COA Bulletin #123 - Spring 2019 by Canadian Orthopaedic Asssociation

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

BULLETIN

Canadian Orthopaedic Association Association Canadienne d’Orthopédie BONE & “JOINT” PAIN:

THE EVOLVING ROLE OF CANNABIS AND MUSCOLOSKELETAL PAIN............................ p. 33

DOULEURS DES OS ET ARTICULATIONS :

LA LÉGALISATION VARIABLE DU CANNABIS ET LES PATIENTS EN ORTHOPÉDIE

Spring Printemps 2019

123

Publication Mail Envoi Poste-publication Convention #40026541

4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3

www.coa-aco.org

New Faces of the COA Bulletin’s Editorial Team � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 11 Vos avantages à titre de membre : Qu’en pensez-vous? Que souhaitez-vous? � � � � � � � � � � � � � � � � � � � 16 So Weird, They’re Wonderful. Unusual Cases Wanted for COA Bulletin Feature � � � � � � � � � � � � � � � � � 18 Diagnosis and Management of Periprosthetic Joint Infections � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 21

visit zimmerbiomet.com to learn more All content herein is protected by copyright, trademarks and other intellectual property rights, as applicable, owned by or licensed to Zimmer Biomet or its affiliates unless otherwise indicated, and must not be redistributed, duplicated or disclosed, in whole or in part, without the express written consent of Zimmer Biomet. This material is intended for health care professionals. Distribution to any other recipient is prohibited. For product information, including indications, contraindications, warnings, precautions, potential adverse effects and patient counseling information, see the package insert and zimmerbiomet.com. Not for distribution in France. Check for country product clearances and reference product specific instructions for use. Legal Manufacturer Zimmer, Inc., 1800 West Center Street, Warsaw, IN 46580, USA. ÂŠ 2018 Zimmer Biomet

Your COA / Votre association

Bulletin Canadian Orthopaedic Association Association Canadienne d’Orthopédie N° 123 - Spring / Printemps 2019 COA / ACO John Antoniou 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 Paul A. Martineau Scientific Editor / Rédacteur scientifique William Weiss Current Issues Editor Rédacteur, questions d’actualité Cynthia Vézina Managing Editor Adjointe au rédacteur en chef Lexie Bilhete Editorial Assistant / Adjointe à la rédaction 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.

Looking Back on a Winter Season Filled with Firsts John Antoniou M.D., PhD, FRCSC President, Canadian Orthopaedic Association

his past winter season was once again a busy one for the COA. The Board of Directors, along with the Executive and various other committees, gathered in Toronto for a productive and successful MidWinter Meeting. Some key transitions for the future of the Association’s projects, initiatives, and governance were addressed, not the least of which being the formalization of our upcoming CEO transition from Doug Thomson to Cynthia Vezina. We are all very happy and grateful that Cynthia has accepted this new challenge and look forward to her very fruitful tenure. In addition, we formed a subcommittee to standardize the process by which the COA and its sister associations generate and maintain position statements. These statements are an important part of the COA’s mission and set the standard of care and medico-legal precedent. It is incumbent upon our Association to ensure that position statements meet appropriate requirements, are reviewed on a regular basis, and updated when necessary. Finally, the COA will formulate a new strategic plan over the next year. During this process, we encourage input from the entire membership in order to address member needs, and improve our advocacy, communications, research, and professional education offerings. In February, I travelled to the Orthopaedic Research Society (ORS) meeting in Austin, Texas. Both the COA and CORS were prominent guests and collaborators at the meeting, giving us the opportunity to encourage our international research colleagues to attend the combined ICORS and COA meeting in Montréal this June. At the same time, a late-breaking abstract initiative was opened for a four-week long period resulting in additional poster and podium submissions. Look out for this late-breaking session in the final program. Our collaboration with the ORS and ICORS has been very strong throughout the year, and we look forward to welcoming them to our upcoming Meeting. March brought us to the AAOS Annual Meeting in Las Vegas, where Johanna and I met up with the Carousel Presidents and their spouses. Drs. William J. Maloney and David A. Halsey were gracious hosts and organized meetings with the international presidents, and AAOS past presidents throughout the week. A new and productive initiative introduced this year was a corporate thought leader engagement breakfast 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 - Spring / Printemps 2019

Your COA / Votre association

(continued from page 3)

with candid presentations from the largest orthopaedic companies. This was followed by separate face-to-face discussions between the Carousel Presidents and the international president/CEOs of the four largest orthopaedic companies in the world. The frank exchanges of ideas both from the corporate and surgeon perspectives that ensued were informative and appreciated by all. We also witnessed a tremendous moment in our medical specialty’s history: Dr. Kristy Weber’s induction as the first female president of the AAOS. Please take a moment to view the recording of her poignant address, stressing the importance of diversity and inclusion throughout the orthopaedic specialty. I was happy to catch up with several of the Canadian surgeons that were in Vegas throughout the week – thank you to all of our members who attended the COA reception.

CAQ government is discriminating against those in our society who elect to wear religious symbols with the proposition of a controversial and unconstitutional secularism bill. I reiterate that the COA does not discourage the wearing of religious symbols, values and encourages diversity, and supports the expression of said diversity at the Annual Meeting.

On our last day in Vegas, the Carousel Presidents held a council meeting to discuss issues that affect all of our societies. These include orthopaedic human resources, diversity and trainee selection, surgeon performance review, end of career transition, and relationships with subspecialty societies. It is sufficient to say that all orthopaedic associations face very similar challenges, and ultimately, exchanging ideas is always beneficial.

Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 18

On a personal note, I am very distressed and saddened by the turn of events in my home province of Québec. The current

I look forward to seeing many of you in Montréal, June 19-22 for the combined COA/ICORS Annual Meeting – an unprecedented event for our Association…don’t miss it!

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 40 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 42 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 46

Retour sur un hiver de premières John Antoniou, MD, Ph.D., FRCSC Président de l’Association Canadienne d’Orthopédie

’hiver dernier a été, encore une fois, une saison fort occupée à l’ACO. Le conseil d’administration de même que le Comité de direction et plusieurs comités se sont réunis à Toronto pour la Réunion d’hiver, qui s’est avérée des plus fructueuses. On a abordé certaines transitions clés pour les projets, les initiatives et la gouvernance futures de notre association, dont l’officialisation de la transition prochaine de Doug Thomson à Cynthia Vezina à la direction générale n’est pas la moindre. Nous sommes tous très heureux et reconnaissants que Cynthia accepte de relever ce nouveau défi et persuadés qu’elle a énormément à apporter à ce poste. Nous avons en outre créé un sous-comité en vue de normaliser le processus de production et de mise à jour des énoncés de position de l’ACO et de ses associations-sœurs. Ces énoncés constituent une part importante de la mission de l’ACO et établissent des normes de soins et des précédents médicolégaux. Il incombe à notre association de s’assurer que les énoncés de position satisfont aux exigences appropriées, sont revus régulièrement et sont mis à jour au besoin. Enfin, l’ACO rédigera un nouveau plan stratégique au cours de l’année qui vient. Dans le cadre de ce processus, nous sollicitons la rétroaction de tous les membres afin de bien répondre à leurs besoins et d’améliorer nos activités de défense des droits et intérêts, nos communications et notre offre en recherche et en éducation médicale continue.

COA Bulletin ACO - Spring / Printemps 2019

En février, je me suis rendu au congrès annuel de l’Orthopaedic Research Society (ORS), à Austin, au Texas. L’ACO et la Société de recherche orthopédique du Canada (SROC) étaient des invités et collaborateurs de premier plan au congrès, ce qui nous a donné l’occasion d’inviter nos collègues chercheurs de l’étranger à assister au congrès annuel des International Combined Orthopaedic Research Societies (ICORS) et à la Réunion annuelle de l’ACO, qui ont lieu conjointement à Montréal, en juin. En même temps, nous avons lancé une catégorie de précis de dernière heure, acceptés pendant une période de quatre semaines, qui a permis de recevoir des précis supplémentaires à présenter sous forme d’affiches ou d’exposés. Vous trouverez les détails sur la séance de présentation de ces précis dans le programme final. Nous avons collaboré étroitement avec l’ORS et les ICORS toute l’année, et ce sera un plaisir de les accueillir à notre réunion annuelle. En mars, ce fut le tour du congrès annuel de l’American Academy of Orthopaedic Surgeons (AAOS) à Las Vegas, où Johanna et moi avons rencontré les présidents du groupe Carousel et leur conjoint. Les Drs William J. Maloney et David A. Halsey ont été des hôtes bienveillants et ont organisé des rencontres avec les présidents du groupe Carousel, et les anciens présidents de l’AAOS, toute la semaine. Une nouvelle initiative productive a été lancée cette année : un déjeuner de leaders d’opinion corporatifs comprenant des présentations spontanées des plus grandes sociétés orthopédiques. Des discussions individuelles entre les présidents du groupe Carousel et le président et les directeurs généraux des quatre plus grandes sociétés ortho-

Your COA / Votre association

(suite de la page 4)

pédiques dans le monde ont suivi. Les échanges francs d’idées, tant du point de vue corporatif que de l’orthopédiste, qui s’en sont suivis, ont été informatifs et appréciés de toutes les parties. Nous avons aussi été témoins d’un moment extraordinaire dans l’histoire de notre spécialité médicale : l’entrée en fonctions de la Dre Kristy Weber à titre de première présidente de l’AAOS. Prenez le temps de voir l’enregistrement de son émouvante allocution, dans laquelle elle souligne l’importance de la diversité et de l’inclusion dans toute la profession. J’ai eu le plaisir de discuter avec plusieurs des orthopédistes canadiens qui étaient à Las Vegas au cours de la semaine; merci à tous les membres qui ont assisté à la réception de l’ACO. À notre dernière journée à Las Vegas, les présidents du groupe Carousel ont tenu une réunion du conseil afin de discuter d’enjeux qui touchent toutes nos associations, comme les ressources humaines en orthopédie, la diversité et la sélection des résidents et fellows, l’évaluation de la performance des orthopédistes, la transition en fin de carrière et les relations avec les sociétés de sous-spécialité. On peut dire que toutes les associations d’orthopédie sont confrontées à des défis très semblables et que, en fin de compte, les échanges d’idées sont toujours bénéfiques.

Sur le plan personnel, je suis très affligé et attristé par la tournure des événements dans ma province, le Québec. Le gouvernement de la CAQ fait preuve de discrimination à l’encontre des membres de notre société qui choisissent de porter des symboles religieux en proposant une loi sur la laïcité controversée et inconstitutionnelle. Je réaffirme que l’ACO ne décourage pas le port de symboles religieux, valorise et favorise la diversité et appuie l’expression de cette diversité à la Réunion annuelle. J’espère vous voir nombreux à Montréal, du 19 au 22 juin, à l’occasion du congrès annuel des ICORS et de la Réunion annuelle de l’ACO, une manifestation conjointe sans précédent pour notre association… C’est à ne pas manquer!

COA Organizational Announcement

Annonce organisationnelle de l’ACO

Kishore Mulpuri, MHS, MBBS, MSc Secretary, Canadian Orthopaedic Association

Kishore Mulpuri, M.Sc.S., MBBS, M.S. Secrétaire de l’Assoication Canadienne d’Orthopédie

New CEO in 2020

fter almost 20 years with the Canadian Orthopaedic Association, Doug Thomson has made the decision to retire and begin the transition out of his role as CEO over the next year. It gives me great pleasure to announce that Cynthia Vezina will be named CEO, effective January 1, 2020. Doug will work closely with Cynthia and the rest of our excellent staff through to the conclusion of our Annual Meeting next year in Halifax. Her vision for the COA and future successes will continue to be instrumental for our organization, and I ask you to join me in congratulating Cynthia on her outstanding performance and wish her every success in her new position.

Nouvelle directrice générale en 2020

près plus de 20 ans à l’Association Canadienne d’Orthopédie (ACO), Doug Thomson a décidé de prendre sa retraite; il profite de l’année qui vient pour assurer la transition à la direction générale. J’ai donc l’immense plaisir d’annoncer que Cynthia Vezina accédera au poste de directrice générale à compter du 1er janvier 2020. Doug travaillera en étroite collaboration avec Cynthia et le reste de notre excellente équipe jusqu’à la conclusion de la Réunion annuelle de l’an prochain, à Halifax. Sa vision pour l’ACO et ses réalisations futures continueront d’être essentielles à notre organisation. Félicitons Cynthia pour son rendement exceptionnel et souhaitons-lui la meilleure des chances à son nouveau poste.

COA Bulletin ACO - Spring / Printemps 2019

This is just the beginning. Two distinct, prospective, consecutive series, single-surgeon studies comparing patients undergoing conventional jig-based total knee replacement versus Mako Total Knee surgery (40 patients1 and 30 patients2 in each cohort), concluded that Mako Total Knee with Triathlon was associated with:

Less bone and soft tissue damage2 (p<0.05)

Less

need for opiate analgesics1 (p<0.001)

Less

time to hospital discharge1 (26% reduction in LOS)

Less need for in-patient physical therapy sessions1 (p<0.001)

Less

postoperative pain1 (p<0.001)

Making healthcare better together, with Mako Total Knee. Find out more @ makoexperience.com References: 1. Haddad, F.S., et al. Robotic-arm assisted total knee arthroplasty is associated with improved early functional recovery and reduced time to hospital discharge compared with conventional jig-based total knee arthroplasty. The Bone & Joint Journal, July 2018. 2. Haddad, F.S., et al. Iatrogenic Bone and Soft Tissue Trauma in Robotic-Arm Assisted Total Knee Arthroplasty Compared With Conventional Jig-Based Total Knee Arthroplasty: A Prospective Cohort Study and Validation of a New Classification System. J Arthroplasty. 2018 Aug;33(8):2496-2501. Epub 2018 Mar 27. Professor Fares S. Haddad is a consultant of Stryker. However, Dr. Haddad and the authors of these publications did not receive financial or in-kind compensation for the research or publications. 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 Strykerâ&#x20AC;&#x2122;s product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any of Strykerâ&#x20AC;&#x2122;s products. The products depicted are CE marked according to the Medical Device Directive 93/42/EEC. 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 sales representative if you have questions about the availability of products in your area. Stryker Corporation or its divisions or other corporate affiliated entities own, use or have applied for the following trademarks or service marks: Stryker, Mako. All other trademarks are trademarks of their respective owners or holders. MAKTKA-AD-4_19014

Your COA / Votre association

Diversity in the COA: Spotlight on Women in Orthopaedics with Jennifer A. Fletcher, M.D., FRCSC Lexie Bilhete Coordinator, Membership Services & Affiliate Programs Canadian Orthopaedic Association

rom Saint John, New Brunswick, Dr. Jennifer A. Fletcher is this edition’s Women in Orthopaedics featured guest. Dr. Fletcher attended medical school at Dalhousie University and subsequently completed orthopaedic residency training at McGill University. Following a fellowship in shoulder and knee surgery at the University of Calgary under the mentorship of Drs. Nic Mohtadi, Cy Frank, and Robert Hollinshead in 1998, she returned to Eastern Canada working at her alma mater, Dalhousie University. Since 1999, Dr. Fletcher has been an Assistant Professor at Dalhousie University and Memorial University of Newfoundland, specializing in sports medicine and shoulder surgery. Dr. Fletcher is highly involved in sports medicine, currently on the Credentials Exam Committee of the Canadian Academy of Sports and Exercise Medicine. She has also worked with many distinguished sports teams, including the AHL Calgary Flames AHL, Quebec Major Junior Saint John Seadogs, and the UNB Saint John Varsity Athletes. She also enjoys curling and skiing. 1. What drew you to orthopaedics (and your subspecialty)? As an athlete, I was always interested in sports, and after starting medical school I wanted to learn how medicine and sport complimented one another. I chose my electives in orthopaedics as I thought this specialty combined my two interests. My “light bulb” moment occurred in my first rotation of clerkship in my 4th year. I spent a day in the operating room with Dr. Ross Leighton and was allowed to perform knee arthroscopy. The decision was made that day to pursue a career in orthopaedic sport medicine. 2. Can you recount a defining moment in your career thus far? There have been many defining moments that have shaped the direction of my career. Certainly, the sports medicine fellowship I completed in Calgary confirmed the type of career I would pursue. Despite coming to a smaller centre in Saint John, where generalization was encouraged, I stood fast to my subspecialty career choice. Our orthopaedic surgery group in Saint John has certainly embraced that idea over the last twenty years. We are a subspecialty teaching centre for Dalhousie and a centre of excellence in all areas of orthopaedics. I have also embraced my love for sports medicine with my involvement in the Canadian Academy of Sport and Exercise Medicine (CASEM) as a former Board Member, Past President and now a member of the Credentials Committee for the CASEM Diploma Exam.

The COA recognizes the strength in diversity and promotes equity across its membership, services, and all community engagement. Each edition of the COA Bulletin will feature one of the many women members of the Association, their experiences and insights, contributions to the specialty and advice for junior colleagues and students. Get to know the membership! 3. What does diversity mean to you? My generation of female surgeons training in the ‘90s tried to avoid thinking about diversity as it pertained to females. Certainly, my goal was to get through residency and start my career without my gender being an issue. However, I was the first female orthopaedic surgeon in New Brunswick when I began my career in 1999, and still the lone female in my group. To me, diversity signifies that we evolve into a time when you could walk into an orthopaedic meeting or conference where one’s gender or the colour of one’s skin is not discussed or even a thought. Diversity in the boardroom and at the podium is essential to move forward with innovation and to promote ideas from individuals of different genders and backgrounds. It is encouraging that the COA is moving forward with the idea and goal of diversity. 4. What advice would you give to orthopaedic residents? As a female surgeon and working mother, I am often asked for words of wisdom from residents and medical students. My best advice to residents is to find the career path that you find the most rewarding. Remember to make time to enjoy the other parts of your life. You can coach your child’s team, maintain your own health and fitness level, and complete your work commitments. Also, having a strong support network from a spouse, partner, family, friends and colleagues is critical to completing all of these goals. In my personal experience, my spouse was essential to reaching all of these goals. 5. What is one professional goal and one personal goal you hope to achieve in the next five years? Over the next five years, one professional goal I hope to achieve is to develop a sports medicine fellowship program in Saint John, part of Dalhousie orthopaedics, with my colleague Dr. Brendan Sheehan. One personal goal in the next five years is to become more involved in competitive curling, now that my children are finishing high school. 6. Name one of your go-to tricks or hacks that has helped you in your day to day life? One of my go-to hacks or tricks is to always dictate my office or clinic before going home. I try to spend time with my family in the evenings which has often been coaching or attending basketball games over the years. Reading cases or preparing talks is usually unavoidable in the evenings, but I try to leave work at the office when I come home. COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

Diversité au sein de l’ACO : Pleins feux sur les femmes en orthopédie avec Jennifer A. Fletcher, MD, FRCSC comme Saint John, où la généralisation est favorisée, je suis restée ferme dans le choix de ma sous-spécialité. Notre équipe de chirurgie orthopédique, à Saint John, a bien profité de cette idée au cours des vingt dernières années. Nous sommes un centre de formation spécialisé pour l’Université Dalhousie et un centre d’excellence dans tous les domaines de l’orthopédie.

Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés

a Dre Jennifer A. Fletcher, de Saint John, au NouveauBrunswick, est l’invitée de l’article Pleins feux sur les femmes en orthopédie de ce numéro. La Dre Fletcher étudie la médecine à l’Université Dalhousie, puis effectue sa résidence en orthopédie à l’Université McGill. Après une spécialisation en chirurgie de l’épaule et du genou à l’Université de Calgary, avec pour mentors les Drs Nic Mohtadi, Cy Frank et Robert Hollinshead, en 1998, elle revient dans l’Est du Canada pour travailler à son alma mater, l’Université Dalhousie. Depuis 1999, la Dre Fletcher est professeure adjointe à l’Université Dalhousie et à l’Université Memorial, à Terre-Neuve-et-Labrador, et se spécialise en médecine sportive et en chirurgie de l’épaule.

L’ACO reconnaît la force inhérente à la diversité et fait la promotion d’une culture d’équité chez ses membres ainsi qu’en ce qui a trait à ses services et à son engagement communautaire. Chaque numéro du Bulletin comprendra le portrait de l’une des nombreuses femmes membres de l’ACO. On en apprendra davantage sur son expérience et ses idées, sa contribution à la profession et ses conseils pour ses jeunes collègues et les étudiants. Apprenez à connaître vos collègues!

La Dre Fletcher est très active dans le domaine de la médecine sportive : elle siège actuellement au sein du comité d’accréditation de l’Académie canadienne de médecine du sport et de l’exercice (ACMSE), en plus de travailler avec de nombreuses équipes sportives de premier ordre, y compris les Flames de Calgary, de la Ligue américaine de hockey; les Seadogs de Saint John, de la Ligue de hockey junior majeur du Québec; et les équipes sportives universitaires du campus de Saint John de l’Université du NouveauBrunswick. Elle pratique aussi le curling et le ski.

1. Qu’est-ce qui vous a amenée à choisir l’orthopédie (et votre sous-spécialité)? En tant qu’athlète, les sports m’ont toujours intéressée. Après avoir commencé mes études en médecine, j’ai voulu comprendre la complémentarité entre la médecine et les sports. J’ai fait mes stages optionnels en orthopédie, car je croyais que cette spécialité combinait mes deux intérêts. Le déclic s’est fait pendant la première rotation de mon stage clinique, en quatrième année. J’ai passé une journée en salle d’opération avec le Dr Ross Leighton, et j’ai pu effectuer une arthroscopie du genou. C’est cette journéelà que j’ai décidé de faire carrière en médecine sportive orthopédique. 2. Racontez-nous un moment marquant de votre carrière. De nombreux moments marquants ont façonné ma carrière. Ma spécialisation en médecine sportive à Calgary a assurément confirmé le type de cheminement de carrière que je suivrais. Même si je venais dans un petit centre COA Bulletin ACO - Spring / Printemps 2019

J’exprime également mon amour de la médecine sportive par ma participation aux activités de l’ACMSE, dont j’ai été membre du conseil d’administration et présidente, et dont je suis aujourd’hui membre du comité d’accréditation en médecine sportive.

3. Pour vous, que signifie la diversité? En formation dans les années 1990, ma génération de femmes en orthopédie essayait d’éviter de penser à la diversité pour ce qui est des femmes. Bien sûr, mon objectif était d’effectuer ma résidence et de commencer ma carrière sans que mon sexe soit un problème. Par contre, j’étais la première femme orthopédiste au Nouveau-Brunswick quand j’ai commencé ma carrière, en 1999, et je reste la seule femme au sein de mon équipe.

Pour moi, la diversité signifierait pouvoir assister à une réunion ou à un congrès sans que son sexe ou la couleur de sa peau ne suscite une discussion ni même une pensée. Que ce soit dans une salle de réunion ou à un podium, la diversité est essentielle à l’innovation et à la promotion d’idées de personnes de genres et de milieux différents. Il est encourageant que l’ACO aille de l’avant avec un concept et un objectif de diversité. 4. Quels conseils donneriez-vous aux résidents en orthopédie? Comme orthopédiste et mère, les résidents et étudiants en médecine me demandent souvent de leur prodiguer de sages conseils. Le meilleur conseil que je puisse donner aux résidents est de choisir la carrière qu’ils trouvent la plus enrichissante. N’oubliez pas de prendre le temps de profiter des autres sphères de votre vie. Vous pouvez entraîner l’équipe de votre enfant, veiller sur votre santé, rester en forme et assumer vos responsabilités professionnelles. De même, avoir un réseau de soutien fiable – un conjoint, un partenaire, une famille, des amis et des collègues –, est essentiel à l’atteinte de tous ces objectifs. Personnellement, mon conjoint a joué un rôle essentiel dans l’atteinte de tous ces objectifs.

Your COA / Votre association

(suite de la page 8)

5. Pouvez-vous me parler d’un objectif professionnel et d’un objectif personnel que vous voulez atteindre au cours des cinq prochaines années? Au cours des cinq prochaines années, un des objectifs que j’aimerais atteindre est la création d’un programme de spécialisation en médecine sportive à Saint John, dans le cadre du programme d’orthopédie de l’Université Dalhousie, avec mon collègue le Dr Brendan Sheehan. Un de mes objectifs personnels au cours des cinq prochaines années est de m’impliquer davantage en curling de compétition, maintenant que mes enfants achèvent leur secondaire.

6. Nommez le truc ou l’astuce que vous appliquez au quotidien pour vous faciliter la vie. Un de mes trucs ou astuces est de toujours utiliser un dictaphone au bureau ou à la clinique avant de rentrer à la maison. J’essaie de passer du temps avec ma famille le soir, ce qui a souvent impliqué d’assister à des matchs de basketball à titre d’entraîneuse ou de spectatrice au fil des ans. On ne peut habituellement pas éviter la lecture de cas et la préparation de présentations le soir, mais j’essaie de laisser le travail au bureau quand je rentre chez moi.

COA Member Becomes Spine Society President

Un membre de l’ACO devient président de la Société canadienne du rachis

COA CPD Committee Member and former CORS President, Dr. Albert Yee from the University of Toronto, was nominated as President of the Canadian Spine Society at the recent Annual Meeting in late February. Building off of last year’s featured subspecialty initiative that highlighted spine at the COA’s 2018 Annual Meeting; we are offering a comprehensive and diverse spine program again at this year’s event in Montréal. Click here to view the spine sessions.

Le Dr Albert Yee, de l’Université de Toronto, membre du Comité de perfectionnement professionnel de l’ACO et ancien président de la Société de recherche orthopédique du Canada (SROC), a été nommé à la présidence de la Société canadienne du rachis (CSS) à sa dernière assemblée annuelle, à la fin février. Dans la foulée de l’initiative de mise en vedette du rachis à la Réunion annuelle 2018 de l’ACO, nous offrons à nouveau un programme exhaustif et varié sur le rachis à la manifestation de cette année, à Montréal. Cliquez ici pour voir les séances sur le rachis.

COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

Still Looking for a Reason to Attend the COA & ICORS 2019 Annual Meeting? See the top 5 right here: 1. Research and Innovation The best innovators, investigators, and experts from around the world are presenting their orthopaedic research at the International Combined Orthopaedic Research Societies (ICORS) meeting held in conjunction with the COA Annual Meeting. An unprecedented orthopaedic 2-for-1! 2. Unique Learning Opportunities Symposia, ICLs, hands-on workshops, tips & tricks, case discussions, debates, and a record number of paper and poster sessions are offered throughout the program. Whatever your interests are, we’ve got you covered. 3. Make Valuable Connections Meet leaders representing all orthopaedic subspecialties, expand your network, mentor the next generation of colleagues, reconnect and make new connections with friends from across the globe. 4. Have Your Voice Heard Be part of the conversations and discussions on some of the most current and critical topics, including implicit bias and gender diversity, physician burnout, surgeon under performance and competence, global surgery, and physician-led health-care system innovation. What do you have to say? 5. Montréal in June Visit the festival city during one of the best times of the year where the great outdoors meets a cosmopolitan centre with European flare. The sights, sounds, flavours, and unique Montréal culture is waiting for you.

View the Program Register Now

www.2019icors.org COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

New Faces of the COA Bulletin’s Editorial Team:

New Scientific and Current Issues Editors, Drs. Paul Martineau and William Weiss

e are pleased to introduce both Drs. Paul Martineau and William Weiss as the latest additions to the COA Bulletin’s editorial team.

Scientific Editor Dr. Paul A. Martineau is an Associate Professor of Surgery at McGill University, Head of Upper Extremity Surgery, McGill University Health Centre (MUHC), and Director of Orthopaedic Sport Medicine Research and investigator of the Bone Engineering Laboratories (RI-MUHC). He is also an affiliate Associate Professor in the Department of Electrical and Computer Engineering of Concordia University. He is a Canadian and American board-certified orthopaedic surgeon (FRCSC, ABOS), certified in orthopaedic sports medicine (SCOSM/ABOS), and an authority in minimally-invasive arthroscopic surgery. Dr. Martineau is a salary supported clinician-scientist (FRSQ) whose research program is based on the development of innovative diagnostic and treatment strategies.

Dr. Martineau has been a member of the COA since 2001. Over the years, his involvement with the Association includes serving as the Quebec Region Representative on the Nominating Committee in 2011, being an ABC fellow in 2011, as well as currently serving on the Exchange Fellowships Committee.

Current Issues Editor Dr. William Weiss completed medical school at Queen’s University before returning to the University of Ottawa for orthopaedic residency training. He then completed three separate fellowships in orthopaedic sports medicine, arthroscopy & extremity reconstruction at the University of Alberta, Plano Orthopaedics & Sports Medicine, and the University of Texas Medical Branch.

A long-standing member of the COA, Dr. Weiss joined the Association during his residency training. Today, he is an engaged US neighbor, maintaining Active International membership within the COA, and sits on the Association’s Communications Committee.

Currently, Dr. Weiss is the Director of Orthopaedic Sports Medicine and Director of Research for the Texas Tech University Health Sciences Centre Department of Orthopaedic Surgery in El Paso, Texas. He is also the Associate Director of Research for the joint Texas Tech University and United States Army William Beaumont Army Medical Centre Orthopaedic Surgery Residency Program - the only combined military and civilian residency program in the country. We would like to extend our most sincere appreciation to Dr. Femi Ayeni for his exceptional work and contributions as past Scientific Editor position. Thank you, Dr. Ayeni for your features that were of great interest to our readership.

“As the new Scientific Editor for COA Bulletin, my plan is to try to adapt the feature to present mediums and sources of dissemination so we can reach as many colleagues as possible. I also would like to give it a Canadian perspective by trying to have the authors engage the readers with content that is pertinent to the quickly evolving practice of orthopaedic surgery in Canada. Finally, I would like to define a specific place for the COA Bulletin among the everexpanding landscape of electronic knowledge resources, with content that is unique to our journal.”

“Through my role as Current Issues Editor, I would like to discuss present-day issues relevant to COA members practicing in both Canada, the United States, and abroad. There are many similarities in practice regardless of location, but also significant differences that may provide opportunity for discussion and change. The face of the COA is changing, with increasing numbers of our members practicing outside Canada. I look forward to the opportunity to remain involved with my Canadian colleagues and explore the issues that we face from these differing perspectives.”

Look out for new features being introduced by our editors in upcoming editions this year. If you have any suggestions for topics that you would like to see covered in the COA Bulletin, please contact Cynthia Vezina, Managing Editor, at cynthia@canorth.org COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

De nouveaux visages au sein de l’équipe de rédaction du Bulletin :

Nouveaux rédacteur scientifique et rédacteur, questions d’actualité, les Drs Paul Martineau et William Weiss

ous sommes heureux de vous présenter les Drs Paul Martineau et William Weiss, nouvelles recrues de l’équipe de rédaction du Bulletin de l’ACO.

Rédacteur scientifique – Le Dr Paul A. Martineau est professeur agrégé de chirurgie à l’Université McGill, chef de la chirurgie des membres supérieurs au Centre universitaire de santé McGill (CUSM), ainsi que directeur de la recherche en médecine sportive orthopédique et chercheur aux laboratoires d’ingénierie osseuse (Institut de recherche du CUSM). Il est en outre professeur agrégé affilié au Département de génie électrique et informatique de l’Université Concordia. Il détient un certificat en orthopédie du Collège royal des médecins et chirurgiens du Canada (FRCSC) et de l’American Board of Orthopaedic Surgery (ABOS), un certificat en médecine sportive orthopédique (SCOSM/ABOS) et un savoir-faire en chirurgie arthroscopique minimalement effractive. Le Dr Martineau est un clinicien-chercheur bénéficiant d’une bourse salariale (Fonds de recherche du Québec – Santé ou FRQS) dont le programme

de recherche est fondé sur le développement de stratégies diagnostiques et de traitement innovatrices.

Rédacteur, questions d’actualité – Le Dr William Weiss effectue ses études en médecine à l’Université Queen’s, avant de revenir à l’Université d’Ottawa pour sa résidence en orthopédie. Il fait ensuite trois spécialisations en médecine sportive orthopédique, arthroscopie et reconstruction des extrémités à l’Université de l’Alberta, au Plano Orthopaedic Sports Medicine, et à l’University of Texas Medical Branch.

liam Beaumont Army Medical Centre de l’armée américaine, le seul programme de résidence militaire-civile au pays.

Le Dr Weiss est actuellement directeur de la médecine sportive orthopédique et directeur de la recherche au département de chirurgie orthopédique du Texas Tech University Health Sciences Centre à El Paso, au Texas. Il est également directeur associé de la recherche pour le programme conjoint de résidence en chirurgie orthopédique de la Texas Tech University et du WilNous profitons de l’occasion pour remercier sincèrement le Dr Femi Ayeni pour son travail exceptionnel et sa contribution à titre de rédacteur scientifique. Merci, Docteur Ayeni, pour les sujets que vous avez mis de l’avant et qui ont su susciter un grand intérêt chez nos lecteurs. COA Bulletin ACO - Spring / Printemps 2019

Le Dr Martineau est membre de l’ACO depuis 2001. Au fil des ans, son engagement auprès de l’Association l’a amené à être représentant du Québec au sein du Comité des candidatures (en 2011) et lauréat de la Bourse de voyage américano-britanno-canadienne (ABC) 2011. Il est actuellement membre du Comité des bourses de voyage.

« En tant que nouveau rédacteur scientifique du Bulletin de l’ACO, je compte l’adapter aux médias et sources de diffusion actuels de sorte à joindre autant de collègues que possible. J’aimerais aussi lui donner une perspective canadienne en essayant d’amener les auteurs à stimuler les lecteurs grâce à un contenu reflétant l’évolution rapide de l’exercice de l’orthopédie au Canada. Enfin, j’aimerais positionner le Bulletin de l’ACO parmi la gamme de sources de savoir électroniques en constante croissance grâce à un contenu propre à notre revue. »

Le Dr Weiss est un membre de longue date de l’ACO, ayant joint les rangs de l’Association à titre de résident. Il est aujourd’hui un voisin engagé, membre du Comité des communications, et il a le statut de membre actif international de l’ACO.

« Par mon rôle de rédacteur, questions d’actualité, j’aimerais aborder des enjeux pertinents pour les membres de l’ACO exerçant à la fois au Canada, aux États-Unis et ailleurs dans le monde. Il existe de nombreuses ressemblances dans notre exercice, peu importe où nous travaillons, mais également des différences considérables qui pourraient constituer autant d’occasions de discussion et de changement. Le visage de l’ACO change, un nombre croissant de nos membres exerçant à l’extérieur du Canada. Je suis enthousiaste devant cette occasion de continuer de travailler avec mes collègues canadiens et d’explorer les enjeux auxquels nous sommes confrontés selon nos perspectives distinctes. »

Ne manquez pas les nouveautés lancées par nos rédacteurs dans les prochains numéros du Bulletin. Si vous souhaitez suggérer des sujets à aborder dans le Bulletin de l’ACO, communiquez avec Cynthia Vezina, adjointe au rédacteur en chef, à cynthia@canorth.org.

Your COA / Votre association

Vous cherchez encore à justifier votre présence à la Réunion annuelle 2019 de l’ACO et au congrès 2019 des ICORS? Voici cinq raisons incontestables : 1. Recherche et innovation Les plus grands innovateurs, chercheurs et spécialistes au monde viendront présenter le fruit de leurs recherches en orthopédie au congrès des International Combined Orthopaedic Research Societies (ICORS), organisé conjointement avec la Réunion annuelle de l’ACO. Profitez de ce deux-pour-un unique en son genre! 2. Possibilités d’apprentissage exceptionnelles Des symposiums, des conférences d’enseignement, des ateliers pratiques, des séances « Trucs et astuces », des études de cas, des débats et un nombre record de précis présentés sous forme d’exposés et d’affiches sont au programme. Peu importe vos intérêts, vous y trouverez votre compte! 3. Rencontres précieuses Rencontrez des leaders de toutes les sous-spécialités orthopédiques, étendez votre réseau, soyez un mentor pour vos jeunes collègues, renouez avec vos connaissances et créez des liens avec des gens de partout dans le monde. 4. Occasions de vous faire entendre Participez aux échanges sur certains des sujets les plus chauds et épineux de la profession, y compris le biais implicite et la diversité en orthopédie, l’épuisement professionnel chez les médecins, les problèmes de performance et de compétence des orthopédistes, l’exercice à l’étranger et les innovations proposées par les médecins au sein du système de santé. Nous brûlons de vous entendre! 5. Montréal en juin Visitez la ville des festivals, qui marie grands espaces et centre-ville cosmopolite aux accents européens, à l’une des périodes les plus effervescentes de l’année. La culture montréalaise et ses sons, ses saveurs et ses attractions uniques vous attendent.

Consultez le programme Inscrivez-vous

www.2019icors.org COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

YOUR ASSOCIATION. YOUR SESSION.

VOTRE ASSOCIATION. VOTRE SÉANCE.

YOUR COA IN REVIEW.

VOTRE COUP D’ŒIL SUR L’ACO.

What is the COA working on in terms of advocacy, access to care, employment, education, membership benefits and communications? What should we be working on? We need input from all members to help chart the direction for the COA and the profession.

Que fait l’ACO en matière de défense des droits et intérêts, d’accès aux soins, d’emploi, de formation, d’avantages de l’adhésion et de communications? Que devrait-elle faire? Nous avons besoin de la rétroaction de tous les membres afin d’établir l’orientation de l’ACO et de la profession.

This Annual Meeting session is your chance to learn more about the current projects and initiatives that are being pursued by the COA, and your opportunity to provide input and feedback to the leadership.

Cette séance de la Réunion annuelle est votre occasion d’en apprendre davantage sur les initiatives et projets actuels de l’ACO et de transmettre vos idées et votre rétroaction à la direction.

All members should attend the Your COA in Review session on Thursday, June 20 during the Annual Meeting in Montréal.

Tous les membres devraient assister à la séance Coup d’œil sur l’ACO, le jeudi 20 juin, à la Réunion annuelle de Montréal.

Meet the COA Executive Committee and staff, learn about new COA programs, vote on Motions to move things forward, have your voice heard.

Venez y rencontrer le Comité de direction et le personnel de l’ACO, en apprendre davantage sur les nouveaux programmes de l’ACO, voter sur des motions pour faire avancer les choses, et vous exprimer.

Include the Your COA in Review session in your Annual Meeting itinerary.

Thursday, June 20 9:45-10:45

Ajoutez la séance Coup d’œil sur l’ACO à votre programme à la Réunion annuelle.

Le jeudi 20 juin De 9 h 45 à 10 h 45

COA Annual Meeting Palais des congrès, Montréal

Réunion annuelle de l’ACO, au Palais des congrès de Montréal

See final program on site for room location

Consultez le programme final sur place pour connaître l’emplacement de la salle.

COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

Your Member Benefits: What do you think? What do you want? Lexie Bilhete Coordinator, Membership Services & Affiliate Programs Canadian Orthopaedic Association

he COA leadership is constantly striving to determine the value of the COA services and benefits currently offered to our members. With 2018 coming to an end, the COA wanted to uncover and evaluate what our membersâ&#x20AC;&#x2122; opinions are on some of the various services accessible through COA membership. Under the direction of Dr. John A. Grant, Chair of the Membership Committee, a short survey was issued at the end of last year, asking all Active members how they ranked their membership services and benefits. The results gave us a better understanding of how Active members use and rank the current membership services. Analyzing the Results: What does this mean? In 2018, the top three services that ranked highest in usage and value were the COAâ&#x20AC;&#x2122;s Annual Meeting, followed by journal access. This places networking and learning opportunities at the forefront of what Active members seek out through the COA. How can we do better? The survey also revealed a strong desire for even more CMEaccredited learning opportunities and a more expansive access to journals and online academic publications. The COA Executive and leadership is listening, and working hard to explore this. Your opinion matters, and your membership makes a difference Your affiliation with the Canadian Orthopaedic Association extends far beyond the Annual Meeting. By being a COA member, you are also contributing to national and local initiatives that support our collective community of orthopaedic surgeons, researchers, and students right here in Canada. Your support transforms a plethora of projects from paper to practice, including advocacy, learning opportunities, resident programs and many other initiatives. Thank you for your ongoing participation and involvement!-

Missed the survey? Not to worry! You can always e-mail Lexie Bilhete at lexie@canorth.org to discuss your COA member benefits, and keep an eye out for any future surveys.

COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

Vos avantages à titre de membre : Qu’en pensez-vous? Que souhaitez-vous? Lexie Bilhete Coordonnatrice, Services aux membres et programmes affiliés Association Canadienne d’Orthopédie

a direction de l’ACO s’efforce continuellement d’établir la valeur des services et avantages offerts aux membres. Avec 2018 qui tirait à sa fin, l’ACO a voulu découvrir et évaluer l’opinion des membres sur certains des services et avantages accessibles grâce à l’adhésion. Sous la direction du Dr John A. Grant, président du Comité d’admission de l’ACO, on a donc diffusé en fin d’année un court sondage dans le cadre duquel les membres actifs devaient noter les services et avantages qui leur sont offerts. Les résultats nous ont permis de mieux comprendre la façon dont les membres utilisent et évaluent actuellement les services et avantages. Analyse des résultats : Qu’est-ce que cela signifie? En 2018, les trois services et avantages les plus utilisés et les mieux notés étaient la Réunion annuelle de l’ACO, suivie de l’accès à des revues. Cela positionne le réseautage et les possibilités d’apprentissage au cœur de ce que les membres actifs attendent de l’ACO. Comment pouvons-nous faire mieux? Le sondage a également révélé une forte demande pour encore davantage d’activités agréées permettant d’obtenir des crédits d’éducation médicale continue (ÉMC) et un accès bonifié aux revues et aux publications universitaires en ligne. La direction de l’ACO vous écoute et étudie sérieusement les possibilités à cet égard. Votre opinion compte, et votre adhésion a une incidence Votre affiliation à l’ACO va bien au-delà de la Réunion annuelle. En étant membre de l’ACO, vous contribuez aussi à des initiatives nationales et locales en soutien à la communauté des orthopédistes ainsi que des chercheurs et des étudiants en orthopédie canadiens. Votre soutien permet de concrétiser une pléthore de projets, dont des initiatives de défense des droits et intérêts, des possibilités d’apprentissage, des programmes pour les résidents et bien d’autres initiatives. Merci pour votre participation et votre engagement!

Vous avez manqué le sondage? Ne vous en faites pas! Vous pouvez toujours écrire à Lexie Bilhete, à lexie@canorth.org, pour lui transmettre vos commentaires et suggestions sur les services et avantages offerts aux membres. Et restez à l’affût des prochains sondages. COA Bulletin ACO - Spring / Printemps 2019

Your COA / Votre association

In Memoriam Gerhard Driedger MD, FRCPRSC, FACS July 21, 1925 - January 23, 2019

orn in Baaronhof in the Free City of Danzig, Gerhard was the second of three sons born to Walter and Helene Driedger. In 1942 he enlisted in the German Army Medical Service. This enabled him to start his medical studies in 1943. While still a Prisoner of War in June 1945, he married Hilda Esau, his childhood sweetheart and wife for the next 72 years. The War over, he resumed his medical studies at the University of Kiel graduating in 1948. He interned at the Mennonite Central Committee hospital in Gronau and began a surgical residence in Coblenz. In 1951, the family emigrated to Canada and settled in Lethbridge Alberta. After success in his Dominion Council Exams and working in General Practice for three years, he embarked on postgraduate Orthopaedics Studies at the University of Pennsylvania. Returning to Lethbridge in 1960, he was made a fellow of the Royal College of Surgeons in Canada. He became Chief of Surgery at the Municipal Hospital for 10 years, President of the Alberta Orthopaedics Society and founding president of the Lethbridge Surgical Society. He

served as a medical missionary at the Lutheran Hospital in Yagaum, New Guinea in 1969-70. By 1988, he reduced his workload for health reasons and retired in 1995. Always an avid history buff, he then wrote a history of his ancestoral homeland, “The Werder” (The Land of the Vistula River Delta). The Driedger family were members of Christ Trinity Lutheran Church in Lethbridge since 1954. Gerhard served on the congregational council as well as the Evangelical Lutheran Church Council for many years. Gerhard was predeceased by his wife, Hilda, in 2017, his parents in 1972 and 1985 and his brother, Walter, in 1944. He is survived by children Walter (Takako), Renate Maria (John), Bernhard (Annette) and Peter (Linda (deceased), now Tatyana) as well as nine grand-children and ten great-grandchildren. In lieu of flowers, donations may be made to the memorial fund of Christ Trinity Lutheran Church in Lethbridge.

John P. Kim, MD, FRCSC April 10, 1929 - January 2, 2019

t is with great sadness that we announce the passing of Dr. John P. Kim on January 2, 2019 at the age of 89. He was a long-standing member of the Canadian Orthopaedic Association and had a career spanning over five decades as an orthopaedic surgeon in Regina, Saskatchewan. Dr. Kim was born in Gwangju, South Korea on April 10, 1929. He served as a Major in the South Korean Army Medical Core affiliated with an American Mash unit during the Korean War. Immediately following the war, he was selected by the Korean President as one of only ten physicians from South Korea to undergo further specialty training in the United States. He completed an internship in Phoenix, Arizona and in recognition of his exemplary surgical skills, was awarded a highly coveted orthopaedic surgery residency position at the University of Iowa. One of his mentors during residency was the world-renowned Dr. Ignacio Ponseti. Following his residency, he immigrated to Canada and began his medical career as an orthopaedic surgeon in October 1958 at the Regina General Hospital where he met his future wife Carolyn. Throughout his career, no case was too difficult or too small; he would take on the most complex of injuries and was a pioneer in the province for many new surgical techniques. His career spanned many seminal changes in the field of orthopaedics including the introduction of total joint replacement surgery, spinal instrumentation and joint arthroscopy just to name a few. He incorporated all these new surgical techniques into his practice long before they became known as “sub-

specialty” areas. He treated tens of thousands of patients in the province of Saskatchewan during his 56-year orthopaedic career and wherever he went would inevitably encounter patients or a family member of someone he had treated. All who worked with him will remember him for his endless energy, drive and dedication. He also inspired his son, Dr. Paul Kim to follow in his footsteps to become an orthopaedic surgeon who currently practices at the University of Ottawa. He was the first Korean to settle in Saskatchewan and later served as President of the Korean Association. He received a Lifetime Achievement Award from the Korean Canadian Cultural Association of Canada in 2001 for his medical work and participation as a member of the North South Korean Reunification Advisory Team. Later in his career he performed medical relief work with Health Volunteers Overseas travelling to China near the North Korean border to perform surgery, teach and provide orthopaedic care. Dr. Kim took great joy hunting and fishing with family, colleagues and friends and in later years kept active with his wife learning ballroom dancing or at least attempting to... As an orthopaedic surgeon, he remained passionate about his profession and was truly fulfilled treating those in need of his skills. He was a gifted surgeon who touched the lives of many. He will be missed greatly.

Robert “Bob” Maclean Glasgow, MD, FRCSC August 22, 1937 – January 15, 2019

n January 15, 2019, Dr. Robert “Bob” Maclean Glasgow of Spruce Grove, Alberta passed away at the age of 81 years. Bob is survived by his wife of 54 years, Lucille; children Monique, Rob (Anne), Diane (Rob), and Don (Jenni); grandchildren Emilie, Sophie and Robbie, Rebecca and Kathleen, Avery and Lowyn; sister Marion (Tom) and brother Bill (Anne). Bob was born in Edmonton on August 22, 1937 and was raised in the Crowsnest Pass. He obtained his Bachelor of Science at the University of British Columbia. He later went on to enter medical school at the University of Alberta where he met Lucille. After graduating with his MD in 1964, Bob married Lucille, welcomed the first of his four children, and spent some time practicing in Radway. Bob then returned to the University of Alberta

where he became a Fellow of the Royal College of Physicians and Surgeons in the Specialty of Orthopaedic Surgery on November 23, 1970. He practiced in Edmonton and Yellowknife for the following 47 years until he retired in January 2017. Throughout his life Bob loved the outdoors and enjoyed many hunting, fishing, and scuba diving trips with his sons, brother and other friends. He enjoyed golfing and travelling with Lucille. He was active in coaching and/or watching his children and grandchildren in their activities from hockey and soccer to cycling to equestrian to Ukrainian dancing. In lieu of flowers, please make a donation to the Cross Cancer Institute. COA Bulletin ACO - Spring / Printemps 2019

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

So Weird, They’re Wonderful. Unusual Cases Wanted for COA Bulletin Feature

Si bizarres, si extraordinaires : Cas insolites recherchés pour une série d’articles du Bulletin de l’ACO

o you have a bizarre or unusual case that has presented in your clinic or OR? Something that may have had unexpected results? We want it! The COA Bulletin includes a new feature where weird (and wonderful) cases will be presented to the membership. Submit the following to cynthia@canorth.org for consideration: 1) 2 3)

Imaging – up to 5 images 500-word case summary including: a) Brief clinical history and diagnosis b) Treatment measures c) Outcomes d) Take-home message 5 references maximum

IMPORTANT TIPS FOR CASES! - The best stories are told through images – make sure that your photos are high-quality and clear. - Keep it brief! Stick to the most important information as it relates to the unusual nature of your case submission.

vez-vous déjà eu un cas bizarre ou insolite en clinique ou salle d’opération? Quelque chose qui a eu des résultats inattendus? Nous voulons le savoir! Le Bulletin de l’ACO propose aux membres une nouvelle série d’articles sur des cas bizarres (et extraordinaires). Soumettez ce qui suit à cynthia@canorth.org : 1) 2) 3)

Jusqu’à 5 images Résumé du cas en 500 mots, y compris ce qui suit : a) Court historique clinique et diagnostic b) Traitement c) Résultats d) Conclusion Maximum de 5 références

CONSEILS IMPORTANTS POUR LES CAS! - Une image vaut mille mots; assurez-vous que vos photos sont de grande qualité et nettes. - Soyez concis! Tenez-vous-en aux renseignements les plus importants afin d’illustrer la nature insolite du cas soumis.

Unheard Of! Early Post-TKA Myonecrosis – A Case Report This edition’s unusual case was submitted by Dr. Brent Lanting from Western University

78-year old diabetic female with an osteoarthritic right knee underwent an apparently uneventful total knee arthroplasty in a peripheral hospital. Seventeen days postoperatively, she underwent an evacuation of a surgical site hematoma secondary to a supratherapeutic INR. However, she also presented with purulent drainage from the incision and a concomitant pre-renal failure. Twenty days after the index surgery, she received irrigation and debridement and an exchange of her polyethylene insert, followed by postoperative antibiotic therapy with Metronidazole. Intra-operative tissue cultures were positive for Clostridium perfringens and Staphylococcus aureus. This patient was referred to our centre four weeks after her index surgery due to persistent peri-incisional necrosis and COA Bulletin ACO - Spring / Printemps 2019

concerns of soft tissue coverage (Figure 1). Although she was hemodynamically stable, laboratory investigations revealed an elevated C Reactive Protein (CRP) of 124 and white blood cell (WBC) count of 17.8 x 103/mm3. The patient underwent urgent debridement, prosthesis removal, and static spacer placement. Intra-operatively, the fascia had a glassy appearance, and the infection extended along fascial planes. Resection of the necrotic skin left a full thickness skin defect with approximate dimensions of 10cm medial to lateral and 12cm cephalad to caudad (Figure 3). Since primary closure was not possible, plastic surgery was consulted intra-operatively, and a VAC dressing was applied. Postoperative antibiotic therapy with Ceftriaxone and Metronidazole was initiated. Inter-aoperative tissue cultures were positive for C. perfrigens along with a mixed flora of beta-hemolytic Streptococcus, Micrococcus, and Actinobacter. Postoperatively, the patient remained hemodynamically stable. Due to the advanced nature of the soft tissue infection and

Clinical Features, Debates & Research / DĂŠbats, recherche et articles cliniques (continued from page 18)

the bacteria present, a second irrigation and debridement was planned in discussion with the patient and her family. They were also informed that due to medical and local tissue factors, an above knee amputation may potentially be required. The patient was taken to our centreâ&#x20AC;&#x2122;s OR for a second time due to the progressive necrosis of the skin. The medial and lateral gutters contained significant purulent discharge along with soft tissue compromise and a non-viable extensor mechanism, which showed significant destruction to the patellar tendon and patella (Figure 4). Plastic surgery was once again consulted intra-operatively, and due to the patientâ&#x20AC;&#x2122;s advanced age, medical co-morbidities, progressive necrosis and difficulty with soft tissue coverage it was determined that it was best to proceed with an above knee amputation. The operation was uneventful, and the patient was discharged 22 days after the admission. The patient was seen again in clinic a month later with a wellhealed stump. At two years postop, she remained systemically well, and her above knee amputation had an intact soft tissue envelope. Take home message: 1. Myonecrosis has not previously been reported in early postoperative TKA. 2. C.perfringens always needs to be treated surgically urgently, and limb amputation needs to be discussed with consent obtained preoperatively. 3. Irreconstructible skin defects and extensor mechanism loss in combination may independently necessitate lower extremity amputation.

Figure 1 Preoperative X-rays showing a right total knee arthroplasty with normal alignment and position of prosthetic components. Air lucency is visible within the right knee joint, the overlying anterior subcutaneous soft tissues and soft tissues adjacent to the proximal tibia and fibula, suggesting gas formation.

Figure 2 Preoperative photograph of right knee. This photograph shows extensive skin necrosis.

Figure 3 Intra-operative photograph of first irrigation and debridement. This was photographed after the irrigation and debridement, and the antibiotic spacer was placed.

Figure 4 Intra-operative photograph of second irrigation and debridement, showing (A) poor tissue perfusion and (B) anterior defect postdebridement.

Figure 5 Intra-operative photograph, showing anterior cutaneous defect postdebridement.

COA Bulletin ACO - Spring / Printemps 2019

YOU MAKE AN IMPACT YOU MAKE THINGS HAPPEN YOUR DUES DOLLARS DIRECTLY SUPPORT ORTHOPAEDICS IN CANADA

As a member of the Canadian Orthopaedic Association (COA), you are directly contributing to the advancement of our specialty. Every membership sustains and develops national and local initiatives for our collective orthopaedic community. Your membership contributions extend far beyond the scope of the Annual Meeting. Instead, consider some of the many recent COA initiatives that your membership dues played a key role in developing.

DIVERSIFYING OUR SPECIALTY Female university and medical students can now participate in an interactive session with leaders in the orthopaedic specialty. This program hopes to increase the number of women applying for residency positions by providing earlier and more comprehensive exposure to orthopaedics.

MENTORSHIP PROGRAM Residents and fellows are matched with active members for a day at the Annual Meeting. This endeavour fosters professional development and career planning, and provides leadership and role modeling opportunities.

ADVOCATING FOR ACCESS TO CARE Lending advocacy support to provincial orthopaedic associations through a lobbyist with expertise in government meetings, drafting briefings/messaging, and gathering intelligence, as well as providing national support to existing provincial advocacy initiatives.

SURGEON EMPLOYMENT Hiring and employment data over a 5-year period has been collected and analyzed for the purposes of strategic discussion related to the ongoing underemployment crisis with orthopaedic training programs, the Royal College, and the media.

CME YEAR-ROUND Accredited learning opportunities through webinars and summarized evidence-based research studies on OrthoEvidence are available to members throughout the year.

SOCIAL RESPONSIBILITY The COA partnered with the Centre for Evidence-Based Orthopaedics at McMaster University to offer members access to EDUCATE, a program that teaches health-care professionals to identify and assist patients who present to the fracture clinic with a history of intimate partner violence.

INTERNATIONAL COLLABORATIONS Educational exchanges and research collaborations are established between the COA and orthopaedic associations in India and Europe, with increasing partnerships developing across the globe. The COA and its members are active participants on the world stage of orthopaedics.

TOGETHER, WE MAKE THE DIFFERENCE Your COA membership is important and your contributions make a difference. These improvements would not be possible without your support. Thank you for being a member.

www.coa-aco.org

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

Diagnosis and Management of Periprosthetic Joint Infections Michael J. Monument, M.D., MSc, FRCSC Assistant Professor, Department of Surgery University of Calgary Calgary, AB

otal joint arthroplasties are some of the most common and successful orthopaedic procedures used to address a variety of musculoskeletal conditions including fractures, degenerative joint disease and neoplastic disorders. In 2016-2017, 123,000 hip and knee arthroplasties were performed in Canada, representing a 16%-18% increase in utilization over the preceding five-year interval (Canadian Joint Replacement Registry (CJRR), 2016–2017, Canadian Institute for Health Information). These numbers are anticipated to steadily increase over the next decade as the population ages and the indications for joint arthroplasties expand1. Acute and chronic periprosthetic joint infections (PJIs) remain a devastating complication of total joint arthroplasties. PJIs are associated with inferior patient outcomes and significant economic burden to the health-care system. In Canada, 23% and 16% of revision TKA and THA procedures, respectively, are performed for infectious etiologies each year (CJRR). Roughly 1-2% and 0.5-1.0% of primary TKAs and THAs will be complicated by an acute or chronic PJI2,3. These numbers are markedly increased in revision TKA/THA (2-6%) and in joint arthroplasties performed for oncologic reconstructions (8-12%)4-7. In the environment of rising rates of anti-microbial resistance, fiscal restraints in health-care delivery and a continuous push towards improving patient outcomes – improving the prevention, detection and multidisciplinary management of PJIs are fundamental priorities in Canadian orthopaedic care. At the 2018 COA Annual Meeting held in Victoria, a combined MSK oncology/hip/knee arthroplasty Instructional Course Lecture (ICL) was organized to discuss the complexities of diagnosing and managing PJIs. Dr. Nelson Greidanus (UBC) opened the session reviewing the diagnostic challenges associated with PJI and summarized the evidence of new diagnostic techniques and algorithms. Dr. Kristen Brown (University of Calgary, Medical Microbiology) provided a highly informative discussion of how orthopaedic surgery and infectious disease specialties can effectively collaborate to improve the multidisciplinary management of PJIs. Dr. Thomas Turgeon (University

of Manitoba) provided an update of the surgical strategies and outcomes for acute and chronic PJI while Dr. Norbert Dion (Université Laval) provided case presentation of challenging, recalcitrant PJI cases associated with bone loss and soft tissue compromise. This ICL underpinned the challenges associated with PJI, the growing need for prospective research and the importance of collaborations within orthopaedics and between specialties. We are pleased to provide a summary of the ICL presentations in this edition of the COA Bulletin. References 1. Kurtz, S., Ong, K., Lau, E., Mowat, F. & Halpern, M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am 89, 780-785, doi:10.2106/JBJS.F.00222 (2007). 2. Namba, R. S., Inacio, M. C. & Paxton, E. W. Risk factors associated with deep surgical site infections after primary total knee arthroplasty: an analysis of 56,216 knees. J Bone Joint Surg Am 95, 775-782, doi:10.2106/JBJS.L.00211 (2013). 3. Lenguerrand, E. et al. Risk factors associated with revision for prosthetic joint infection after hip replacement: a prospective observational cohort study. Lancet Infect Dis 18, 1004-1014, doi:10.1016/S1473-3099(18)30345-1 (2018). 4. Mortazavi, S. M., Schwartzenberger, J., Austin, M. S., Purtill, J. J. & Parvizi, J. Revision total knee arthroplasty infection: incidence and predictors. Clin Orthop Relat Res 468, 20522059, doi:10.1007/s11999-010-1308-6 (2010). 5. Bohl, D. D. et al. How Much Do Adverse Event Rates Differ Between Primary and Revision Total Joint Arthroplasty? J Arthroplasty 31, 596-602, doi:10.1016/j.arth.2015.09.033 (2016). 6. Henderson, E. R. et al. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am 93, 418-429, doi:10.2106/JBJS.J.00834 (2011). 7. Thornley, P. et al. Causes and Frequencies of Reoperations After Endoprosthetic Reconstructions for Extremity Tumor Surgery: A Systematic Review. Clin Orthop Relat Res 477, 894-902 (2019).

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 - Spring / Printemps 2019

Now Ready to Use

GRAFTJACKET NOW™ Regenerative Tissue Matrix

GRAFTJACKET NOW™ is the new and improved, next generation of GRAFTJACKET™, and this outstanding product is available to your customers at no additional cost from the current GRAFTJACKET™ product.

For more information, visit:

wright.com/graftjacket All products not available in all markets. ™ and ® denote Trademarks and Registered marks of Wright Medical Group N.V. or its affiliates. ©2019 Wright Medical Group N.V. or its affiliates. All Rights Reserved. AP-011188A_14-Feb-2019

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

Making the Diagnosis of Surgical Site Infection in Total Joint Replacement Nelson V. Greidanus, M.D., MPH, FRCSC Assistant Professor, Department of Orthopaedics, University of British Columbia, Vancouver, BC

rosthetic joint infection (PJI) creates an enormous burden on patients and health-care resources in Canada. Infection affects 0.7% to 2.4% of all primary joint replacement (CJRR 2.2%, US Medicare data 2.2%), and is the reason for revision arthroplasty surgery in 15% of failed THA and 25% of failed TKA (CJRR 10%, Swedish Registry 10%, Australian Registry 9%)1. Often the diagnosis can be challenging, confounded by imperfect or inadequate diagnostic techniques along with an imperfect definition of PJI. The objectives of this article are to define prosthetic joint infection, identify optimal techniques to diagnose PJI, and formulate a strategic ‘work-up’ that has relevance to orthopaedic practice in Canada. Establishing the diagnosis of infection can be relatively straightforward when evaluating a prosthetic joint with a draining sinus or when a patient is febrile and has a warm swollen joint with symptoms that appear relatively ‘classic’ for infection. However, many patients will present to the orthopaedic surgeon with an ‘unclear’ clinical history, vague or inconsistent symptoms, and may have already been subjected to various diagnostic tests and a course of antibiotics, all of which confounds the ability to make a clear diagnosis and plan definitive treatment. Due to the diverse array of symptoms that may or may not be present with PJI, it is imperative that the orthopaedic surgeon consider infection in the differential diagnosis for every painful or ‘loose’ total joint replacement. Studies suggest that up to 12% of revision surgeries for so-called ‘aseptic loosening’ were actually due to infection that was incorrectly evaluated or wrongly diagnosed as aseptic2. To efficiently establish or refute the diagnosis of infection requires the clinician to have a good working knowledge of an appropriate and cost-effective diagnostic testing strategy and to utilize a precise and valid definition for infection. Diagnosis relies on a combination of clinical suspicion, pertinent history and physical examination, haematological work-up, synovial fluid assessment, cultures, and in some cases histology or additional adjuvant tests. Various definitions of PJI have been used in the past decade, and across different studies, which may make it difficult and confusing for the clinician to formulate a precise diagnostic algorithm and then produce the correct diagnosis. In an effort to standardize the diagnosis of PJI, numerous medical societies, or working groups, have proposed definitions along with recommendations for diagnostic tests. In 2011 the Musculoskeletal Infectious Society (MSIS) proposed a set of criteria for the diagnosis of PJI that was subsequently revised at the International Consensus Meeting (ICM) on PJI in 20133. These recommendations formed the basis of a Clinical Practice Guideline by the American Academy of Orthopaedic Surgeons (AAOS). In 2013, the Infectious Disease Society of America (IDSA) published a set of criteria for the definition of PJI4. It is

important to understand that these definitions are somewhat different from each other. In recent years, there has been extensive research into additional cytokines and biomarker tests and further data pertaining to diagnostic test characteristics has necessitated an ‘updated’ definition of PJI and recommendations for ‘patient work-up’5,6. In 2018 a further International Consensus Meeting (ICM) was held to provide for the inclusion of recent biomarker tests and update the evidence-based recommendations and guidelines accordingly7. Diagnostic Evaluation The published literature suggests the following factors are important to consider when evaluating/considering the diagnosis of prosthetic joint infection: 1) Clinical Presentation While a sinus tract is diagnostic for infection, other features of infection may not be readily discernible on history and physical examination8: a. varies depending on: i. time of onset following arthroplasty procedure ii. mechanism or route of infection iii. virulence of pathogen iv. host comorbidities and immune status b. acute versus chronic infection: i. acute: more likely to be associated with challenging wound, hematoma, prolonged drainage from incision, +/-erythema, cellulitis, fever ii. chronic: may be associated with indolent course, joint pain, with or without prosthetic fixation failure 2) Hematology, Bloodwork and Serum Biomarkers a. CBC, WBC and differential: not reliable, poor diagnostic utility unless patient is in systemic sepsis b. ESR and CRP: inexpensive, widely available, elevated immediately post-surgery as well as with other chronic or acute systemic diseases, renal disease, malignancy, advanced age i. may be suppressed and unreliable if antibiotics have been administered over a prolonged period or slow-growing indolent organisms (i.e. P. acnes)9,10 ii. established thresholds demonstrate good diagnostic utility for infection (optimal positivity criterion): 1. ESR > 30mm/h 2. CRP > 10mg/L c. Procalcitonin: not widely used, accepted cut-off threshold of >0.5 ng/ml significant for infection, diagnostic utility affected by low sensitivity (33%) despite high specificity (98%)11 d. IL-6: –a cytokine produced by monocytes/macrophages, has recently attracted attention as it may have a higher diagnostic odds ratio than ESR and CRP i. >10ng/ml or >12ng/ml associated with high sensitivity and specificity12 COA Bulletin ACO - Spring / Printemps 2019

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 23)

e. Serum D-Dimer: elevated during fibrinolytic activities associated with infection i. >850ng/ml has high sensitivity (89%) and specificity (93%)13 3) Synovial Fluid Analyses a. WBC/leukocyte counts and percentage neutrophils i. >3,000 WBC/ml and a neutrophil percentage >80% indicative of chronic infection ii. >10,000 WBC/ml and a neutrophil percentage >90% indicative of acute infection iii. most labs perform an ‘automated’ count however must request a ‘manual’ count in cases involving metallosis, ALVAL or where metal-on-metal bearings are used as they may have a non-reliable automated count b. Bacterial cultures: multiple specimens preferred (aerobic and anaerobic) i. incubation for 5-14 days (slow growing organisms i.e P. acnes need prolonged/extended incubation) ii. may be falsely negative if antibiotics already administered c. Synovial leukocyte esterase: produced by neutrophils, can be tested via colorimetric strip with high specificity (100%) and good sensitivity (81%) d. Synovial Procalcitonin: >0.08ng/ml has sensitivity of 90% and specificity of 83%. e. Synovial CRP: >2.5 mg/L has high sensitivity (96%) and high specificity (93%)14 f. Synovial IL-6: > 8,671 ng/ml has good sensitivity (81%) and high specificity (96%)15, alternate thresholds are reported by other authors (ie. >2,300ng/ml) g. Synovial alpha-defensin: >5.2 mg/ml highly indicative of infection, the defensins are endogenous peptides of the host-defense innate immune system released by PMN cells in response to infection, an almost ‘perfect’ test with close to 100% accuracy in lab testing, however be aware that reported results vary depending on whether the lab immunoassay or lateral flow test are used i. lab based immunoassay (centrifuged, not available widely, currently difficult to obtain in Canada, select centres only), sensitivity 95%, specificity 97% ii. lateral flow test (filtered, readily available as an ELISA ‘kit’, sold and distributed by Zimmer-Biomet Inc as ‘Synovasure’), sensitivity 77%, specificity 91% iii. risk of false positive in cases: 1. involving metallosis 2. involving crystal-deposition arthropathies 3. prior to second-stage revision surgery for infection 4. less reliable in shoulder prosthesis infection1,16 4) Intra-operative Histology a. Histopathology/frozen section analysis can be highly specific for infection and a useful adjuvant for confirming or refuting a PJI b. Current guidelines recommend a positive diagnosis for infection be made when there are >5 neutrophils per high power field in at least five microscopic fields17 COA Bulletin ACO - Spring / Printemps 2019

5) Intra-operative Cultures a. Multiple periprosthetic tissues should be sent for aerobic and anaerobic cultures at the time of surgery, at least three and preferably five or six specimens, for a minimum of five days incubation (preferably 14 days if concerned about slow-growing organisms)18 6) Molecular Biology a. The use of polymerase chain reaction (PCR) methods is being investigated in an attempt to improve the accuracy of diagnosing PJI, specific or broad-range PCR methods have been used and may assist with cases that remain ‘culture negative’ or in other select indications19 The Definition of Infection: An ‘Evidence-based and Validated Algorithm’ In the absence of a single diagnostic test with perfect ability to discriminate infection from absence of infection, it appears that a combination of tests and criteria is required to obtain the best diagnostic acumen. Ideally, these tests should be cost-effective, minimally invasive, easy to interpret, and readily available. With this in mind, a number of researchers and stakeholders from the MSIS, IDSA, and ICM 2018 panelists researched/developed an ‘evidence-based’, ‘weight-adjusted’ scoring system for the definition of PJI of the hip and knee7. This definition of PJI was then evaluated on an external cohort and compared against other current published definitions of PJI. To use this ‘weighted’ scoring system the clinician must assign zero, one, two, or three points to select ‘preoperative diagnostic variables’ associated with infection (elevated serum CRP or D-Dimer is two points, elevated ESR is one point, elevated synovial wbc or leukocyte esterase is three points, positive alpha defensin is three points, elevated synovial PMN percentage is two points, elevated synovial CRP is one point) (see Figure 1 and 2 below). If the total score is zero or one after scoring preoperative variables, then the case is considered ‘notinfected’, if the total score is greater than or equal to six then the case is considered ‘infected’, if the score is in the range of two through five then the case is considered ‘possibly infected’ and the clinician should consider ‘intra-operative diagnostic variables’ (positive histology is three points, positive purulence is three points, single positive culture is one point) to create an aggregate score. If the aggregate score is greater than or equal to six then the diagnosis is ‘infected’, if it is less than or equal to three it is ‘non-infected’, and if it is four or five it would still be considered ‘inconclusive’.

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

ity of the ‘Synovasure’ test, and how quickly it can be performed and interpreted, it may be most appropriate to consider using it in ‘inconclusive’ yet suspicious PJI cases as an intra-operative test to ‘rule in’ or more-importantly ‘rule-out’ infection1. In the rare case where the diagnosis continues to be ‘inconclusive’, additional intra-operative features including frozen section/ histo-pathology and tissue cultures may help with the diagnosis. In the future, with the refinement and inclusion of additional molecular biology/PCR techniques, the so-called ‘inconclusive’ PJI workup should hopefully become obsolete. References 1. Bonanzinga T. et al. The role of alpha defensin in prosthetic joint infection diagnosis: a literature review. EFORT Open Rev 2019;4:10-13 2. Parvizi J. et al. New definition for periprosthetic joint infection: from the workgroup of the MSIS. Clin Orthop Relat Res. 2011 Nov; 469(11):2992-4. This algorithm was evaluated against an external cohort of 422 revisions and demonstrated a correct diagnosis in 95.5% of cases (true positives) with 2.3% false negatives and 2.3% indeterminate. Comparing the new algorithm with previous MSIS 2011 and ICM 2013 definitions demonstrated an improvement in diagnostic utility with a sensitivity of 97.7% and a specificity of 99.5%. It is important to understand that certain ‘patients’ or circumstances exist where these proposed criteria may be inaccurate. Such cases include; patients with adverse local tissue reaction (ALTR) and ALVAL associated with metal-on-metal hip prostheses, crystalline deposition arthropathy, inflammatory arthropathy flare, or an infection involving a slow-growing organism. A Cost-effective Approach with Relevance to Canadian Orthopaedic Surgeons In summary, it is important to understand that there is no need for the so-called ‘million dollar workup’ for the vast majority of cases presenting for evaluation of PJI. In a health-care system that has finite resources, it is prudent that the clinician have an understanding as to the costs and limitations of diagnostic tests and utilize an efficient and cost-effective strategy to come to a precise diagnosis of PJI. Ideally, a highly sensitive test should be used to ‘rule in’ the diagnosis of infection and a highly specific test to confirm or ‘rule out’ infection. An astute history, physical examination, serum ESR and CRP, joint aspiration for culture and cell count with differential will reveal the diagnosis of ‘infected’ or ‘not-infected’ in the majority of cases. Nuclear medicine and additional imaging are costly, often do not add additional diagnostic utility, and are therefore not widely recommended in recent guidelines. For complex or inconclusive cases, an additional preoperative test such as the synovial alpha defensin or synovial CRP tests may be helpful. The recent ‘evidencebased, weight adjusted scoring algorithm’ for the definition and diagnosis of infection by Parvizi et al. is a useful tool that incorporates recent biomarker and cytokine data. Currently, it is difficult to obtain the synovial alpha-defensin test as a lab immunoassay in Canada, however the clinician may use the relatively quick ten-minute ‘Synovasure’ ELISA lateral flow kit as an alpha-defensin test but its diagnostic test performance may not be as ‘perfect’ as the lab immunoassay. Given the high specific-

3. Parvizi J. et al. International Consensus Group on PJI. Definition of PJI. J Arthroplasty 2014;27:302-45 4. Osmon D.R., et al. Infectious Diseases Society of America. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013;56:e1-e25 5. Deirmengian C. et al. Diagnosing periprosthetic joint infection: has the era of the biomarker arrived? Clin Orthop Relat Res 2014;472:3254-62 6. Frangiamore S.J. et al. Alpha-defensin accuracy to diagnose periprosthetic joint infection-best available test? J Arthroplasty 2016;31:456-60 7. Parvizi J. et al. The 2018 definition of periprosthetic hip and knee infection: an evidence-based and validated criteria. J Arthroplasty 2018;33:1309-1314 8. Gomez-Urena E.O. et al. Diagnosis of prosthetic joint infection: cultures, biomarkers, and criteria. Infec Dis Clin North Am 2017; 31:219-35 9. Spangehl, M.J. et al. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999;81(5):672-683 10. Greidanus N.V. et al. Use of erythrocyte sedimentation rate and C-reactive protein level to diagnose infection before revision total knee arthroplasty. A prospective evaluation. J Bone Joint Surg Am 2007;89(7):1409-1416 11. Bottner F. et al. Interleukin-6, procalcitonin and TNF-alpha: markers of peri-prosthetic infection following total joint replacement. J Bone Joint Surg Br 2007;89:94-9 12. Berbari F. et al. Inflammatory blood laboratory levels as markers of prosthetic joint infection: a systematic review and meta-analysis. J Bone Joint Surg Am 2010;92:2102-9 COA Bulletin ACO - Spring / Printemps 2019

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

(continued from page 25)

13. Shahi A. et al. Serum D-Dimer test is promising for the diagnosis of periprosthetic joint infection and timing of reimplantation. J Bone Joint Surg Am 2017;99:1419-27 14. Omar et al. Synovial C-reactive protein as a marker for chronic periprosthetic infection in total hip arthroplasty. Bone Joint J. 2015 Feb;97-B(2):173-6 15. Lee Y.S. et al Synovial fluid biomarkers for the diagnosis of periprosthetic joint infection: a systematic review and metaanalysis. J Bone Joint Surg Am 2017;99:2077-84 16. Marson B.A. et al. Alpha-defensin and the Synovasure lateral flow device for the diagnosis of prosthetic joint infection: a systematic review and meta-analysis. Bone Joint J 2018;100B:703-11

17. Tsaras G. et al. Utility of intraoperative frozen section histopathology in the diagnosis of periprosthetic joint infection: a systematic review and meta-anlysis. J Bone Joint Surg Am 2012; 94:1700-41 18. Butler-Wu S.M. et al. Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection. J Clin Microbiol 2011;49:2490-5 19. Tarabichi M. et al. Diagnosis of periprosthetic joint infection: the potential of next-generation sequencing. J Bone Joint Surg Am 2018;100:147-54

Prosthesis-related Infections: Five Things Infectious Disease Consultants and Medical Microbiologists Want Orthopaedic Surgeons to Know Kristen L. Brown, M.D., FRCPC Infectious Disease Consultant and Medical Microbiologist Clinical Assistant Professor, Departments of Medicine and Pathology and Laboratory Medicine, University of Calgary Calgary, AB

nfections are an uncommon but devastating complication of prosthetic joint infection (PJI) involving repeated operations and long courses of antibiotics. Appropriate antibiotic selection requires accurate identification of the pathogen, which is entirely dependent on appropriate specimen selection, collection and transport to the laboratory. The following are five tips to help you arrive at the best antibiotic choice for your patient. 1. Swabs are an inadequate specimen type, especially from the OR Swabs are inferior to tissues, fluids and aspirates in the recovery of clinically-significant pathogens for all types of infection including PJI. As the IDSA Guideline for utilization of the microbiology laboratory states, “the lab needs a specimen, not a swab of a specimen”1. The sensitivity of synovial fluid culture in blood culture bottles is 90-92 %, that of tissue culture 77-82%, while the sensitivity of intraoperative swab cultures is only 68-76 %2. Swabs provide a smaller volume sample than tissues or fluids, are more likely to be contaminated during collection, and do not allow for uniform inoculation of sample across multiple agar plates1. In the OR where an anaesthetized patient and the appropriate equipment are available; there are few circumstances where collection of tissue or fluid is not possible. The Choosing Wisely Canada campaign further suggest that swabs should be made unavailable in the OR setting3.

COA Bulletin ACO - Spring / Printemps 2019

2. Collect three to six periprosthetic tissue samples Guidelines recommend collecting at least three and optimally five to six periprosthetic tissues samples, a synovial fluid sample, and if possible, the explanted prosthesis itself for aerobic and anaerobic culture4,5. Two positive cultures for the same organism are considered definitive evidence of a PJI4,6,7. Many organisms responsible for PJI are also normal skin colonizers and without sufficient sample collection, it is difficult to tell contamination apart from true infection. Skin colonizers such as coagulase-negative staphylococci and Cutibacterium acnes (formerly Propionibacterium acnes) should not be deemed the etiology of a PJI unless found in two or more specimens4. For example, when C. acnes is found in one of one samples, it is impossible to say if it is truly the cause of PJI or a contaminant. When C. acnes is present in one of five specimens, it is often a contaminant and if the patient truly does have a PJI, should be treated as a culture-negative infection with broad spectrum antibiotic therapy not directed toward the contaminant. When present in two or more of five specimens, one feels much more confident deeming C. acnes the etiology of infection and adjusting antibiotic therapy accordingly. When this definition is used, five to six specimens are required to achieve sufficient sensitivity and specificity8. The interface membrane, as opposed to the joint pseudocapsule, has been shown to provide the highest yield in terms of positive histology9 as well as highest microbial burden10. DeHaan et al. found that collecting five or more intra-operative tissue specimens compared to collecting only one intra-operative swab led to a change in antibiotic therapy in 30% of cases11. More is not always better however, and collection of greater than six specimens causes a great amount of work for the microbiology laboratory without significantly increasing yield.

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

Once collected, specimens should be placed in the appropriate container and transported STAT to the laboratory. Larger tissue specimens can be sent in standard sterile containers, while smaller (<2cm) specimens should be placed in anaerobic transport media. Most laboratories have a guide to laboratory services outlining how specimens should be collected and transported (example http:// www.calgarylabservices.com/lab-services-guide/lab-tests/ <accessed March 11, 2019>) and the IDSA has published general guidelines as well1.

3. Treat the requisition as a request for consultation with the medical microbiologist When consulting an infectious disease colleague for antibiotic management advice, it would be standard to provide information on who the patient is and what kind of infection you are suspecting. It is equally important that your medical microbiology colleagues be privy to this information. The laboratory has developed different protocols for different patients and leaving out key clinical data on the requisition may make the final report you receive less valuable. It is particularly important that the lab know the sample is from a prosthesis-related infection as this indicates to the lab to extend the usual incubation time of four days to 14 days to look for C. acnes, which takes a longer time than most bacteria to grow12. The antibiotics reported may also be different when a prothesis-related infection is indicated. For example, fluoroquinolones and rifampin may not be routinely tested or released on specimens growing staphylococci unless a prosthesis-related infection is indicated on the requisition. Patient age, allergies and pregnancy status also affect which drugs appear on the final report. Growth from superficially-collected specimens (i.e. superficial wound swab) may not be reported to the degree of detail required for a prosthesis-related tissue specimen, so it is important that the collection site is described in the greatest detail possible. For example, coagulase-negative staphylococci found from a superficial wound sample may be reported as â&#x20AC;&#x2DC;skin flora suggestive of contaminationâ&#x20AC;&#x2122;, whereas from a prosthesis-related tissue specimen would be reported as coagulase-negative staphylococci with antibiotic susceptibility data included. 4. Order the right test for the right patient Requisitions are often crowded with small typeface lists of every test the laboratory offers and it can be difficult to find the test you need. When unsure of what to order, the solution is not to check all the boxes and hope for the best. For most prosthetic-related tissues specimens, aerobic and anaerobic culture with extended incubation to 14 days to rule out C. acnes is all that is required. This will also detect candida spp. which grow easily on routine culture media. Moulds (i.e.: aspergillus), dimorphic fungi (i.e.: blastomyces, histoplasma) and mycobacteria (TB and non-tuberculous mycobacterium or acid-fast bacilli (AFB)) are uncommon causes of PJI and therefore fungal and mycobacterial cultures do not need to be routinely ordered for every patient. Consultation with an infectious disease consultant or medical microbiologist is advised prior to ordering tests for these rare organisms which require a lot of extra work for the laboratory (incubation time of four weeks for fungi and seven weeks for mycobacteria), with little need for most patients.

Separate samples for histopathology should also be sent, especially when the diagnosis of PJI is uncertain1,5. These samples should be sent to the laboratory in formalin. Once specimens have been put into formalin, they cannot be used for culture thus it is crucial specimens for histopathology and microbiology are sent separately in their own designated containers.

5. Know how your lab is handling PJI specimens There is no standardized laboratory guideline for how to handle PJI specimens. In most laboratories, specimens sent for routine anaerobic culture are plated onto agar media as well as a broth and incubated for four days. As noted above, PJI specimens should be incubated for 14 days to maximize sensitivity for C. acnes12. While incubation of synovial fluid samples in blood culture bottles is becoming more common13,14, Peel et al. recently showed that incubation of tissue specimens in blood culture bottles as opposed to other broths or agar culture alone increases sample sensitivity15. Newer technology includes sonication of the explanted joint which is thought to remove biofilm and have increased sensitivity over any one tissue specimen16. Some laboratories may have access to molecular tests which can be particularly helpful in culture-negative infections. Broad-range 16S rDNA sequencing or directed PCR toward common PJI pathogens have been used and more recently, next generation sequencing17,18. In summary, your medical microbiologist colleagues are also invested in arriving at a correct diagnosis for patients with PJI. It is worth the time to call and ask your laboratory director what their current protocols are for these specimens and if they are able to implement any new technology. References 1. Miller J.M., Binnicker M.J., Campbell S., Carroll K.C., Chapin K.C., Gilligan P.H., et al. A Guide to Utilization of the Microbiology Laboratory for Diagnosis of Infectious Diseases: 2018 Update by the Infectious Diseases Society of America and the American Society for Microbiology. Clin Infect Dis 2018 Aug 31;67(6):e1-e94. 2. Larsen L.H, Lange J., Xu Y., Schonheyder H.C. Optimizing culture methods for diagnosis of prosthetic joint infections: a summary of modifications and improvements reported since 1995. J Med Microbiol 2012 Mar;61(Pt 3):309-316. 3. Association of Medical Microbiology and Infectious Diseases Canada (AMMI). Choosing Wisely Canada Medical Microbiology Recommendations. 2017; Available at: https://choosingwiselycanada.org/medical-microbiology/. Accessed 05/05, 2019. 4. Osmon D.R., Berbari E.F., Berendt A.R., Lew D., Zimmerli W., Steckelberg J.M, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis 2013 Jan;56(1):e1-e25.

COA Bulletin ACO - Spring / Printemps 2019

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

5. American Academy of Orthopedic Surgeons. Diagnosis and Prevention of Periprosthetic Joint Infections Clinical Practice Guideline. 2019; Available at: https://www.aaos. org/pjiguideline. 6. Parvizi J., Gehrke T., Chen A.F. Proceedings of the International Consensus on Periprosthetic Joint Infection. Bone Joint J 2013 Nov;95-B(11):1450-1452. 7. Parvizi J., Tan T.L., Goswami K., Higuera C., Della Valle C., Chen A.F., et al. The 2018 Definition of Periprosthetic Hip and Knee Infection: An Evidence-Based and Validated Criteria. J Arthroplasty 2018 May;33(5):1309-1314.e2. 8. Atkins B.L., Athanasou N., Deeks J.J., Crook D.W., Simpson H., Peto T.E., et al. Prospective evaluation of criteria for microbiological diagnosis of prosthetic-joint infection at revision arthroplasty. The OSIRIS Collaborative Study Group. J Clin Microbiol 1998 Oct;36(10):2932-2939. 9. Bori G., Munoz-Mahamud E., Garcia S., Mallofre C., Gallart X., Bosch J., et al. Interface membrane is the best sample for histological study to diagnose prosthetic joint infection. Mod Pathol 2011 Apr;24(4):579-584. 10. Bjerkan G., Witso E., Nor A., Viset T., Loseth K., Lydersen S., et al. A comprehensive microbiological evaluation of fifty-four patients undergoing revision surgery due to prosthetic joint loosening. J Med Microbiol 2012 Apr;61(Pt 4):572-581. 11. DeHaan A., Huff T., Schabel K., Doung Y.C., Hayden J., Barnes P. Multiple cultures and extended incubation for hip and knee arthroplasty revision: impact on clinical care. J Arthroplasty 2013 Sep;28(8 Suppl):59-65.

12. Butler-Wu S.M., Burns E.M., Pottinger P.S., Magaret A.S., Rakeman J.L., Matsen F.A.,3rd, et al. Optimization of periprosthetic culture for diagnosis of Propionibacterium acnes prosthetic joint infection. J Clin Microbiol 2011 Jul;49(7):2490-2495. 13. Church D. Paratechnical Processing of Specimens for Aerobic Bacteriology. In: Leber A., editor. Clinical Microbiology Procedures Handbook. 4th ed. Washington, DC: ASM; 2016. 14. Geller J.A., MacCallum K.P., Murtaugh T.S., Patrick D.A.,Jr, Liabaud B., Jonna V.K. Prospective Comparison of Blood Culture Bottles and Conventional Swabs for Microbial Identification of Suspected Periprosthetic Joint Infection. J Arthroplasty 2016 Aug;31(8):1779-1783. 15. Peel T.N., Dylla BL, Hughes J.G., Lynch D.T., GreenwoodQuaintance K.E., Cheng A.C., et al. Improved Diagnosis of Prosthetic Joint Infection by Culturing Periprosthetic Tissue Specimens in Blood Culture Bottles. MBio 2016 Jan 5;7(1):e01776-15. 16. Trampuz A., Piper K.E., Jacobson M.J., Hanssen A.D., Unni K.K., Osmon D.R., et al. Sonication of removed hip and knee prostheses for diagnosis of infection. N Engl J Med 2007 Aug 16;357(7):654-663. 17. Hartley J.C., Harris K.A. Molecular techniques for diagnosing prosthetic joint infections. J Antimicrob Chemother 2014 Sep;69 Suppl 1:i21-4. 18. Tarabichi M., Shohat N., Goswami K., Alvand A., Silibovsky R., Belden K., et al. Diagnosis of Periprosthetic Joint Infection: The Potential of Next-Generation Sequencing. J Bone Joint Surg Am 2018 Jan 17;100(2):147-154.

Management of Acute and Chronic Prosthetic Joint Infections Thomas Turgeon, M.D., MPH, FRCSC Director of Arthroplasty Research, Concordia Hip and Knee Institute Fellowship Director for Hip and Knee Arthroplasty, Concordia Joint Replacement Group Associate Professor, University of Manitoba Winnipeg, MB

from both the immune system and antibiotics. While this three to four week boundary has been dogmatically accepted for many years, there have been some recent moves to challenge this fixed time-frame with evidence that biofilms begin to form within hours, and may be managed successfully for months after initiation4.

With acute infections, there are a few treatment options. Antibiotics alone are rarely successful and not recommended. Debridement and Implant Retention (DAIR) involves aggressive synovial debridement, copious lavage of the tissue and prosthesis and exchange of the modular implants. The modular exchange allows for greater access to the recesses of the joint and a more extensive irrigation of the implant surface. It also debulks the knee of bacteria in early biofilm on the modular components. Combined with six weeks of intravenous antibiotics, the success rate is generally quoted between 50 and 60%, although with a dual set-up, success has been reported as high

rosthetic joint infection (PJI) is a source of major concern for both patients and surgeons. They affect 0.5-2.2% of primary arthroplasty cases of the hip and the knee with risks in the range of 7-10% for revision procedures1-3. Treatment options vary based on the acuity of the infection. Traditionally, infections are classified as either acute or chronic, typically using a three to four week boundary. This is based on an assumption of glycocalyx biofilm fully establishing itself on the implants at this approximate time point. This biofilm secures the bacteria to the implant and shields the bacteria COA Bulletin ACO - Spring / Printemps 2019

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

as 83%5,6. For patients with acute postoperative infections, there is an argument for uncemented single-stage revision. This generally needs to be done within three weeks of surgery. At this early time point, uncemented implants will not be fully in-grown allowing for complete implant exchange. This also allows for greater debridement all of the synovial tissue and bone surfaces. The published success rate for this ranges from 56% to 75%7. Despite the less than stellar success rates of the other alternatives, surgeons are often reluctant to consider two-stage revision for early infections. However, in severe cases with immune suppression, resistant organisms, and soft tissue deficiencies, two-stage revision should be strongly considered even in an acute infection. In the case of chronic infections, the biofilm is presumed to be well established. Bacteria can invade the bone-cement or bone-implant interface preventing adequate debridement. Two-stage revision continues to be considered the goldstandard treatment. In the first of the two stages, the removal of all foreign material is carried out including metal, plastic and cement. Aggressive tissue debridement of both the soft tissue and any necrotic or infected bone is required. Between three and six specimens for culture should be collected followed by six to nine litres of lavage. After the irrigation, either a static or dynamic antibiotic-loaded spacer is inserted. Dynamic spacers tend to have better function between the two stages of surgery, however there has been no proven benefit between these two options at a year following the second stage revision8. In general, the spacers are made with polymethyl methacrylate bone cement and one or more water-soluble, heat-stable bacteriocidal antibiotics. Common antibiotics include gentamicin, tobramycin, and vancomycin. Successful antibiotic mixes have been reported with up to 9 g of antibiotics per bag of cement. Care should be taken with regard to nephrotoxicity and ototoxicity in susceptible individuals especially in the case of patients with renal impairment. The optimal timing between the stages of surgery is not yet known. Intravenous antibiotics are typically administered for period of four to six weeks following the first-stage procedure. There is generally a desire to have the patient off antibiotics for a minimum of two weeks before considering any subsequent re-implantation surgery. Many surgeons prefer a period off of antibiotics to follow the pattern of the ESR and C-reactive protein serum tests. More recently, interleukin-6 (IL-6) and synovial alpha defensin and have been promoted as possible additional tests that can be done through joint aspiration. Aspiration culture results have a significant false-negative rate of up to 45% even with patients off of antibiotics9. At reimplantation, repeat debridement of the joint is performed in conjunction with removal of the spacer. Multiple cultures are repeated. Cemented, uncemented and hybrid fixation of the new definitive implants have all be reported with success. With two-stage revision, the success rate is quoted between 68 and 96%10. Knees typically have lower success rates reported than hips. Extended oral prophylaxis has also been recommended for three or more months following two-stage revision resulting in nearly a four-fold reduction in infection recurrence11.

Single-stage revision has been reported as a successful option for chronic prosthetic joint infection in selected individuals. The single-stage revision is essentially an abridged version of a two-stage revision. The success rate is dependent upon selecting appropriate patients for this procedure. The patient should not be immunosuppressed, must have a healthy soft tissue envelope around the joint, and should have a non-resistant, Gram-positive organism infection. The technique involves complete removal of the hardware with excision of devitalized tissue. The knee undergoes the same lavage as in the two-stage revision. The wound is packed with an iodine-soaked sponge and is provisionally closed and dressed. The contaminated drapes are all removed. The surgical team re-scrubs and regowns and all new instruments are opened. The joint is then re-prepped, and draped and reopened. The wound is then lavaged and the definitive implants are ideally secured with antibiotic-loaded cement. Published success rates for this technique are between 75 and 100%12. In summary, acute PJI can be managed with debridement and implant retention with acceptable success, but consideration should be given to staged revision in cases of resistant organisms and immune system compromise. In chronic infections, two-stage revision continues to be the gold standard with consideration for single-stage revision in select cases. References 1. Australian Orthopaedic Associate National Joint Replacement Registry. Annual Report. In: Graves S., ed. Adelaide: Australian Orthopaedic Association, 2017. 2. National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. 13th Annual Report Hemel Hempstead: NJR, 2018. 3. Kurtz S.M., Lau E., Watson H., Schmier J.K., Parvizi J. Economic burden of periprosthetic joint infection in the United States. The Journal of arthroplasty 2012;27-8 Suppl:61-5 e1. 4. Maillet M., Pavese P., Bruley D., Seigneurin A., Francois P. Is prosthesis retention effective for chronic infections in hip arthroplasties? A systematic literature review. European journal of clinical microbiology & infectious diseases : official publication of the European Society of Clinical Microbiology 2015;34-8:1495-502. 5. Hansen E., Tetreault M., Zmistowski B., Della Valle C.J., Parvizi J., Haddad F.S., Hozack W.J. Outcome of one-stage cementless exchange for acute postoperative periprosthetic hip infection. Clinical orthopaedics and related research 2013;471-10:3214-22.

COA Bulletin ACO - Spring / Printemps 2019

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

(continued from page 29)

6. Argenson J.N., Arndt M., Babis G., Battenberg A., Budhiparama N., Catani F., Chen F., de Beaubien B., Ebied A., Esposito S., Ferry C., Flores H., Giorgini A., Hansen E., Hernugrahanto K.D., Hyonmin C., Kim T.K., Koh I.J., Komnos G., Lausmann C., Loloi J., Lora-Tamayo J., Lumban-Gaol I., Mahyudin F., ManchenoLosa M., Marculescu C., Marei S., Martin K.E., Meshram P., Paprosky W.G., Poultsides L., Saxena A., Schwechter E., Shah J., Shohat N., Sierra R.J., Soriano A., Stefansdottir A., Suleiman L.I., Taylor A., Triantafyllopoulos G.K., Utomo D.N., Warren D., Whiteside L., Wouthuyzen-Bakker M., Yombi J., Zmistowski B. Hip and Knee Section, Treatment, Debridement and Retention of Implant: Proceedings of International Consensus on Orthopedic Infections. The Journal of arthroplasty 2019;34-2S:S399-S419. 7. Bialecki J., Bucsi L., Fernando N., Foguet P., Guo S., Haddad F., Hansen E., Janvari K., Jones S., Keogh P., McHale S., Molloy R., Mont M.A., Morgan-Jones R., Ohlmeier M., Saldana A., Sodhi N., Toms A., Walker R., Zahar A. Hip and Knee Section, Treatment, One Stage Exchange: Proceedings of International Consensus on Orthopedic Infections. The Journal of arthroplasty 2019;34-2S:S421-S6. 8. Park S.J., Song E.K., Seon J.K., Yoon T.R., Park G.H. Comparison of static and mobile antibiotic-impregnated cement spacers for the treatment of infected total knee arthroplasty. International orthopaedics 2010;34-8:1181-6.

10. Bian T., Shao H., Zhou Y., Huang Y., Song Y. Tests for predicting reimplantation success of two-stage revision for periprosthetic joint infection: A systematic review and meta-analysis. Orthopaedics & traumatology, surgery & research : OTSR 2018;104-7:1115-23. 11. Frank J.M., Kayupov E., Moric M., Segreti J., Hansen E., Hartman C., Okroj K., Belden K., Roslund B., Silibovsky R., Parvizi J., Della Valle C.J. The Mark Coventry, MD, Award: Oral Antibiotics Reduce Reinfection After Two-Stage Exchange: A Multicenter, Randomized Controlled Trial. Clinical orthopaedics and related research 2017;475-1:56-61. 12. Kunutsor S.K., Whitehouse M.R., Blom A.W., Board T., Kay P., Wroblewski B.M., Zeller V., Chen S.Y., Hsieh P.H., Masri B.A., Herman A., Jenny J.Y., Schwarzkopf R., Whittaker J.P., Burston B., Huang R., Restrepo C., Parvizi J., Rudelli S., Honda E., Uip D.E., Bori G., Munoz-Mahamud E., Darley E., Ribera A., Canas E., Cabo J., Cordero-Ampuero J., Redo M.L.S., Strange S., Lenguerrand E., Gooberman-Hill R., Webb J., MacGowan A., Dieppe P., Wilson M., Beswick A.D. One- and two-stage surgical revision of peri-prosthetic joint infection of the hip: a pooled individual participant data analysis of 44 cohort studies. European journal of epidemiology 2018;33-10:93346.

9. Shanmugasundaram S., Ricciardi B.F., Briggs T.W., Sussmann P.S., Bostrom M.P. Evaluation and Management of Periprosthetic Joint Infection-an International, Multicenter Study. HSS journal : the musculoskeletal journal of Hospital for Special Surgery 2014;10-1:36-44.

Managing the Impossible: The Challenge of Deep Infection with Endoprostheses Following Bone Sarcoma Resection Norbert Dion, M.D., FRCSC Associate Professor, Division of Orthopaedic Surgery Department of Surgery Faculty of Medicine, Université Laval Québec, QC

time and the extensive soft tissue dissection associated with tumour resection6. Other risk factors have also been identified, such as tibial and pelvic implants, radiation therapy, use of expandable implants in children4,5, as well as an overall poor soft tissue condition2.

Most infections occur within two years after the implantation of the endoprosthesis5, but further surgery, such as bushing exchanges, insertion or revision of a patellar component also increases the risk5,9. In a series of 230 cemented endoprostheses with a minimal follow-up of 25 years, Grimer et al. estimated an annual lifelong risk of 1% for deep infection10. These cases can be quite challenging (Figures 1-4) .

n a retrospective multicentric review of 2,174 endoprostheses implanted after tumour resection of long bones (femur, tibia, humerus), Henderson et al. described modes of failure as mechanical (soft tissue failure, aseptic loosening, structural failure) and non-mechanical (infection, tumour progression)1. Infection was found to be the most common cause of failure overall1. Why is there such a large gap between the infection rate in primary joint replacement (1-2%) and the rate in oncologic procedures requiring an endoprosthesis (8-15%2,3,4,5,6,7,8)? Surely, one should expect a higher infection rate with longer surgical COA Bulletin ACO - Spring / Printemps 2019

Prevention Peri-operative prophylactic IV antibiotics is well accepted as an important means to decrease the risk of periprosthetic joint infections. In oncology, it is important to repeat them intra-operatively every four hours, considering the extent of

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

soft-tissue dissection and the prolonged duration of some surgical procedures. But how long should we keep them postoperatively? It is not certain that we can apply the same rules as primary joint replacement. A Canadian-driven international multicentric randomized prospective study11 will be addressing this particular question, trying to determine whether a one or five-day postoperative antibiotic regimen is best to prevent surgical site infection in these patients. The study should reach complete enrollment of patients by the end of this year. Although their study has limitations including its retrospective nature, small cohort size and short one-year follow-up, Riesgo et al. showed a significant decrease in failure rates following acute periprosthetic joint infections using adjunctive povidone-iodine lavage and intra-wound vancomycin powder to one-stage revision with exchange of the removable components12.

There is a growing interest with silver-coated endoprostheses, considering the high infection rate following a primary oncologic reconstruction. Hardes et al.13 showed a reduction, although not statistically significant (p=0.062), in the infection rate of endoprosthetic reconstruction following primary tumour resections, favouring the silver-coated endoprostheses (5.6%) over the titanium prostheses (17.6%). Wafa et al. reviewed their experience with the use of 85 Agluna®-coated tumour implants in high-risk patients14. When matched with 85 uncoated implants, their study showed an overall postoperative infection rate of 11.8% for the silver-coated group, compared with 22.8% for the control group (p=0,033)14. Sixtynine percent of their coated implants were used in one-stage or two-stage revisions. However, an update of their series15, focusing on primary reconstructions following tumour resections (excluding revision cases), did not show any significant difference between silver-coated and non-silver-coated prostheses for the infection rate.

Nine years following a left distal femur resection for a dedifferentiated parosteal osteosarcoma, a 53-year-old female presented with a late deep infection.

Figure 1 AP of the left knee showed no lytic changes or periosteal reaction, and no signs of loosening.

Figure 2 A bone scan showed an area of decreased uptake (see arrow) in the proximal tibia, compatible with some bone necrosis. This was proven later with histology.

Figure 3 Removal of the whole prosthesis, as well as partial resection of the proximal tibia, was done in the first stage. A temporary arthrodesis was achieved with a nail and antibiotic-impregnated cement.

Figure 4 Following six weeks of IV antibiotics, the knee joint was reconstructed with a combination of a distal femoral and a proximal tibial endoprosthesis, using a synthetic tube and a medial gastrocnemius flap to reconstitute the extensor mechanism. After more than three years postop, her active range of motion is 0-90°, with a 20° extensor lag. There are no signs of infection. COA Bulletin ACO - Spring / Printemps 2019

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

There is definitely a need for a prospective randomized study to clarify the role of silver-coating in the prevention of deep infection with endoprostheses15, both in the primary as well as the revision setting16. Acute and Acute Hematogenous Infections For acute ≤ (£ four weeks after primary surgery) and acute hematogenous infections17-18, one-stage revision with retention of the intramedullary stems have shown superior infection control over local debridement and antibiotics alone4,5,9 Authors recommend a two-step approach in a single operation6. First, a thorough debridement is achieved with removal of all exchangeable components, pulse lavage and temporary closure as the first step of the procedure. Povidone-iodine soak is also suggested6,19. The second portion involves a new skin disinfection and complete re-draping; all the instruments, gowns and gloves of the operating personnel are also changed. Then, the wound is re-opened and a second wash-out is done before implantation of the new components6. As a personal note, I usually consider doing two separate irrigation and debridement procedures at a one-week interval for an acute or acute hematogenous infection, before changing the implants at the second operation. This is considered especially if frank pus is found at the initial procedure, or if the surrounding tissues have already been irradiated. Re-infection rate for one-stage revision in acute infection with endoprostheses in oncology is reported to be 27%4. Early and Late Infections For early (from four weeks to two years) and late (more than two years after the index procedure) peri-prosthetic infections17-18, a two-stage revision is recommended, with removal of all components including both intramedullary stems4,5,6. In these situations, re-infection rate after one-stage and twostage revisions are respectively 47% and 28%6 in early and late periprosthetic infections. Two-stage revision is the preferred method of treatment4,5,6. However, in selected situations, such as patients infected with low virulence and highly susceptible pathogens, and especially for patients in poor general condition or with a poor prognosis, a one-stage revision with retention of the stems might be considered as a reasonable option6, with consideration for prolonged or chronic oral suppressive antibiotics. Salvage Procedures In cases where multiple operations fail to control infection, an amputation must be considered. The secondary amputation rate varies from 5,9% to 54,5% in the literature2,3,4,5,6,7,8. Hillmann et al. also reported on the use of rotationplasty, either at the hip or knee, as a salvage procedure20. But their risk of complications leading to an amputation was 25%20. In some situations, when the functional outcome is still reasonable or when the patient’s general condition and/or prognosis is poor, it might be justified to leave the patient with a chronic fistula, using periodic or chronic suppressive antibiotics6. Deep infection is a serious complication following oncologic resection with reconstruction using an endoprosthesis. Acute COA Bulletin ACO - Spring / Printemps 2019

and acute hematogenous infections should be managed with one-stage revision, keeping the intramedullary stems in place. For early and late infections, a two-stage revision remains the gold standard. We should continue to seek and study new ways to decrease the risk of this limb-threatening complication. References 1. Henderson E.R., Groundland J.S., Pala E., Dennis J.A., Wooten R., Cheong D., Windhager R., Kotz R., Mercuri M., Funovics P.T., Hornicek F.J., Temple H.T., Ruggieri P., Letson G.D. Failure mode classification for tumor endoprostheses: retrospective review of five institutions and a literature review. J Bone Joint Surg Am. 2011, 93: 418-29. 2. Hardes J., Gebert C., Schwappach A., Ahrens H., Streitburger A., Winkelmann W., Gosheger G. Characteristics and outcome of infections associated with tumor endoprostheses. Archiv Orthop Trauma Surg. 2006, 126: 289-96. 3. Malawer M.M., Chou L.B. Prosthetic survival and clinical results with use of large-segment replacements in the treatment of high-grade bone sarcomas. J Bone Joint Surg Am. 1995, 77: 1154-65. 4. Mavrogenis A.F., Pala E., Angelini A., Calabro T., Romagnoli C., Romantini M., Drago G., Ruggieri P. Infected prostheses after lower extremity bone tumor resection: clinical outcomes of 100 patients. Surgical Infections. 2015, 16: 267-75. 5. Jeys L.M., Grimer R.J., Carter S.R., Tillman R.M. Periprosthetic infection in patients treated for an orthopaedic oncological condition. J Bone Joint Surg Am. 2005, 87: 842-49. 6. Sigmund I.K., Gamper J., Weber C., Holinka J., Panatopoulos J., Funovics P.T., Windhager R. Efficacy of different revision procedures for infected megaprostheses in musculoskeletal tumour surgery of the lower limb. PLoS One. 2018, 13: e0200304. 7. Morii T., Morioka H., Ueda T., Araki N., Hashimoto M., Kawai A., Moshizuki K., Ishimura S. Deep infection in tumor endoprosthesis around the knee: a multi-institutional study by the Japanese musculoskeletal oncology group. BMC Musculoskeletal Disorders. 2013, 14: 51. 8. Flint M.N., Griffin A.M., Bell R.S., Wunder J.S., Ferguson P.C. Two-stage revision of infected uncemented lower extremity tumor endoprostheses. J of Arthroplasty. 2007, 22: 859-65. 9. Zajonz D., Zieme A., Prietzel T., Moche M., Tiepoldt S., Roth A., Josten C., von Salis-Soglio G.F., Heyde C.E., Ghanem M. Periprosthetic joint infections in modular endoprostheses of the lower extremities: a retrospective observational study in 101 patients. Patient Safety in Surgery. 2016, 10:6. 10. Grimer R.J., Aydin B.K., Wafa H., Carter S.R., Jeys L., Abudu A., Parry M. Very long-term outcomes after endoprosthetic replacement for malignant tumours of bone. Bone Joint J. 2016, 98-B: 857-64.

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

11. Ghert M., Deheshi B., Holt G., Randall R.L., Ferguson P. Wunder J., Turcotte R., Werier J., Clarkson P., Damron T., Benevenia J., Anderson M., Gebhardt M., Isler M., Mottard S., Healey J., Evaniew N., Racano A., Sprague S., Swinton M., Bryant D., Thabane L., Guyatt G., Bandharit M., The PARITY investigators. Prophylactic antibiotics regimens in tumour surgery (PARITY): protocol for a multicenter randomized controlled study. BMJ Open. 2012, 2: e002197. 12. Riesgo A.M., Park B.K., Herrero C., Yu S., Schwarzkopf R., Iorio R. Vancomycin povidone-iodine protocol improves survivorship of periprosthetic joint infection treated with irrigation and debridement. J Arthroplasty. 2018, 33: 847-50. 13. Hardes J., Von Eiff C., Streitbuerger A., Balke M., Budny T., Henrichs M.P., Hauschild G., Ahrens H. Reduction of periprosthetic infection with silver-coated megaprostheses in patients with bone sarcomas. J Surg Oncol. 2010, 101: 389-95. 14. Wafa H., Grimer R.J., Reddy K., Jeys L., Abudu A., Carter S.R., Tilmann R.M. Retrospective evaluation of the incidence of early periprosthetic infection with silver-treated endoprostheses in high-risk patients. Bone Joint J. 2015, 97: 252-57.

15. Parry M.C., Laitinen M.K., Albergo J.I., Gaston C.L., Stevenson J.D., Grimer R.J., Jeys L.M. Silver-coated (Agluna®) tumour prostheses can be a protective factor against infection in high-risk failure patients. Eur J Surg Oncol. 2019, 45: 704-10. 16. Schmodt-BraeklingT., Streitburger A., Gosheger G., Boettner F., Nottrott M., Ahrens H., Dieckmann R., Guder W., Andreou D., Hauschild G., Moellenbeck B., Waldstein W., Hardes J. Silver-coated megaprostheses: review of the literature. Eur J Orthop Surg Traumatol. 2017, 27: 483-89. 17. Coventry M.B. Treatment of infections occurring in total hip surgery. Orthop Clin North Am. 1975, 6: 991-1003. 18. Fitzgerald R.H. Jr, Nolan D.R., Ilstrup D.M., Van Scoy R.E., Washington J.A. 2nd, Coventry M.B. Deep wound sepsis following total hip arthroplasty. J Bone Joint Surg Am. 1977, 59: 847-55. 19. Ruder J.A., Springer B.D. Treatment of periprosthetic joint infection using antimicrobials: dilute povidine-iodine lavage. J Bone Joint Infect. 2017, 2: 10-14. 20. Hillmann A., Gosheger G., Hoffmann C., Ozaki T., Winkelmann W. Rotationplasty – surgical treatment modality after failed limb salvage procedure. Arch Orthop Trauma Surg. 2000, 120: 555-58.

Bone and “Joint” Pain

Editor’s Commentary: The emergence of cannabis in the ongoing opioid crisis William M. Weiss, M.D., MSc, FRCSC Current Issues Editor, COA Bulletin

ith the opioid crisis dominating headlines in Canada and the United States, pain management in orthopaedic surgery has become a controversial issue. Musculoskeletal pain is among the leading indications for opioid prescription, and the addictive potential and narrow therapeutic window of these medications make them a poor option. Despite this, widespread use and abuse of these medications has led to extensive addiction and considerable death. Although indications are both broad and controversial, Canada has allowed the use of medical marijuana in the past, and recently legalized recreational use. The combination of the evolving opioid crisis, with increased access to cannabis as a potential alternative, has led to interest in these products for pain control. As it stands currently, there is limited understanding and evidence to support the use of cannabis for musculoskeletal pain. Cannabis contains hundreds of potentially active compounds, including psychoactive cannabinoids, with no standardization of content outside government regulated preparations.

Receptors for cannabinoids are proposed to be involved in bone development, inflammation and pain, but also implicated in learning, synaptic plasticity, psychomotor behaviour, memory, stress and regulation of emotional states. Due to the potentially wide spectrum of effects, and current lack of quality research, use of cannabis for pain control should be approached with caution. As improved understanding of the impact and effectiveness of these compounds may benefit Canadian orthopaedic surgeons in their practice and patient education, Dr. Herman Johal from McMaster University will share his expertise. In this edition of the COA Bulletin, he will provide a primer on cannabis and its impact in the current environment of orthopaedic pain management (Part I). An outline of the evidence for cannabis in pain control, including his own work in orthopaedic trauma, will follow-up (Part II) in a future edition. COA Bulletin ACO - Spring / Printemps 2019

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

The Evolving Role of Cannabis and Musculoskeletal Pain Herman Johal, M.D., MPH, FRCSC, PhD (cand) Mohit Bhandari, M.D., PhD, FRCSC Division of Orthopaedics (MacOrtho), Department of Surgery, McMaster University Department of Health Research Methods, Evidence and Impact, McMaster University Michael G. Degroote Centre for Cannabis Research, McMaster University Hamilton Health Sciences, General Trauma Centre Hamilton, ON Kim Madden, PhD Division of Orthopaedics (MacOrtho), Department of Surgery, McMaster University Michael G. Degroote Centre for Cannabis Research, McMaster University St. Josephs Hospital Hamilton, ON

Part 1: A primer on cannabis legalization and use in orthopaedic patients

he opioid epidemic is arguably the greatest public health challenge facing health-care providers, policy makers, and most importantly, patients. It continues to dominate headlines as opioid-related hospitalizations and emergency department visits in Canada have ballooned by over 50% during the last decade, with the majority occurring over the last three years1. Even more staggering is the 500% increase seen in opioid-related deaths across North America over the last year, with over 50,000 reported fatalities; more than a third of which are related to prescription medications2,3. Acute and chronic musculoskeletal pain continues to be among the leading indications for opioid prescriptions from providers, including orthopaedic surgeons4, and one in five patients on chronic opioid therapy obtained their initial prescription from an orthopaedic surgeon5. While the initiation of this class of analgesics may often be considered when treating severe injuries or intractable pain, its addictive potential and narrow toxic range make it a high-risk first-line medication. Canadian and American guidelines have been put forth for responsible prescribing of opiates, and discourage their use in the treatment of chronic, non-cancer pain6,7, including the recent Canadian Orthopaedic Association position statement8. However, opiates remain the default choice for the majority of orthopaedic providers across North America, with deeply ingrained practice patterns leading to their routine prescription following a fracture, surgery, or worsening degenerative bone and joint disease. In parallel with the worsening opioid crisis, October 17, 2018 marked the day that Canada became the second country to fully legalize the recreational use of cannabis. Currently, recreational and medical use of cannabis is legal across Canada and 10 US states, with an additional 23 US states providing legal medical access9. Surrounding this shift in cannabis legislation, the spotlight has been on the evidence for both the efficacy and safety of cannabinoids for an array of medical indications, including its use as an opiate alternative. Cannabis is a plant genus that is indigenous to the temperate and tropical climates of Central and South Asia, but due largely COA Bulletin ACO - Spring / Printemps 2019

to proliferation under the illegal market, can be found in nearly every country across the globe10,11. The leaves and flowering tops of cannabis plants contain nearly 500 distinct compounds and more than 70 different cannabinoids, of which delta-9-tetrahydrocannabinol (∆9-THC, THC), cannabidiol (CBD), and cannabinol (CBN) are the most common11-14. The relative proportions of these and other cannabinoids varies and are not standardized outside the plants cultivated by federal agencies or licensed producers15,16. Among the chemical constituents of cannabis, ∆9-THC is the most extensively studied and responsible for the majority of the physical and psychotropic effects17. The average amount of THC is typically 10-12.5% (range 1 - 30%) in cannabis found on both the illicit and legal markets in Canada. Other cannabinoids (such as CBD, CBN, etc.) are present in lesser amounts (0.5%), with the rest consisting of compounds such as terpenes and flavonoids that have little, if any, psychotropic properties, but may have additional actions (e.g. anti-oxidant, anti-anxiety, anti-inflammatory, anti-bacterial, anti-neoplastic)11,17. Terpenes, for example, vary widely among cannabis varieties and are thought to be principally responsible for fragrance, flavour, and contribute to characteristics of the associated “high”15. In living plants, the phytocannabinoids exist as both inactive monocarboxylic acids (e.g. THC-A) and active decarboxylated forms (e.g. THC); with biologic activation occurring when heated (above 120 °C)18-20. This leads to transformation into a number of active compounds, many of which remain to be characterized both chemically and pharmacologically, contributing further to the varied nature and physiological effects of different cannabinoid forms. The overarching message emerging from both the Canadian and American Medical Associations remains one of extreme caution21-23. They emphasize that, while there may be a limited role for cannabis in select patients with terminal illness or chronic disease refractory to conventional therapies, there is an overall lack of clinical evidence for most of the purported indications for cannabis. This includes musculoskeletal pain which has been a driver of prescriptions since 2001, when Health Canada first granted access through the Marijuana Medical Access Regulations (MMAR). Prior to legalization in 2018, this program (most recently known as the Access to Cannabis for Medical Purposes Regulations; ACMPR) allowed physicians to prescribe medicinal cannabis for any condition they believed it would aid24,25. Under these programs, 65% of Canadians that were authorized to possess medicinal cannabis claimed to need it for severe arthritis. Similarly, in one US pain clinic, up to 80% of cannabis users report myofascial pain as their primary diagnosis11,26.

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

As is often the case with emerging therapeutics, demand for cannabis is outpacing the evidence. This is fueled by largely by anecdotal evidence, as well as pre-clinical and basic science studies detailing the mechanisms of action for cannabis on the body’s endocannabinoid system (ECS), which is implicated in inflammation, bone development, and pain. However, the ECS is also involved in synaptic plasticity, learning, reproduction, psychiatric disease, psychomotor behaviour, memory, appetite, digestion, sleep/wake cycles, stress and the regulation of emotion27. This has led to concerns regarding the non-specific effects of cannabis, including unwanted side-effects. The ECS is comprised of two main receptors; cannabinoid receptor type-1 (CB1) and type-2 (CB2), as well as endogenous ligands that bind and activate these receptors (N-arachidonylethanolamide [AEA] and 2-arachidonyl glycerol [2-AG]). There is considerable variation in the expression of the components of the ECS throughout the body. The expression of CB1 receptors is highly localized to the central and peripheral nervous systems, whereas CB2 receptor expression is greatest in the immune tissues, and can also be found in bone and muscle28. In addition, a number of cannabinoids and other constituent compounds are believed to bind to target receptors, outside of the ECS, furthering the complexity of determining the impact of cannabis use; not to mention the interaction with route of administration, individual body composition, age and tolerance. Opinion and access to cannabis has undergone a significant recent shift leading to rapidly growing societal acceptance and patient interest, while the clinical evidence is scrambling to catch up. Encouraging preclinical data, on the background of the ongoing opioid crisis, has helped push patients and providers to consider cannabis use for a range of indications, including musculoskeletal pain. There is limited evidence to support efficacy in both acute and chronic settings, and data regarding harm is mixed largely due to variable reporting and lack of long-term followup29-39. Additionally, only a small number of investigations include patients with fractures, osteoarthritis, or acute muscle or ligament injuries typically referred to an orthopaedic surgeon. Further basic science and clinical research aims to clarify the response and effectiveness of cannabis-based interventions for pain control. While there may be therapeutic promise in this area, the clinical evidence remains scarce, and caution is warranted to simply avoid replacement of one pain medication crisis with another. References 1. Canadian Institute for Health Information / Institut canadien d’information sur la santé. Opioid-related harms in canada. 2017:1–42. https://secure.cihi.ca/free_products/opioidharms-chart-book-en.pdf. 2. Katz J. Drug deaths in america are rising faster than ever. New York Times. Jun 5, 2017. [Internet] New Your Times. [cited 2019 April 18]. https://www.nytimes.com/interactive/2017/06/05/upshot/opioid-epidemic-drug-overdosedeaths-are-rising-faster-than-ever.html. 3. Public Health Agency of Canada. Overview of national data on opioid-related harms and deaths. [Internet] Government of Canada 2018. [cited 2019 April 18]. https://www.canada. ca/en/health-canada/services/substance-use/problematicprescription-drug-use/opioids/data-surveillance-research/ harms-deaths.html

4. Sabatino M.J., Kunkel S.T., Ramkumar D.B., Keeney B.J., Jevsevar D.S. “Excess opioid medication and variation in prescribing patterns following common orthopaedic procedures.” JBJS 100, no. 3 (2018): 180-188. 5. Callinan CE, Neuman MD, Lacy KE, Gabison C, Ashburn MA. The initiation of chronic opioids: a survey of chronic pain patients. J Pain. 2017;18(4):360–5 6. Morris B.J., Mir H.R. The opioid epidemic: Impact on orthopaedic surgery. J AM Acad Orthop Surg 2015;23(5):267271. https://journals.lww.com/jaaos/fulltext/2015/05000/ The_Opioid_Epidemic___Impact_on_Orthopaedic.1.aspx. doi:10.5435/JAAOS-D-14-00163 7. Busse J.W., Craigie S., Juurlink D.N., et al. Guideline for opioid therapy and chronic noncancer pain. CMAJ 2017;189(18):E666. http://www.cmaj.ca/content/189/18/ E659.long. doi:10.1503/cmaj.170363 8. Canadian Orthopaedic Association / L’Association Canadienne d’Orthopédie. COA position statement: Opioids and orthopaedic surgical practice. 2018. https:// coa-aco.org/wp-content/uploads/2017/01/COA-PositionStatement-Opioids-and-Orthopaedic-Surgical-Practice2018-June-ENG.pdf 9. Berke J., Gould S. States where marijuana is legal. Business Insider. Jan 4, 2019. Available from: https://www.businessinsider.com/legal-marijuana-states-2018-1. Accessed Jan 5, 2019. 10. Bazzaz, F.A., Dusek, D., Seigler, D.S., and Haney, A.W. (1975). Photosynthesis and cannabinoid content of temperate and tropical populations of Cannabis sativa. Biochemical Systematics and Ecology. 3: 15-18. 11. Health Canada. Information for Health-care Professionals: Cannabis (marihuana, marijuana) and the cannabinoids. https://www.canada.ca/content/dam/hc-sc/documents/ services/drugs-medication/cannabis/information-medicalpractitioners/information-health-care-professionals-cannabis-cannabinoids-eng.pdf 12. Zhu, H.J., Wang, J.S., Markowitz, J.S., Donovan, J.L. and others. (2006). Characterization of P-glycoprotein inhibition by major cannabinoids from marijuana. J.Pharmacol.Exp.Ther. 317: 850-857. 13. Balducci, C., Nervegna, G., and Cecinato, A. (2009). Evaluation of principal cannabinoids in airborne particulates. Anal. Chim.Acta. 641: 89-94. 14. Yamaori, S., Kushihara, M., Yamamoto, I., and Watanabe, K. (2010). Characterization of major phytocannabinoids, cannabidiol and cannabinol, as isoform-selective and potent inhibitors of human CYP1 enzymes. Biochem.Pharmacol. 79: 1691-1698. 15. Hillig, K.W. and Mahlberg, P.G. (2004). A chemotaxonomic analysis of cannabinoid variation in Cannabis (Cannabaceae). Am.J.Bot. 91: 966-975. COA Bulletin ACO - Spring / Printemps 2019

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

16. Mehmedic, Z., Chandra, S., Slade, D., Denham, H. and others. (2010). Potency Trends of Delta(9)-THC and Other Cannabinoids in Confiscated Cannabis Preparations from 1993 to 2008*. J.Forensic Sci. 55: 1209-1217. 17. Ashton, C.H. (2001). Pharmacology and effects of cannabis: a brief review. Br.J.Psychiatry. 178: 101-106. 18. Whittle, B.A. and Guy, G.W. Development of cannabis-based medicines: risk, benefit and serendipity. The Medicinal Uses of Cannabis and Cannabinoids. Guy, G. W., Whittle, B. A., and Robson, P. J. London: Pharmaceutical Press, 2004. 19. Huestis, M.A. (2007). Human cannabinoid pharmacokinetics. Chem.Biodivers. 4: 1770-1804. 20. Dussy, F.E., Hamberg, C., Luginbuhl, M., Schwerzmann, T. and others. (2005). Isolation of Delta9-THCA-A from hemp and analytical aspects concerning the determination of Delta9-THC in cannabis products. Forensic Sci.Int. 149: 3-10. 21. Owens B. CMA position against separate regulations for medical cannabis draws ire and insults. CMAJ 2018 May 7;190:E574-5. doi: 10.1503/cmaj.109-5594 22. Canadian Medical Association. CMA Response: Health canada consultation on canadian drugs and substances strategy. December 2018. https://policybase.cma.ca/en/permalink/ policy14017 23. Humphreys K., Saitz R. Should Physicians Recommend Replacing Opioids With Cannabis? JAMA. February 2019. doi:10.1001/jama.2019.0077. 24. Justice Laws Website. Marihuana for Medical Purposes Regulations (SOR/2013-119) [Internet]. Government of Canada; 2014 [cited 2019 Apri 18]. Available from: www. laws-lois.justice.gc.ca/eng/regulations/ SOR-2013-119/. 25. Justice Laws Website. Access to Cannabis for Medical Purposes Regulations (SOR/2016-230) [Internet]. Government of Canada; 2016 [cited 2019 April 18]. Available from: www.laws-lois.justice.gc.ca/eng/regulations/SOR2016-230/index.html. 26. Aggarwal, S.K., Carter, G.T., Sullivan, M.D., et al. Characteristics of patients with chronic pain accessing treatment with medical cannabis in washington state. J Opioid Manag 2009;5(5):257. https://www.wmpllc.org/ojs-2.4.2/index. php/jom/article/view/946. doi:10.5055/jom.2009.0028 27. Mechoulam R., Parker L.A. The endocannabinoid system and the brain. Annu Rev Psychol 2013;64:21-47.2019. https://w w w.annualreviews.org/doi/abs/10.1146/ annurev-psych-113011-143739. doi:10.1146/annurevpsych-113011-143739 28. Mackie, K. Cannabinoid receptors: where are they and what do they do? J Neuroendocrinol 2008;20(s1):10-14. https://onlinelibrary.wiley.com/doi/full/10.1111/j.13652826.2008.01671.x. doi:10.1111/j.1365-2826.2008.01671.x

COA Bulletin ACO - Spring / Printemps 2019

29. Patel S. Cannabis for Pain and Posttraumatic Stress Disorder: More Consensus Than Controversy or Vice Versa? Ann Intern Med. 2017;167(5):355–356. doi:10.7326/M17-1713. 30. Nugent S.M., Morasco B.J., O’Neil M.E., et al. The Effects of Cannabis Among Adults With Chronic Pain and an Overview of General Harms: A Systematic Review. Ann Intern Med. 2017;167(5):319–331. doi:10.7326/M17-0155. 31. Stockings E., Campbell G., Hall W.D., et al. Cannabis and cannabinoids for the treatment of people with chronic noncancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain. 2018;159(10):1932–1954. doi:10.1097/j. pain.0000000000001293. 32. Campbell G., Hall W.D., Peacock A., et al. Effect of cannabis use in people with chronic non-cancer pain prescribed opioids: findings from a 4-year prospective cohort study. The Lancet Public Health. 2018;3(7):e341–e350. doi:10.1016/ S2468-2667(18)30110-5. 33. Bekker A. Cannabis use and non-cancer chronic pain. The Lancet Public Health. 2018;3(10):e468. doi:10.1016/S24682667(18)30178-6. 34. Häuser W., Finnerup N.B., Moore R.A. Systematic reviews with meta-analysis on cannabis-based medicines for chronic pain: a methodological and political minefield. Pain. 2018;159(10):1906–1907. doi:10.1097/j. pain.0000000000001295. 35. Whiting P.F., Wolff R.F., Deshpande S., et al. Cannabinoids for Medical Use. JAMA. 2015;313(24):2456. doi:10.1001/ jama.2015.6358. 36. Lynch M.E., Campbell F. Cannabinoids for treatment of chronic non-cancer pain; a systematic review of randomized trials. Br J Clin Pharmacol. 2011;72(5):735–744. doi:10.1111/j.1365-2044.2004.03674.x. 37. Campbell F.A., Tramèr M.R., Carroll D., Reynolds D.J., Moore R.A., McQuay H.J. Are cannabinoids an effective and safe treatment option in the management of pain? A qualitative systematic review. BMJ. 1910;323(7303):13–16. http://eutils. ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed &id=11440935&retmode=ref&cmd=prlinks. 38. Martín-Sánchez E., Furukawa T.A., Taylor J., Martin J.L.R. Systematic Review and Meta-analysis of Cannabis Treatment for Chronic Pain. Pain Med. 2009;10(8):1353– 1368. doi:10.1016/S0885-3924(96)00176-5. 39. Madden K., van der Hoek N.J., Baldawi H., George A., Chona S., Dalchand T., Mammen G., Bhandari M. Cannabinoids in the Management of Musculoskeletal Pain: A Scoping Review. JBJS Reviews. 2018 May;6(5):e7.

VOUS AVEZ UNE INCIDENCE VOUS FAITES BOUGER LES CHOSES VOTRE COTISATION SOUTIENT DIRECTEMENT L’ORTHOPÉDIE AU CANADA.

En tant que membre de l’ACO, vous contribuez directement à l’avancement de notre profession. Chaque adhésion à l’ACO soutient et stimule des initiatives nationales et locales pour notre communauté orthopédique. Votre contribution à titre de membre va bien au-delà de la Réunion annuelle. En effet, votre cotisation a joué un rôle clé dans de nombreuses initiatives de l’ACO, dont voici quelques exemples récents :

DIVERSIFICATION DE NOTRE SPÉCIALITÉ Des étudiantes en médecine et d’autres étudiantes universitaires participent à une séance interactive avec des leaders en orthopédie. Nous espérons ainsi accroître le nombre de candidatures de femmes pour les places en résidence en les exposant plus tôt et plus exhaustivement à la spécialité.

PROGRAMME DE MENTORAT Les résidents et fellows sont jumelés à des membres actifs pendant une journée à la Réunion annuelle. Ce programme favorise le perfectionnement et la planification de carrière, en plus de constituer une occasion d’exercer son leadership et d’être un exemple.

LUTTE POUR UN MEILLEUR ACCÈS AUX SOINS Soutenir les associations provinciales d’orthopédie dans leurs efforts de défense des droits et intérêts par l’intermédiaire d’un lobbyiste spécialisé dans les réunions gouvernementales, la rédaction de notes d’information et d’autres messages et la collecte de renseignements, et offrir un soutien national à des initiatives provinciales existantes de défense des droits et intérêts.

SITUATION D’EMPLOI DES ORTHOPÉDISTES On a recueilli et analysé des données sur l’embauche et la situation d’emploi sur une période de 5 ans à des fins de discussion stratégique sur la crise persistante du sous-emploi avec les responsables des programmes de formation en orthopédie, le Collège royal et les médias.

ÉDUCATION MÉDICALE CONTINUE À L’ANNÉE Des possibilités de formation agréée grâce à des webinaires et aux résumés de travaux de recherche fondés sur des données probantes publiés dans OrthoEvidence, accessibles toute l’année.

RESPONSABILITÉ SOCIALE L’ACO et le Centre for Evidence-Based Orthopaedics de l’Université McMaster collaborent afin d’offrir aux membres l’accès au programme EDUCATE, qui enseigne aux professionnels de la santé œuvrant dans les cliniques de traitement des fractures à repérer les victimes de violence conjugale et à les aider.

COLLABORATIONS INTERNATIONALES Des programmes d’échange à des fins de formation et des collaborations en recherche ont été établis entre l’ACO et des associations d’orthopédie en Inde et en Europe, et les partenariats du genre sont en croissance partout dans le monde. L’ACO et ses membres jouent un rôle actif sur la scène mondiale.

ENSEMBLE, NOUS AVONS UNE INCIDENCE Votre adhésion à l’ACO est importante, et votre contribution a une incidence. Ces améliorations ne seraient pas possibles sans votre soutien. Merci d’être membre.

www.coa-aco.org/fr

More possibilities

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

A surgeon must always rely on his or her own professional clinical judgment when deciding whether to use a particular product when treating a particular patient. Stryker does su not dispense medical advice and recommends that surgeons be trained in the use of any particular product before using it in surgery. The information presented is intended to demonstrate the breadth of Stryker product offerings. A surgeon must always refer to the package insert, product label and/or instructions for use before using any Stryker 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 uc Stryker representative if you have questions about the availability of Stryker products in your area. Stryker Corporation or its divisions or other corporate af�iliated entities own, use or have applied for the following trademarks or service marks: AxSOS 3, SOMA, Stryker. All other trademarks are trademarks of their respective owners or holders. AXSOS-FL-2 Rev. 1, 11-2015 Copyright © 2015 Stryker

Join Us As We Celebrate 75 Years of Being Your COA

Venez célébrer le 75e anniversaire de votre ACO

Celebrate the COA’s 75th Anniversary in Halifax, Nova Scotia at the 2020 Annual Meeting from June 3-6.

Venez célébrer le 75e anniversaire de l’ACO à Halifax, en Nouvelle-Écosse, à l’occasion de la Réunion annuelle 2020, qui aura lieu du 3 au 6 juin.

Mark your calendars and make your plans to join us in Halifax.

www.coa-aco.org

Faites une croix à votre calendrier et planifiez dès maintenant votre séjour à Halifax.

www.coa-aco.org/fr

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

A Focus on Wellness: Building Capacity and Improving Joint Replacement Care in Nova Scotia Krista Wood, BPR Senior Communications Advisor, Perioperative Services Public Engagement and Communications Nova Scotia Health Authority Dr. Marcy Saxe-Braithwaite, BScN, MScN, MBA, DBA Senior Director, Perioperative (Surgical) Services Nova Scotia Health Authority

new approach to joint replacement care offers Nova Scotia patients education and support to help them get the most from their surgery. For some, it could mean delaying or even avoiding surgery altogether. In October 2017, Nova Scotia Health Authority (NSHA) launched a multi-year Hip and Knee Action Plan to improve access, promote wellness and improve the quality of care offered to hip and knee joint replacement patients. The strategy was borne from the need to address the province’s high wait times for joint replacements, with the goal of achieving the national six-month benchmark. At that time, patients were waiting more than 450 days for total knee replacements and more than 380 days for total hip replacements.

The COA invites members to feature innovative orthopaedic care pathways from across the country. If you would like to submit your model of care for publication in the Bulletin, please contact Trinity Wittman at policy@canorth.org.

NSHA’s plan is based on the earlier work of NSHA’s Orthopedic Working Group, involving surgeons and other clinical and administrative leaders. Its implementation is supported by the working group and sitebased teams, with oversight by a steering committee involving a patient representative as well as leaders, physicians and staff from the Department of Health and Wellness and NSHA. The plan includes various resources and investments including additional operating room time, four additional surgeons and anesthesiologists, and more than 50 additional full-time equivalent (FTE) roles in nursing, physiotherapy, and occupational therapy. The plan however is not simply aimed at completing more joint replacements. In fact, for teams leading the implementation of the new model, it represents a fundamental shift in how Nova Scotia thinks about and cares for joint replacement patients.

“Patients with hip or knee issues are not necessarily sick, so why treat them like they are?” says Dr. Marcy Saxe-Braithwaite, NSHA’s Senior Director, Perioperative (Surgical) Services. “Our wellness model is helping us make wellness a bigger focus in the care we offer before, during and after surgery. We believe it will give patients the best chance at a successful surgery, a faster, more complete recovery, and a more positive overall experience of care.”

COA Bulletin ACO - Spring / Printemps 2019

NSHA engaged an implementation team to share their expertise in carrying out joint replacement models, and to provide access to clinical and performance measurement tools and patient education resources. The programs described below are, in part, based on learnings from best practices across the country. Some elements of the plan are also being advanced through a 2018 Canadian Foundation for Healthcare Improvement (CFHI) EXTRA: Executive Training Program project. Dr. Saxe-Braithwaite, along with other members of NSHA’s EXTRA project team, are leading Optimizing Access to Joint Replacement Surgery in Nova Scotia, a project to reduce wait times for surgical consultation from referral to surgical consultation (Wait 1). Components of the plan include a standardized clinical pathway, centralized in-take and more.

Past joint replacement patients have also been invited into the planning process, working with the team to map their journey of care and identify opportunities for improvement. Standardized Clinical Pathway Within the first several months of launching the action plan, clinicians adopted a new provincial clinical pathway to guide joint care and support greater consistency. “This was an important first step,” said Dr. Michelle O’Neill, orthopaedic surgeon and Chair of the Orthopedic Working Group. “Regardless of where they live, we want all of our patients to be able to rely on the same quality of care, aimed at helping them live their best, most active lives possible.”

Rehabilitation Assistant Christina Clansey with orthopaedic patient Marianne McCormick and Manager Sally Blenkhorn at a recent prehabilitation clinic in Kentville, Nova Scotia (left to right).

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 40)

Referrals to Orthopedic Assessment Clinics Rather than being referred to individual surgeons to await a consultation, joint replacement candidates are now referred to enhanced and expanded orthopedic assessment clinics. Launched in the fall of 2018, the aim is to offer patients a timely initial assessment, by an inter-professional team that assesses their need, readiness for surgery and connects them with the supports needed to optimize them for surgery, including: • A group exercise and physiotherapy program to increase their strength and mobility. • Supports to achieve a healthier weight and to stop smoking if able. • Advice to make their home safe and accessible (e.g. shower bars) ahead of their surgery and for their return home.

Joint Coaches Patients are encouraged to identify a coach. This friend or family member will join them for appointments, classes and more to support and encourage them.

Shifting Inpatient Care In November 2018 teams began to transform the care patients receive following surgery as well. “Mobility and recovery go hand and hand and we know movement plays a big role in reducing the risk of complications such as blood clots,” Sally Blenkhorn, Manager Rehabilitation Services and Orthopedic Assessment Clinic, Valley Regional Hospital. “Our wellness model emphasizes getting patients moving early and often after surgery.” Following surgery, patients recover in special chairs that allow them to get up and move more easily than from a hospital bed. Most patients take their first steps the day of their surgery and join a group activity class early the following day. Patients are asked to bring in running shoes, t-shirts and shorts to wear, instead of hospital gowns.

According to Blenkhorn, small changes like this can help change the “I’m sick” mindset, encouraging patients and motivating them to keep moving. While patients have traditionally been admitted for two to three days, the goal is to move towards most patients returning home the day after surgery, with the right support, where it is safe and appropriate. Some otherwise healthy patients may choose to return to the comfort of their own home the same day as their surgery, with support of their care team a phone call away. Patients with other health issues and needing extra support at home may stay longer. All patients receive a follow-up call from a health professional within a few days of their return home.

Extra Motivation Patients receive daily newsletters offering tips and encouragement and are invited to track and celebrate their walking progress on an ambulation board on their unit.

Measuring Progress In the first partial year of the plan, teams accomplished an 8.1 per cent increase in joint replacements and a 4.6 per cent wait list reduction. Early data also shows that lengths of stay are decreasing following these surgeries. This progress is expected to accelerate with other further implementation elements of the strategy being put in place. “It’s a journey, not a race, but we are excited by the early progress made possible by our teams,” said Saxe-Braithwaite. “We are optimistic that our approach will improve the quality of care and quality of life of our patients, while helping us achieve and sustain the national benchmark.” Learn more about the NHSA Hip and Knee Action Plan at www.nshealth.ca/hip-and-knee. For questions, contact Dr. Marcy Saxe-Braithwaite at: marcy.saxe-braithwaite@nshealth.ca.

COA Position Statement: Daytime Orthopaedic Trauma Block Time

Énoncé de position de l’ACO : Temps réservé aux soins en orthopédie traumatologique le jour

he concept of dedicated daytime orthopaedic trauma time has been implemented in many centres across the country. The significant advantages of this approach to trauma case management would support its inclusion as an integral part of any orthopaedic service providing 24/7 trauma coverage. Thank you to members of the COA Practice Management Committee for their dedication to this project. Click here to read the complete COA position statement.

e concept de temps réservé aux soins en orthopédie traumatologique le jour a été mis en œuvre dans de nombreux centres partout au pays. Les avantages considérables de cette approche de la gestion des cas de traumatologie justifieraient d’en faire une partie intégrante de tout service d’orthopédie offrant des soins traumatologiques 24 heures sur 24. Merci aux membres du Comité sur la gestion de l’exercice de l’ACO pour le dévouement dont ils ont fait montre dans ce projet. Cliquez ici pour lire l’énoncé de position de l’ACO.

COA Bulletin ACO - Spring / Printemps 2019

Foundation / Fondation

Still Leading the Pack!

n the same way they led in orthopaedics in their early careers, two renowned surgeons continue to lead the way ... with notable contributions to the Canadian Orthopaedic Foundation. Dr. Cecil Rorabeck, Patron of the COF and a member of the Powering Pain Free Movement Cabinet, made a donation of stock earlier this year in support of the Cabinet’s mandate. Powering Pain Free Movement is a fundraising campaign aimed at securing major gifts that will allow the Foundation to grow its research program significantly while maintaining its much-needed programs in patient education and care. Phase 1 of the program, launched in 2016, enabled the growth of the research program from $35,000 to over $250,000 in research awards. With the launch of phase II this year, the Cabinet intends to continue that growth. “Research funds from many sources are shrinking,” says Dr. Rorabeck. “The COA Executive challenged the COF to fill the niche in orthopaedic research funding by significantly enhancing its Dr. Rorabeck research investment. We are succeeding; still, much remains to be done to continue that growth. The COF is well-positioned to be a major research funding body in Canada, while still providing educational resources and care programs to our patients.” In 2018 there were an unprecedented 34 applications to the COF’s annual research awards program, and 11 applications were approved for funding. However, the Research Review Panel noted that of the ones which were declined, an additional 9 were scored “highly fundable” if the money was available. Dr. Rorabeck hopes that his contribution of stock to the Powering Pain Free Movement campaign will inspire other surgeons to lend their support, too, to ensure that good Canadian orthopaedic research moves forward. Last year, Dr. Robin Richards made a large donation of stock to establish an eponymous endowment fund with interest to be used to support a new COF award competition: The Robin Richards Award for Upper Extremity Research. The award will be presented annually for the best paper on upper extremity research presented at the COA Annual Meeting each year. The first award will be presented in Montréal in June 2019.

The award allows Dr. Richards to make a difference in an area of orthopaedics that is near to his heart. He says, “I spent my orthopaedic career on performing upper extremity reconstruction, and I have seen first hand the advancements made through research in this area. I’m always impressed by the papers presented at the COA AGM and want to recognize excellence, and encourage upper extremity research.” Dr. Richards’ contribution of stock was converted to an endowment fund, ensuring that his legacy as a supporter of upper extremity research lives on in years to come. These surgeons’ actions will inspire others to give, big or small, to contribute to change. Be a part of that change! To learn more about planned giving through the Canadian Orthopaedic Foundation please contact the Foundation directly at giving@canorth.org.

Dr. Richards

Charitable Donations of Stock or Securities Donating to the Canadian Orthopaedic Foundation provides an opportunity to make a difference in the orthopaedic research, education and care programs of the COF. Gifts of publicly traded stocks and securities offer immediate tax advantages. Donating stock, bonds, and mutual funds to the Canadian Orthopaedic Foundation allows you to: • Eliminate the capital gains tax on the increase in the value of the asset. • Qualify for a tax credit based on the asset’s fair market value. Click here for further information about Gifts of Stock or Securities (Tax Benefits).

COA Bulletin ACO - Spring / Printemps 2019

The Canadian Orthopaedic Foundation is pleased to have awarded the following research grants for 2018: J. Edouard Samson Award Dr. Michelle Ghert (Hamilton, ON) – “The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) Trial: Unprecedented international collaboration in orthopaedic oncology” Carroll A. Laurin Award Dr. Geoffrey P. Wilkin (Ottawa, ON) – “Periacetabular Osteotomy with and without Arthroscopic Management of Central Compartment Pathology” Robert B. Salter Award Dr. Sasha Carsen, Dr. T. Mark Campbell and Dr. F. J. Dilworth (Ottawa, ON) – “Determining the optimal bonederived stem cell source for cartilage regeneration in the treatment of osteoarthritis” Cy Frank Award Dr. Darren L. de SA (Hamilton, ON) – “Soft-tissue QUadriceps autograft ACL-reconstruction in the Skeletallyimmature vs. Hamstrings (SQUASH): A Multi-Centre Pilot Randomized Controlled Trial” Canadian Orthopaedic Research Legacy (CORL) Awards Dr. Hesham Abdelbary (Ottawa, ON) – “Developing a new therapeutic approach to Improve Treatment of Periprosthetic Joint Infections Using a Novel, and Clinically Representative Hip Replacement Rat Model” Dr. Anthony Adili (Hamilton, ON) – “Topicals for Osteoarthritis Pain in Knee Surgery (TOPIKS): A Pilot Randomized Controlled Trial” Dr. Bashar Alolabi (Hamilton, ON) – “Randomized control trial of ultrasound-guided erector spinae block (ESP) versus shoulder periarticular anesthetic infiltration (PAI) for pain control after arthroscopic shoulder surgery” Dr. Eric Bohm (Winnipeg, MB) – “Randomized controlled trial of staged versus simultaneous bilateral knee arthroplasty” Dr. Michael J. Monument (Calgary, AB) – “Sting Activation as an Immunotherapy for Soft Tissue Sarcoma” Dr. Diane Nam (Toronto, ON) – “The microbiome: can it influence fracture healing?” Dr. Neil White (Calgary, AB) – “The C3PO Trial - Canadian Prospective Pragmatic Perilunate Outcomes Trial” For research summaries, go to www.whenithurtstomove.org: click on ‘Grant and Award Recipients’ under ‘Research & Awards’. The COF thanks all generous donors who make our research program possible, with special thanks to Powering Pain Free Movement Partners: Benefactor:

Champion:

DePuy Synthes Canada

Supporter:

Foundation / Fondation

Toujours en tête!

out comme ils ont été des leaders en orthopédie dès le début de leur carrière, deux orthopédistes réputés continuent de tracer la voie... grâce à des dons remarquables à la Fondation Canadienne d’Orthopédie. Le Dr Cecil Rorabeck, président d’honneur de la Fondation et membre du cabinet de la campagne Misons sur une vie sans douleur, a donné des actions plus tôt cette année afin de soutenir le mandat du cabinet. Misons sur une vie sans douleur est une campagne de financement qui vise à recueillir des dons d’envergure afin de permettre à la Fondation d’accroître considérablement la portée de son programme de financement de la recherche tout en maintenant ses programmes essentiels de sensibilisation des patients et de soins. Lancée en 2016, la première phase de la campagne a fait passer son programme de financement de la recherche de 35 000 $ à plus de 250 000 $. Cette année, avec le lancement de la deuxième phase, le cabinet entend bien poursuivre cette croissance. Dr Rorabeck « De nombreuses sources réduisent le financement alloué à la recherche, explique le Dr Rorabeck. Le Comité de direction de l’ACO a mis la Fondation au défi d’occuper le créneau du financement de la recherche en orthopédie en augmentant considérablement ses investissements. Nos efforts sont couronnés de succès, mais il reste beaucoup à faire pour assurer une croissance continue. La Fondation est bien placée pour être un organe majeur de financement de la recherche au Canada tout en continuant d’offrir des ressources et des programmes de soins à l’intention de nos patients. » En 2018, la Fondation a reçu un nombre record de 34 candidatures pour ses différents prix et bourses de recherche, dont 11 ont été approuvées. Le comité d’examen a toutefois souligné que, parmi les candidatures rejetées, neuf avaient été jugées « très finançables », si les fonds étaient disponibles. Le Dr Rorabeck espère que son don d’actions à la campagne Misons sur une vie sans douleur inspirera d’autres orthopédistes à faire un don de sorte à favoriser la concrétisation de bons projets canadiens de recherche en orthopédie. L’an dernier, le Dr Robin Richards a de son côté fait un don considérable d’actions dans le but d’établir un fonds de dotation à son nom dont les intérêts doivent servir à doter un nouveau prix de la Fondation, le Prix Robin Richards de la recherche sur les membres supérieurs. Le Prix sera remis chaque année au meilleur précis sur les membres supérieurs présenté à la Réunion COA Bulletin ACO - Spring / Printemps 2019

annuelle de l’ACO. Le premier prix sera remis à la Réunion annuelle de Montréal, en juin 2019. Ce prix permet au Dr Richards d’avoir une incidence sur un domaine de l’orthopédie qui lui tient à cœur. « J’ai passé ma carrière en orthopédie à effectuer des chirurgies de reconstruction des membres supérieurs; j’ai donc pu constater directement les progrès réalisés grâce à la recherche dans ce domaine, raconte-t-il. Je suis toujours impressionné par les précis présentés à la Réunion annuelle de l’ACO, et je souhaite souligner l’excellence et stimuler la recherche sur les membres supérieurs. » Le don d’actions du Dr Richards a été converti en un fonds de dotation, ce qui lui permet de veiller à ce que son soutien à la recherche sur les extrémités supérieures devienne un legs durable. Les gestes de ces orthopédistes inspireront d’autres donateurs, petits et grands, à être des instigateurs de changement. Soyez-en!

Dr Richards

Pour en apprendre davantage sur les dons planifiés à la Fondation Canadienne d’Orthopédie, veuillez écrire directement à la Fondation, à giving@canorth.org.

Don d’actions ou de titres à un organisme de bienfaisance Donner à la Fondation Canadienne d’Orthopédie permet d’avoir une incidence sur ses programmes de recherche, de sensibilisation et de soins en orthopédie. Donner des actions et titres négociés sur le marché public se traduit par des avantages fiscaux immédiats. Donner des actions, des obligations et des fonds mutuels à la Fondation Canadienne d’Orthopédie vous permet : • d’éliminer l’impôt sur les gains en capital quand un bien mobilier prend de la valeur; • de bénéficier d’un crédit d’impôt axé sur la juste valeur de marché du bien mobilier. Cliquez ici pour obtenir de plus amples renseignements sur les dons d’actions et de titres (avantages fiscaux).

La Fondation Canadienne d’Orthopédie est heureuse d’accorder les prix et bourses de recherche suivants pour 2018 : Prix J.-Édouard-Samson re D Michelle Ghert (Hamilton, Ont.) – The Prophylactic Antibiotic Regimens in Tumour Surgery (PARITY) Trial: Unprecedented international collaboration in orthopaedic oncology Bourse Carroll-A.-Laurin r D Geoffrey P. Wilkin (Ottawa, Ont.) – Periacetabular Osteotomy with and without Arthroscopic Management of Central Compartment Pathology Bourse Robert-B.-Salter rs D Sasha Carsen, T. Mark Campbell et F. J. Dilworth (Ottawa, Ont.) – Determining the optimal bone-derived stem cell source for cartilage regeneration in the treatment of osteoarthritis Prix Cy-Frank r D Darren L. de SA (Hamilton, Ont.) – Soft-tissue QUadriceps autograft ACL-reconstruction in the Skeletallyimmature vs. Hamstrings (SQUASH): A Multi-Centre Pilot Randomized Controlled Trial Bourses de l’Héritage de la recherche orthopédique au Canada (HROC) r

D Hesham Abdelbary (Ottawa, Ont.) – Developing a new therapeutic approach to Improve Treatment of Periprosthetic Joint Infections Using a Novel, and Clinically Representative Hip Replacement Rat Model r

D Anthony Adili (Hamilton, Ont.) – Topicals for Osteoarthritis Pain in Knee Surgery (TOPIKS): A Pilot Randomized Controlled Trial r

D Bashar Alolabi (Hamilton, Ont.) – Randomized control trial of ultrasound-guided erector spinae block (ESP) versus shoulder periarticular anesthetic infiltration (PAI) for pain control after arthroscopic shoulder surgery r

D Eric Bohm (Winnipeg, Man.) – Randomized controlled trial of staged versus simultaneous bilateral knee arthroplasty r

D Michael J. Monument (Calgary, Alb.) – Sting Activation as an Immunotherapy for Soft Tissue Sarcoma re

D Diane Nam (Toronto, Ont.) – The microbiome: can it influence fracture healing? r

D Neil White (Calgary, Alb.) – “The C3PO Trial - Canadian Prospective Pragmatic Perilunate Outcomes Trial” Pour le sommaire de ces projets de recherche, rendez-vous à www.whenithurtstomove.org/fr et cliquez sur « Lauréats des bourses de recherche », dans le menu « Prix, bourses et subventions ». La Fondation Canadienne d’Orthopédie remercie tous les généreux donateurs qui soutiennent ses programmes de financement de la recherche, et tout particulièrement les partenaires de la campagne Misons sur une vie sans douleur : Bienfaiteur :

Champion :

DePuy Synthes Canada

Contributeur :

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

Machinery Trauma in Children Merv Letts, M.D., FRCSC Ottawa, ON

Part 2 of a special COA Bulletin series Train Trauma ecause of my professional interest in childhood trauma, as well as initially practicing on the Prairies, I saw and treated a myriad of farm machinery accidents in children. Most, unfortunately, were amputations secondary to augers, lawnmowers, snowmobiles, all terrain vehicles and various sundry pieces of farm equipment that children shouldn’t be working or playing with! As a result, I became an advocate for prevention of such injuries, wrote many papers related to prevention and spoke at several conferences regarding farm accident prevention for children. I treated many children with traumatic amputations, mostly from farm machinery as mentioned, but one of the more memorable cases was a ten-year-old boy named Billy who was hit by a train. He presented in emergency at the WCH with both legs amputated: one above the knee and one below the knee, typical for this injury since the limbs are always asymmetrical on the tracks as the wheels of the train pass over the legs. As I walked past Emerg to the X-ray department, the head nurse asked me to come in and see this child. She already had applied tourniquets to both thighs. I told her that he had to go to the OR immediately! Dr. Tenenbien, the very talented Head of Emergency, had started an IV and already ordered blood. I asked if he had any other injuries besides the amputations and was told that his belly was soft and his chest was clear. Hemo was only ten but he had a large bore in and blood was on its way.

When I took Billy up to the OR, he was white from blood loss but wide awake and lucid. He asked me plaintively if he’d ever be able to wear cowboy boots again. There was a moment of silence and then in full confidence I replied, “Of course you will Billy, of course you will!”

Train amputations are always asymmetric.

ing with her father (as she had done many times before!) when the mower went over a prominent tree root, tipped enough to throw Sally off into the path of the powered mower. Before her father could kill the motor, it had run over her right leg. Considering the blades turn at 400-500 revolutions per minute, any one of which could amputate an extremity, there is never a “minor” injury with lawnmowers. Sally lost her right leg through the mid thigh. Her dad saved her life by using his belt as a tourniquet and Sally made it to hospital. I took her to the OR that day and spent most of the time trying to clean the wound as it was full of cut grass, We did our best with powered lavage, but she developed a wound infection postop which delayed her healing by a month. However, she was up and walking with an above knee prosthesis independently. Kids generally learn to walk with prosthesis so well, even those above knee. A lot of credit must go to the physiotherapists who work with them on gait training as well as to the counsellors who work with the patients and their families.

We got him into the OR immediately, debrided his stumps (his leg remnants had arrived just after him and were too mangled and crushed to even consider reimplantation, although we did conserve some skin for grafting) and amazingly, he went on to heal uneventfully with no infections or stump breakdown. We had a marvellous Child Amputee Clinic at the WCH and the prosthetists were superb. One day a few months after the accident in my regular clinic, my nurse Sandy, knocked on my door and told me that special patient was there to see me. I stepped out and there was Billy, standing with no walking aids and he strode off down the hall enthusiastically shouting, “See Dr. Letts, I’m wearing my cowboy boots!”….and he was! We all had tears in our eyes. Lawnmower Injuries Another serious injury that presented frequently in Winnipeg was secondary to the riding lawnmower. Great fun for kids to ride but not such fun when the mower tips or the child falls off. This is what happened to seven-year-old Sally as she was rid-

COA Bulletin ACO - Spring / Printemps 2019

Child riding on power mower with parent - a No! No! From Pfizer Annual Report….. shame!

Child riding on tractor fender…. another No! No.! From a front cover of the CMAJ... more shame!

Training & Practice Management / Formation et gestion d’une pratique (continued from page 46)

Farm Injuries to Children Farm trauma is a major cause of childhood death and morbidity around the world. Of all the farm machinery trauma I’ve dealt with, auger injuries are the most devastating to treat. Every turn of the auger is an amputation! The unfortunate thing about any piece of machinery is the person using it, or children playing in the vicinity of it, often lose respect for its power to cause injury. When that happens, it’s only a matter of time until an injury occurs. The auger has the added danger of usually being hidden under a pile of grain that moves as it is gets sucked up by the auger. Once a hand or foot becomes entangled, Upper limb caught in auger. Note severe Power Barn cleaner amputation of a child’s foot the entire limb is lost. These are high grain contamination - every cut an amputation. Playing in barn when cleaner activated! amputations and life-threatening trauma. Practicing on the Prairies, I saw dozens of these heartbreaking auger injuries. We tried of POSNA, he asked me to be the Presidential Guest Speaker and to enforce safety devices on the augers but even the farmers deliver a talk on “Injury Prevention, An Olympian Goal”, since it resisted as it slowed down the flow of grain by 40%. At one was an Olympic year. Today to my delight, there is now a sepapoint, we were advised by the John Deere Company that if the rate journal on Injury Prevention: http://dx.doi.org/10.1136/ Manitoba Government enforced mandatory safety devices for injuryprev-2018-042768. Hospitalisation of children and youth augers, their company would no longer offer augers for sale in under 20 years of age accounted for 15% of all injury hospitalithe province. sations in Canada in 2005–2006 (n=29 244). Between 1994 and 2003, an estimated average 25 500 children age 14 and under Injury prevention was a lifelong interest of mine and I published were hospitalised annually for serious injuries. Injury prevenmany papers and lectured around the world on the subject. tion is still very important today and PediPods have a major role When my good friend Dr. Morris “Chick” Duhaime was President to play in this type of advocacy.

Click here to read Part 1 of Dr. Letts’ article on machinery trauma in children Journal of Injury Prevention.

Auger with protective device - but not effective for a child’s extremity.

COA Bulletin ACO - Spring / Printemps 2019

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

New Paradigm for Tax And Corporate Planning For Surgeons Michelle L. Connolly, CPA, CA, TEP, CFP Director of Advanced Planning, Tax and Estates Sun Life Financial

s surgeons, you often work with the patient and a team of professionals who all play a role in your patient’s care and outcome.

Similarly, Your Wealth Professionals Should Work Collaboratively As a medical professional, you run a practice, which is a business interest that you and/or your professional partners oversee. You possess the technical expertise and focus on your patients, and likely count on other professionals for your practice’s infrastructure needs, practice management and other wealth planning needs. These professionals, whether they are financial, insurance, retirement, tax or legal, all play a role in your practice and personal wealth needs and outcomes. They should communicate proactively and collaborate, as poor coordination increases your costs and can lead to missed opportunities. Impact of TOSI Measures on Incorporated Medical Professionals In July, 2017 the Federal Government dropped a bomb on all Canadian business owners, including incorporated medical professionals, when it introduced its Tax on Split Income (TOSI) initiatives. I use the term initiatives, as they were truly a moving target between July 2017 to the delivery of the 2018 Federal Budget, when the proposed TOSI income tax legislation (TOSI measures) were at long last made available and eventually passed by the Government later in 2018. The TOSI measures targeted passive corporate investments, income splitting and other traditional tax planning tools that the Government perceived to provide unfair tax advantages to all Canadian Controlled Private Corporations (CCPC) and their respective shareholders. Post-2017, the TOSI measures have forced incorporated medical professionals and wealth professionals to reconsider the following wealth planning: • Nature of compensation: To cover personal lifestyle needs, there are two primary means to compensate yourself from your professional corporation: salary and dividends. Salary is a pre-tax deduction to your professional corporation, and reported in your hands personally as earned, employment income. Dividends, on the other hand, are paid from after-tax corporate dollars. In order to implement the tax concept of integration, dividends are subject to the grossup, dividend tax credit regime in your hands. Ultimately, your wealth and tax professionals seek to trigger the lowest amount of income tax collectively – corporate and personal – to cover your personal lifestyle needs and use corporate tax account balances such as Refundable Dividend Tax on Hand (RDTOH) and the Capital Dividend Account (CDA). COA Bulletin ACO - Spring / Printemps 2019

TOSI has greatly diminished the tax savings associated with paying dividends over salary. Two elements in particular are the cause: the $50,000 passive income threshold on clawing back the active business tax rate, and the introduction of a second RDTOH account. In the month or two leading up to your corporate year-end, your wealth advisor and tax advisor should review your current compensation plan and discuss your anticipated personal lifestyle needs to determine if there is any impact to your corporate investment portfolio.

• Quantum of compensation: In the past, the quantum of your compensation was likely minimized to cover only personal lifestyle needs, not wants. Such planning was due to the preferred corporate active business tax rate, maximizing the deferral of the second layer of tax - at the personal level, thus maximizing investments at the corporate level. As well, you may have planned to use your professional corporation as your retirement plan (as opposed to a more traditional RRSP). Corporate investments would have been earmarked to fund the payment of dividends and cover your retirement needs in post-practice years.

With the introduction of TOSI, and depending upon net income levels projected over your remaining practice years, some tax professionals are recommending upping the quantum of compensation taken, and compensation taken primarily in the form of salary. By increasing salary beyond lifestyle needs and perhaps to mid- to upper-tier personal tax brackets, the intention is to minimize the potential of corporate passive investment income exceeding $50,000 (or the upper threshold of $150,000) which will punitively impact the corporate tax rate applied to practice taxable income in future years.

Given the provincial corporate tax rates on professional income, and whether the province you reside in has indicated if they intend to mirror the Federal TOSI measures, your wealth advisor and tax professional should work collaboratively to plan the nature and quantum of your compensation.

Training & Practice Management / Formation et gestion d’une pratique (continued from page 48)

Nature of Investments Owned and the Investment Income Generated The stage you are at in your professional practice will impact the nature of investments held by your professional corporation, and the investment income or gains generated from such. • Growing a young practice and the need to access cash or investment capital for assets or improvements; • Managing a stable practice; or • Winding down a mature practice and gearing up for retirement. In growth years, your wealth advisor has options in recommending certain investment structures depending upon your needs – is there a chance the invested funds may be needed in the short term, or are they for retirement? In the latter instance, investment structures are available that minimize realized income and gains. Such investments would be more focused on capital appreciation, and aligned with your investment mandates. Your tax professional should be aware of an investment’s nature of return and not be quick to judge in cases where realized income is minimal and accrued and unrealized capital gains are significant: that may be the whole point. For those managing a stable practice, managing the $50,000 (or upper threshold of $150,000) is key. Your wealth advisor and tax professional should discuss the quantum of your compensation, where your investment capital should be held (personal versus corporate), and managing your corporate tax rate proactively.

With the introduction of the TOSI measures, corporate Individual Pension Plans (IPPs) and life insurance are more readily recognized and recommended as investment structures to: • shelter or minimize corporate passive income; • and set the stage for retirement or other wealth transfer measures. For physicians nearing retirement, the $50,000 (or upper threshold of $150,000) should not be a significant concern, as the professional corporation will no longer be generating active business income. Provided it is not associated with another active business corporation, the clawback of the active business tax rate will be a non-issue. In the two to three years leading up to retirement, collaboration between your wealth and tax advisor is crucial as investments, and the nature of investment income should be re-evaluated. At this stage, the focus is on “de-accumulation” and generating passive income that flows easily from the professional corporation, now characterized as an investment holding company, to the shareholder. Once you cease practicing, as active income is no longer generated, the ability to pay salaries ceases and only dividends are paid to you as the shareholder. As outlined above, there is not one black-and-white answer addressing physicians’ compensation or corporate investment strategies in response to the TOSI provisions. With all things “tax”, it depends… Both your wealth advisor and tax professional should be asking you questions that foster dialogue that allows them to identify what is important to you, and tailor their investment and tax recommendations to deliver best outcome.

The information in the article has been provided to the COA by O’Neill Financial Inc. and COAplan Inc. It is always recommended to seek independent advice related to your particular circumstances as necessary.

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

2020

2021

June 3-6 juin

June 16-19 juin

CORA Meeting / Réunion de l’ACRO June 3 juin Halifax, NS

CORA Meeting / Réunion de l’ACRO June 16 juin Vancouver, BC

COA Bulletin ACO - Spring / Printemps 2019

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

Current Trends in Orthopaedics, Sicily, Italy April 26-May 2, 2020 Paul R. Kim, M.D., FRCSC Course Chair

he University of Ottawa Division of Orthopaedics is pleased to present Current Trends in Orthopaedics in beautiful Sicily, Italy April 26-May 2, 2020. This event follows the incredible success of our inaugural meeting in the Loire Valley, France in 2018. We are now heading to Sicily known for its rich history, delicious food, and magnificent views of the Mediterranean. There will be an in-depth, educational program concentrating on current trends in orthopaedics designed specifically for orthopaedic professionals. First class speakers, interactive sessions including case reviews are all accompanied with ample time for discussion.

The academic portion of the meeting is complemented by daily guided cycling and hiking options allowing you to explore the countryside and ancient Roman ruins up close. The program includes accommodation at the stunning beachfront five-star Verdura Resort, gourmet dining, fabulous wines and some of the best hiking and cycling in all of Italy. The resort is also home to three top rated Kyle Phillips golf courses. Please join us to experience this fascinating and unique educational event. Click here for information and registration. Space is limited. This University of Ottawa CME event is an Accredited Group Learning Activity (Section 1) as defined by the Maintenance of Certification program of The Royal College of Physicians and Surgeons of Canada and approved by the Canadian Orthopaedic Association.

ADVERTISING SPACE AVAILABLE

ESPACE PUBLICITAIRE

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.

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

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. COA Bulletin ACO - Spring / Printemps 2019

With more than 5100 summaries from over 360 journals, and with 50 new ACE Reports added every month, COA members can earn and submit most of their CME Credits through OrthoEvidence.

Have you activated your online subscription? If youâ&#x20AC;&#x2122;re an Associate or Active Member of the COA, you receive a complimentary online subscription to The Bone & Joint Journal (formerly JBJS Br) andBone & Joint

360

Go to: online.boneandjoint.org.uk/action/registration If you do not know your login details to activate please email subs@boneandjoint.org.uk

Form e know rly n as JBJS ( Br)

www.bj360.boneandjoint.org.uk

www.bjj.boneandjoint.org.uk

Would you like to receive print copies in addition to your online access? Email subs@boneandjoint.org.uk for more information

Follow us on twitter @BoneJointJ and @BoneJoint360 The British Editorial Society of Bone & Joint Surgery. Registered Charity No. 209299