaging Adam Hart, McGill University Thiru Sivakumaran, Mark Burman, Tom Powell, Paul Martineau Purpose: The recent emphasis on anatomic reconstruction of the anterior cruciate ligament (ACL) is well supported by clinical and biomechanical research. Unfortunately, the location of the native femoral footprint is usually difficult or impossible to see at the time of surgery. Most surgeons therefore rely on anatomic landmarks, custom drill guides, or general rules-ofthumb to guide femoral tunnel placement; however, the accuracy of these techniques to reconstruct each patient’s native anatomy is poorly understood. The objective of this study was to use a novel isotropic magnetic resonance sequence (3D MRI) to image patients with torn ACLs before and after reconstruction and thereby assess the accuracy of graft position on the femoral condyle in comparison to each patient’s native ACL footprint. Method: Fourty patients with unilateral ACL tears were prospectively recruited into our study. Each patient received a 3D MRI of both the injured and uninjured knees before surgery. The contralateral (uninjured) knee scan was used to define the patient’s native footprint. Patients then underwent ACL reconstruction with hamstring autograft by four experienced sports orthopaedic surgeons (10 patients per surgeon). The injured knee was reimaged again after surgery. The location and percent overlap of the reconstructed femoral footprint was compared to the patient’s native footprint. Results: The centre of the native ACL femoral footprint was a mean of 1.65 +/- 0.25 cm distal and 0.56 +/- 0.12 cm anterior to the apex of the deep cartilage (anatomic reference point).

Second Prize CORA Paper Alexandra Kirkley Award Articular Cartilage Repair with Mesenchymal Stromal Stem Cells Following Chondrogenic Priming in Normoxic and Hypoxic Conditions: A Preclinical Pilot Study Troy Bornes, University of Alberta Adetola B. Adesida, Nadr M. Jomha Purpose: Bone marrow-derived mesenchymal stromal stem cells (BMSCs) are a promising cell source for treating articular cartilage defects. Quality of cartilaginous repair tissue following BMSC transplantation has been shown to correlate with functional outcome in a clinical setting. Therefore, tissue COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

The position of the reconstructed graft was significantly different, with mean distance of 1.04 +/- 0.06 cm distal (P < 0.0001) and 0.78 +/- 0.07 cm anterior (P = 0.004). The mean distance between the centre of the graft and the centre of the native ACL femoral footprint (error distance) was 5.7 +/- 3.6 mm. Comparing error distances amongst the four surgeons demonstrated no significant difference using the Kruskal-Wallis oneway ANOVA (P = 0.78). On average, 21% of the graft was within the native ACL femoral footprint. Of the 40 patients, 16 (40%) had the graft placed entirely outside the native ACL footprint. Conclusion: Despite contemporary techniques and a concerted effort to perform anatomic ACL reconstructions by four experienced sports orthopaedic surgeons, the position of the femoral footprint was significantly different between the native and reconstructed ligaments. Furthermore, each of the four surgeons uses a different technique but all had comparable errors in their tunnel placements. In order to achieve a truly anatomic reconstruction, surgeons may consider using a preoperative 3D MRI, which enables excellent visualization of the ACL’s native anatomy and could potentially be used as a roadmap to guide anatomic tunnel placement.

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(continued from page 16)

engineering and transplantation variables are currently under investigation with the goal of improving repair tissue quality and outcome. The first objective of this pilot study was to assess a novel protocol for BMSC transplantation that involved BMSCs that were isolated, expanded, seeded within a hyaluronic acid scaffold, and chondrogenically primed using a short (four-day) culture period in chondrogenic medium prior to implantation in an ovine model. The rationale of this protocol was to expose BMSCs to chondrogenic factors with the goal of predisposing them to the chondrogenic lineage while avoiding a time- and resource-intensive differentiation period. The second objective of this study was to assess the impact of oxygen tension during pre-implantation culture of BMSCs on neo-cartilage formation in vivo within full-thickness cartilage defects. It was hypothesized that chondrogenically primed BMSC-seeded scaffolds would produce superior cartilaginous repair tissue relative to control defects, and pre-implantation culture under hypoxia would yield improved repair tissue in comparison to normoxia. Method: Ovine BMSCs were isolated, expanded to passage two, seeded within an esterified hyaluronic acid (HYAFF) scaffold at 10 million BMSCs per cubic centimetre, and primed ex vivo for four days in chondrogenic medium containing transforming growth factor-beta three and dexamethasone for four days under normoxia (21% oxygen) or hypoxia (3% oxygen). Fullthickness, seven-millimetre-diameter articular cartilage defects were created in the medial and lateral femoral condyles of five sheep. Twenty defects were treated with normoxia-cultured BMSC-seeded scaffolds (eight), hypoxia-cultured BMSC-seeded scaffolds (eight), cell-free scaffolds (two), or no implants (two).

Pre-implantation priming was evaluated through gene expression analysis using reverse-transcription quantitative polymerase chain reaction. After six months, histological assessment was performed on repair tissues with a modified O’Driscoll scoring system and tissue dimension analysis. Results: Priming of pre-implantation BMSC-seeded scaffolds in chondrogenic medium for four days resulted in significantly increased gene expression of hyaline cartilage-related collagen II, aggrecan and sex determining region Y-box nine (SOX9) relative to unprimed BMSCs (p<0.05). Chondrogenically primed BMSC-seeded scaffolds were shown to be capable of producing hyaline-like cartilaginous repair tissues that were rich in safranin O-positive proteoglycans. Defects implanted with primed BMSC-seeded scaffolds had significantly larger repair tissue areas, higher percentages of defect fill and improved modified O’Driscoll histological scores than cell-free controls (p<0.05). With respect to oxygen tension, a consistent difference in histological scores was not found between normoxiaand hypoxia-seeded BMSC-seeded scaffolds (p=0.90). Conclusion: Chondrogenic priming of BMSCs for four days enhanced expression of genes associated with hyaline cartilage. BMSCs that were isolated, expanded and chondrogenically primed prior to implantation were capable of producing hyaline-like cartilaginous tissue that was superior to cellfree controls within full-thickness articular cartilage defects. Incubator oxygen tension during pre-implantation culture did not consistently modulate repair tissue formation in this model.

Third Prize CORA Paper COA Award The Effect of Glenohumeral Offset on Postoperative Function in Total Shoulder Arthroplasty: A Retrospective Review using a Novel Method of Measuring Glenohumeral Offset using Standardized Re-Slicing of Computed Tomography Andrew Bodrogi, University of Ottawa Lisa Howard, Hakim Louati, George Athwal, Peter Lapner Purpose: Total shoulder arthroplasty (TSA) is currently used widely to treat glenohumeral arthritis. It provides consistent pain relief but the restoration of premorbid function is variable. Glenohumeral offset (GHO) has been identified as a factor that affects shoulder mechanics and strength. Various radiographic methods have been used to measure GHO, yet reliability and accuracy remain modest. Methods employing Computed Tomography (CT) have shown better reliability, yet without standardization of the measurement planesto control for the three-dimensional positioning of the scapula or humerus, comparisons of GHO from preoperative to postoperative imaging cannot be made accurately. Perhaps secondary to the inconsistencies in measurement, no study has shown a significant correlation between functional outcomes after TSA and GHO. As such, the objectives of this study were twofold. First, we sought to develop a reliable and standardized

CT reformatting and measurement technique that controlled for the variability of the glenohumeral relationship in space to retroactively compare preoperative and postoperative GHO. Second, using this method, it was determined whether an association exists between preoperative and/or postoperative GHO and functional outcomes. Method: Thirty-seven patients recruited at two centres underwent TSA. Using advanced imaging software, two independent observers reformatted both preoperative and postoperative CT scans using a novel protocol to standardize oblique measurement planes for the glenoid and humerus individually. This COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Your COA / Votre association

(continued from page 17)

protocol used reproducible landmarks only on either the scapula or the humerus respectively so as to avoid any variability secondary to the glenohumeral relationship in space. Glenoid offset and humeral offset were then measured independently using two different methods adapted from previously described planar radiographic techniques. The interobserver and intra-observer reliability were used to identify the optimal bone specific measurement techniques, which were subsequently used for functional analysis. The degree of association between glenohumeral offset and preoperative and postoperative functional outcomes was determined using a multivariable regression analysis. Results: The intra-class correlation coefficients for the preferred humeral and glenoid measurement methods were 0.83 and 0.75, respectively. After controlling for age and sex, postoperative glenoid and combined glenohumeral offset signifi-

cantly correlated with postoperative Constant Shoulder scores (p=0.019 and p=0.023 respectively). There was no significant correlation between preoperative functional scores and preoperative offset measurements. Additionally, no significant correlation was found between the change in GHO from preoperative to postoperative and functional outcomes. Conclusion: A highly reliable technique was developed and used to measure GHO using regular diagnostic CT scans in patients after TSA. Increased postoperative glenoid and combined glenohumeral offset are related to improved functional outcomes. However, there appears to be no relation of functional outcomes to change in GHO from preoperative to postoperative. This highlights the importance of surgically restoring the absolute value of pre-arthritic GHO as opposed to relative increases based on preoperative GHO.

CORA First Prize Poster Award ACL Reconstruction with Supplemental Tibial Fixation: a Biomechanical Study Comparing a Novel All-Soft Tissue Technique for Secondary Fixation with other Techniques Naser AlNusif, McGill University Jason Khoury, Fahad Abduljabbar, Naif Alhamam, Ron Dimentberg, Moreno Morelli Purpose: Fixation failure after an anterior cruciate ligament (ACL) reconstruction occurs more frequently at the tibial site. There are many different techniques and modalities used to supplement the tibial fixation in ACL reconstruction procedures. Those include: metal staples or bio-tenodesis screws. In certain cases, where bony supplemental fixation was used, poor bony purchase was observed. This is mainly seen in patients with poor bone quality, usually encountered in revision surgeries and patients with metabolic diseases. The objective of our study is to compare the biomechanical efficacy of bony versus soft tissue supplemental fixation. We hypothesize that ACL graft-tibial tunnel fixation with bio-interference screw supplemented with a novel technique using medial collateral ligament (MCL) fixation will provide superior strength in mechanical testing when compared to bio-interference screw plus a bio-tenodesis screw. Method: Twelve matched human knees (total of 24 specimens) were used and divided into two groups matched by gender, age, bone mineral density (BMD) and graft diameter. The first group will compare bio-interference screw (BIS) alone versus BIS + bony supplemental fixation “a bio-tenodesis screw”, while the second group will compare BISalone versus BIS + MCL supplemental fixation. In all specimens, the tibial tunnel was prepared using a standard and reproducible way by setting the tibial guide at 55 degrees. The graft was passed through the tibial tunnel and hooked on a custom made hook

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

attached to a servohydraulic device. A bio-interference screw was inserted into the tibial tunnel of all specimens. For the bony supplemental fixation group, a bio-tenodesis screw was used. On the other hand, for the MCL supplemental fixation group, the graft was sutured to the superficial MCL using fiber sutures. Finally, all grafts were pre-tensioned then subjected to cyclical displacement followed by load to failure testing. Results: We expect that using supplemental fixation is superior than using a bio-interference screw alone. Furthermore, when comparing both methods of supplemental fixation, we predict that MCL supplemental fixation would be superior in poor bone quality specimens. Conclusion: Based on the expected results, our novel technique of MCL supplemental fixation would be a strong fixation option in all patients, but more importantly in patients with low BMD. Moreover, this technique is more cost effective than most other options of supplemental fixation.

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Awards of Distinction

The 2017 Recipients of the COA Award of Merit and the Presidential Award for Excellence Peter B. MacDonald, M.D., FRCSC Immediate Past President Canadian Orthopaedic Association

on the Olympic anti-doping front. He is also Past President and an honourary life member of the Sport Medicine Council of British Columbia.

Bob is also a long-time physician for the CFL’s BC Lions and countless other local and national sporting organizations. He has over 150 publications and almost 500 national and international presentations.

lease join me 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 Ottawa. It was a privilege to honour Dr. William R.J. Rennie (Bill) with the 2017 Award of Merit. Bill is a mentor and former section head orthopaedics for 16 years at the University of Manitoba. Prior to that, he spent many years as head of orthopaedics at the Royal Victoria Hospital in Montreal. Bill was a coauthor of Adult Orthopaedic Surgery with Dr. Richard Cruess, which was a go-to mainstay when I was a resident. Bill is a dedicated longtime member of the COA having served on many of its committees leading up to his presidency in 2002. That year was particularly challenging due to the SARS epidemic that led to the COA having to cancel its Annual Meeting in Toronto at the last minute, and rescheduling it for later Dr. Bill Rennie receives the Award of Merit that year in Winnipeg. from Dr. Peter MacDonald He was always known for his organization skills, his no-nonsense approach and his ability to simplify a complex issue. There was never any doubt as to where Bill stood on an issue. Today, we pay tribute to Bill’s commitment and endless dedication to the organization and we must not forget the important role his lovely wife Norma has played in supporting Bill’s career with her grace and style. I also had the pleasure to recognize my colleague and good friend Dr. Robert G. McCormack (Bob) with the Presidential Award for Excellence. Bob has been a stalwart on the Canadian orthopaedic scene for decades. He has led countless meetings and chaired orthopaedic sports and trauma sessions more times than we can count. Bob is a Past President of the Canadian Academy of Sport and Exercise Medicine and has been a dedicated leader in Canadian sports medicine including being Chief Medical Officer for the Canadian Olympic Committee from 2005 to present. In this capacity, he has led the medical staff at many Olympic Games and has been active

A true leader in Canadian orthopaedics, we are fortunate to have Bob as an ardent Dr. Bob McCormack is honoured with the supporter of orthopae- Presidential Award for Excellence dic excellence on so many levels. It had the opportunity to also present the Presidential Award for Excellence to Dr. Kishore Mulpuri (Kish) from the University of British Columbia. Kishore received his medical and orthopaedic residency education in Manipal, India graduating in 1997. He later obtained a Masters in Epidemiology at UBC in 2004. He completed fellowships in paediatric orthopaedics in Australia and at UBC where is currently Associate Professor. Kish is currently serving as Secretary of the COA, was an ABC fellow in 2015 and was instrumental in rebuilding the paediatric program and sessions offered at the COA Annual Meeting. He is well-known for excellence in research and teaching having contributed to the education of 131 residents Dr. Kishore Mulpuri is recognized with the and 65 clinical fellows Presidential Award for Excellence as well as two post-doctoral fellows. He has been also an active volunteer in teaching and training at the Balaji Institute of Surgery in Tirupati, India. In recognition of his outstanding career so far, it was a pleasure to present Kish with this award.

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Where Are You Sleeping? Victoria Annual Meeting Accommodations Will Book Up Quickly!

Où déposerez-vous vos valises?

Les chambres partent vite à Victoria!

he COA has a conference room block at both the Fairmont Empress Hotel (where the Annual Meeting will be held) as well as the Hotel Grand Pacific (less than 5-minute walk from the Empress Hotel). Don’t wait for registration to open – go ahead and book your accommodations now!

’ACO a déjà réservé un bloc de chambres à l’hôtel Fairmont Empress (où la Réunion aura lieu) de même qu’à l’hôtel Grand Pacific (situé à moins de 5 minutes à pied du Fairmont Empress). N’attendez pas que la période d’inscription soit commencée : réservez votre chambre dès aujourd’hui!

To reserve a room, please visit http://coa-aco.org/annual-meeting-2018/ and click on the Accommodations tab. A preliminary meeting schedule can be found in the Program section. Need help? Contact meetings@canorth.org

Cliquez sur http://coa-aco.org/fr/reunion-annuelle-2018/, puis sur le bouton « Hébergement » pour réserver une chambre. Vous pouvez également consulter le programme provisoire de la Réunion annuelle en cliquant sur l’onglet « Programmes ». Besoin d’aide? Écrivez à meetings@canorth.org.

Peter B. MacDonald Reflects on His Presidential Year

r. Peter B. MacDonald completed his term as the 71st President of the COA during the 2017 Annual Meeting recently held in Ottawa. We asked him about some of the highlights of his presidential year, where he thinks the COA should be heading and which issues we should be tackling as a national professional society. COA BULLETIN: What are some of the highlights of your presidential year? DR. P. MACDONALD: The COA presidency was a highlight of my career and a very memorable year for Sherry as well. There were many notable aspects to the year, but being able to serve and try to positively influence the orthopaedic climate in Canada was top of the list.

Dr. Peter MacDonald with the presidents from the Carousel associations COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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For Sherry and I, being able to meet and befriend so many of the orthopaedic leaders from various associations around the world was also a great experience. So many of them were not only talented orthopaedic surgeons, but also visionaries with a unique ability to see the “big picture”. Finally, learning first-hand about other medical systems allowed me to bring different perspectives and insight to the table when discussing improvements to our own health-care system with our Executive and other decision makers. So many of the problems that face our profession are not unique understanding how they are addressed in other countries was very enlightening and productive. COA BULLETIN: Where do you think the Association should be focused? What issues should we be addressing as united group? DR. P. MACDONALD: 1) Access to care. This is our primary challenge and one that we share with our patients. So much talent is available amongst the orthopaedic surgeons serving this country, yet we are unable to adequately utilize that talent because of limited resources and long wait lists. 2) The job crisis. Lack of resources also prevents us from hiring some of our brightest graduates who are unfairly treated after over a decade of training. We need to continue to monitor and assess the number of training positions across the country, and encourage better manpower planning through late career transition and guidelines for locums. 3) The efficient use of health-care resources. We are all aware that the rising cost of health care is unsustainable. Along these lines, models of care that deliver health-care efficiently and effectively are essential as we try to reform our system. The biggest challenge is buy-in from government as we know that these types of successful models are already running in many Canadian centres. 4) Social issues. The opioid crisis and intimate partner violence are areas where the COA membership needs to participate in the Association’s advocacy efforts in addressing these issues.

COA BULLETIN: If you could ask one thing of your membership, what would that be? DR. P. MACDONALD: The membership needs to be committed and must be involved. We are part of the only unified voice for orthopaedic surgery in Canada and should remain true to the importance of our national purpose and lobbying potential. We are much stronger collectively than as individuals and must be committed to our united strength. Join a committee, publish in our communications, attend a COA event – there are so many ways that you could get involved. COA BULLETIN: The COA Annual Meeting is a significant event for the President. Share with us some of your favourite moments from the Annual Meeting held this past June in Ottawa? DR. P. MACDONALD: The organization of this meeting by our COA staff along with the Local Arrangements Committee and Program Chair was superb. The keynote speakers including Milt Stegall, Dr. Richard Hawkins, Dr. Jim Wright and others were pillars of the meeting and did not disappoint. The overall academic and social aspects were very strong and I was grateful to see so many of our members in attendance. COA BULLETIN: Any words of advice for your successor, Dr. Kevin Orrell? DR. P. MACDONALD: Kevin is very talented and has a long history of service and leadership. He is a wonderful person and a great thinker. He has a great appreciation for the challenges facing the COA. In that regard, he doesn’t need much advice. However, I would respectfully suggest that he listen carefully, as I know he will, to all members of the organization. Although the year will be a very busy one, I hope that he and Anne make sure to take some time to enjoy the opportunity and the tremendous experience that is the COA presidency. In the end, it will be a very rewarding one.

Réflexions de Peter B. MacDonald sur son année à la présidence

e Dr Peter B. MacDonald a terminé son mandat à titre de 71e président de l’ACO à la Réunion annuelle 2017, qui a eu lieu récemment à Ottawa. Nous lui avons demandé de nous parler des moments marquants de son année à la présidence, de l’orientation que devrait prendre l’ACO, ainsi que des enjeux auxquels elle devrait s’attaquer en tant que société professionnelle nationale. BULLETIN DE L’ACO : Quels ont été les moments marquants de votre année à la présidence? Dr P. MacDONALD : La présidence de l’ACO a été un point fort de ma carrière, et Sherry a aussi passé une année fort mémorable. Il y a eu beaucoup d’aspects importants, mais servir la communauté orthopédique et essayer d’avoir une influence

Le Dr Peter MacDonald, et sa femme, Sherry, au Souper des anciens présidents de l’ACO, à Ottawa COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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positive sur le climat d’exercice au Canada figurent au sommet de la liste.

BULLETIN DE L’ACO : Si vous pouviez demander une chose aux membres, qu’elle serait-elle?

Pour Sherry et moi, avoir l’occasion de rencontrer autant d’orthopédistes de premier plan représentant des associations de partout dans le monde et de nouer des liens avec eux a également été une belle expérience. Bon nombre d’entre eux sont non seulement des orthopédistes talentueux, mais aussi des visionnaires qui ont une aptitude unique, celle de pouvoir prendre le recul nécessaire pour avoir une perspective globale.

Dr P. MacDONALD : Les membres doivent s’engager et participer. Nous faisons partie de la seule association qui parle d’une voix unie pour le milieu orthopédique au Canada. Notre engagement devrait être à la hauteur de notre vocation nationale et de notre capacité de lobbyisme. Nous sommes bien plus forts ensemble que chacun de notre côté, et nous devons œuvrer au maintien de cette force. Devenez membre d’un comité, publiez dans les communications de l’ACO ou participez à une de ses activités. Il existe tant de façons de jouer un rôle actif.

Enfin, constater directement ce qui se passe dans d’autres systèmes médicaux m’a permis d’apporter une perspective différente aux discussions sur l’amélioration de notre propre système de santé avec notre direction et d’autres décideurs. Bien des problèmes auxquels notre profession est confrontée ne lui sont pas uniques; comprendre la façon dont on les aborde dans d’autres pays a été très enrichissant et productif. BULLETIN DE L’ACO : Sur quoi l’Association devrait-elle se concentrer? Sur quels enjeux devrions-nous faire front commun? Dr P. MacDONALD : 1) L’accès aux soins. Il s’agit de notre plus grand défi, et nous l’avons en commun avec nos patients. Il y a tant de talent chez les orthopédistes au pays, mais nous sommes incapables de l’utiliser adéquatement en raison des ressources limitées et des longues listes d’attente. 2) La crise de l’emploi. Le manque de ressources nous empêche aussi d’embaucher certains de nos jeunes orthopédistes les plus brillants, qui sont traités injustement après plus d’une décennie de formation. Nous devons continuer de suivre de près et de réévaluer le nombre de places en formation offertes partout au pays, en plus de favoriser une meilleure planification de la main-d’œuvre grâce à une bonne transition en fin de carrière et à des lignes directrices sur les suppléances. 3) L’utilisation efficace des ressources en santé. Nous sommes tous conscients que les coûts croissants des soins de santé ne sont pas viables. Par conséquent, des modèles de soins efficaces sont essentiels à nos efforts pour réformer le système. Le principal défi est leur adoption par le gouvernement, puisque nous savons que des modèles efficaces sont déjà appliqués dans bien des centres canadiens. 4) Enjeux sociaux. Les membres de l’ACO doivent participer à ses efforts de sensibilisation à la crise des opioïdes et à la violence conjugale, entre autres.

Site Web de la Réunion annuelle 2018, à Victoria Cliquez sur le bouton « Réunion annuelle », sur la page d’accueil du site Web de l’ACO, à www.coa-aco.org, pour obtenir tous les renseignements sur la prochaine réunion annuelle, qui aura lieu du 20 au 23 juin 2018, dans la magnifique ville de Victoria, en ColombieBritannique. Les renseignements sont régulièrement mis à jour, alors revenez-y souvent! COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

BULLETIN DE L’ACO : La Réunion annuelle de l’ACO est une manifestation importante pour le président. Raconteznous quelques-uns de vos moments préférés de la Réunion annuelle de juin dernier, à Ottawa? Dr P. MacDONALD : L’organisation de cette réunion par le personnel de l’ACO, le Comité organisateur et le président du Comité responsable du programme a été merveilleuse. Les conférenciers invités, dont Milt Stegall et les Drs Richard Hawkins et Jim Wright, entre autres, étaient les piliers de la Réunion, et ils ne nous ont pas déçus. En général, les volets scientifiques et sociaux étaient très forts, et je suis reconnaissant qu’un si grand nombre de nos membres y aient participé. BULLETIN DE L’ACO : Avez-vous des conseils pour votre successeur, le Dr Kevin Orrell? Dr P. MacDONALD : Kevin est très talentueux et compte une vaste expérience à titre d’orthopédiste et de leader. C’est une personne fabuleuse et un grand penseur. Il connaît bien les défis auxquels l’ACO est confrontée; je ne crois donc pas qu’il ait besoin de bien des conseils. Par contre, je dirais, en tout respect, qu’il doit écouter attentivement les membres de notre organisation, et je sais qu’il le fera. Même si l’année s’annonce chargée, j’espère qu’Anne et lui prendront le temps de profiter de cette occasion et de l’extraordinaire expérience de la présidence de l’ACO, qu’ils trouveront assurément enrichissante.

Your COA / Votre association

The 2017 ABC Travelling Fellowship Tour Invokes the Spirit of “Ubuntu” The 2017 ABC Fellows: Wade Gofton M.D., FRCSC David Sheps, M.D., FRCSC Eric Strauss, M.D. Nicholas Bernthal, M.D. Joseph Hsu, M.D. Brett Freedman, M.D. Jonathan Braman M.D.

he 2017 American, British, and Canadian (ABC) Travelling Fellows visited the United Kingdom and South Africa, enjoying the spirit of “ubuntu”, which loosely translated is “the belief in a universal bond of sharing that connects all humanity”1. Nelson Mandela once described this complex concept of selflessness and community the following way: “A traveller through a country would stop at a village and he didn’t have to ask for food or for water. Once he stops, the people give him food, (and)entertain him1.” The manifestation of “ubuntu”, as we discovered, is the unending hospitality demonstrated by our hosts as we were welcomed into their towns, hospitals, and homes as family2. Our travels began in London with introductions and tour briefings at the Grange Hotel given by Ms. Hazel Choules and Ms. Deborah Eastwood (ABC fellows 1994). This day marked the first time many of the 2017 ABC fellows had met, and few of us appreciated the friendships that would develop over the next six weeks. While COA members may have met the Canadian fellows (Wade Gofton – University of Ottawa, David Sheps – University of Alberta) at past events, the fellows from the American Orthopaedic Association (AOA) would have been less well known to members of the COA. It is clear, however, that these individuals will be future leaders in the orthopaedic community, and you will undoubtedly hear about them in the future. Eric Strauss, from NYU, is a sports medicine surgeon with a research focus on meniscal transplant and biomarkers in ACL injury, and their potential use to time surgery or modify the inflammatory response following injury. Eric also has a strong interest in education, the NY Yankees, and plays a leading role as the assistant program director in the largest training program in the United States. Nicholas Bernthal, a tumour surgeon from UCLA, has a research focus centered on patient-specific chemotherapy and infection prevention strategies. He uses a mouse avatar program to tailor chemotherapy regimens to patients without needing to expose patients to potentially harmful and less effective chemoptherapy agents. Nick also uses a glowing, spinning animal model for infection control experiments, such as the use of ‘smart’ prosthetic coatings for prevention of prosthetic joint infections, and has investigated the role of Vitamin D in prevention of infection.

A lean start. The groups’ second day in London - enjoying London weather in a meeting with Prof. Fares Haddad (Editor-in-Chief BJJ) at the Gerkin. L to R: Nic Bernthal, Joe Hsu, Brett Freedman, Fares Haddad, Eric Strauss, Wade Gofton, Jonathon Braman, David Sheps)

Joseph Hsu, a former military surgeon, is now located in Charlotte, North Carolina. His clinical and academic focus has been on lower limb reconstruction and limb salvage, and has developed disease-specific outcome measures to evaluate his techniques to return military personal to active duty and non-military patients to activities of daily living. He has also been a leader with respect to the opioid epidemic in the North America and opportunities for orthopaedic surgeons to tailor postoperative pain control regimens to reduce opioid dependency and decrease morbidity and mortality associated with the abuse of opioids. Brett Freedman, presently working as a spine surgeon-scientist at the Mayo Clinic in Rochester, Minnesota, has a long distinguished career in the United States military. His research focuses on the objective diagnosis of compartment syndrome and advancing sub-atmospheric pressure therapy in the management of severe, post-traumatic wounds. Brett’s unique view of the world allows him to see issues from a variety of angles, which will be his ticket to continued scientific success. Jonathan Braman, originally from Washington, practices at the University of Minnesota as a shoulder surgeon developing safe day-care programs for shoulder arthroplasty. Jonathan’s research interest is in education - from arthroscopic simulator development, to technical training, to mentorship and leadership within the AOA. Jonathan, “The Paparazzi”, has a creative writing background, and was the individual responsible for the brilliant ABC/AOA blog that chronicled our travels. During our second day in the United Kingdom, we toured the laboratories of the Imperial College with Professor Justin Cobb, who exposed us to a wide range of scientific work. Following this exciting tour, we met Professor Fares Haddad (ABC 2004) COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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for lunch at the top of the Gherkin Tower in central London and a tour and meeting with the Bone and Joint Journal Editorial Board. The next day, we were taken to the University College London Hospitals, hosted by Sam Oussedik (ABC 2016). Our final stops in London were hosted by Jonathan Miles (ABC 2016) and John Skinner (ABC 2004), who led us on a tour of the Tower of London, Westminster Abbey, and the Royal National Orthopaedic Hospital (RNOH) at Stanmore with Tim Briggs (ABC 1998). We were then welcomed to the annual British Orthopaedic Association Dinner, a true British black tie affair.

football. Our final activity in Cambridge was a lovely formal dinner with the university faculty in the historic Queen’s College, which dates back to 1448. Next we jetted off to Edinburgh and were welcomed with a wonderful dinner at the home of Professor Hamish Simpson (ABC 1996). He and his family welcomed us with a delicious home cooked meal where we had an opportunity to interact with other members of the Edinburgh faculty, many of whom had been former ABC fellows. The following day we were hosted in the officer’s mess at Edinburgh Castle by Surgeon Commander Calam Arthur, a special treat that typified the unique experiences we had throughout the tour. We had an opportunity to tour Edinburgh and hike Arthur’s seat, allowing us to marvel at the city and sea below. We met numerous ABC alumni either socially or at an enriching academic day, highlighted by the quality research being performed on both sides of the Atlantic. Our brief time in Edinburgh was capped off with a black tie dinner at the New Club followed by libations at some of the city’s finer establishments.

We travelled to Oxford, and had an afternoon to bond, which happened to include a tour of many of the finer establishments Oxford has to offer. Matthew Costa (ABC 2010) and Andrew Carr (ABC 1998) hosted us in Oxford the following day, where we were first exposed to the trauma system in the UK. Later in the day we had an academic afternoon with the Oxford Clinical Trials Group, which focused on both pragmatic trials and multicentered randomized clinical trials. We toured the clinical and research facilities at the John Radcliffe Hospital in Oxford, in addition to the historical Oxford campus itself. We met with Profesor Keith Willett, the architect of the current UK trauma network, who provided an insightful lecture on the past, present, and future state of the UK trauma system. We attended a gala dinner at Balliol College in Oxford with other ABC alumni. Our Oxford experience typified the many relationships made and the privileged exposure granted throughout the ABC tour.

Crossing back over the Scottish-English border, we made our way to Wrightington, famous as the home of John Charnley and the low-friction arthroplasty. We were given the opportunity to present our research as part of their Gold Medal academic session, Wrightington’s annual resident research day. Since Writington is set on the grounds of a former manor property that was converted into a tuberculosis sanitorium, it is quite different from a traditional academic hospital. Despite its unimposing size and pastoral setting, Wrightington presented an impressive array of research that continues a tradition of high-quality academic work begun by John Charnley. Bodo Purbach, a Charnley disciple, took us through the Charnley museum and shared many radiographs of Professor Charnley’s cemented total hips, some dating back 50-years, demonstrating the durability of the prosthesis. Our host, Martyn Porter (ABC 1994), graciously took us to a Premier League football match, with Burnley pitted against West Bromwich Albion. As it was a bit of a grey and chilly day, a number of the fellows purchased all sorts of Burnley gear, more than some of even the most dedicated Burnley fan might own. Following football, we travelled to the Lake District, staying at the manor home of Peter Kay (ABC 1998) and his wife Thelma for the weekend. We relaxed, were very well fed, and were taken on a “leisurely” walk along Striding Edge at Helvellyn. We all managed to survive the hike, although some better than others, but we were all better for the experience. Leela Biant (ABC 2010) drove over from Manchester to join us for breakfast before the academic day. This kind of willingness to host, and go out of the way to meet with us was seen by alumni of this tour at many sites.

Cambridge was our next stop on the tour, and we were graciously hosted by Vikas Khanduja and Professor Andrew McCaskie. We attended trauma rounds, toured the hospital, and viewed the new clinical trials unit and translational research lab that was to open in the upcoming weeks. Professor McCaskie led us through their bio-engineering research laboratory where he leads the academic work being undertaken at Cambridge. We took advantage of the Bank Holiday with a jog through town and a tour of the Cambridge campus and an afternoon of punting on the Cam river, a slow canoeing-like activity, rather than a means for converting field position on third down in Canadian

Ajay Malviya (ABC 2016) and Will Eardly (ABC 2016) hosted us in Northumbria. We were also joined by Michael Reed (ABC 2012). The academic session was excellent, and our accommodations at Slaley Hall were sublime. Paul Partington hosted a dinner and bonfire at his beautifully renovated home. We enjoyed some rare free time shooting sporting clays at Slaley Hall. The following day we travelled to York where Amar Rangan (ABC 2010) introduced the York Clinical Trials Unit. They have led a large multi-centered study assessing proximal humerus fractures (PROFER trial) and are assisting other researchers in the development and management of other large scale trials.

Dressed to kill! The tour kicks off with the BOA Dinner. L to R: Jon Braman, Brett Freedman, Joe Hsu, Mr. Ian Winson (President of the BOA), Eric Strauss, Clare Marx (President of the Royal College of Surgeons of England), David Sheps, Nic Bernthal, Wade Gofton

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We engaged in a spirited discussion on the impact of pragmatic trials on health policy and the National Health Service, including the implications for healthcare policy decisions in Canada and the United States. We returned to London following our time in Northumbria and each of us took advantage of some downtime to recharge our batteries prior to our departure to South Africa. Our free day in London and our departure from the United Kingdom was perfectly timed, since a cyber-attack crippled many of the NHS computers the day we left the UK. We were happy to leave the ransomware behind and begin the lengthy journey to South Africa.

and others, partaking in a game drive that allowed for amazing views of game in their natural environment. The reserves not only provide an opportunity to see the animals, but also allows for controlled hunting which helps defray the cost of preserving and protecting these animals. While poaching is down year over year in South Africa, the rhino horn and ivory trade remains lucrative, and the government and game parks are working hard to reduce the threat to these endangered animals. Durban, KawZulu-Natal was the next stop on our itinerary. We had an academic day at Albert Luthuli Central Hospital covering both our talks and a discussion of the trauma system in South Africa. Following the academic day and a social lunch of curry with the consultants and registrars, we left for the Hluhluwe Imfolozi Game Park. We spent the weekend on the game park with our hosts Len Marais, Alberto Puddu, and Charles Serfontein. It was our first exposure to a traditional braii (a South African Barbeque), the taste of African game, and the opportunity to see more wild animals on safari. This preserve had dense jungle terrain and we were able to see many large mammals. We also had our first night safari, where we saw a bushbaby (galago) under the spotlights. Peter Kay told us it would be a leisurely walk in the lake district…turned out to be an incredible opportunity for us all in different ways. He still insists it is easier than trying to manage health-care reform. Nic Bernthal leading the team to the top

We arrived in Johannesburg and settled in to our hotel. The following day, we began our tour of South Africa. Chris Hani Baragwanath Academic Hospital was an eye-opening experience for most of us. Our host Greg Firth (ABC 2014) led us through the massive, 3000 bed hospital, giving us a taste of the breadth and volume of work that he and his colleagues are challenged with on a daily basis. We also visited Cynthia Sathekga in the hand and brachial plexus clinic where they routinely work with the registrars through long queues of patients with complex upper extremity injuries. Dr. Sathekga summarized the spirit of selfless service that dominates Baragwanath. She told us why, given her advanced training and experience, she continues to choose to work in such a challenging environment – “if not me, then who”. Our visit to Baragwanath was followed by a tour of the apartheid museum and an academic session at Witswatersrand Medical School. Dinner was positively carnivorous, including a visit to a meat locker where prime cuts of beef were both dry and wet aged. Joining us for dinner were Andrew Barrow (ABC 2008) and Mkhului Lukhele (ABC 1994). After a very filling meal, we transferred to Pretoria to settle in for the night. Thomas Kruger hosted us in Pretoria and we participated in a traditional academic grand rounds with paediatric patients examined by the registrars who fielded questions from the consultants. We visited Freedom Park, overlooking Pretoria, a project of the Truth and Reconciliation Commission, as well as the Voortrekker museum that commemorated a battle between the Afrikaners and Zulus in 1838. We visited the Pilanesberg Game Preserve with Christian Snickers (ABC 2012)

Upon arriving in Bloemfontein, we were greeted by Johan van der Merwe, F.P. du Plessis, and Professor John Shipley (ABC 1986). We piled into their cars for a drive to the Letsatsi Game Preserve. This was a true bush camp, although a luxurious one, and we had the opportunity to stay in tents and disconnect from world due to the lack of Wi-Fi and cellular range. The preserve demonstrated the amazing savannah grasslands of the region that was in contrast to the terrain at our previous stops. We toured through a private preserve, and were able to see a pride of lions, bringing our game viewing to four out of the “big five”. Back in Bloemfontein, Gerhard Greeff hosted an academic day for consultants and registrars with research talks and case presentations, followed by a fantastic dinner in his beautiful home. In Stellenbosch, we were met by Cameron Anley (ABC 2016) and were hosted by Cameron and Professor Jacques du Toit during our visit to Tygerberg. It was in Tygerberg that we were exposed to the South African trauma system, watching the morning trauma report. Registrars presented the work completed the day and night before, with a critique from the consultants, and plan made for future management. The sheer volume of trauma work

On to Africa. “Trauma Joe” offering some thoughts on frames at Chris Hani Baragwanth Academic Hospital. An eye opener for all of us, a group of dedicated physicians dealing with massive patient need COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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places great demands on the registrars and requires the early development of independent practice. It was interesting to observe the tension between the preservation of an elective practice and timely trauma care. Professor du Toit spoke on the challenge of “Second World” orthopaedics in South Africa that he defined as the bridge between current standard of care in cities like Cape Town, and the difficulty of managing care in other centres with less resources and access to modern care. In his talk, he provided statistics from Tygerberg (the busiest trauma centre in South Africa): 26 poly-trauma patients a month, 42 non-gunshot open fractures a month, and 68 orthopaedic gunshot surgeries a month (not counting washouts in the emergency department). They average 20 major emergency orthopaedic surgery cases a day or 620 per month! Additionally, he spoke about the opportunity for South African orthopaedic surgeons to lead research in areas where they have unique expertise: HIV, tuberculosis, and high-volume blunt and penetrating trauma. The reality of practice in South Africa was in stark contrast with a lovely visit to the stunning Stellenbosch wine country, where we sampled local wines, and enjoyed a gourmet dinner at Professor du Toit’s home. Our final stop was at the University of Cape Town where we were hosted by Maritz Laubscher and Stewart Dix-Peek (ABC 2010). We toured the Red Cross War Memorial Children’s Hospital, visiting a long ward of children in traction for femoral fractures. We also toured their state of the art simulation centre. We visited Groote Schuur Hospital and the museum dedicated to the site of the first heart transplant performed in the world by Christian Barnard. We had a lovely dinner, joined by Stephen Roche and Robert Dunn (ABC 2004).

Touring the region around Cape Town with Maritz. Wine, sun and friendship. A nice way to finish the tour ….. all of us a little less lean.

During the course of our journey, we learned much from the discussions we shared with our hosts. Each of us brought new ideas to the fellowship and the discussions during travel and over drinks were as educational as the hospital tours and academic sessions.

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

In the end, it seems that there is much more in common than there are differences. In each system, including our own, stresses are shifting the balance of available care and workforce between the public and private sector. At each site, we learned about the struggle that surgeons have in providing high quality and compassionate care in an oversubscribed system. In the UK and South Africa, we heard repeatedly that the volume of orthopaedic surgery performed in each centre strains the respective health systems. Surgeons are working hard to improve the environment in which they work, in order to reduce cost and improve value. Whether by expanding efficiencies in the operating rooms, performing value-based research to identify best pathways of care, or by educating trainees to provide efficient, high-quality care, these challenges are similar as they are in Canada and the United States. As for research, each system has its strengths and opportunities to advance knowledge and care. The United States has the resources to drive innovation while Canada is able to focus on collaboration amongst centres in clinical and outcome-based trials. The UK, driven by the National Health Service and the National Institutes for Health Research, has been able to create efficiencies, establish registries, and evaluate outcomes utilizing pragmatic trials and large data sets. South Africa, especially in trauma, has been able to evaluate conditions unique to their environment such as tubercular infections, chronic osteomyelitis, late open injuries, and management of complex and late deformity. Focusing on our individual strengths, but sharing through travelling fellowships and collaborative publication, will only continue to improve care for all of our patients. Although much of the fellowship was social experience as we participated in gala dinners in ancient libraries, game viewing rides on open safari trucks, and beautiful braais under the stars, we were establishing relationships and connections that will carry forward, helping us to collaboratively address issues that plague all of our health-care systems. Capturing the spirit of ubuntu, as described by President Barack Obama at Nelson Mandela’s memorial service, is a “recognition that we are all bound together in ways that are invisible to the eye; that there is a oneness to humanity; that we achieve ourselves by sharing ourselves with others, and caring for those around us.” We left for home feeling more connected than ever – connected with one another, with the field of orthopaedic surgery, and with the humanity embodied in the doctor/patient relationship. The trip inspired us by the work of our colleagues worldwide, educated us on the commonality of humanity, and energized us for the challenges ahead2. References 1. http://worldafropedia.com/wiki/images/0/0c/Experience_ ubuntu.ogg 2. Braman et al., JBJS 2017 – in print

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COA Bulletin – Online Reading Tip #1

Bulletin de l’ACO – Conseil de lecture en ligne no 1

1) Click the little magnifying glass in the bottom right corner of your viewer.

1) Cliquez sur la petite loupe, dans le coin inférieur droit du lecteur.

2) Type in what you’re searching for in the box that appears at the top of the Bulletin. Your search term will then be highlighted wherever it appears throughout the journal.

2) Entrez l’objet de votre recherche dans le champ qui s’affiche en haut du Bulletin. Ainsi, toutes les occurrences du ou des mots entrés sont surlignées dans tout le Bulletin.

Using the ‘Find’ Feature

ooking for something in particular? Use the FIND feature when reading the COA Bulletin to quickly locate what you’re looking for.

LOOK FOR MORE ONLINE READING TIPS IN FUTURE EDITIONS OF THE COA BULLETIN

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ous cherchez quelque chose de précis? Utilisez la fonction « Find » pour trouver rapidement ce que vous cherchez dans le Bulletin de l’ACO.

D’AUTRES CONSEILS DE LECTURE EN LIGNE SERONT PUBLIÉS DANS LES PROCHAINS NUMÉROS DU BULLETIN DE L’ACO.

2018 Victoria Annual Meeting Web Site Click on the “Annual Meeting” option on the COA’s home page www.coa-aco.org for complete information about our upcoming Annual Meeting being held from June 20-23, 2018 in beautiful Victoria, BC. Updates and new information is posted regularly so be sure to check back often!

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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COA Global Surgery Committee Announces the First Norman Bethune Scholar Andrew Furey, M.D., FRCSC COAGS Chair St. John’s, NL Neil White, M.D., FRCSC COAGS Vice-Chair Calgary, AB

he COA Global Surgery (COAGS) Committee is pleased to announce the winner of the first COAGS Norman Bethune Orthopaedic Travel Scholarship, Dr. Vaughan Bowen from Calgary, Alberta. Dr. Bowen has been a highly specialized hand and wrist surgeon since becoming a Fellow of the Royal College of Physicians and Surgeons of Canada in 1980. He is currently a Clinical Professor at the University of Calgary and the Lead Physician at the University of Calgary Collaborative Hand Programme, which has developed considerably under his leadership. Dr. Bowen is known by his colleagues to be an excellent mentor and leader to his junior colleagues, and an extraordinary educator to medical professionals at all levels. He has extensive and varied teaching experience, having been a guest speaker or visiting professor in 22 countries on five continents. Numerous awards and honours have been bestowed upon Dr. Bowen throughout his career, including the ABC Travelling Fellowship and the Nicolas Andry Award of the Association of Bone and Joint Surgeons, among many others.

Outside of academics, Dr. Bowen’s accomplishments include being a pilot, an active contributor to his local community, a competitive national age group team duathlete, and a proud father of two children, now aged 26 and 27. The aim of the Bethune scholarship is to forge bonds and exchange knowledge between China and Canada, and COAGS is confident that Dr. Bowen will be a tremendous ambassador for Canadian orthopaedics. He will travel to Wenzhou, China, as both a teacher and a learner, during a two-week period in the spring of 2018. COAGS is very grateful to the Second Affiliated Hospital of the Wenzhou Medical University (WMU), for this opportunity, which hopefully will be offered to COA members on an annual basis. Click here to visit the COAGS web site.

Hommage à Jean-Marie Cloutier 1926-2017

é en 1926 dans une famille modeste du nord de Sudbury, Jean-Marie Cloutier est l’aîné d’une fratrie de quatre enfants. Il perd son père dans un terrible accident à l’âge de 4 ans. La famille survit à la Grande Crise en partie grâce à des voisins qui lui donnent une vache laitière. Poussé par sa curiosité innée, c’est très tôt qu’il développe le goût de la lecture, grâce auquel il décroche une bourse; c’est le coup d’envoi d’études qui lui permettent de s’extraire de la misère : il fait des études de médecine à l’Université d’Ottawa, puis une résidence en orthopédie à l’Université de Montréal, avant d’avoir la brillante carrière qu’on lui connaît. Quel destin pour un homme d’exception! C’est à Ottawa qu’il rencontre Elizabeth, sa compagne pendant 60 ans, avec qui il fonde une famille de quatre enfants, Odile, Blaise, Marie et Catherine, qui était le centre de sa vie.

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Lorsque, à la fin de ma résidence, je me suis présenté à celui qui était alors chef du service d’orthopédie à l’Hôpital Saint-Luc, je ne savais pas à qui j’avais affaire; on ne parlait pas de lui dans le programme d’orthopédie Édouard-Samson – comme dit l’adage, « nul n’est prophète en son pays ». Il m’a dit qu’il voulait me voir travailler avant de décider s’il m’acceptait ou non dans le service, et c’est ainsi que, pendant trois mois, j’ai été pour ainsi dire son fellow. J’ai pu alors réaliser quel formidable professeur il était, tant dans la parole que dans le geste.

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(suite de la page 28)

Puis il a pris le téléphone pour appeler nul autre que John Insall, qui était alors le gourou de l’arthroplastie du genou aux États Unis et membre fondateur, comme lui, de l’American Knee Society, pour m’envoyer à New York. À mon retour de New York, j’ai eu la chance d’être associé à l’aventure de sa vie, à savoir la prothèse à conservation des 2 ligaments croisés, et le privilège de le côtoyer et de travailler avec lui pendant 17 ans. Il m’a dit alors : « Tu verras, tu auras longtemps une longueur d’avance. » Je me souviens d’une réunion scientifique dans les années 1980 où, par sa connaissance de l’anatomie du genou et sa maîtrise des concepts de l’arthroplastie, il avait dominé. Lui, il avait plusieurs longueurs d’avance sur tous : c’était un pionnier. En 1997, à l’étage d’orthopédie, il m’avait tiré par la manche pour me présenter sa première patiente qui avait eu sa PTG en 1977 et fait l’objet d’une publication dans l’Union médicale, il y a 40 ans déjà. Sa prothèse était encore parfaite; la patiente revenait 20 ans plus tard pour son autre genou. Et je peux témoigner que beaucoup de ses patients ont fait plus de 25 ans avec leur prothèse; j’en vois encore une qui en est même à 31 ans, et sa prothèse encore intacte va probablement faire 40 ans. Au moment de sa retraite, il y a 17 ans, j’ai eu l’honneur de prononcer quelques mots en concluant que l’avenir lui donnerait raison. Eh bien, nous y sommes puisque, depuis peu, plusieurs compagnies orthopédiques font maintenant une prothèse à conservation des deux ligaments croisés. Si le grand Édouard Samson a été l’un des fondateurs de l’Association Canadienne d’Orthopédie et du programme de formation en orthopédie qui porte son nom, avec sa boucle de ceinturon à l’effigie du Sacré-Cœur, qui faisait appel à l’intervention divine, il était par sa pratique un héritier du XIXe siècle. Jean-Marie Cloutier, lui, a résolument pavé la voie du XXIe siècle. Il a été de la génération de ceux qui ont inventé l’orthopédie moderne.

Personne dans le milieu de l’orthopédie du Québec – à l’exception peut-être de LouisJoseph Papineau – n’a eu un tel rayonnement international : • • • • • • • •

Professeur titulaire à l’Université de Montréal Membre de nombreuses sociétés savantes 51 publications 80 communications 58 fois professeur invité dans le monde entier Une pléiade de visiteurs, plus de 100 12 fellows Sa prothèse à conservation des deux ligaments croisés, la prothèse Cloutier, au Musée des sciences de Toronto

Bien sûr, il prenait beaucoup de place, et quand il n’y avait pas de lit à l’étage, il faisait entrer ses patients par l’urgence, bloquant toute possibilité d’opérer pour les autres. Dans ces années-là, j’avais la fin quarantaine et il approchait de la retraite. Un jour que je me plaignais qu’il n’y avait pas de place pour les jeunes dans le service – il est vrai qu’on ne voit pas le temps passer –, il s’est tourné vers moi, l’œil narquois, pour me répondre avec son sens aigu de la répartie : « Mais tu sais, Pierre, tu n’es plus tout jeune. » Et nous avons ri. Aujourd’hui, je me sens orphelin. Comme père et fils, maître et élève, il était resté le maître pour moi. Il se tenait encore à la fine pointe de la spécialité et, jusqu’à tout récemment, donnait encore son avis et faisait des suggestions éclairées. Non seulement garderons-nous le souvenir de ce qu’il a accompli par son intelligence vive et sa grande puissance de travail, mais resteront aussi à jamais inscrits dans nos esprits son sourire, l’intelligence pétillante de son regard et son grand sens de l’humour. Pierre Sabouret, MD, chirurgien orthopédiste au CHUM

COA Member Services & Dues Payments Moved to a New Site

Nouvelle adresse pour les services aux membres et le paiement des cotisations

The COA Membership Portal is now being hosted by a new system provider. Please visit: https://www.xcdsystem.com/coa/member to pay your dues, access your profile, view the COA Job Board and other services. Please bookmark this new site as well. If you need assistance, please contact: info@canorth.org.

Le portail des membres de l’ACO est maintenant hébergé par un nouveau fournisseur. Rendez-vous à https://www.xcdsystem.com/coa/member pour payer votre cotisation ou accéder à votre profil, au babillard des possibilités d’emploi et à d’autres services. N’oubliez pas d’ajouter ce nouveau site à vos favoris. Si vous avez besoin d’aide, veuillez nous écrire à info@canorth.org. COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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

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COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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

Evolution of Orthopaedic Trauma Care in Canada William N. Dust, M.D., FRCSC, FACS Saskatoon, SK

rthopaedic trauma care and trauma as a subspecialty have evolved greatly since I was a resident in the early 1980s. In the 1980s there were very few orthopaedic surgeons in Canada with orthopaedic trauma fellowship training, and even fewer who restricted their practices to trauma care. The development of daytime operating room time for fracture care was in its infancy and not available in most centres with much of the routine fracture care being done in the evenings or worse, in the middle of the night. At that time, the standard of care for an open tibia fracture was external fixation and a femoral shaft fracture was 8-12 weeks Dr. William N. Dust in balanced traction in a Thomas splint. Although the array of ropes was aesthetically pleasing sive than conventional plating, and reminded me of rigging on a locking plates are still commonly square rigged sailing ship, it was used and in some cases, the only a long and difficult treatment technique our residents know. The practice of orthopaedic surgery continues to evolve. We that was often met with comare faced with an explosion of information stemming from plications. IM nails had a very published cutting-edge research (bench and clinical). Likewise, Orthopaedic Trauma Future limited role as we were unable an increasingly informed public has rapid access to information Challenges to lock them. In fractures where about novel therapies and surgical techniques. Oftentimes the With the baby boom generainternal fixation was indicated, best way to integrate evidence-based practice and innovative tion now becoming our senior we would spend hours anaand forming an increastomically reducing, inserting lag treatments is unknown or challenging. To add some perspective citizens ing proportion the Canadian screws and neutralization plates, on how to approach emerging and/or controversial topics, we population, it isofexpected that and then be disappointed when have developed this Horizons feature in the COA Bulletin. geriatric fractures, both high and we ended up with an infeclow energy injury, will greatly tion or nonunion. I remember In the Horizons articles, thought leaders from various increase in the upcoming years. Dr. A. Grosse from Strasbourg, subspecialties will provide insights based on their extensive Currently, approximately 30% France coming to McGill to show clinical experience and ongoing research. The goal of this feature of Canada’s population is of us how to use the Grosse-Kempf is to “shed some light” on the best way forward. the baby boom generation; the locking nail. The ability to use youngest of the generation will interlocking screws revolutionFemi Ayeni, M.D., FRCSC be turning 65 around 2030. To ized the management of femoral Scientific Editor, COA Bulletin date we have found, through fractures and markedly improved increasing numbers of high qualpatient outcomes. In addition, ity trials, that the outcomes of many fractures in the over 65 the results of nailing caused us to refocus our thoughts on population are not as good as we thought or expected based internal fixation from a technical exercise to one of biological on outcomes of similar fractures in younger patients. In fact, fracture management. it is difficult to show that the results of surgery are any better than nonoperative care. This is not to say that these fractures Research and Advancements do well, but rather that our current surgical techniques and Orthopaedic surgeons’ understanding of epidemiology and implants don’t work. The reasons are multifactorial and are study design was starting to develop and through higher qualinfluenced by poor bone quality and co-morbid conditions that ity studies, we quickly moved forward revolutionizing the care may impede rehabilitation programs and are associated with of femoral and tibial fractures, open and closed, with locking higher perioperative complication rates. nails. Our Canadian Orthopaedic Trauma Society (COTS) has been a world leader in successfully conducting multi-centered In addition to finding the best management of geriatric fracrandomized controlled trials that have answered many of our tures, perhaps the greatest challenge facing orthopaedics fracture-related questions. and our Canadian health-care system is how to deal with the rapidly increasing volume of geriatric fractures, particularly hip Despite the dramatic advance with locked nails, not all techfractures. Although many centres now have dedicated daynological advances have been as successful. We enthusiastitime operating for fractures, much of this time is in dedicated cally adopted locking plate technology however we’ve been trauma centres. Unfortunately dealing with hip fractures in hard pressed to show that there has been any improvement these centres may be less than ideal as hip fractures are often in patient outcomes. Despite being several times more expen-

Horizons

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

relegated to the bottom of the list as more urgent patients are dealt with. To meet the benchmark standard of getting hip fractures to the operating room within 48 hours will require increased resources in beds and operating room time to tertiary trauma centres, or redirection of hip fracture patients away from these centres - perhaps to specialized hip fracture units co-staffed by geriatricians. An even bigger issue is what to do with these patients once their fractures are dealt with. Many who were living on their own should not have been and are unable to be discharged. With approximately 1:4 single seniors already living in poverty and the dire news reports of a significant number of Canadians with inadequate savings approaching retirement age, this problem can be expected to markedly increase in the near future and persist for 20 or more years. Unfortunately long-term care facilities as originally proposed in a comprehensive Medicare program have never been fully developed - meaning these patients have nowhere to go and hence occupy an acute care hospital bed often for an extended period. In addition to the expense of occupying acute care beds, their presence may preclude the centre’s ability to care for additional patients, acute and elective, resulting in patients having to be treated elsewhere or elective surgeries cancelled resulting in longer waiting lists. This has been a predictable

problem and despite warnings and advocacy by the COA and CMA, is rapidly becoming a real issue that will need to be dealt with by governments. Most health regions are trying to keep patients in their own home with enhanced home care which is a laudable goal. However, there is a point where it is no longer feasible, often related to a fragility fracture. These individuals have to be placed in some form of long-term care facility. Home care services and long-term care facilities are a mixture of provincially funded and private enterprises with a variety of funding schemes. The publicly funded facilities provide a very basic level of care and usually have waiting lists that may be months long. The Future As orthopaedic trauma surgeons, we must continue to research and determine the best care for our geriatric fracture patients. As orthopaedic surgeons in general, we must continue to advocate for our patients and press for the resources necessary to manage this impending crisis as it affects all of us, regardless of what community or setting we work in.

Vitamin D Use in Orthopaedics these cutoffs1,4,5,6. Based on these definitions, approximately 75% of the general population have serum 25(OH)D levels below 30 ng/mL7,8.

Sheila Sprague, PhD Sofia Bzovsky, BSc Taryn Scott, MSW McMaster University Hamilton, ON

Fragility Fractures Vitamin D supplementation is important in the prevention Gerard Slobogean, M.D., MPH, FRCSC and management of osteoporosis3,9. Health Canada advises University of Maryland School of Medicine, Department of Orthopaedics that all adults over the age of 50 take a daily vitamin D supR Adams Cowley Shock Trauma Centre plement of 400 IU1. This recommendation is from the 2010 Baltimore, MD Institute of Medicine report jointly commissioned by the U.S. and Canadian governments that reviewed the recommended dietary allowances for vitamin D (Table 1)1. To help reduce the itamin D is a nutrient necessary for building strong risk of fragility fractures, Osteoporosis Canada has developed a bones and preserving skeletal health across all ages1. summary of the guideline recommendations on the treatment Individuals obtain vitamin D from exposure to sunand management of osteoporosis that includes information light or by consuming food on the importance of vitathat contains vitamin D1. min D for use by health However, it can be difficult care professionals10. Prior to obtain adequate vitamin D research on vitamin D comfrom these sources alone, These vignettes are a series of articles led by experts and thought leaders pliance in 65- to 71-year so individuals often also women who are at risk who advise on how to manage clinical controversies or address emerging old derive vitamin D through of a hip fracture found that treatment trends while applying evidence-based principles. With these most individuals were taksupplements1,2. Vitamin D vignettes, we aim to help provide the best evidence-based strategies to ing daily vitamin D supdeficiency and insufficiency enable clinicians to incorporate new treatment and diagnostic strategies into plements in combination are prevalent and recognized as worldwide health current practice. Although no patient or condition fits into the proverbial with calcium carbonate11. 3 problems . Although “box,” we often need to solve problems in “real time” and these comprehensive Another study showed most experts define vitathat adherence to daily opinions will, hopefully, provide some useful and applicable insights. min D deficiency as levels vitamin D supplementa<20 ng/mL and insufficiention for 90 days was 83% in Dr. Femi Ayeni cy as 21-29 ng/mL, there is acute fragility hip fracture Scientific Editor, COA Bulletin no universal agreement for patients12. This is in con-

Evidence-based Vignettes

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

trast to recent research which found that surgically managed elderly hip fracture patients were not consistently taking the recommended vitamin D supplements for longer periods (within six and 12 months after their surgery) 13,14. Non-fragility Fractures Multiple observational studies have reported that up to 75% of healthy adult fracture patients (ages 18-50) have serum 25(OH)D levels <30 ng/ml15. Additionally, there is emerging, but inconclusive, evidence that vitamin D levels decrease following a fracture16-20 and it is hypothesized by many that post-fracture vitamin D supplementation may improve fracture healing21-22. Specifically, clinical studies have suggested that vitamin D supplementation increases the callus volume of proximal humerus fractures21, increases the number and diameter of type II muscle fibres22, and can improve wound healing23, but further definitive evidence is required to confirm these findings. Currently, there are no published trials evaluating the efficacy of vitamin D to improve fracture healing outcomes. In previous retrospective studies, vitamin D improved the majority of patients’ serum 25(OH)D levels, but serum 25(OH)D levels did not significantly affect the likelihood of fracture healing complications requiring surgery24,25. A small pilot randomized controlled trial suggested that there may be a reduced risk of nonunion following a single loading dose of vitamin D26. However, previous research has also raised concerns regarding the safety of megadoses (i.e. 300,000 to 600,000 IU) due to the possibility of increased fracture risks, more frequent falls, altered biochemical markers, and gastrointestinal tolerability issues27-32. Given the conflicting results and paucity of data, additional high-quality research is needed to guide care, establish the dosing safety in the immobilized fracture healing population, optimize the dosing strategy, and overcome potential medication adherence issues. To address this need, two studies are currently underway. The first is a 4-arm phase II exploratory randomized controlled trial seeking to determine the effect of vitamin D3 supplementation on fracture healing in patients ages 18-50 years with non-osteoporotic femoral or tibial shaft fractures (ClinicalTrials.gov Identifier: NCT02786498). The second is a multi-centre, concealed 2x2 factorial randomized controlled trial assessing the impact of nutritional supplementation (vitamin D supplementation versus placebo) on young adults (aged 18-60) with a femoral neck fracture (ClinicalTrials.gov Identifier: NCT01908751). The fracture healing efficacy, adherence, and safety results from these trials are poised to have a high impact on clinical practice and provide guidance as to the role of vitamin D in treating these injuries. Sports Medicine Current evidence also suggests that there is a high prevalence of vitamin D deficiency and insufficiency in sports athletes, which raises concerns that they may be at an increased risk for bone and muscle/soft-tissue injuries33. A systematic review, which included 23 articles, found that of 2,313 male and female sports athletes aged 10-40, 56% had either vitamin D deficiency or insufficiency33. The risk of vitamin D deficiency and insufficiency was specifically found to be higher among the athletes living in the United Kingdom and Middle East (in comparison to the USA, Australia, Spain, and France), for winter and spring seasons, indoor sport activities, and mixed sport activities.33

Vitamin D supplementation in the area of sports medicine has gained popularity due to its function in musculoskeletal health, physical performance, and stress fractures34. A recent systematic review found that attaining sufficiency (>75 nmol/L (>30 ng/mL)) in vitamin D concentrations from ≥3000 IU supplementation did not significantly improve physical performance (assessed by measuring hand grip strength, vertical jump height, one-rep max bench press, and 10-30 m sprint) in athletes, but suggested that supplementation of ≥3000 IU may allow athletes who were vitamin D insufficient at baseline reach sufficiency during winter months when sun exposure is minimal and at latitudes >45O34. However, given the large heterogeneity presented in both these reviews, additional high quality research is needed to acquire a better understanding of vitamin D’s role in sports medicine. Table 1: Dietary Reference Intakes for Vitamin D

Age group Infants 0-6 months Infants 7-12 months Children 1-3 years Children 4-8 years Children and Adults 9-70 years Adults > 70 years Pregnancy & Lactation

Recommended Dietary Allowance (RDA) per day 400 international units (IU) (10 mcg)* 400 IU (10 mcg)* 600 IU (15 mcg) 600 IU (15 mcg) 600 IU (15 mcg)

Tolerable Upper Intake Level (UL) per day 1000 IU (25 mcg)

800 IU (20 mcg) 600 IU (15 mcg)

4000 IU (100 mcg) 4000 IU (100 mcg)

1500 IU (38 mcg) 2500 IU (63 mcg) 3000 IU (75 mcg) 4000 IU (100 mcg)

*Adequate intake rather than RDA Recommended Readings for Further Information on Vitamin D Use in Orthopaedics: 1. Sprague S., Petrisor B., Scott T., Devji T., Phillips M., Spurr H., Bhandari M., Slobogean G.P. What Is the Role of Vitamin D Supplementation in Acute Fracture Patients? A Systematic Review and Meta-Analysis of the Prevalence of Hypovitaminosis D and Supplementation Efficacy. J Orthop Trauma. 2016 Feb;30(2):53-63 2. Tran E.Y., Uh R.L., Rosenbaum A.J. Vitamin D in Orthopaedics. JBJS Rev. 2017 Aug 1. [Epub ahead of print]. 3. Gorter E.A., Krijnen P., Schipper I.B. Vitamin D status and adult fracture healing. J Clin Orthop Trauma. 2017 JanMar;8(1):34-37. 4. Bernhard A., Matuk J. Vitamin D in Foot and Ankle Fracture Healing: A Literature Review and Research Design. Foot Ankle Spec. 2015 Oct;8(5):397-405. 5. Gorter E.A., Hamdy N.A., Appelman-Dijkstra N.M., Schipper I.B. The role of vitamin D in human fracture healing: a systematic review of the literature. Bone. 2014 Jul;64:288-97.

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6. Bodendorfer B.M., Cook J.L., Robertson D.S., Della Rocca G.J., Volgas D.A., Stannard J.P., Crist B.D. Do 25-hydroxyvitamin D Levels Correlate with Fracture Complications? J Orthop Trauma. 2016 Sep;30(9):e312-7. 7. Farrokhyar F., Tabasinejad R., Dao D., Peterson D., Ayeni O.R., Hadioonzadeh R., Bhandari M. Prevalence of vitamin D inadequacy in athletes: a systematic-review and meta-analysis. Sports Med. 2015 Mar;45(3):365-378. 8. Farrokhyar F., Sivakumar G., Savage K., Koziarz A., Jamshidi S., Ayeni O.R., Peterson D., Bhandari M. Effects of vitamin D supplementation on serum 25-hydroxyvitamin D concentrations and physical performance in athletes: a systematic review and meta-analysis of randomized controlled trials. Sports Med. 2017 Jun 2. References 1. Health Canada. Vitamin D and calcium: updated dietary reference intakes. Updated March 22, 2012. Available at: https://www.canada.ca/en/health-canada/services/foodnutrition/healthy-eating/vitamins-minerals/vitamin-calcium-updated-dietary-reference-intakes-nutrition.html. Accessed August 13, 2017. 2. Osteoporosis Canada. Vitamin D: an important nutrient that protects you against falls and fractures. 2017. Available at: http://www.osteoporosis.ca/osteoporosis-and-you/nutrition/vitamin-d/. Accessed August 21, 2017. 3. Langlois K., Greene-Finestone L., Little J., Hidiroglou N., Whiting S. Vitamin D status of Canadians as measured in the 2007 to 2009 Canadian Health Measures Survey. Health Rep. 2010;21:47–55. 4. Holick M.F. Vitamin D status: measurement, interpretation, and clinical application. Ann Epidemiol. 2009 Feb;19(2):7378. 5. Holick M.F., Binkley N.C., Bischoff-Ferrari H.A., Gordon C.M., Hanley D.A., Heaney R.P., Murad M.H., Weaver C.M.; Endocrine Society. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011 Jul;96(7):19111930. 6. Institute of Medicine, Food and Nutrition Board. Dietary reference intakes for calcium and vitamin D. 2010. Washington, DC: National Academy Press. 7. Binkley N., Coursin D., Krueger D., Iglar P., Heiner J., Illgen R., Squire M., Lappe J., Watson P., Hogan K. Surgery alters parameters of vitamin D status and other laboratory results. Osteoporos Int. 2017 Mar;28(3):1013-1020. 8. Bee C.R., Sheerin D.V., Wuest T.K., Fitzpatrick D.C. Serum vitamin D levels in orthopaedic trauma patients living in the northwestern United States. J Orthop Trauma. 2013;27(5):e103106.

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

9. Mazahery H. and von Hurst P.R. Factors affecting 25-hydroxyvitamin D concentration in response to vitamin D supplementation. Nutrients. 2015 Jul;7(7):5111-5142. 10. Osteoporosis Canada. Osteoporosis Canada’s 10 year fracture risk assessment tool. http://www.osteoporosis.ca/ health-care-professionals/clinical-tools-and-resources/fracture-risk-tool/. Accessed August 21, 2017. 11. Salovaara K., Tuppurainen M., Kärkkäinen M., Rikkonen T., Sandini L., Sirola J., Honkanen R., Alhava E., Kröger H. Effect of vitamin D(3) and calcium on fracture risk in 65- to 71-year-old women: a population-based 3-year randomized, controlled trial--the OSTPRE-FPS. J Bone Miner Res. 2010 Jul;25(7):1487-1495. 12. Papaioannou A., Kennedy C.C., Giangregorio L., Ioannidis G., Pritchard J., Hanley D.A., Farrauto L., DeBeer J., Adachi J.D. A randomized controlled trial of vitamin D dosing strategies after acute hip fracture: no advantage of loading doses over daily supplementation. BMC Musculoskelet Disord. 2011 Jun 20;12:135. 13. Sprague S., Slobogean G.P., Bogoch E., Petrisor B., Garibaldi A., O’Hara N., Bhandari M.; FAITH Investigators. Vitamin D use and health outcomes following hip fracture surgery. Orthopedics [Accepted May 2017]. 14. Sprague S., Madden K., Slobogean G., Petrisor B., Adachi J.D., Bogoch E., Kleinlugtenbelt Y.V., Bhandari M.; HEALTH Investigators. A missed opportunity in bone health: vitamin D and calcium use in elderly femoral neck fracture patients following arthroplasty. Geriatr Orthop Surg Rehabil. [Submitted July 2017] 15. Sprague S., Petrisor B., Scott T., Devji T., Phillips M., Spurr H., Bhandari M., Slobogean G.P. What Is the role of vitamin D supplementation in acute fracture patients? A systematic review and meta-analysis of the prevalence of hypovitaminosis D and supplementation efficacy. J Orthop Trauma. 2016 Feb;30(2):53-63 16. Lidor C., Dekel S., Hallel T., Edelstein S. Levels of active metabolites of vitamin D₃ in the callus of fracture repair in chicks. Journal of Bone and Joint Surgery-British Volume. 1987;69-B:132-136. 17. Ettehad H., Mirbolook A., Mohammadi F., Mousavi M., Ebrahimi H., Shirangi A. Changes in the serum level of vitamin D during healing of tibial and femoral shaft fractures. Trauma Mon. 2014 Feb;19(1):e10946. 18. Alkalay D., Shany S., Dekel S. Serum and bone vitamin D metabolites in elective patients and patients after fracture. J Bone Joint Surg Br. 1989 Jan;71(1):85-87. 19. Lamberg-Allardt C., von Knorring J., Slätis P., Holmström T. Vitamin D status and concentrations of serum vitamin D metabolites and osteocalcin in elderly patients with femoral neck fracture: a follow-up study. Eur J Clin Nutr. 1989 May;43(5):355-361.

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

20. Jingushi S., Iwaki A., Higuchi O., Azuma Y., Ohta T., Shida J.I., Izumi T., Ikenoue T., Sugioka Y., Iwamoto Y. Endocrinology. Serum 1alpha,25-dihydroxyvitamin D₃ accumulates into the fracture callus during rat femoral fracture healing. 1998 Apr;139(4):1467-73. 21. Doetsch A.M., Faber J., Lynnerup N., Wätjen I., Bliddal H., Danneskiold-Samsoe B. The effect of calcium and vitamin D₃ supplementation on the healing of the proximal humerus fracture: a randomized placebo-controlled study. Calcified Tissue International. 2004;75:183-188. 22. Hamilton B. Vitamin D and human skeletal muscle. Scandinavian Journal of Medicine and Science in Sports. 2010;20:182-190.

28. Rossini M., Gatti D., Viapiana O., Fracassi E., Idolazzi L., Zanoni S., Adami S. Short-term effects on bone turnover markers of a single high dose of oral vitamin D₃. J Clin Endocrinol Metab. 2012 Apr;97(4):E622-E626. 29. Premaor M.O., Scalco R., da Silva M.J., Froehlich P.E., Furlanetto T.W. The effect of a single dose versus a daily dose of cholecalciferol on the serum 25-hydroxycholecalciferol and parathyroid hormone levels in the elderly with secondary hyperparathyroidism living in a low-income housing unit. J Bone Miner Metab. 2008;26(6):603-608. 30. von Restorff C., Bischoff-Ferrari H.A., Theiler R. High-dose oral vitamin D₃ supplementation in rheumatology patients with severe vitamin D₃ deficiency. Bone. 2009 Oct;45(4):747749.

23. Burkiewicz C.J., Guadagnin F.A., Skare T.L. do Nascimento M.M., Servin S.C., de Souza G.D. Vitamin D and skin repair: a prospective, double-blind and placebo controlled study in the healing of leg ulcers. Revista do Colégio Brasileiro de Cirurgiões. 2012;39:401-407.

31. Leventis P., Kiely P.D. The tolerability and biochemical effects of high-dose bolus vitamin D2 and D₃ supplementation in patients with vitamin D insufficiency. Scand J Rheumatol. 2009 Mar-Apr;38(2):149-153.

24. Robertson D.S., Jenkins T., Murtha Y.M., Della Rocca G.J., Volgas D.A., Stannard J.P., Crist B.D. Effectiveness of vitamin D therapy in orthopaedic trauma patients. J Orthop Trauma. 2015 Nov;29(11):e451-453.

32. Sakalli H., Arslan D., Yucel A.E. The effect of oral and parenteral vitamin D supplementation in the elderly: a prospective, double-blinded, randomized, placebo-controlled study. Rheumatol Int. 2012 Aug;32(8):2279-2283.

25. Bodendorfer B.M., Cook J.L., Robertson D.S., Della Rocca G.J., Volgas D.A., Stannard J.P., Crist B.D. Do 25-hydroxyvitamin D levels correlate with fracture complications? J Orthop Trauma. 2016 Sep;30(9):e312-317.

33. Farrokhyar F., Tabasinejad R., Dao D., Peterson D., Ayeni O.R., Hadioonzadeh R., Bhandari M. Prevalence of vitamin D inadequacy in athletes: a systematic-review and meta-analysis. Sports Med. 2015 Mar;45(3):365-378.

26. Haines N., Kempton L., Seymour R., Karunakar M., Bosse M., Hsu J., Sims S., Kellam J. The effect of acute high-dose vitamin D supplementation on fracture union in patients with hypovitaminosis D: a pilot study. Orthopaedic Trauma Association Annual Meeting. 2014.

34. Farrokhyar F., Sivakumar G., Savage K., Koziarz A., Jamshidi S., Ayeni O.R., Peterson D., Bhandari M. Effects of vitamin D supplementation on serum 25-hydroxyvitamin D concentrations and physical performance in athletes: a systematic review and meta-analysis of randomized controlled trials. Sports Med. 2017 Jun 2.

27. Sanders K.M., Stuart A.L., Williamson E.J., Simpson J.A., Kotowicz M.A., Young D., Nicholson G.C. Annual high-dose oral vitamin D and falls and fractures in older women: a randomized controlled trial. JAMA. 2010 May 12;303(18):18151822.

Treatment Options for High-grade AC Joint Injury in Young Adults Introduction to this edition’s debate

hat treatment do you recommend when a young adult sustains a high-grade acromioclavicular joint injury? This question often triggers pensive moments and conflicting opinions in clinics and rounds across the country. Clinical experience, current evidence, knowledge of the patients’ activity demands as well as emerging/promising technological advances contribute to the thought process or potential answer. Needless to say, the answer has not been

definitively settled. In this debate, experts from the University of Toronto, University of Calgary and Duke University contribute opinions that may enhance our decision making. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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

Surgical Intervention for High-grade Acromioclavicular Joint Injury Devin Lemmex, M.D., FRCSC Fellow Duke University Durham, NC Cory Kwong, M.D. Resident University of Calgary Calgary, AB Justin Leblanc, M.D., MSc FRCSC Clinical Assistant Professor University of Calgary Calgary, AB

he acromioclavicular (AC) joint is a diarthrodial articulation between the acromion and clavicle. It plays a vital role in the proper function of the upper extremity through its contribution to the superior shoulder suspensory complex1. Stability of a normal AC joint is achieved through the synergistic action of the joint capsule, AC ligaments, coracoclavicular (CC) ligaments, and muscular insertions of the trapezius and deltoid. Together, these structures form a stable link, known as a screw-axis, on which the scapula rotates in order for the shoulder to achieve full range of motion2. Disruption of this relationship between the clavicle and scapula can lead to significant scapular dyskinesis and the painful SICK scapula syndrome3. High-grade AC joint injuries are defined as Rockwood Grade IV, V, and VI. Historically, surgical intervention was the treatment of choice despite not fully understanding the natural history of these relatively uncommon injuries. Moreover, approximately 150 different procedures have been described in the literature to treat these shoulder processes with mixed results4. It is intuitive that a posterior (Grade IV) or inferior (Grade VI) dislocation of the clavicle can result in chronic shoulder pain, but the morbidity of extreme superior dislocation (Grade V) has not been well described until recently. Dunphy et al. (2016) describe that only 23% of patients with nonoperatively treated Grade V AC joint injuries are able to achieve normal functional outcomes. Surprisingly, these patients tend to be young (<40 years old) and employed as manual labourers. The remainder of this nonoperative cohort were able to return to work but had clearly inferior results when analyzing functional outcome scores (DASH and ASES scores). As our understanding of nonoperatively treated high-grade AC joint injuries grows, so should our awareness of the necessity of surgical intervention. As previously mentioned, a large catalogue of procedures exists to address AC joint instability, however these are mostly small variations on similar themes. Kirschner wire fixation and Bosworth screw placement should no longer be considered adequate procedures, as these have been proven to be inferior biomechanically and associated with significant complications6. Nonanatomic reconstruction COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Figure 1 Depiction of the Kibler et al. technique13 demonstrating the graft being docked on the medial aspect of the acromion through drill holes

of the CC ligaments using autograft semitendinosus tendon was first published in 2001 by Jones et al. and later modified by many authors ultimately leading to the description of anatomic CC and AC ligament reconstruction. The advent of these techniques was inspired in response to failed Weaver-Dunn (distal clavicle excision and coracoacromial ligament transfer) and hook plate procedures. Furthermore, biomechanical studies have shown that anatomic CC ligament reconstruction is superior to the classic Weaver-Dunn procedure and more closely restores native ligament function8,9. Clinically, anatomic reconstruction techniques have shown positive results. Tauber et al. (2009) performed a prospective comparative study of anatomic CC ligament reconstruction using semitendinosus autograft tendon versus a modified Weaver-Dunn technique in chronic cases of Grade III, IV and Grade V AC joint dislocations. At a mean of 37 months follow-up, the anatomic reconstruction group showed significantly greater ASES and Constant scores when compared to the modified Weaver-Dunn group. Additionally, horizontal stability of the clavicle under stress radiographs was maintained when treating Grade IV injuries at final follow-up. Of note, in this particular study, five Grade V dislocations underwent revision surgery for failure of prior hook plate fixation. Carofino and Mazzocca (2010) also presented a series of 17 patients undergoing anatomic CC ligament reconstruction for Grade III and Grade V AC joint dislocations that failed 6-12 weeks of nonoperative management. Similar to Tauber et al. (2009), they showed significantly improved Constant and ASES scores at a mean 21-months follow-up. Although clinical and radiographic outcomes appear to be promising in these small case series of anatomic CC ligament reconstruction, these procedures are associated with a relatively high rate of complications. Millett et al. (2015) published

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

an excellent summary of case series on anatomic CC ligament reconstruction and tabulated a complication rate of 39.8%. These included graft rupture, clavicle fracture, coracoid fracture and hardware failure. Despite our ability to adequately restore the biomechanics of both the CC and AC joint ligaments with anatomic reconstructions, the high rate of complications continues to be the main drawback to operative intervention in high-grade AC joint injuries. A recently published modification to the original Carofina and Mazzocca technique was introduced by Kibler et al. (2016). They suggested incorporating smaller drill holes in the clavicle without the use of interference screws and augmenting the AC ligament repair by docking the tendon graft to the medial edge of the acromion (Figures 1 & 2). The authors reported the 1.5-year follow-up of 15 patients and only acknowledge one complication in the form of increased CC distance after a fall. Although optimistic, this may mark the advent of a viable reconstruction technique with a lesser complication profile than previously published interventions.

2. Sahara W., Sugamoto K., Murai M., Tanaka H., Yoshikawa H. 3D Kinematic Analysis of the Acromioclavicular Joint During Arm Abduction Using Vertically Open MRI. J Orthop Res 2006;24:1823-1831.

Surgical intervention for high-grade AC joint dislocations remains a popular option. The lack of long-term results for anatomic ligament reconstruction and their complication profile remain contentious issues however. With recent natural history evidence surrounding nonoperatively treated Grade V injuries, we should be more diligent at identifying those patients at increased risk of failing conservative management. An open discussion with the patient surrounding the potential complications of anatomic CC and AC ligament reconstruction is of paramount importance and should not be taken lightly. As newer long-term evidence becomes available, we are optimistic that a reliable surgical technique will emerge and allow us to treat these difficult injuries.

6. Lee S., Bedi A. Shoulder Acromioclavicular Joint Reconstruction Options and Outcomes. Curr Rev Musculoskelet Med 2016;9:368-377.

3. Burkhart S.S., Morgan C.D., Kibler W.B. The Disabled Throwing Shoulder: Spectrum of Pathology Part III – The SICK Scapula, Scapular Dyskinesis, the Kinetic Chand, and Rehabilitation. Arthroscopy 2003;19(6): 641-661. 4. Beitzel K., Cote M.P., Apostolakos J., Solovyova O., Judson C.H., Ziegler C.G., Edgar C.M., Imhoff A.B., Arciero R.A, Mazzocca A.D. Current Concepts in the Treatment of Acromioclavicular Joint Dislocations. Arthroscopy 2012;29(2): 387-397. 5. Dunphy T.R., Damodar D., Heckmann N.D., Sivasundaram L., Omid R., Hatch III G.F. Functional Outcomes of Type V Acromioclavicular Injuries With Nonsurgical Treatment. J Am Acad Orthop Surg 2016;24:728-734.

7. Jones H.P., Lemos M.J., Schepsis A.A. Salvage of failed acromioclavicular joint reconstruction using autogenous semitendinosus tendon from the knee. Surgical technique and case report. Am J Sports Med. 2001;29: 234–7.   8. Costic R.S., Labriola J.E., Rodosky M.W., Debski, R.E. Biomechanical Rational for Development of Anatomical Reconstructions of Coracoclavicular Ligaments After Complete Acomioclavicular Joint Dislocations. Am J Sports Med 2004;10 (32): 1-8. 9. Bontempo N.A., Mazzocca A.D. Biomechanics and Treatment of Acromioclavicular and Sternoclavicular Joint Injuries. Br J Sports Med 2010;44: 361-369. 10. Tauber M., Gordon K., Koller H., Fox M., Resch H. Semitendinosus tendon graft versus a modified weaver-Dunn procedure for acromioclavicular joint reconstruction in chronic cases a prospective comparative study. Am J Sports Med. 2009;37:181–90. 11. Carofino B.C., Mazzocca A.D. The anatomic coracoclavicular ligament reconstruction: surgical technique and indications. J Shoulder Elb Surg. 2010;19:37–46.

Figure 2 Final repair of the native AC ligaments with semitendinosus graft in situ

References 1. Goss T.P. Double Disruptions of the Superior Shoulder Suspensory Complex. J Orthop Trauma 1993;7(2): 99-106.

12. Millett P.J., Horan M.P., Warth R.J. Two-year outcomes after primary anatomic coracoclavicular ligament reconstruction. Arthrosc J Arthrosc Relat Surg Off Publ Arthrosc Assoc N Am Int Arthrosc Assoc. 2015;31:1962–73. 13. Kibler W.B., Sciascia A.D., Morris B.J., Dome D. Treatment of Symptomatic Acromioclavicular Joint Instability by a Docking Technique: Clinical Indications, Surgical Technique, and Outcomes. Arthrosc J Arthrosc Relat Surg. 2016;33:696-708.

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

High-grade AC Joint Separations: The Role for Nonoperative Management Patrick D.G. Henry, M.D., FRCSC Aaron Nauth, M.D., MSc, FRCSC Toronto, ON

n 400 BC, Hippocrates made the statement regarding Acromioclavicular (AC) Joint injuries that â&#x20AC;&#x153;no impediment, small or great, will result from such an injuryâ&#x20AC;?1. Almost 2500 years later, this statement holds true for the vast majority of these injuries. Despite the extraordinary proliferation of surgical techniques for AC joint reconstruction, an effective intervention that is a substantial improvement over the natural history of this condition managed nonoperatively remains elusive. In addition, surgical interventions for AC joint injuries have led to alarmingly high rates of complication and loss of reduction. In essence, our outcomes are no better than those achieved by Hippocrates 2500 years ago, and as such, surgical intervention should be reserved for a minority of exceptional cases. AC joint dislocations are classified according to the Rockwood Classification in order of increasing displacement and soft tissue disruption as Grades I through VI2. A large proportion of AC joint injuries are Grades I and II, representing sprains of the AC and Coraco-Clavicular (CC) ligaments. These are universally managed nonsurgically, with generally excellent outcomes. Controversy exists regarding the management of injuries that are Grade III and higher, where the CC ligaments are torn plus or minus disruption of the delto-trapezial fascia. In this setting, some have advocated for surgical intervention, although the evidence supporting such a contention is lacking.

two groups. Interestingly, they did recommended surgery for heavy labourers with high-grade AC joint injuries, despite the fact that their results did not support this. Bannister et al. published their RCT in 1989, comparing nonoperative management to coraco-clavicular screw fixation (Bosworth screw) for high-grade AC joint injuries4. They found that patients treated nonoperatively had a faster return of motion and function, returned to work/sport sooner, and had overall superior results. The authors did recommend surgery for young patients with severe displacement, however, similar to the previous study, their results did not support this statement. Joukainen et al. reported on the 20-year results of their randomized trial comparing nonoperative treatment to K-wire and suture fixation for Grade III and IV AC joint injuries5. The authors reported no significant differences in long-term functional outcomes between the two groups. It is important to note that in all three of these studies, the rate of delayed surgery for AC joint reconstruction in patients randomized to nonoperative treatment (i.e. patients who were unhappy with their shoulder following conservative treatment) was low (8-12%). Much more recently, the Canadian Orthopaedic Trauma Society (COTS) reported on a prospective randomized clinical trial of 83 patients comparing nonoperative treatment to hook plate fixa-

Several historical trials have been conducted comparing operative to nonoperative treatment for high-grade AC joint injuries. Larsen et al. compared nonoperative management to K-wire fixation for high-grade AC joint dislocations in 1986 [Larson 1986].3 The authors reported no Figure 1 differences in clinical Constant scores for the operative and nonoperative groups in the COTS randomized trial. Constant scores were signifioutcome between the cantly better (higher) in the nonoperative group at six weeks, three months, and six months postoperatively. Reproduced with permission from the Canadian Orthopaedic Trauma Society, 2015.

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Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 38)

tion for Grade III-IV AC joint injuries6. There were no significant differences in functional outcomes (DASH or Constant) or ROM at one or two years of follow-up. In fact, the only differences between the two groups were improved early function (up to six months) and earlier return to work in the nonoperative group (Figure 1). In addition, there were seven major complications in the operative groups (18%) versus two in the nonoperative group (5%) (Figure 2). The available level 1 evidence does not support surgical intervention for high-grade AC joint injuries, although it is important to recognize that injuries above Grade III were uncommon in these studies (e.g. less than 10% of patients in the COTS study).

Figure 3 Failure of cortical button fixation for an acute AC joint injury in a 42-year-old male labourer

References 1. Adams F.L. The Genuine Works of Hippocrates. Vol 1 & 2. New York, New York: Williams Wood; 1986. 2. Hindle P., Davidson E.K., Biant L.C., Court-Brown C.M. Appendicular joint dislocations. Injury. 2013;44(8):1022-1027. Figure 2 Failure of hook plate fixation six weeks post-surgery for an acute AC joint injury in a 50-year-old male

There has been recent significant interest in the use of cortical button fixation for acute AC joint injuries. Advocates of this technique have cited the advantages of flexible fixation and the potential for minimally-invasive (arthroscopic) insertion. However, several recent publications have reported high rates of reduction loss (33%), complications (27-44%) and high reoperation rates (24%) when this fixation technique is used (Figure 3)7,8. There is no prospective literature comparing cortical button fixation to nonoperative treatment for AC joint injuries. The best available evidence clearly does not support surgical intervention for the majority of high-grade AC joint injuries. Moreover, the evidence suggests that we may actually be causing harm when we operate on acute high-grade AC joint injuries due to the delayed recovery and increased rates of complication. Much like the authors of earlier studies, we do agree that there is a small subset of patients (10-15%) who will progress to being unhappy with their outcome following nonoperative management of an acute AC joint injury. This is based on our experience with the COTS trial and referrals to our upper extremity practice. Unfortunately, studies to date have been unable to define this subset of patients acutely, and evidence-based indications for acute intervention in high-grade AC joint injuries remain elusive. In addition, relatively effective surgical options exist for the delayed reconstruction of chronic symptomatic AC joint injuries. As a result, we manage the vast majority of acute AC joint injuries conservatively and counsel our patients that there is a small risk that they may go on to require surgical management if their shoulder remains symptomatic following an appropriate period of conservative treatment.

3. Larsen E., Bjerg-Nielsen A., Christensen P. Conservative or surgical treatment of acromioclavicular dislocation. A prospective, controlled, randomized study. J Bone Joint Surg Am. 1986;68(4):552-555. 4. Bannister G.C., Wallace W.A., Stableforth P.G., Hutson M.A. The management of acute acromioclavicular dislocation. A randomised prospective controlled trial. J Bone Joint Surg Br. 1989;71(5):848-850. 5. Joukainen A., Kroger H., Niemitukia L., Makela E.A., Vaatainen U. Results of Operative and Nonoperative Treatment of Rockwood Types III and V Acromioclavicular Joint Dislocation: A Prospective, Randomized Trial With an 18- to 20-Year Followup. Orthop J Sports Med. 2014;2(12):2325967114560130. 6. Canadian Orthopaedic Trauma Society. Multicenter Randomized Clinical Trial of Nonoperative Versus Operative Treatment of Acute Acromio-Clavicular Joint Dislocation. J Orthop Trauma. 2015;29(11):479-487. 7. Shin S.J., Kim N.K. Complications after arthroscopic coracoclavicular reconstruction using a single adjustable-loop-length suspensory fixation device in acute acromioclavicular joint dislocation. Arthroscopy. 2015;31(5):816-824. 8. Martetschlager F., Horan M.P., Warth R.J., Millett P.J. Complications after anatomic fixation and reconstruction of the coracoclavicular ligaments. Am J Sports Med. 2013;41(12):2896-2903.

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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

On Waiting for Care and Waiting for Justice Brian Day, MRCP, FRCS, FRCSC Vancouver, BC

he trial began over a year ago and it has been almost nine years since we first sought justice for patients suffering as they stagnate on government enforced wait lists. During the break in trial, we have heard from the Court of Appeal that certain decisions made by the trial judge cannot be revisited by the Appeal Court until the trial is over. They did state, however, that the judge is free to revise earlier rulings if he feels that is appropriate. We are hoping. Our case is expected to be precedent setting for Canada as it makes its way to the Supreme Court of Canada. During the break in court activities we have been fundraising through a charitable society, the Canadian Constitution Foundation. Their web site http://www.yourhealthcantwait.ca/ was built to inform Canadians of arguments being made in court. We remain optimistic that our efforts will succeed. Many assume that living under an authoritarian regime, where civil rights are not respected, is very different from living in Canada. We might think that we have all the freedoms that go with living in a democracy, and that our constitution protects us from oppression. In reality, few are in a position to mount a constitutional challenge when their rights are violated. To do so is exorbitantly expensive. Government has unlimited funds (your tax dollars) to counter any such efforts. Challengers must fund legal costs, witness expenses, and other disbursements. Outrageously, they must also pay the government a daily court fee of $800 for the privilege of fighting for their rights. This is why it took so many years to strike down unjust laws that permitted racial and sexual discrimination, not to mention laws that outlawed abortion, same sex marriage, safe injection, assisted dying. During the adjournment period, our lawyers have prepared witness statements from those we will call to the stand. We will soon receive the governments’ and opponents’ witness statements. We hope this process will limit the ability of government lawyers to their prior stalling tactics. A new development in BC is the election of a minority NDP government (supported by the Green Party). The new Attorney General and defendant in the case, David Eby, is the representative member from my riding and a former civil liberties lawyer. I am often asked if having a new NDP government will have a negative impact on our case. I don’t believe it will. By going to court we have bypassed the political rhetoric that is responsible for the failure of our health system to evolve over the last 50 years. The new BC government is in an excellent position to address health reform. I remind everyone that our private centre opened in the middle of the NDP’s ten- year rule of the province. At trial, I will review the meetings of that era when we negotiated with senior NDP government and labour leaders. They supported the venture (albeit on condition that their sup-

port would not be publicized). They endorsed our contracts with WCB. As with socialist Labour Prime Minister Tony Blair in the UK, during his expansion of the private sector role in health, the opposition parties did not raise objections. The former NDP government was not opposed to a role for the private sector in health, and was a founding shareholder in one of the largest private health corporations in Canada (Interhealth Canada). Interhealth focused on the development of private hospitals internationally. They recruited Canadian health workers who left the country, and were pivotal in the UK expansion of private health care. Its founding CEO was a former NDP provincial cabinet minister and founding shareholders included several provincial NDP governments, as well as the largest provincial nursing association in Canada. The late NDP Leader, Jack Layton, stated publicly that he was not concerned with private clinics as long as they do not receive public money. He explained that an NDP federal government would not do anything to stop such clinics provided they are 100-per-cent private and pointed out that entirely private health care has always been an option for Canadians. “That’s been available since Medicare was established. That’s a fundamental aspect of what Tommy Douglas established in Canada. There’s nothing new about that. Our focus is on what happens to the public tax dollars that we all contribute to help take care of Canadians”, he said. Our lawyers have repeatedly explained that the changes we seek do not violate the Canada Health Act. Many opposing us are ignorant of this fact. The crisis in orthopaedic manpower will feature prominently, since it is a symptom of our ailing system. The peculiar paradox of a massive demand from patients for orthopaedic treatment, while almost 200 young orthopaedic specialists are simultaneously denied the ability to offer care, is evidence of a seriously dysfunctional system. This is not a new phenomenon. As recorded in the 2001 minutes of the Senate Committee on Health, chaired by Senator Michael Kirby, I used the following analogy to describe the motive behind our doctors getting together in the early 90’s to build a private surgery centre: “Imagine a mechanic with thousands of cars to fix and the staff to do it, but the government owns the garage and it will not allow the mechanics and the cars to go into that COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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

(continued from page 41)

garage. The mechanic goes out and builds his own garage. That is essentially what we did.” In April of this year, former Supreme Court of Canada Justice Michel Bastarache, who sat on the Chaoulli decision, mentioned our case in a speech to BC Crown Counsel. “Here in British Columbia, you are certainly aware of the Cambie case. I’ve been told that over the last few weeks there have been 17 decisions on admissibility of evidence, four of which are now being appealed. One would think the rules of evidence are so vague that there is absolutely no certainty in their application. I’m told that Cambie is set to be continued for another six to eight months. There must be more rigour in our courts. The judges must exercise their authority to prevent irrelevant questioning and limit the time for certain presentations.” We expect a more efficient process within the courtroom when the trial resumes. Our new Attorney General was leader of the BC Civil Liberties Association. It is difficult to believe he supports BC patients being denied the same civil rights that the Supreme Court of Canada granted to Quebec patients.

Ayn Rand stated, “Government was set to protect man from criminals – and the Constitution was written to protect man from the government”. That’s why we are in court. In editions of the COA Bulletin, Dr. Brian Day will be contributing trial updates from the Constitutional Challenge to B.C.’s ban on the purchase of private health insurance for medically necessary services that are already covered by the public system, led by the Cambie Surgery Centre. The outcome of this trial is important to orthopaedic surgeons across Canada as the decision in British Columbia will likely set a precedent for other provinces. Improving access will be beneficial to patients, to the economy of Canada, is compassionate, and will provide resources so that our orthopaedic graduates will have jobs in the future. Regardless of how you feel about the trial and its outcome, the debate on access and funding of care is critical to the future care of our patients – Ed.

Private Costs and Public Queues Doug Thomson CEO, Canadian Orthopaedic Association

he Globe and Mail published a series of articles that included a rather odious piece entitled “Doubledipping doctors defy the spirit of Canadian health-care”. This opinion piece included allegations that physicians working in private clinics are billing both the patient directly and the public system for the same treatments. Never mind that the article used false and misleading distortions of the term “double-dipping,” it didn’t take long for both the federal and provincial white knights to ride in and lay down some fierce sounding threats of audits and investigations into possible violations of the Canada Health Act. While this excitement was bubbling along, Lauren Heuser helpfully reminded us in a July 28 opinion piece in the National Post that the feds, along with the B.C. Health Ministry, are spending tens of millions of tax dollars fighting Dr. Brian Day’s lawsuit that claims that denying Canadians the right to access private care is a violation of the Canadian Charter of Rights and Freedoms. In May of this year, the Fraser Institute study, “The Private Cost of Public Queues for Medically Necessary Care,” reported that just under one million Canadians who are waiting for care lost $1.7 billion last year in wages alone. To make matters worse, that number would be north of $3 billion if the lost time of the Wait 2 period were included. COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Earlier this year, another Fraser Institute report found that 63,459 Canadians left the country for medical care in 2016, up nearly 40% from 2015. Meanwhile, COA members cannot treat patients because of a shortage of OR resources. As Gwyn Morgan pointed out in an August 23 column in the Financial Post, removing prohibitions against private care would reverse the flow of medical tourism money that is now going to foreign private hospitals. This would result in more efficient use of our own highly educated and well-trained health professionals and foster a job-creating investment in one of the world’s fastest growing sectors. To quote from the Morgan article, “Canada’s universal no-charge public healthcare system would remain sacrosanct, while Canadians who choose to access the private clinics would help reduce both wait-times and costs.” Makes sense to me.

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

Coûts au privé et attente au public Doug Thomson Directeur général, Association Canadienne d’Orthopédie

ans une série d’articles, le Globe and Mail a publié un billet particulièrement ignoble intitulé « Double-dipping doctors defy the spirit of Canadian health-care ». Ce billet d’humeur alléguait entre autres que des médecins travaillant pour des cliniques privées facturent le patient directement et le système public pour les mêmes traitements. Qu’importe l’utilisation trompeuse de l’expression « double-dipping » (double rémunération), les preux chevaliers du fédéral et des provinces ont vite brandi les menaces de vérification et d’enquête sur de possibles infractions à la Loi canadienne sur la santé. Dans tout ce branle-bas, Lauren Heuser a eu l’obligeance de nous rappeler, dans un billet d’humeur publié le 28 juillet dans le National Post, que le gouvernement fédéral de même que le ministre de la Santé de la Colombie-Britannique consacrent des dizaines de millions de dollars de nos impôts à leur défense dans la poursuite du Dr Brian Day, qui allègue que refuser à la population canadienne l’accès aux soins privés est une violation de la Charte canadienne des droits et libertés. En mai, dans une étude intitulée « The Private Cost of Public Queues for Medically Necessary Care », l’Institut Fraser rapportait qu’un peu moins de 1 million de Canadiens en attente

de soins ont perdu 1,7 milliard de dollars en salaires seulement l’année dernière. Pire, ce montant dépasserait les 3 milliards de dollars si le temps d’attente pour la période 2 était comptabilisé. Plus tôt cette année, un autre rapport de l’Institut Fraser estimait à 63 459 le nombre de Canadiens qui ont voyagé à l’étranger pour recevoir des soins médicaux en 2016, près de 40 % de plus que l’année précédente. Pendant ce temps, les membres de l’ACO ne peuvent pas traiter certains patients faute de ressources en salle d’opération. Comme le signalait Gwyn Morgan dans une chronique publiée le 23 août dans le Financial Post, supprimer les interdictions relatives aux soins privés permettrait de garder ici l’argent du tourisme médical, au lieu d’en faire profiter des hôpitaux privés à l’étranger. Cela entraînerait une utilisation plus efficace de nos professionnels de la santé dûment formés et favoriserait un investissement créateur d’emplois dans l’un des secteurs les plus dynamiques dans le monde. Comme le dit M. Morgan, le système de santé universel public et sans frais du Canada resterait intact, tandis que les Canadiens qui optent pour les cliniques privées contribueraient à réduire à la fois les temps d’attente et les coûts. Ça me paraît plein de bon sens.

A Model for the Centralized Delivery of Musculoskeletal Care Victor T. Jando, MDCM, FRCSC North Vancouver, BC

ions Gate Hospital in North Vancouver is the tertiary referral centre for the Coastal Health Region of British Columbia. This Region encompasses a geographically diverse and extensive catchment area that extends from the urban centres on Vancouver’s North Shore to the more remote areas along the Central Coast of BC. In 2010, the orthopaedic surgeons from Lions Gate Hospital formed Pacific Orthopaedics and Sports Medicine (POSM). Outside of the hospital, the POSM offices are co-located, centrally managed, and digitally linked by an Electronic Medical Records (EMR) System (Plexia Electronic Medical Systems Incorporated). The North Shore Division of Family Practice (NSDoFP) was also established in 2010 and comprises almost all primary care physicians practicing in our area. The NSDoFP has funding and a formal organizational structure which enable it to investigate various aspects of primary care and undertake complex initiatives for quality improvement.

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

In 2012, the NSDoFP and The COA will regularly be inviting POSM embarked on a joint with administramembers to feature innovative initiative tive support and funding orthopaedic care pathways from provided by Shared Care. across the country. If you would The primary goals of the like to submit your model of care initiative were to improve for publication in the Bulletin, communication between please contact Trinity Wittman at health-care providers and to redesign the standard policy@canorth.org. referral and consultation processes. After forming a steering committee, we hosted several meetings with stakeholders and analyzed the barriers to effective care. Common issues, or gaps in care, were identified and the steering committee then developed solutions which have been implemented over the past four years. The result is our model for the centralized delivery of musculoskeletal care. Identification of Gaps in Care To help identify gaps in care, surveys were administered to the family physicians (FPs) and the surgeons. Patient journey mapping provided additional information from the patient’s

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 45)

Table 1

Gap in Care

Effect on Care Delivery

excessive wait-one times

• negative impact on quality of life for patient • FP sends referrals to multiple surgeons in an effort to have patient assessed sooner • additional visits to the FP or ER to manage symptoms • additional phone calls from patients to offices

lack of communication on referral status

• FP office unsure if referral was received or is being processed by the surgeon

lack of knowledge on subspecialty interests of surgeons

• misdirected referrals where the surgeon receives a referral for a problem outside their scope of practice, causing further delays in wait-one times

incomplete referrals lacking important information such as medical history, medications, investigations

• more difficult to properly triage the referral • delay in wait-one time while the surgeon waits for the missing information

inadequate or inappropriate medical imaging ordered by the FP

• more difficult to properly triage the referral • delay in wait-one time while the surgeon waits for the necessary imaging • new imaging may need to be requested which is costly • inappropriate imaging may result in unnecessary costs (e.g. MRI performed for knee osteoarthritis in an elderly patient)

lack of clarity on the respective roles of the FP and surgeon in managing care (e.g. pain management)

• confusion about who prescribes pain medication • confusion about who arranges diagnostic or therapeutic injections • confusion about who prescribes braces and how they can be obtained • confusion about who manages the patient when the current treatment is failing

perspective. Table 1 summarizes the commonly cited issues and their impact on care delivery. Solutions The keystone of our care delivery model has been the adoption of EMR technology by both the surgeons and the FPs. The EMR has facilitated the implementation and integration of the solutions described below. A significant amount of time and effort was spent educating FPs and their staff on the process. This dissemination of information was accomplished through meetings, presentations, and on-site training in primary care clinics. The various components of our model for the centralized delivery of musculoskeletal care include: 1. Common referral tool – To streamline the initial step in seeking musculoskeletal care, we developed a new referral form to be used for all patients. The referral form is a tool that guides the FP to include the most pertinent information with respect to patient demographics, affected body region, bone/joint versus soft tissue pathology, and the acuity of the problem. The referring physician is also prompted for other information including medications and medical history. To ensure that the correct medical imaging accompanies the referral, the tool includes the recommended plain radiographs for a particular body

region. The referral tool has been embedded into the EMR used by the FP. This digital integration simplifies the referral process by auto-populating the form with demographic information and facilitating the attachment of other important files such as medical imaging reports. 2. Centralized intake and triage – All referrals to our clinic are sent to a single fax number and received into a single electronic inbox. The referral tool promotes higher quality referrals from FPs. As a result, these referrals can be triaged more accurately and rapidly by an appropriately trained staff in the POSM office. The EMR and shared database allow for the immediate distribution of incoming referrals. Once triaged, most referrals are then scheduled into the musculoskeletal assessment clinic (see below) where the Wait 1 time is significantly shorter than the traditional referral to see a specific surgeon. A referral acknowledgement is sent back to the FP within 24-48 hours. The acknowledgement form is also embedded into the EMR so that it can be auto-populated and faxed. In addition, the acknowledgement is used to notify the FP of any special instructions for the patient or if any additional information is required to properly triage the referral.

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 45)

3. Rapid Access Musculoskeletal Assessment Clinic – The patient experience begins with a complete evaluation by a non-surgical, appropriately qualified physician. Currently, our assessment clinic employs a foot/ankle physician, two sports medicine specialists, an orthopaedic surgeon who has retired from surgical practice, and several recent orthopaedic graduates performing locum work. The clinic also provides follow-up care and a “one-stop shop” with access to a variety of non-surgical treatments. Such treatments may include diagnostic or therapeutic injections, ultrasound-guided joint injections, assessment by an inhouse orthotist and bracing, or referral for physiotherapy. If a surgical opinion is warranted, an internal referral is made to one of the eight surgeons with the most appropriate subspecialty expertise and with the shortest surgical waitlist. 4. Telephone advice line – We offer FPs a telephone advice line for that is coordinated through the POSM office. The phone line operates during weekdays and regular business hours. There is a single phone number to which all calls are placed. Upon receiving a call, the POSM staff will create a patient profile in the EMR and notify one of the surgeons. The surgeon will then contact the FP to discuss the case. The purpose of the advice line is not to obtain a complete consultation by phone, but rather to improve the timely communication for the management of a patient. Use of the EMR allows the phone call to be logged and helps to create a proper chart entry to document the encounter. Results and Improvements in Care Prospective data was collected on approximately 6000 referred patients from June 2013 to June 2015. In addition, surveys were completed by family physicians, surgeons, patients, and office staff, and were used to obtain more qualitative feedback. The most dramatic benefit to patients was a significant decrease in the Wait 1 time from approximately 18 months down to 3-4 months (average). Eighty-three percent of patients did not require a surgical opinion and 50% of those were managed with other treatment modalities, or sent for further specialized investigations. As a result, patients who were assessed and deemed non-surgical did not have to languish on long waitlists to see a surgeon. Instead they were promptly directed toward the most appropriate nonoperative treatment option. Our model also resulted in more effective communication between the offices of FPs and the surgeons. Those FPs using an EMR-embedded referral tool were able to efficiently produce a good quality referral and quickly receive an acknowledgement of its receipt by our central intake. This simplified referral process was especially beneficial in our large catchment where rural primary care physicians may be unaware of surgeon practice patterns. Use of the telephone advice line may avoid unnecessary referral for a consultation, avoid unnecessary ER visits, and minimize the ordering of inappropriate or unnecessary investigations.

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

The surgeons also experienced an improvement in their office efficiency. Centralizing and collecting all incoming referrals into a common pool eliminated the duplication of referrals sent to multiple surgeons. This common pool also provided a more accurate snapshot of the total musculoskeletal referral demand in the region. MOAs spent less time sorting through referrals and dealing with patients calling to enquire about their appointment status (or to complain of the lengthy wait time). By filtering out the nonoperative patients managed through the musculoskeletal assessment clinic, surgeons could more efficiently use their time to evaluate patients most likely requiring surgical management. Having a centralized process can facilitate the collection of data pertaining to referral patterns and volumes, patient disorders, treatments, and outcomes. For example, we can allocate clinic time and surgical resources based on the relative volumes of patients and the specific musculoskeletal problems for which they have been referred. Data can easily be obtained for quality and performance monitoring. For example, if our clinic receives a large volume of referrals for patients with knee arthritis for whom an MRI has been ordered, we can target the referring physician with education about the lack of indications for an MRI in most patients with degenerative joint disease. Conclusion Our model for centralized care continues to evolve into a “medical home” for comprehensive musculoskeletal care within our region. Our own analysis has demonstrated a high satisfaction amongst patients and physicians, a reduction in Wait 1 times, more timely access to appropriate treatment, the ability to collect meaningful data, and potential cost savings to the healthcare system. Unfortunately, our success in improving the delivery of care for our patients in the community has emphasized the significant lack of access to hospital-based care and surgical services for many orthopaedic patients. In the future, we hope to secure sustainable funding for our model of care. We anticipate the transfer of knowledge and spread of our model to other communities and surgeon groups. Feel free to contact me at drjando@pacificortho.ca with any questions. Acknowledgements I would like to recognize the following individuals who have made a significant contribution to the success of our project: Dr. Alan Baggoo – Orthopaedic Surgeon Co-Lead Dr. Lisa Gaede – Family Practice Co-Lead Dr. Ruth Campling – Family Practice Co-Lead Bethina Abrahams – Shared Care Lead and Liaison Chisato Ito – Project Administrative Lead Tara Muncey – Orthopaedic Administrative Lead

Resident Scholarship Opportunity – Call for Applications The Canadian Orthopaedic Foundation is pleased to announce that applications are now being accepted for the 2018 Bones and Phones Legacy Scholarship Award. One thousand dollars is awarded on an annual basis to an orthopaedic resident in his or her year prior to their final year of clinical training who is a member of the Canadian Orthopaedic Association (COA) and who meets the criteria as outlined in the guidelines and application documentation. More information, including eligibility criteria, application forms and guidelines, is available at www.whenithurtstomove.org: click on ‘Bones and Phones Scholarship’ under ‘Research & Awards’.

Bourses offertes aux résidents — Soumission des candidatures La Fondation Canadienne d’Orthopédie est heureuse d’annoncer qu’il est maintenant possible de soumettre sa candidature pour la Bourse d’études Bones and Phones 2018 : Chaque année, 1 000 $ sont remis à un résident en orthopédie membre de l’Association Canadienne d’Orthopédie effectuant son avant-dernière année de formation clinique et respectant tous les critères établis dans les directives et le formulaire de demande. Pour accéder à de plus amples renseignements, y compris les critères d’admissibilité, le formulaire et les directives, rendez-vous à www.whenithurtstomove.org/fr et cliquez sur « Fonds de bourses d’études Bones and Phones », dans le menu « Prix, bourses et subventions ». 2017 Scholarship Recipient / Lauréat de la bourse d’études 2017 :

Ahmed Aoude for his role in / pour son rôle dans

The International Orthopaedic Surgery Committee, McGill University / le comité international de chirurgie orthopédique de l’Université McGill

Foundation / Fondation

COF 2016 Samson Award Recipient: Dr. George Athwal

uring the COA Annual Meeting in Ottawa in June, the Canadian Orthopaedic Foundation (COF) was pleased to present the 2016 J. Edouard Samson award to Dr. George Athwal, Professor of Surgery at London’s Western University, St. Joseph’s Health Care. The Samson Award is the COF’s premier research award, recognizing the best career orthopaedic research over a period of five years. The annual award was increased this year to $30,000. Dr. Athwal’s research is entitled “The Biomechanical Assessment of Complex Shoulder Instability.” He provided the following summary of his research: “Shoulder instability is a disabling condition, associated with pain and an inability to participate in sports and work. Recurrent instability is more common when there are associated bony defects, such as anterior glenoid bone loss (bony Bankart) and humeral head impression fractures (Hill-Sachs defect). Shoulder instability with associated bone defects has been termed “complex” instability. “The occurrence of these associated defects is directly related to the risk of recurrence and importantly, the failure of standard surgical stabilization techniques. Due to this high failure rate, several new, alternative and controversial surgical techniques have been developed. While each surgical technique has purported advantages and disadvantages, there is a lack of high level of evidence clinical outcomes literature comparing the various procedures. In circumstances of insufficient clinical literature, biomechanical studies can assist with decision

making. Unfortunately, in 2011 the biomechanical literature on the management of complex shoulder instability with these newer procedures was sparse. Therefore, the purpose of this work was to employ an experimental biomechanical approach to study the advanced surgical techniques used to manage complex shoulder instability. “Since 2011 we have been devoted to assessing several surgical procedures, such as the Latarjet procedure, Bristow transfer, remplissage procedure, allograft humeral head reconstruction, and partial resurfacing arthroplasty.” Dr. Athwal’s research program has led to over 15 peer-reviewed articles on the biomechanics of shoulder instability and has had a substantial effect on the clinical management of these pathologies. In addition, the research has been presented at numerous national and international meetings. Ultimately, Dr. Athwal’s research has led to an improved understanding of the advantages and disadvantages of the advanced surgical techniques used to manage complex shoulder instability, and has addressed the gaps in the biomechanical literature on complex shoulder instability reconstructive surgeries. The COF is proud to support Dr. Athwal’s research program.

Le Dr George Athwal, lauréat du Prix J.-Édouard-Samson 2016 de la Fondation Canadienne d’Orthopédie

a Fondation Canadienne d’Orthopédie a eu le plaisir de remettre le Prix J.-Édouard-Samson 2016 au Dr George Athwal, professeur de chirurgie au St. Joseph’s Health Care de l’Université Western, à London, à l’occasion de la Réunion annuelle de l’ACO à Ottawa, en juin dernier. Distinction la plus prestigieuse de la Fondation, le Prix J.-Édouard-Samson reconnaît la meilleure recherche en orthopédie menée sur une période de cinq ans. Cette année, la valeur du Prix a été augmentée à 30 000 $. Le projet de recherche du Dr Athwal s’intitule « The Biomechanical Assessment of Complex Shoulder Instability ». Voici le résumé qu’il fait de ses travaux : « L’instabilité de l’épaule est une affection incapacitante; elle cause de la douleur et empêche les activités sportives et professionnelles. Une instabilité chronique est plus courante en COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

présence de déficits osseux, comme une fracture de la partie inférieure de la glène (Bankart osseux) ou une lésion de la tête humérale (encoche de Hill-Sachs). L’instabilité de l’épaule associée à des déficits osseux est qualifiée de «complexe». L’occurrence de ces déficits est directement liée aux risques de récidive et, surtout, à l’échec des techniques chirurgicales standard de stabilisation. En raison du taux d’échec élevé, on a élaboré plusieurs techniques nouvelles, non conventionnelles et controversées. Bien que chacune ait ses avantages et ses inconvénients, il y a peu de littérature fiable faisant la comparaison de leurs résultats cliniques probants. En l’absence d’une littérature clinique suffisante, les recherches en biomécanique peuvent éclairer le processus décisionnel. Malheureusement, en 2011, la littérature sur la biomécanique dans le traitement de l’instabilité complexe de l’épaule grâce à ces nouvelles procédures était rare. Le but de ces travaux est donc d’étudier les techniques chirurgicales de pointe employées pour traiter

Foundation / Fondation

(suite de la page 48)

l’instabilité complexe de l’épaule d’après une approche biomécanique expérimentale.

gies. De plus, ces travaux ont été présentés dans divers congrès nationaux et internationaux.

Depuis 2011, nous évaluons plusieurs techniques, comme la chirurgie de Latarjet, la chirurgie de Bristow (transfert osseux), le remplissage, la reconstruction par allogreffe de la tête humérale et le resurfaçage partiel. »

Au bout du compte, les travaux du Dr Athwal ont permis de mieux comprendre les avantages et inconvénients des techniques chirurgicales de pointe utilisées pour traiter l’instabilité complexe de l’épaule et de combler une lacune dans la littérature sur la biomécanique dans les chirurgies de reconstruction en présence d’une instabilité complexe de l’épaule.

Le programme de recherche du Dr Athwal s’est traduit par la publication de plus de 15 articles revus par des pairs portant sur la biomécanique de l’instabilité de l’épaule et a eu une incidence marquée sur le traitement clinique de ces patholo-

Canadian Orthopaedic Foundation’s Annual Report Now Available Did you know that the COF awarded more research grants than ever before? That our up-to-date library of educational resources went virtual? That we matched many orthopaedic patients across Canada with trained volunteers to lessen their fears and isolation? And that the GLA:D program grew across Canada? These and other facts are detailed in the Report, where you can also read our condensed financial statements, and see the lists of our top surgeon and public donors. Take a few moments to read through the report and learn more about the Canadian Orthopaedic Foundation on the COF web site.

La Fondation est heureuse de soutenir le programme de recherche du Dr Athwal.

Le Rapport annuel de la Fondation Canadienne d’Orthopédie est en ligne Saviez-vous que la Fondation a remis un nombre record de prix et bourses de recherche? Que notre bibliothèque de ressources à jour est maintenant virtuelle? Que nous avons jumelé un grand nombre de patients en orthopédie de tout le pays avec des bénévoles formés de sorte à réduire leurs craintes et l’isolement? Que le programme GLA:DMC Canada a pris de l’expansion partout au pays? Ce sont là quelques-uns des faits détaillés dans le Rapport annuel, où vous trouverez en outre l’état condensé de notre situation financière et nos listes des orthopédistes et autres donateurs les plus généreux. Prenez le temps de lire le Rapport annuel et, pour en savoir davantage sur la Fondation, consultez son site Web.

www.whenithurtstomove.org COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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

Using the CanMEDS Roles in Your Practice Collaborator

Ryan Perlus, BSc, MSc, M.D. PGY-3 Resident, Division of Orthopaedic Surgery, University of Toronto Toronto, ON Markku T. Nousiainen, B.A.(Hons), MS, MEd, M.D., FRCSC Associate Professor, Department of Surgery, University of Toronto Program Director, Division of Orthopaedic Surgery, University of Toronto Toronto, ON

indicated a discrepancy between the perceived importance of the role of collaborator among attending surgeons, and senior and junior residents3. Junior residents thought that the intrinsic roles were of lower importance than senior residents or attending surgeons. This is consistent with other studies that have shown that junior trainees fail to acknowledge the importance of good communication and collaboration7. This finding is concerning because in orthopaedic surgery, junior residents are often the ones who are first to be contacted by consulting services and the first to see patients in the emergency room and ward.

ince 2005, the Royal College of Physicians and Surgeons of Canada introduced the CanMEDS framework as a means to idenIf the collaborator role is so important, then tify and describe the abilities of physicians how well is it being taught? Perhaps not as to effectively meet the health-care needs good as we think it is. Research has shown of the people they serve1. The role of that residents report learning about colmedical expert was organized as the laboration through faculty role modelcentral pillar that interacted with an ling but they do not perceive that it additional six other roles, referred to is part of the formal teaching curricuas intrinsic roles. These included the lum4. In addition, faculty have reportcollaborator, communicator, health ed that they have never been trained advocate, scholar, and manager roles. in how to effectively model this role4. The CanMEDS framework was integrated Both residents and faculty have reported a into the Royal College’s accreditation standneed for training in how to appropriately teach ards, specialty training documents, final inthis role4. training evaluations, exam blueprints and the Maintenance of Certification Program. In 2015, Although a wide variety of assessment tools modifications of all the roles occurred (for examfor the intrinsic CanMEDS roles exist, including ple, the manager role was replaced with the leader in-training evaluation reports (ITERs), structured role)2. This article discusses the how the collaboraoral examinations, 360° assessments, and objector role can be taught and assessed in the tive structured clinical examinations (OSCEs), Copyright © 2015 specialty of orthopaedic surgery. the ITER has become the most widely used The Royal College of Physicians evaluation tool to assess the CanMEDS and Surgeons of Canada. According to the CanMEDS framework, a roles5. A recent study from the Division of http://rcpsc.medical.org/canmeds. collaborator is a physician who works effecOrthopaedic Surgery at the University of Reproduced with permission tively with other health-care professionals to Toronto has shown that the use of an OSCE provide safe, high-quality, patient-centered care1. Furthermore, to evaluate the intrinsic CanMEDS roles is valid and reliable it involves patients and their families, physicians, and other in the current CBME curriculum6. This study had varying level members of the multidisciplinary team. Collaboration requires residents undertake an OSCE which evaluated their ability to relationships based on trust, respect, and shared decisionperform the intrinsic CanMEDS roles. After scoring, residents making1. were provided with immediate feedback from their assessors and were given recommendations for future improvements, if In the current climate of competency-based medical educaneeded. Total test scores, individual station scores and individtion (CBME), the CanMEDS framework is heavily utilized to ual CanMEDS role scores all showed a significant effect by PGY guide the education and development of physicians. In the level, where senior residents outperformed junior residents. patient-care setting there is an ongoing need for exemplary collaborative skills amongst trainee and attending orthopaedic Another method of assessing the level of competence in this surgeons, their patients, and their health-care teams. Despite role going forward may involve the use of role play with standthis, there have been many challenges in teaching this role and ardized patients in simulated multi-disciplinary team meetings. in finding reliable and valid methods for assessing it and the In a recent study, this tool was found to be effective in identifyother intrinsic roles. ing deficiencies in the performance of the collaborator role in resident trainees7. The importance of interpersonal abilities to appropriately collaborate in orthopaedic surgery has been recognized by At this time, no evidence exists on how to effectively teach program directors, staff surgeons, and patients. Interestingly, and assess the collaborator role in the continuing professional a study looking at the perception residents and attending development (CPD) realm for the practicing orthopaedic sursurgeons have towards the importance of the CanMEDS roles geon. Despite this, CPD credits must be accumulated by a pracCOA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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ticing surgeon for Royal College Maintenance of Certification; many of the CPD activities that can be recorded involve the collaborator role. Surgeons in practice can avail themselves to local, national or international courses, such as the International Conference on Residency Education (that is run annually in Canada) that teach the collaborator role. The role of collaborator focuses on working effectively with other members of the health-care team, identifying and resolving conflicts, and pursuing common goals to improve patient outcomes. With the implementation of CBME, residency training and CPD programs are recognizing the importance of developing competence amongst all CanMEDS roles. Medical educators need to continue to work on identifying not only how to evaluate performance in this role but also how to appropriately teach it. While some naturally possess a greater degree of innate collaborative skills, all members of the healthcare team should understand the importance of this role on patient outcomes. Attending surgeons, fellows, and residents should focus on providing mentorship for not only their trainees but also their peers. References 1. Frank J., Danoff D. The CanMEDS initiative: implementing an outcomes-based framework of physician competencies. Medical Teacher. 2007:29(7):642-647.

3. Arora S., Sevdalis N., Suliman I., Athanasiou T., Kneebone R., Darza A. What makes a competent surgeon? Experts’ and trainees’ perceptions of the roles of a surgeon. The American Journal of Surgery. 2009:198(5):726-732. 4. Berger E., Chan M.K., Kuper A., Albert M., Jenkins D., Harrison M., Harris I. The CanMEDS role of Collaborator: How is it taught and assessed according to faculty and residents? Paediatric Child Health. 2012;17(10):557-60. 5. Chou S., Cole G., McLaughlin K., Lockyer J. CanMEDS evaluation in Canadian postgraduate training programmes: tools used and programme director satisfaction. Medical education. 2008;42(9):879-886.. 6. Dwyer T., Glover-Takahashi S., Kennedy Hynes M., Herold J., Wasserstein D, Nousiainen M., Ferguson P., et al. How to assess communication, professionalism, collaboration and the other intrinsic CanMEDS roles in orthopedic residents: use of an objective structured clinical examination (OSCE). Canadian Journal of Surgery. 2014:57(4):230-236.. 7. Ouellet K., Sabbagh R, Bergeron L., Mayer S.K., St-Onge C. Exploring residents’ spontaneous collaborative skills in a simulated setting context: an exploratory study on CanMEDS collaborator role. Advances in Medical Education Practice. 2016;21(7):401-5.

2. http://www.royalcollege.ca/rcsite/canmeds/canmedsframework-e

Multiple Billing Codes Produce Multiple Problems Roger Haene, M.D., FRCSC Fredericton, NB

ditor’s note: The Practice Management Committee hopes to assist the membership by focusing on various billing issues and will provide a series of related articles in the COA Bulletin. Dr. Roger Haene’s letter explaining that he is leaving Canada was received by all of us in foot and ankle surgery with sadness and regret. In the following article, Dr. Haene discusses the issues around multiple fee items, which are a necessity for reimbursement of complex procedures (or in areas where fee codes do not exist), as well as the challenges in changing fee codes. These issues are not unique to New Brunswick. Different provinces have diverse ways of dealing with procedures requiring multiple fee codes. In general, they are not liked by the billing agencies as they require individual review (which is costly) and are potentially subject to abuse. The committee that reviews these claims remains anonymous (at least in British Columbia), preventing any discussion and resolution and the decisions are often inconsistent and arbitrary. For surgeons having to bill multiple fee items - more common in complex or revision surgery - they remain a source of contention. Some surgeons address the issue by simply refusing to do this type of surgery and sticking to single fee items, I would contend to the

detriment of patients, and resulting in more costly care. Although the article that follows represents the perspective of one member, it may be reflective of a systematic problem in foot and ankle orthopaedic care remuneration and possibly in orthopaedic care in general. This is a much-needed discussion and hopefully we can engage our provincial health ministries to address this issue to the benefit of patients, surgeons and billing agencies. Thank you for the opportunity to share my experience with you. I am an orthopaedic foot and ankle surgeon and have been practicing in Fredericton, New Brunswick, since February 2011. My experience with the billing system has led directly to my decision to leave Canada and seek a fairer deal in another country. It has become increasingly non-viable to run a foot and ankle practice in New Brunswick, especially over the course of the last year. Foot and ankle surgery is a relatively new and rapidly-evolving subspecialty. Current billing codes in New Brunswick are outdated, and therefore the billing codes for foot and ankle procedures are either low, or non-existent. Foot and ankle reconstructions almost universally involve surgical intervention at multiple sites during the same operation, COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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and there is no single code to represent a complex multi-step surgical procedure. In order to fairly claim for work done, codes representing individual steps need to be stacked. Even though stacking these low codes gives a low total, in the past the ability to stack codes has kept my foot and ankle practice barely viable. I did need to perform more hip and knee surgeries than I wanted to, so as to increase the overall monthly billings and thereby keep my practice financially safe. About a year and a half ago, I noticed that many of my multistep foot surgeries resulted in Medicare only reimbursing me for the first code, and perhaps 50% of the second code, if I was lucky. The remaining codes were held back for months, and would eventually vanish off the reconciliation statement. Ironically, the bigger the surgery, the more of a loss I experienced, as more steps went unpaid. Of course, as a fellowshiptrained foot and ankle surgeon, it is precisely the complex cases requiring major surgeries that are typically transferred to me by colleagues. These frequent referrals, especially for trauma and diabetic/Charcot cases, significantly harmed the financial health of my practice. Over the past year and a half, the Medicare payments frequently dipped below levels required to cover my practice expenses. I wrote several letters to Medicare to inquire about the billing codes, highlighting the exceptionally poor payment related to several specific patients, and I also had a couple of telephone conversations with the appropriate Management Support Consultant at Medicare. Unfortunately, nothing changed in real terms from a payment perspective. I then tried to submit the larger cases for consideration based on surgical time rather than billing of individual steps. However, those requests languished in the Medicare offices for up to nine months, and were clearly not a viable option. This left me with no mechanism by which to fairly claim for multistep foot and ankle surgeries performed. In parallel, for more than seven years (since prior to my arrival to New Brunswick), a committee has been working on an overhaul of New Brunswick billing codes, with new codes based on Canadian averages. The committee deliberating on the changes has consisted of physician and government representatives. Many new foot and ankle codes have been introduced into the proposed schedule, which at first glance sounds quite promising. However, a couple of big obstacles arose. Firstly, talks stalled many times. Somehow, for several years, the different orthopaedic subspecialties were being pitted against each other. In brief, in order for foot and ankle surgeons to earn more, spinal surgeons would have to earn less. I hold no grudges towards any of my colleagues. The concept that another colleague has to first earn less before I can earn more is illogical, unless we start from the premise that the provincial health-care system is already broke. It is the latter idea that has worried me the most. Secondly, the absence of a mechanism to stack codes would render meaningless the proposed code improvements for the individual steps. I therefore spent several weeks creating a set of single codes for all of the major foot and ankle surgeries. The process was open and transparent, using tables to demonCOA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

strate how I used existing codes to arrive at the final composite code. These codes were ratified at the New Brunswick Medical Society meeting attended by orthopaedic surgeons in the province representing all of the subspecialties. Unfortunately, the government disagreed with the proposed composite codes. The reason given was that it is feasible that not every single surgical step will be performed every single time such a major operation is performed, and it might therefore be marginally more expensive to cover single composite codes. The government’s counter-offer was to ask why foot and ankle codes could not simply be stacked to represent the surgical steps actually performed during the operation. I never did get a straight answer from Medicare as to why the payment of stacked billing codes became a problem approximately a year and a half ago. From fragments I have picked up in conversation at meetings, possibilities range from software that could not handle more than a couple of codes per operation, to problems with manually sorting through multiple codes at the Medicare offices (which I would surmise presumably led to a decision to stop manual processing of the extra codes). It is difficult for me to understand how the government is now asking me to do precisely the thing that I have been trying unsuccessfully to do for the last year and a half. The very billing system that led to my underpayment is now being held up as the correct path forward, presumably because it is the (marginally) cheaper option for Medicare compared to single composite codes. In my opinion, this is debatable, as single codes would save on administrative costs. Since stacking codes has now been deemed by the government as the preferred foot and ankle billing method in New Brunswick, I believe it would be proper to settle back pay for the codes that have gone unpaid over the past year and a half. I raised this request during the most recent teleconference with the billing committee, but it was denied, because “when we agree on a policy, we tend to move forward from that point”. This has forced my practice to swallow an unsustainable financial shortfall. A practice can end the month in worse financial shape than at the beginning of the month, in spite of working at overmaximum capacity, for only a very limited time. Even though the new code schedule has been “coming soon” for some time now, we are still using the old codes at the time of this writing, and I still cannot stack codes. Any changes coming are too little, too late in my case, and I am forced to close my practice and move on. Other foot and ankle surgeons in the province have faced similar issues. In my opinion, the only reason they have not yet closed down is because they started practicing in the province later than I did, and I fear they may suffer a similar challenge. In the proposed new billing schedule, many trauma codes and upper-limb surgical codes have also been introduced or upgraded. In line with the aforementioned suspicion that the New Brunswick health-care system might be running out of

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money, several participants have expressed concern that the new codes may not even be financially sustainable for the province. I do not anticipate that New Brunswick will easily be able to recruit new foot and ankle surgeons in the near future. I believe that it is the management of complex diabetic and trauma cases that is going to cost Medicare and the New Brunswick government the greatest amount of money in future. If not managed properly, permanent disability will mean the patient will never again work or contribute to the society, and their health costs and social costs will need to be carried by the taxpayer. Reduction in access to foot and ankle surgeons will

hurt the Canadian Armed Forces. Base Gagetown is one of the largest military bases in Canada, and their infanteers in particular suffer a very high incidence of foot and ankle injuries during training and deployment. The Stan Cassidy Centre for Rehabilitation in Fredericton also relies very heavily upon the services of foot and ankle surgeons to help benefit their patients’ rehabilitation. I hope in moving forward that policies will be chosen to ensure ongoing access for the population of New Brunswick to highquality foot and ankle surgical care, and I hope that the proposed new billing schedule is sustainable.

Tax Planning & Health Spending Accounts (HSAs) Adam O’Neill, BSc, MBA, CLU, CHS COAplan Director, Financial Advisor

here has been considerable anxiety recently around the proposed tax changes and how they will affect professionally incorporated physicians in Canada. While it remains to be seen how many of the proposed tax changes will be enacted and what impact they will have, it is safe to assume that some of the tax management strategies used by Canadian orthopaedic surgeons may be affected. With that in mind, let’s examine one often overlooked strategy which can be a powerful tool for many surgeons: Health Spending Accounts, or HSAs. Health Spending Accounts is a general term, encompassing a number of different types of plans and strategies, but for now, I will use that term broadly to avoid over complication. The Problem Whether or not you have access to group benefits (through a spouse, an affiliated hospital, or your own corporate plan), Health Spending Accounts can have a significantly positive impact on your finances. HSAs enable you to fund eligible medical expenses with corporate pre-tax dollars, effectively deducting all eligible medical expenses from corporate profits, without many of the restrictions common in group benefits plans. Individuals with Benefits Coverage For surgeons who have access to group benefits, HSAs offer the ability to cover those expenses which are not covered by your plan, in a more tax efficient manner. Usually this is an expense or portion thereof which is not covered by your plan, either because it surpasses some capped threshold, is a non-eligible expense such as a dispensing fee or deductible, or is in a cat-

egory which your plan simply does not cover. In years where there are large expenses (such as my wife’s $4,000 tooth replacement in 2016), this can be significant. Individuals without Benefits Coverage Surgeons with no access to group benefits coverage have likely been paying all medical expenses out of pocket with personal after-tax dollars. HSAs enable you to transform these expenses into a corporate deductible expense. This makes acquiring effective ensured coverage more affordable and tax efficient. How These Plans Work Essentially a Health Spending Account is a trust account into which your corporation contributes funds. This would be considered a deductible expense to the corporation. Those funds are held in trust, and then used to reimburse you (and your dependents) for medical expenses. This structure allows for complete control over your health spending. There are no deductibles or category limits, and no unnecessary or unwanted coverage. You decide how much and where you want to spend. These plans can be used as a replacement for some group benefits coverage, but are best combined with some level of insured drug coverage. The Structure The term ‘Health Spending Account’ is actually a term which encompasses a number of different structures. For most incorporated orthopaedic surgeons, especially those who have no employees, a common strategy is a Personal Health Services Plan (PHSP) held inside a Health and Welfare Trust (HWT). Different structures, depending on whether you have employees and the province you reside in, all impact which strategy is best suited and which restrictions, if any, may be applicable. It is important to note that while Health Spending Accounts (and all their various iterations) can be powerful tax planning tools, the rules regulating them are complex and should only COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

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be undertaken with advice from knowledgeable professionals including your financial planner and accountant. Benefits There are a number of situations and applications where health spending accounts can provide real benefit to incorporated surgeons. These include: Regular Health Maintenance Expenses Group benefits plans and private health insurance operate by charging premiums which, in most cases, are much more than the benefit paid out. This can make sense as a protection strategy for large catastrophic medical expenses, but is generally an inefficient and more costly option for most common preventative expenses such as dental cleanings, small medical issues, and benefits such as massage, chiropractic, and physiotherapy. HSAs allow business owners to deduct these costs and pay for only what they need and use. Expenses Not Covered by Group or Private Plans Health Spending Accounts enable surgeons to ensure that all eligible expenses are covered. This can include deductibles, amounts over benefits plan caps, and some expenses not covered by an individual’s benefits plan. Depending on your family’s usage, this can be several hundred to several thousand dollars per year. Large, Planned Medical Expenses Many large planned expenses, such as braces, large dental procedures, in-vitro fertilization, and serious surgeries, incur costs and expenses which are either not covered or only partially covered by insurance plans. HSAs allow a surgeon to plan effectively for these events and reduce the overall costs. *Expense eligibility as defined by the CRA: https://www.canada.ca/en/revenue-agency/services/tax/individuals/topics/about-your-tax-return/tax-return/completing-a-taxreturn/deductions-credits-expenses/lines-330-331-eligible-medical-expenses-you-claim-on-your-tax-return.html#mdcl_xpns Flexibility HSA accounts allow a surgeon and their dependents to decide for themselves how much to use paramedical services such as massage, physiotherapy, nutritionist, and others. This ensures you pay for only what services you use, and allows you to use as much of one service as you need. Lifestyle and Wellness Expenses In some cases, a portion of the account funds (often up to 10%) may be used for “wellness” expenses such as gym or health memberships, supplements, and others. Tax Efficiency The cost of HSAs vary, but usually range between 7% to 15% of contributed funds. When compared to the after tax cost of paying out of pocket with personal, after-tax dollars, which depending on your tax bracket, could near or at 53%. Even after taking into account any applicable tax credits, these costs can be a very attractive alternative. COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Limitations While the above benefits can be very attractive, it is also important to understand what HSAs cannot do. • You are limited by the funds contributed to a plan, and therefore it may make sense to maintain some level of insurance to cover catastrophic medical events (especially drug coverage). • Care must also be taken to avoid building up an “unreasonable” surplus inside your account. There is no clear CRA definition on what constitutes “unreasonable”, advice from your accountant is highly recommended. • Once funds are allocated to the account, they cannot be withdrawn unless for eligible medical or wellness expenses. There is some flexibility in terms of rolling unused funds forward to future years, and in changing the annual or monthly contribution amount, but this is an important consideration. • Depending on the province you live in and the specifics of your corporation, there may be additional restrictions or limitations on the type of HSA available to you or the amount of contributions you can make in a given year. Retirement One other key attribute to understand is how Health Spending Accounts function after you retire. No further contributions can be made to the account, but you and all your dependents can still access the remaining funds in the same way. Even once you pass, your spouse and other dependents can continue to access the remaining funds in the account as before. However, upon the death of the final covered individual or trustee (you, your spouse, or your dependents), there are limited options for any remaining funds in the account. One common action is to donate any remaining funds to charity. Summary Despite the prevailing sense of doom in the news for incorporated surgeons in Canada, there are still strategies to reduce expenses and manage tax. HSAs, in all their various forms, offer one often overlooked but potentially very powerful tool to do this through a more efficient use of your health care dollars, and through the transformation of eligible medical expenses into corporate deductible expenses. For more information and a more detailed discussion if this strategy would be effective for your business, contact us at COAplan.ca (accessible through the Membership: Member Benefits tab).

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

History of Orthopaedics in British Columbia – Part II Robert W. McGraw M.D., FRCSC COA Past President, 1990

e are pleased to present Part II in our three-part series outlining the history of the specialty in BC. Click here to view Part I of the series and stay tuned for Part III in an upcoming edition of the COA Bulletin – Ed. The Beginnings of Academic Orthopaedics in British Columbia • 1950 – Opening of the University of British Columbia Medical School • 1951 – Creation of the Division of Orthopaedic Surgery At the end of World War II in 1945, there was no medical school in British Columbia and much controversy ensued over where the new medical school would be located. Arguments for both a UBC site and Vancouver General Hospital site were presented and finally, VGH was chosen as the medical school’s location. A campus hospital was not built until much later on. In 1951, F. P. Patterson Jr. was appointed Head of the new Division of Orthopaedic Surgery by H. Rocke Robertson at the Vancouver General Hospital. F. P. Patterson Jr. F. P. Patterson Jr. (Figure 1) was an ABC Fellow and a member of the first North American group to be guests of the British Orthopaedic Association. He immediately divided the existing Vancouver General Hospital (Figure 2) orthopaedists into two services with two and a half OR days for each and alternate all-day Saturdays. Dr. Patterson took no emergency calls.

Figure 2 Staff at VGH – 1951. W.J. Thompson; F.C. Preston; D.E. Starr; C.S. Allen; H.H. Boucher; A.M. Inglis; K.S. Morton; F.P. Patterson; H.S. Gillepsie; W.H. Fahrni

The London Rotation Dr. J. C. Kennedy was the Head of Orthopaedic Surgery at the University of Western Ontario which did not have a resident training program. As a result of a close personal friendship between Drs. Kennedy and Patterson, an orthopaedic rotation from Vancouver to London was established. In this rotation, a resident, one year before completion, spent a year training at the University of Western Ontario. The following residents participated in this program: • 1961 – J. Watt • 1962 – H. McNeil • 1963 – Dr. Brown • 1964 – R. McGraw • 1965 – J. Hunt • 1966 – J. Schweigel

In 1951, there were 2,294 orthopaedic inpatients, 3,434 operations and 120 Figure 1 beds.

F. P. Patterson in his RAF Uniform

The objectives for the new division were to: 1. Develop a highly-rated clinical service. 2. Develop a resident education program. 3. Develop a research program.

• 1967 – D. Harder • 1968 – R. Rusch • 1969 – S. Tredwell • 1970 – J. Poulsen • 1971 – M. Piper • 1972 – R. Loomer

Post-fellowship Education Dr. Patterson observed the benefits of education outside of the UBC’s Division of Orthopaedics. Early on, he established a policy that all academic appointments in the University’s orthopaedic division must have a post-fellowship education. As a result of this decision, the Vancouver program became one of the most subspecialized orthopaedic groups in Canada. American Board of Orthopaedic Surgery Dr. Patterson highly valued affiliations with orthopaedics in the United States and strongly recommended that all graduates sit the American Board of Orthopaedic Surgery examination. This way, they could qualify for fellowship in the American Academy of Orthopaedic Surgeons in order to facilitate personal continuing education.

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Early on in the development of the residency program, Dr. Patterson adopted the principles set down in 1965 by Dr. George Miller, University of Illinois, known for his Study of Competence. In order to achieve a high level of competence in a graduating resident, it must be determined that he or she would be able to: 1. Recall information. 2. Observe, analyze and interpret data. 3. Solve clinical problems. 4. Communicate effectively with patients and colleagues. 5. Exhibit surgical skills. For many years Drs. Patterson and McGraw were the only two Canadian examiners on the American Board of Orthopaedic Surgery. This provided not only Canadian input into the Board, but also was beneficial for the constant update of the Vancouver Resident Education Program. Dr. McGraw represented Canada on the AAOS Board of Figure 3 “Group of Seven” graduating year 1975. Included in the picture are B. Day, R. Davidson, K. Outerbridge, Councillors for eight years. C. Duncan, P. Wing, R. Loomer, G. Ponsford, P. McConkey, S. Tredwell

Resident Education Program The Resident Education Program was popular from the outset. By 1970, the program had 20 residents. It pioneered a selection process, structured curriculum, anatomy demonstrations, seminar series, practice examinations, and a detailed evaluation process. An example shown is the 1975 resident program which included the graduating “Group of Seven”: Duncan, Hawkins, Loomer, McConkey, Manley, Tredwell and Wing (Figure 3). Bone Tumour Registry In 1957, Dr. K. S. Morton created the UBC Bone Tumour Registry and assembled a musculoskeletal treatment team. He demonstrated that the management of musculoskeletal tumours was beyond the scope of the community orthopaedic or general surgeon, stating, “Treatment can only be delivered by a highly specialized team in a tertiary setting.” Dr. Morton is to be acknowledged for being a catalyst for advocating an approach to MSK tumour care which is now considered the standard. Basic Science In 1961, Dr. Sun Shik Shim was recruited by F.P.P. as a PhD orthopaedist to establish a basic science laboratory. He developed a world-class reputation for the study of circulation of blood through bone. Dr. Patterson funded the laboratory partly by funds he solicited from the late Doris Murray.

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As a testament to the success of this program, Dr. Shim and Duncan published “Autonomic Nerve Supply of Bone” and were awarded the J. Édouard Samson Award. Also receiving the same award were Drs. Shim and Day for “Circulation Changes in the Hip Following High Femoral Osteotomy and Innominate Osteotomy – A New Physiological Basis”. Medical Engineering Resource Unit (MERU) In 1971, the Medical Engineering Resource Unit (MERU) was established with the appointment by Dr. Patterson of Mr. James Foort as Director of Prosthetics and Engineering Research. There were five members of this unit, having a varied background in mechanical engineering, kinesiology and engineering physics. Notable was the development of CAM/CAD and computer-aided socket design, the CARS-UBC electrogoniometer, and the CARS-UBC unloader brace (CARS - Canadian Arthritis and Rheumatism Society, now The Arthritis Society). St. Paul’s Hospital and Royal Columbian Hospital Following a long association and friendship, Dr. Patterson welcomed Drs. Outerbridge (Royal Columbian Hospital) and McConkey Sr. (St. Paul’s Hospital). These institutions were incorporated into the orthopaedic residency and undergraduate teaching programs.

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Annual Research Day In 1970, the Annual Research Day was instituted beginning with a competition among resident papers. Regular speakers were invited to participate and an annual Patterson Lecture was established. Listed here are the annual Patterson lecturers during the early Division years: • 1970 • 1971 • 1972 • 1973 • 1974 • 1975 • 1976 • 1977 • 1978 • 1979 • 1980 • 1981 • 1982 • 1983 • 1984

Dr. Josep Trueta (Spain) Dr. J. C. Mulier (Belgium) Dr. Joseph J. Janes (Mayo Clinic) Dr. Harold E. Kleinert (Louisville) Dr. Donald E. Slocum (Portland, Oregon) Dr. Vernon L. Nickel (Los Amigos, Downey, California) Dr. William Enneking (Gainesville, Florida) Dr. Robert Judet (Paris) Dr. Richard Cruess (Montreal) Dr. Ian Macnab (Toronto) Dr. Augusto Sarmiento (Miami, Florida) Dr. Marvin Tile (Toronto) Dr. Robert B. Salter (Toronto) Dr. J. Leonard Goldner (Duke University) Dr. John Huckell (Edmonton)

Spinal Cord Injury Unit In 1975, Dr. Patterson appointed Dr. Joe Schweigel to head the new unit at Shaughnessy (formerly military) Hospital. Dr. Schweigel had a fellowship at Rancho Los Amigos National Rehabilitation Centre with Drs. Vernon Nickel and Jacquelin Perry. This was the beginning of a specialized orthopaedic spinal service.

Hand Service and Microsurgical Laboratory In 1977 Dr. Peter Gropper was appointed to head this new development. Gropper had a post-fellowship education with Harold Kleinert and colleagues in Louisville, Kentucky. Gropper was the first full-time orthopaedic hand surgeon in British Columbia. Children’s Hospital In 1933, the “new” Crippled Children’s Hospital was established on West 59th Avenue in Vancouver. In 1947, it was renamed the Children’s Hospital. In 1964, there was a Children’s health centre at the Vancouver General Hospital where Dr. William Thompson worked part-time as a paediatric orthopaedist. Later, Dr. Michael Bell joined as the first full-time paediatric orthopaedist in British Columbia, having had post-fellowship at the Radcliffe Infirmary in Oxford, the University of Edinburgh and Boston Children’s Hospital. Traumatology In 1951, open reduction internal fixation was in its infancy. Femoral fractures were treated in traction, resulting in a large bed population and long hospital stays. Rigid immobilization of fractures resulted in fracture disease. Drs. Patterson and Naden introduced the Kuntscher nail. Indications were less than ideal with a high infection rate. Patterson bravely presented his results at the COA Annual Meeting. A frank discussion followed and Patterson was dubbed “Pus” Patterson. He was, nevertheless, congratulated for his intellectual honesty.

Combined Rheumatology and Orthopaedic Clinic This clinic was established in 1964 by rheumatologist, Harold Robinson, and Dr. Patterson. This was prior to the development of DMARDs and biologics. A common problem was advanced multiple end-stage joint disease in all age groups. In 1968, Dr. McGraw joined after a oneyear travelling fellowship sponsored by the Canadian Arthritis & Rheumatism Society. It was a weekly clinic with dedicated beds in the Vancouver General Hospital, Holy Family Rehabilitation Hospital, GF Strong Rehabilitation Hospital and hotel facilities for outof-town patients (Rufus Gibbs Lodge). 40% of the patients were from outside of the Vancouver area. Later, Drs. Duncan and Gropper joined the clinic. It was a pioneer approach to the management of rheumatic disease that attracted world attention including the US Government. It paved Figure 4 the way for the development of the Research Day: J.P. Thompson, D. Wickham, R. McGraw, K. Favro; S. Lui, P. Sabiston, K. Morton, W. Mackenzie, D. Werry, L. Goldner, G. MacKenzie, F. Patterson, R. Claridge, P. Blachut, R. Beauchamp, Reconstructive Service. R. McCormack

COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

Training & Practice Management / Formation et gestion d’une pratique (continued from page 57)

Hugh S. Miller received a McLaughlin Travelling Fellowship and returned in 1960 as Director of the Vancouver General Emergency Department, a position he held until 1985. Fracture care was exclusively within the purview of orthopaedic surgeons. In 1975, Dr. Robert N. Meek returned after a fellowship in Davos, Switzerland. He introduced the AO technique. Through his efforts, leadership and education of younger surgeons, the orthopaedic trauma subspecialty was developed in B.C. The Vision of Orthopaedic Surgery Leadership Dr. Patterson led the division from 1951 to 1973 and was succeeded by Dr. Ken S. Morton in 1973, a position he held until 1984. The Division of Orthopaedic Surgery began in 1951 and ended in 1984, when orthopaedics separated from the Department of Surgery. In 1984, the Department of Orthopaedics was created and as of 2017, it remains the only Department of Orthopaedics in Canada. Creation of the Separate Department Creation of the department was strongly opposed, particularly by other surgical disciplines. The criteria laid down by the university were stringent and included: 1. Sufficient body of knowledge. 2. Sufficiently separate from the previous parent department to give reason to believe that the academic discipline would be fostered in its growth by independent standing. 3. That the discipline have an active undergraduate and/ or graduate program which is of sufficient magnitude to justify greater status as a full department.

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

2018

June 20-23 juin CORA Meeting/Réunion de l’ACRO June 20 juin Victoria, BC

2019

Combined with the 2nd ICORS Meeting June 19-22 juin CORA Meeting/Réunion de l’ACRO June 19 juin Montréal, QC www.2019icors.org COA Bulletin ACO - Fall/Winter - Automne/Hiver 2017

4. That the research productivity of the discipline and, in its present setting, give sufficient promise to believe that even greater academic output would be achieved with departmental status. In 1965, the University of British Columbia Senate stated, “This organization encompasses a distinct portion of the intellectual, artistic or professional world. It contains within it internal subspecialization. It undertakes research and teaching at the undergraduate and usually also at the graduate level. It is in the area of subject matter which is likely to be of interest over an extended period of time.” In making its successful submission for departmental status, it was specified, “Orthopaedics is distinct from other surgical specialties in that it involves the musculoskeletal system. It is a specialty of long-duration care, not only from infancy to old age, but individual patients with a single disease condition. “More than in any other specialty, the surgical aspects of patient care represent a relatively small percentage of patients where the medical aspects of patient care are relatively large. Rehabilitation is a much greater commitment in orthopaedics than it is in any other surgical specialty and the orthopaedic surgeon’s daily liaison is not with other surgeons with the exception of the area of trauma, but rather, with general practitioners, paediatricians, rheumatologists, hematologists, physiatrists, oncologists, orthotists and engineers.” 1984 In 1984, the Division of Orthopaedic Surgery was removed from the Department of Surgery and a new department created, the Department of Orthopaedics, the Head being Robert W. McGraw (1984 to 1995). So began Phase III of orthopaedics in British Columbia. Stay tuned for more!

Make your plans now to join us in Victoria in June 2018 The 2018 COA, CORS and CORA Annual Meeting will be held in beautiful Victoria, British Columbia from June 20-23.

Planifiez dès maintenant votre participation à la Réunion annuelle de Victoria, en juin 2018! La Réunion annuelle 2018 de l’ACO, de la Société de recherche orthopédique du Canada (SROC) et de l’Association canadienne des résidents en orthopédie (ACRO) aura lieu dans la superbe ville de Victoria, en Colombie-Britannique, du 20 au 23 juin.

Get complete Annual Meeting information by visiting:

www.coa-aco.org/annual-meeting-2018 Pour plus de renseignements sur la Réunion annuelle, rendez-vous à :

www.coa-aco.org/fr/reunion-annuelle-2018

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