COA Bulletin #120 - Summer 2018 by Canadian Orthopaedic Asssociation

Canadian Orthopaedic Association Association Canadienne d’Orthopédie

Summer Été 2018 Publication Mail Envoi Poste-publication Convention #40026541 4060 Ste-Catherine W., Suite 620 Westmount, QC H3Z 2Z3

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

BULLETIN

120

Hand & Wrist Injuries Basilar joint arthritis, Kienbock’s disease, fractures of the scaphoid, and scaphoid non-unions are discussed in this edition’s feature............. Page 19 Blessures à la main et au poignet – Arthrite du pouce, maladie de Kienböck et fractures et pseudarthrose du scaphoïde sont en vedette dans ce numéro...................... Page 19

Profound Exchange of Ideas and Culture during Inaugural Norman Bethune Orthopaedic Travel Scholarship � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 10 . esident Morale is ‘Cautiously Reasonable’ While Graduate Underemployment R Remains at the Forefront of COA Efforts � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 38 Obtention de crédits dans la section 3 du programme de MDC � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 53 .Orthopaedic Surgery Residency – Is the Juice Worth the Squeeze? � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 54 Operate Through Your Initials - The history of “Wrong-sided Surgery” initiative in Canada � � � � � 58

Latest findings on Trabecular Metal™ Technology used in Acetabular Revision

An independent analysis based on data from National Joint Registry for England, Wales, Northern Ireland and the Isle of Man (NJR) was conducted by the NJR with the following findings: •

Trabecular Metal ™ cups used in revision THA have shown to be 21% less likely to be re-revised due to infection (statistically significant, p-value=0.036). 1, 2

•

For high risk patients (1st revision indication being infection) Trabecular Metal cups appear to be 35% less likely to be re-revised for infection. However, this has not reached statistical significance due to limited sample size (not statistically significant, p-value=0.108).3

•

Trabecular Metal cups used in revision THA have shown to be 11% less likely to be re-revised for any reason (statistically significant, p-value=0.015).1

The complete NJR report can be found at:

www.zimmerbiomet.com/TM

For additional questions regarding this data, please contact: Zimmer Biomet Medical Affairs Phone: (888) 210-8234 Email: medinfo@zimmerbiomet.com 1. According to NJR data from 2003 to 2015 where 9,573 Trabecular Metal and 30,452 non-Trabecular Metal cups were used in revision THA and based on hazard ratios adjusted by patient gender, age group, and indications (OA/non-OA). 2. NJR data shows a higher percentage of TM cups were used with antibiotic bone cement compared to all other non-TM cementless cups. 3. According to NJR data from 2003 to 2015 where 628 Trabecular Metal and 2,114 non-Trabecular Metal cups were used in revision THA and based on hazard ratios adjusted by patient gender, age group, and indications (OA/non-OA). 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 complete product information, including indications, contraindications, warnings, precautions, potential adverse effects and patient counselling information, see the package insert and www.zimmerbiomet.com. Check for country product clearances and reference product specific instructions for use. The statements have not been evaluated by the FDA for the Zimmer Biomet Trabecular Metal shells and do not alter the cleared indications for use. Document not for distribution in France. Not intended for surgeons practicing medicine in France. © 2018 Zimmer Biomet

Your COA / Votre association

Bulletin CanadianOrthopaedic Association Association Canadienne d’Orthopédie N° 120 - Summer / Été 2018 COA / ACO Kevin Orrell President / Président Kishore Mulpuri Secretary / Secrétaire Doug Thomson Chief Executive Officer / Directeur général Publisher / Éditeur Canadian Orthopaedic Association Association Canadienne d’Orthopédie 4060 Ouest, rue Sainte-Catherine West Suite 620, Westmount, QC H3Z 2Z3 Tel./Tél.: (514) 874-9003 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Web site/Site internet: www.coa-aco.org COA Bulletin Editorial Staff Personnel du Bulletin de l’ACO Alastair Younger Editor-in-Chief / Rédacteur en chef Femi Ayeni Scientific Editor / Rédacteur scientifique Cynthia Vézina Managing Editor / Adjointe au rédacteur en chef Communications Committee Comité des communications Advertising / Publicité Tel./Tél.: (514) 874-9003, ext. 3 Fax/Téléc.: (514) 874-0464 E-mail/Courriel: cynthia@canorth.org Paprocki & Associés Graphic Design / Graphisme Page Setting / Mise en page Publication Mail/Envoi Poste-publication Convention #40026541 Contents may not be reproduced, in any form by any means, without prior written permission of the publisher. Toute reproduction intégrale ou partielle, sous quelque forme que ce soit, doit être autorisée par l’éditeur. The COA is a content partner of Orthopaedia® (www.orthopaedia.com), the online collaborative orthopaedic knowledgebase. Certain articles from COA Bulletin are reprinted on Orthopaedia® as part of our content partnership agreement. If your article is selected, you will receive a copy for review from the Orthopaedia® staff prior to posting on the Orthopaedia® website. L’ACO est l’un des fournisseurs de contenu d’Orthopaedia® (www. orthopaedia.com), une base de connaissances orthopédiques collective en ligne. Certains articles du Bulletin de l’ACO sont reproduits sur le site Web d’Orthopaedia® dans le cadre de notre entente de partenariat. Si votre article est choisi à cette fin, le personnel d’Orthopaedia® vous en fera parvenir une copie à des fins d’examen avant toute diffusion sur le site.

Collaboration, Development, and Advocating for Change Kevin Orrell, M.D., FRCSC President, Canadian Orthopaedic Association

ith the arrival of spring and the proximity of our Annual Meeting in Victoria, it is time to take stock and examine what has been accomplished by the COA since we were together last year in Ottawa. Without a doubt, advocacy is and continues to be, one of our Association’s most important concentrations. This is essential, of course, for many reasons. On behalf of our residents and fellows, our organization recognizes its duty to work hard and advocate for full-time employment on behalf of residents and graduates of Canadian orthopaedic training programs. The unacceptable wait times for orthopaedic surgery, in the face of underemployed specialists, cannot be supported. All levels of government must be held responsible for the deficient access to care for our patients. Encouragingly, there has been some improvement in the employment numbers for young surgeons. Data from 2016 – 2017 show that there were a greater number of newly hired orthopaedic surgeons compared to residents trained. Residents and fellows are still rightfully concerned, but we are seeing a rise in morale around the future of orthopaedic work in Canada. The COA continues to address this critical employment situation through developing a surgeon mentorship program, practice transition initiatives, as well as continuing to advocate for improved efficiency and innovative models of care, which ultimately allow for hiring of more surgeons. As President, I will present an update related to employment to the residents at the start of the CORA meeting on June 20, as well as to the general membership during the ‘Your COA in Review’ session at the COA Annual Meeting. A more comprehensive update can be found on page 38 of this edition. Relevant updates have been applied to Access to Care Position Paper by the COA leadership. Dr. Jeff Gollish and the Standards Committee members are finalizing a COA Position Statement on Opioids and Orthopaedic Surgical Practice. These new statements will be presented to the Board for approval at our Annual Meeting. It is no longer reasonable to attempt advocacy initiatives in isolation of our provincial associations. After accepting Dr. Steven Papp’s invitation to attend the Ontario Orthopaedic Association’s Annual Meeting last October, both Cynthia Vezina, Executive Director, Strategic Initiatives, and myself recognized the value of a more 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 - Summer / Été 2018

Your COA / Votre association

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intimate relationship with all provincial and regional organizations. Advocacy efforts are difficult. They are time consuming, expensive and frustrating. The combined efforts of the COA with provincial leaders create a synergy that will be more effective at both levels of government. The COA is increasing our participation and collaborations with provincial associations. Recent discussion focuses on the need to address gender diversity in both our profession and our organization. Data collection is currently taking place in an effort to identify the number of women and their roles as leaders and active participants in Canadian orthopaedics. A gender, leadership, and life balance discussion will be held ahead of the CORA meeting this year on Wednesday morning from 10:30-11:30. This roundtable session will assist the COA in improving support, advocacy, and mentorship for women and minority groups within the Canadian orthopaedic profession. This is also consistent with the international efforts of our Carousel member nations, with whom we are closely associated. At this time of year, I am particularly grateful for the assistance provided to the COA by very busy volunteers. I extend my profound thanks to the chairs and members of the various COA committees for their active involvement, engagement, and contributions to our Association. We are very appreciative of the efforts of Dr. Geoff Johnston, who will be finishing his term of office this June, as chair of the COF Board. He will leave the COF in a very strong position to support Canadian research and education. Many thanks to those who have served with him. We are also very grateful to our colleagues in Victoria for their dedication and effort in organizing this year’s Annual Meeting. Drs. Peter Dryden, Melissa Collins and Colin Landells have provided valuable assistance and leadership throughout the planning and development of the event and program.

Contents / Sommaire Your COA / Votre association . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Clinical Features, Debates & Research / Débats, recherche et articles cliniques . . . . . . . . . . . . . . . . . . . . 15 Advocacy & Health Policy / Défense des intérêts et politiques en santé . . . . . . . . . . . . . . . . 37 Foundation / Fondation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47 Training & Practice Management / Formation et gestion d’une pratique . . . . . . . . . . . . . . . . . . . . . 50 Following up on our Featured Subspecialty initiative inaugurated in 2018, the Annual Meeting will include the most expansive spine program that the COA has offered in over a decade, including collaborations with the Canadian Spine Society. We are delighted to welcome back, as members of the COA, many of the leaders in spine in our country. Our usual Business Meeting has been reworked into a more inclusive session, offering a town hall discussion where members can address the COA Executive and committee chairs with questions and suggestions. Please be sure to participate in this open forum during the Your COA in Review session on Thursday, June 21 at 16:30. We look forward to this discussion and to receiving your feedback. This has been a busy but very rewarding year for both Anne and I, and we look forward to seeing you soon in Victoria.

It goes without saying, once again, that we must recognize our COA staff who have been particularly busy at this time of year preparing for our Annual Meeting and related projects.

Collaboration, développement et promotion du changement Kevin Orrell, MD, FRCSC Président de l’Association Canadienne d’Orthopédie

e printemps est arrivé et notre réunion annuelle, à Victoria, approche à grands pas! Il est donc temps de faire le bilan des réalisations de l’ACO depuis celle de l’an dernier, à Ottawa. Il va sans dire que la défense des droits et intérêts demeure l’un des centres d’activité les plus importants de l’ACO. Il est essentiel, bien sûr, et pour bien des raisons. Notre organisation reconnaît qu’il est de son devoir de travailler dur au nom de ses résidents et boursiers et de promouvoir l’emploi à temps COA Bulletin ACO - Summer / Été 2018

plein des résidents et diplômés des programmes canadiens d’orthopédie. Les temps d’attente inacceptables en chirurgie orthopédique, dans un contexte de sous-emploi des spécialistes, doivent être dénoncés. Tous les ordres de gouvernement doivent être tenus responsables de l’accès déficient aux soins. Heureusement, on constate une certaine amélioration de la situation d’emploi chez les jeunes orthopédistes : les données de 2016 et 2017 montrent qu’ils ont été plus nombreux à être embauchés par rapport au nombre de résidents formés. Les résidents et boursiers demeurent inquiets, à juste titre d’ailleurs, mais nous constatons une plus grande confiance quant à l’avenir de l’exercice orthopédique au pays. L’ACO continue de travailler sur la crise de l’emploi : elle élabore actuelle-

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ment un programme d’orthopédistes-mentors, de même que des initiatives de transition vers la retraite et vers l’exercice, en plus de poursuivre ses efforts de promotion d’une efficacité accrue et de modèles de soins novateurs, ce qui permettra au bout du compte d’embaucher plus d’orthopédistes. En tant que président, je ferai le point sur la situation d’emploi devant les résidents au début de la Réunion annuelle de l’ACRO, le 20 juin, de même que devant l’ensemble des membres à la séance Coup d’œil sur l’ACO, à la Réunion annuelle de l’ACO. Vous trouverez une mise à jour détaillée à la page 41. La direction de l’ACO a également apporté les modifications nécessaires à l’Énoncé de position sur l’accès aux soins orthopédiques au Canada. Le Dr Jeff Gollish et les membres du Comité sur les normes nationales de l’ACO mettent quant à eux la dernière touche à l’énoncé de position sur les opioïdes et la chirurgie orthopédique. Les nouveaux énoncés seront soumis au conseil d’administration de l’ACO à la Réunion annuelle. Il n’est plus raisonnable de lancer des initiatives de défense des droits et des intérêts sans l’apport des associations provinciales. Après avoir accepté l’invitation du Dr Steven Papp et assisté au congrès annuel de l’Ontario Orthopaedic Association, en octobre dernier, Cynthia Vezina, directrice générale des Initiatives stratégiques de l’ACO, et moi-même avons constaté à quel point il est utile d’entretenir des liens plus étroits avec toutes les organisations provinciales et régionales. Les efforts de défense des droits et des intérêts sont difficiles. Ils demandent beaucoup de temps, coûtent cher et sont sources de frustration. En jumelant ses efforts à ceux des leaders provinciaux, l’ACO crée une synergie qui a une incidence accrue au provincial comme au fédéral. L’ACO collabore donc plus étroitement avec les associations provinciales d’orthopédie. Les discussions récentes au sein de l’ACO portaient sur la nécessité de promouvoir la mixité tant au sein de notre profession que de notre organisation. On recueille actuellement des données pour établir le nombre de femmes en orthopédie au Canada de même que leur rôle de leaders et de participantes actives au sein de notre profession. Une discussion sous le thème « Sexe, leadership et conciliation travail-vie personnelle » aura lieu avant la Réunion de l’ACRO cette année, soit le mercredi matin, de 10 h 30 à 11 h 30. Cette table ronde permettra à l’ACO d’améliorer le soutien aux femmes et aux minorités du milieu de l’orthopédie au Canada, la défense de leurs droits et intérêts, ainsi que le mentorat qui leur est offert. Cette initiative s’inscrit en outre dans les efforts déployés par les pays

membres du groupe Carousel, avec lesquels nous œuvrons en étroite collaboration. Je suis particulièrement reconnaissant de l’aide que nous apportent nos bénévoles, très sollicités en cette période de l’année. Je tiens à remercier de tout cœur les présidents et membres des comités de l’ACO pour leur participation active, leur engagement et leur contribution à notre association. En outre, nous souhaitons témoigner ici de toute notre appréciation pour les efforts du Dr Geoff Johnston, qui termine son mandat à la présidence du conseil d’administration de la Fondation Canadienne d’Orthopédie en juin. Il laisse la Fondation en très bonne posture pour soutenir la recherche et la formation au pays. Merci beaucoup à ses collègues du conseil également. Nous sommes aussi extrêmement reconnaissants envers nos collègues de Victoria pour leur dévouement et les efforts qu’ils déploient pour organiser la Réunion annuelle. Les Drs Peter Dryden, Melissa Collins et Colin Landells ont été d’une aide précieuse, et leur leadership a été fort apprécié durant toute la planification de cette manifestation et de son programme. Je m’en voudrais aussi de ne pas souligner une fois de plus le travail du personnel de l’ACO, qui est particulièrement occupé en cette période de l’année par les préparatifs de la Réunion annuelle et les projets connexes. Conformément à une nouvelle initiative de mise en vedette des sous-spécialités lancée cette année, la Réunion annuelle comprend le programme sur le rachis le plus exhaustif offert par l’ACO en plus d’une décennie, y compris des collaborations avec la Société canadienne du rachis (CSS). Nous sommes très heureux du retour au sein de l’ACO de nombreux chefs de file de cette spécialité au pays. Enfin, la Séance de travail de l’ACO a été revue afin d’être plus interactive : les membres pourront poser des questions ou formuler des suggestions au Comité de direction et aux présidents des comités. Assurez-vous d’assister à ce forum dans le cadre de la séance Coup d’œil sur l’ACO, le jeudi 21 juin, à 16 h 30. Nous attendons cette discussion avec enthousiasme et avons hâte de vous y entendre. L’année a été aussi occupée que gratifiante pour Anne et moi, et nous avons hâte de vous voir à Victoria.

Rising to the Challenge – Incoming COA President Delivers Important Address

Se montrer à la hauteur : Le prochain président de l’ACO prononce une allocution d’importance

Dr. John Antoniou will deliver his President Elect Address entitled, Rising to the Challenge, at the upcoming Annual Meeting on Friday, June 22. Following his address, he will be named the 73rd President of the COA during the Transfer of Office ceremony. Look for his address on the COA web site after the Annual Meeting and in the Fall edition of the COA Bulletin in case you miss it on site!

À l’occasion de la Réunion annuelle, le vendredi 22 juin, le Dr John Antoniou donnera son allocution à titre de président élu de l’ACO, intitulée « Se montrer à la hauteur ». Il sera ensuite officiellement nommé le soixante-treizième président de l’ACO pendant la cérémonie de transfert des charges. Après la Réunion annuelle, son allocution sera publiée sur le site Web de l’ACO, puis dans le numéro automnal du Bulletin de l’ACO, au cas où vous l’auriez manquée!

COA Bulletin ACO - Summer / Été 2018

Your COA / Votre association

Meet Your New Membership Coordinator! Cynthia Vezina Executive Director, Strategic Initiatives

e are pleased to introduce Lexie Bilhete, the newest member of the COA’s head office staff. Lexie joined our team in mid-March as the Association’s Coordinator of Membership Services & Affiliate Programs. She executes and develops the COA’s various membership services, benefits, travelling fellowships programs, and works closely with our related committees. Lexie has a strong background in communications, editing, project management, and research which make her a valuable addition to our membership department. Members are encouraged to contact Lexie at lexie@canorth.org or 514 874-9003 x 6 with any general inquiries about the COA or questions related to the following: - Paying your membership dues, obtaining a receipt, or confirmation that your membership is in good standing. - Updates to your membership profile, contact information, or career changes (e.g. now in practice, on a fellowship). - Recruitment - let her know which of your colleagues are interested in getting signed up as COA members!

- Interest and application to any of the COA travelling fellowship programs (ABC, NATF, CFBS), or hosting a visiting fellow. - Questions about an upcoming COA committee meeting, or circulating communications to your committee members. - If you are an invited keynote speaker at the COA’s Annual Meeting and have a question about your presentation. - Any general inquiries about the COA, our membership services and benefits. Look for Lexie at the upcoming Annual Meeting in Victoria and welcome her to the COA! How to Reach Lexie: Lexie Bilhete can be reached at lexie@canorth.org or 514 874-9003 x 6.

Voici votre nouvelle coordonnatrice des services aux membres! Cynthia Vezina Directrice générale, Initiatives stratégiques

ous sommes heureux de vous présenter Lexie Bilhete, nouvelle employée des bureaux de l’ACO. Lexie s’est jointe à l’équipe à la mi-mars à titre de coordonnatrice des services aux membres et programmes affiliés de l’ACO. Elle soutient et développe les différents services aux membres de l’ACO, ainsi que les avantages et les bourses de voyage, et travaille en étroite collaboration avec les comités concernés. Lexie possède une vaste expérience en communications, en édition, en gestion de projets et en recherche, ce qui en fait un atout considérable pour nos services aux membres. Vous pouvez communiquer avec Lexie, à lexie@canorth.org ou au 514-874-9003, poste 6, pour toute question générale sur l’ACO ou sur les sujets suivants : - Paiement de votre cotisation, obtention d’un reçu ou confirmation que votre compte est en règle - Mise à jour de votre profil de membre, de vos coordonnées ou à la suite d’un changement professionnel (p. ex. en exercice ou en formation spécialisée) COA Bulletin ACO - Summer / Été 2018

- Recrutement (faites-lui savoir que certains de vos collègues aimeraient devenir membres de l’ACO!) - Intérêt et soumission de candidature pour toute bourse de voyage de l’ACO (Bourse de voyage américano-britannocanadienne, Bourse de voyage nord-américaine et Bourse de voyage canado-franco-belge-suisse) ou accueil d’un lauréat - Questions sur une réunion à venir d’un comité de l’ACO ou besoin de transmettre des renseignements aux membres du comité - Questions à propos d’une présentation que vous êtes invité à donner à la Réunion annuelle de l’ACO - Questions générales sur l’ACO, les services aux membres et les avantages de l’adhésion Venez voir Lexie à la Réunion annuelle à Victoria et souhaitezlui la bienvenue à l’ACO! Coordonnées de Lexie : On peut la joindre à lexie@canorth.org ou au 514-874-9003, poste 6.

Your COA / Votre association

Exhibit Hall Enhances Your COA Annual Meeting Experience

he Exhibit Hall at the COA Annual Meeting provides a unique opportunity for meeting attendees to learn more about the latest in orthopaedic devices, instruments, products and techniques offered by leaders in the Canadian orthopaedic industry. Take a look through the displays at your own pace during the event’s exhibit hours throughout the upcoming Annual Meeting in Victoria, BC. With more than 40 exhibiting companies participating in this year’s event, you will get hands-on experience through product demonstrations and Q&A with industry representatives and experts. More than Just Booths! The Exhibit Hall also features the Showcase Theatre where Poster Tours and Lunch and Learn sessions will be held during the breaks. Earn CME while participating in these accredited sessions.

Why Visit the Exhibit Hall? • See the latest in orthopaedic devices, techniques and services from leaders in the Canadian orthopaedic industry • See product demos and have your questions answered by company reps • Earn CME credits while participating in the Poster Tours and Lunch and Learn sessions • See the scientific poster displays and meet the presenting authors • Network with your colleagues over refreshments

Scientific poster displays and presentations will be set up inside the Exhibit Hall and surrounding foyer. Meet the poster authors during the Poster Pub on Thursday, June 21 from 17:30 to 19:00. Networking & Refreshments Catch up with your colleagues during the President’s Welcome Reception in the Exhibit Hall on Wednesday, June 20 at 19:00. This is your first chance to see what’s on display in the booths and meet company representatives. Coffee, tea and juice will be served during the morning breaks, as well as a full lunch service on Thursday and Friday. Location & Schedules The Exhibit Hall is located in Carson Hall on Level 2 of the Victoria Conference Centre. The following schedules and list of participating exhibitors can also be found in the final program distributed on site, as well as in the COA App. EXHIBIT HALL HOURS • 19:00-21:00 Wednesday, June 20 - President’s Welcome Reception • 10:45-19:00 Thursday, June 21 - Coffee, Lunch & Learn, Poster Tours & Pub • 10:35-14:00 Friday, June 22 - Coffee, Lunch & Learn, Poster Tour

SHOWCASE THEATRE SCHEDULE Thursday, June 21 • 10:45 - 11:15 Morning Break - Poster Tour: Sports/ Arthroscopy • 12:45 - 14:00 Lunch & Learn Session - Education Through Exchange: Expert presentations by the Visiting ABC Fellows • 17:30-19:00 Poster Pub with 2 Poster Tours (Spine and Trauma) Friday, June 22 • 10:35 - 11:15 Morning Break - Poster Tour: Arthroplasty • 12:45 - 13:45 Lunch & Learn Session - Journal Club Session: OrthoEvidence’s Must Read Papers of the Last Year EXHIBITING COMPANIES Company 3M Canada Acelity Canada Acumed Biocomposites Bioventus CIHI Carestream Health Canada CeramTec Medical Products ConMed Canada Consensus Medical Systems DepuySynthes DJO Canada EOS Imaging Héma-Québec Hologic Canada Integra Canada Medtronic Canada

Booth 217 405 500 310 417 419 415 316 301 305 219 213 106 108 402 404 421

Company Booth Microport Orthopedics Inc. 209 NuVasive Specialized Orthopedics 409 Ondine Biomedical 100 Össur Canada Inc. 206 Pega Medical 504 Pendopharm 308 QHR Technologies 400 Sanofi 102 Smith & Nephew 317 Stryker Canada 201 Tribe Medical Group Inc. 202 Venture Medical 502 Verve Medical Products Inc. 508 VirtaMed AG 411 Wright Medical Technology Canada 216 Zimmer Biomet Canada 311

COA Bulletin ACO - Summer / Été 2018

Your COA / Votre association

Optimisez votre expérience à la Réunion annuelle de l’ACO grâce à la salle d’exposition

a salle d’exposition à la Réunion annuelle de l’ACO est une occasion unique d’en apprendre davantage sur les tout derniers dispositifs, instruments, produits et techniques offerts par les chefs de file de l’industrie canadienne de l’orthopédie. Venez explorer les stands à votre rythme pendant les heures d’exposition lors de la Réunion annuelle à Victoria, en Colombie-Britannique. Cette année, plus de 40 exposants vous proposeront des démonstrations de produits et des foires aux questions avec des spécialistes et des représentants de l’industrie, pour une expérience pratique.

Pourquoi visiter la salle d’exposition? • Voir les tout derniers dispositifs, techniques et services offerts par les chefs de file de l’industrie canadienne de l’orthopédie. • Assister à des démonstrations et obtenir des réponses de représentants de l’industrie. • Accumuler des crédits d’ÉMC en participant aux visites d’affiches et aux dîners-causeries. • Voir les affiches scientifiques et rencontrer leurs auteurs. • Réseauter avec ses collègues en prenant quelques rafraîchissements.

Bien plus que des stands! La salle d’exposition accueille aussi la vitrine promotionnelle, où l’on tiendra des visites d’affiches et des séances de type dîner-causerie pendant les pauses. Vous pourrez accumuler des crédits d’éducation médicale continue (ÉMC) pendant ces activités agréées.

Les affiches scientifiques seront exposées et présentées dans la salle d’exposition (et le foyer juste à l’extérieur). Il sera possible d’en rencontrer les auteurs pendant le Pub des affiches, le jeudi 21 juin, de 17 h 30 à 19 h. Réseautage et rafraîchissements Venez renouer avec vos collègues à la Réception de bienvenue du président, dans la salle d’exposition, le mercredi 20 juin, à 19 h. Ce sera votre première occasion d’explorer les stands et de rencontrer les représentants de l’industrie. Du café, du thé et des jus seront servis aux pauses du matin, et un dîner complet sera servi le jeudi et le vendredi. Emplacement et horaires La salle d’exposition est située dans la salle Carson, au 2e étage du Victoria Conference Centre. Les horaires et la liste des exposants qui suivent se trouveront également dans le programme final, qui sera remis sur place, de même que dans l’application de l’ACO. HEURES D’EXPOSITION • De 19 h à 21 h, le mercredi 20 juin – Réception de bienvenue du président • De 10 h 45 à 19 h, le jeudi 21 juin – Café, dîner-causerie, visites d’affiches et Pub des affiches • De 10 h 35 à 14 h, le vendredi 22 juin – Café, dîner-causerie et visite d’affiches

COA Bulletin ACO - Summer / Été 2018

HORAIRE DE LA VITRINE PROMOTIONNELLE Le jeudi 21 juin • De 10 h 45 à 11 h 15, Pause du matin – Visite d’affiches : Médecine sportive et arthroscopie • De 12 h 45 à 14 h, Dîner-causerie – La formation par l’échange : Présentations spécialisées par les lauréats de la Bourse de voyage ABC en visite au Canada • De 17 h 30 à 19 h, Pub des affiches et deux visites d’affiches (rachis et traumatologie) Le vendredi 22 juin • De 10 h 35 à 11 h 15, Pause du matin – Visite d’affiches : Arthroplastie • De 12 h 45 à 13 h 45, Dîner-causerie – Séance de type club de lecture : Les incontournables d’OrthoEvidence de la dernière année EXPOSANTS Entreprise 3M Canada Acelity Canada Acumed Biocomposites Bioventus Institut canadien d’information sur la santé (ICIS) Carestream Health – Canada CeramTec Medical Products ConMed Canada Consensus Medical Systems, Inc. DePuySynthes DJO Canada EOS Imaging Héma-Québec Hologic Canada Integra Canada Medtronic Canada

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Entreprise MicroPort Orthopedics, Inc. NuVasive Specialized Orthopedics Ondine Biomedical Össur Canada Pega Medical PENDOPHARM

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Using forced-air warming on patients doesn’t increase the risk of surgical site infections. Science says so. 3M™ Bair Hugger™ Normothermia System is the world’s leading forced-air warming system, providing safe and effective warming therapy to surgical patients. Visit BairHugger.com/ScienceSaysSo or contact your 3M Sales Representative to learn more.

Research shows that forced-air warming does not increase the bacterial count at the surgical site.1-4 And there is no disruption of laminar airflow tied to the use of forced-air warmers. 5-8 By maintaining normothermia, the 3M Bair Hugger system can help to decrease surgical site infection9 rates, shorten the length of hospital stays,10 and help hospitals avoid additional costs.11

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Zink RS, Iaizzo PA. Conductive warming therapy does not increase the risk of wound contamination in the operating room. Anesth Analg 1993;76:50-3. 2. Huang JK, Shah EF, Vinodkumar N, Hegarty MA, Greatorex RA. The Bair Hugger patient warming system in prolonged vascular surgery: an infection risk? Crit Care 2003;7:R13–R16. 3. Moretti B, Larocca AM, et al. Active warming systems to maintain perioperative normothermia in hip replacement surgery: a therapeutic aid or a vector of infection? J Hospital Infect 2009; 73:58–63. 4. Sharp RJ, et al. Do warming blankets increase bacterial counts in the operating field in a laminar-flow theatre? J Bone Joint Surg Br 2002; 84-B:486-8. 5. Sessler DI, Olmsted RN, Kuelpmann R. Forced-Air Warming Does Not Worsen Air Quality in Laminar Flow Operating Rooms. Anesth Analg.113 (6): 1416-1421. 2011 6. Olmsted RN, Kulpmann R, Schlautmann B. Effect of Forced-Air Warming on Operating Theatre Air Quality: assessment using submicron particle release, Hospital Infection Society, 2010. 7. Tumia, N., Ashcroft, C.P., Convection warmers – a possible source of contamination in laminar airflow operating theatres? Journal of Hospital Infection 2002; 52: p. 171-174. 8. Memarzadeh, F. Active warming systems to maintain perioperative normothermia in hip replacement surgery. J. Hosp. Infect. 2010; doi:10.1016/j.jhin.2010.02.06. 9. Kurz, A., D.I. Sessler, and R. Lenhardt, Perioperative normothermia to reduce the incidence of surgical wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med. 1996. 334(19): p. 1209-15. 10. Ibid. 11. Mahoney, C.B., and Odom, J. Maintaining intraoperative normothermia: a meta-analysis of outcomes with costs. American Association of Nurse Anesthetists Journal. 1999 Apr;67(2): p. 155-63. 1.

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Profound Exchange of Ideas and Culture during Inaugural Norman Bethune Orthopaedic Travel Scholarship Vaughan Bowen, M.D., FRCSC University of Calgary Calgary, AB

orman Bethune, known as Bai Qiuen in China, was Canadian. Born in Gravenhurst, Ontario in 1890, he tunity to see the countryside or, at least what was not obscured graduated MD from the University of Toronto in 1916, by the pervasive heavy fog. Along the way we noticed massive fought in WW1 and did postgraduate training in the UK at Great construction projects, heavy indusOrmond Street and in Edinburgh. try and large farms. It was obvious From 1927 to 1936, he worked as We look forward to Dr. Bowen’s plenary address at the that this was a country where things an innovative thoracic surgeon in COA Annual Meeting in Victoria. For more reflections on are happening. Xi’an was an attracMontreal. He feared being medithis inaugural exchange, read Dr. Bowen’s detailed tive city with a picturesque city ocre, was interested in socioecowall, a vibrant Muslim market, and travel and photo blog by clicking here. nomic aspects of disease, and was a theatre, where we enjoyed music strongly anti-fascist. In 1936, he and dance. The main attraction was went to Europe and developed the Would you like to be the next Norman Bethune the Terracotta Warriors, which were world’s first mobile blood transfuOrthopaedic Travel Scholar? The application deadline as impressive as advertised. After sion service in the Spanish Civil War is August 1. Click here for application details. a short flight to Chongqing, where but it is what he did later, in China, the magnolias were in blossom, we which earned him lasting fame. In boarded a boat to take us along the Yangzi River to the contro1938 he joined the Chinese Eighth Route Army, waging war versial Three Gorges Dam and Yichang. We saw cities, villages against a Japanese invasion, and profoundly impressed the and river traffic. We went through steep sided stone gorges Chinese people. He was respected for treating everyone alike – and stopped to visit pagodas and street markets. Our boat his own wounded soldiers, enemy soldiers and sick villagers – used the world’s biggest ship lift to get past the massive dam. and for his tireless commitment and unselfish hard work. He From Yichang we flew to Shanghai, where we enjoyed sweet taught rural physicians and is acclaimed as the founder of modtasting cuisine and viewed the illuminated futuristic cityscape ern medicine in China. After dying from septicaemia in 1939, from across the river after dark. Another high-speed train took Mao Zedong wrote a Eulogy ‘In Memory of Norman Bethune’, us to Wenzhou, where we were met by Dr. Jiang Yiang-Fu. which became required reading for all Chinese people during the Cultural Revolution. The Second Affiliated Hospital of WMU is a large Since Bethune, other Canadian surgeons have visited China. complex of medical buildWenzhou Medical University (WMU) has developed strong ings in the city centre. bonds with Canadian orthopaedic surgeons, visiting and teachAcross the street is the old ing under the auspices of Health Volunteer Overseas (HVO). university campus, which is In 2017, the COA Global Surgery (COAGS) Committee, worknow used for postgraduate ing with Dr. Alan Giachino for HVO and Prof. Xu Huazi and work and research. The new Prof. Weiyang Gao for WMU, announced a competition for the campus, with architecturally first Norman Bethune Orthopaedic Travel Scholarship. I was impressive buildings and honoured to receive this award. In March 2018, my partner, garden-like grounds, is an Dorothy, and I left Canada to travel, explore, and live in China. hour’s drive away, near the Our mandate was to forge bonds and exchange knowledge mountains on the edge of between Canada and China, working with orthopaedic surthe city. One day, Dr. Jiang geons at the Second Affiliated Hospital of WMU. Yiang-Fu and Dr. Li took us there to visit the amazing We travelled through China for two weeks on our way to Human Body Museum. Wenzhou, recovering from jet lag, visiting tourist attractions, seeing the country, learning about Chinese culture, and findBuilding 8 is a 23-floor ing out about its people and their ways. We flew into Beijing, tower. The bottom four China’s capital: a huge city and a bustling mass of people. floors are for check in, lab Professor Gao presenting Everything was different: food, traffic, weather, architecture, tests and clinics. Floors 5 Dr. Vaughan Bowen with a language, currency and toilets. Thank goodness we had and 6 contain 28 operating commemorative certificate during arranged for a guide! We visited the Great Wall, the Summer rooms. The higher levels are the farewell banquet. Palace, the Forbidden City, Tiananmen Square and many other inpatient wards, ten of which are orthopaedic. The Division of amazing places. Then, by high speed train to Xi’an, an opporOrthopaedic Surgery is directed by Professor Gao, a hand surCOA Bulletin ACO - Summer / Été 2018

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(continued from page 10)

geon. Hand Surgery occupies floors 12 and 13. There are seven Hand Surgery teams, each consisting of a staff surgeon and three trainees, taking 1:5 call. Each morning started with teaching rounds. Selected elective and emergency cases, treated the previous day, were briefly reviewed, a research paper was discussed in English and other material was presented. Every day I presented cases on a specific topic, usually something I was not seeing in Wenzhou, with an explanation of what was important and a review of the Dr. Bowen at the entrance to most recent literature: wrist Orthopaedic Ward 7: Hand Surgery arthritis, thumb CMC joint and Plastic Surgery. reconstruction, SLAC/SNAC wrist, Dupuytren’s contracture, etc. In turn, my hosts presented something that interested me. Rounds were followed by a quick ward round before going to clinics or operating rooms. The clinics were extremely busy with pre-booked and walk-in patients, clambering to be seen, each holding a ‘credit card’ containing their medical records. Patients’ problems were wide ranging and included benign finger lesions, fractures and dislocations, carpal tunnel syndrome, recovering mutilating injuries, TFCC tears, tennis elbow, cubital tunnel syndrome, rotator cuff tears, gout and many other conditions. Patients were generally younger than in my practice. I saw almost no arthritis. CT scans and MRIs could be obtained almost immediately. There was no waiting list. Booked operations were done on the next OR day. The operating rooms were equipped, staffed and functioned in a manner very similar to ours. The OR list, of course, was typed in Chinese characters so I needed help to know what was going on. Professor Gao operated on many children. It was a delight to work with such a master surgeon. He reconstructed ten thumb duplications while I was there. He also did a ray resection for an interesting metacarpal tumour. I did wrist arthroscopies, tennis elbow releases, Chow endoscopic carpal tunnel decompressions, glomus tumour resections, ORIF distal radius fracture, a Camitz opponensplasty and other cases with Dr. Yan. With Dr. Yiang-Fu, I watched endoscopic rotator cuff repairs and helped plate a clavicle fracture and internally fix a lateral epicondyle fracture in a child. Dr. Li asked me to join him when he did a lateral thigh free tissue transfer to cover a large tibial defect, at the time spanned by an antibiotic impregnated cement spacer. I saw other surgeons doing many other operations such as ORIF radius fractures, IM nailing of an intertrochanteric femur fracture, skin grafting a leg wound. Operating days went on until the lists were finished.

Dr. Bowen and Dorothy in front of the Red Monument to Chairman Mao in Beijing.

Dorothy spent time with nurses, whose company we enjoyed both in and out of the hospital. She organized six 90-minute English language classes, getting them to read and speak our language. Her PowerPoint presentations showed pictures of us doing fun things at home and on vacation, so they were both a language and cultural experience! Rather sadly, our time in Wenzhou came to an end all too quickly. We were given a great send off, with a banquet, speeches and presentations. It seemed as if we all enjoyed this Scholarship. It was a wonderful opportunity to exchange information, to make personal friends and to help form a lasting bond between the orthopaedic surgeons at WMU and the COA. For me, it was a very special experience. It was a privilege, and a highlight of my career, to have been selected as the Norman Bethune Scholar.

COAGS Welcomes Dr. Anton Kurdin as Resident Representative The COA Global Surgery (COAGS) Committee is pleased to announce the winner of the 2018 Resident Representative Competition, Dr. Anton Kurdin, R4 at Memorial University of Newfoundland. Among many relevant interests and accomplishments, Dr. Kurdin travelled to Haiti with Team Broken Earth in 2017, and has completed a Master’s degree focusing on ways to improve trauma care in low resource settings. His committee position will entail various projects to promote global surgery opportunities to orthopaedic residents across Canada, so don’t hesitate to get in touch with him with questions or suggestions. Join us in welcoming Dr. Kurdin.

COA Bulletin ACO - Summer / Été 2018

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2019 ABC Fellowship Application Reminder July 13

Rappel : date limite de soumission des candidatures pour la Bourse de voyage ABC 2019 : Le 13 juillet

he COA is accepting applications for the 2019 ABC Travelling Fellowship until July 13, 2018. The tour will take place during the Spring of 2019 over approximately five weeks. This fellowship opportunity is open to candidates who are 45 years of age or under as of December 31, 2018 and who are either Canadian citizens or permanent residents with full-time positions in Canadian hospitals. Guidelines, application forms and further information can be found here.

’ACO accepte les candidatures pour la Bourse de voyage américano-britanno-canadienne (ABC) 2019 jusqu’au 13 juillet 2018. La tournée aura lieu au printemps 2019 et durera environ cinq semaines. Les candidats doivent être âgés de 45 ans ou moins au 31 décembre 2018 et être citoyens canadiens ou résidents permanents, en plus d’occuper un poste à temps plein dans un hôpital canadien. Vous trouverez les lignes directrices, le formulaire de demande et de plus amples renseignements ici.

Want to learn more about the ABC fellowship? Attend the Lunch and Learn session featuring presentations from the COA’s most recent ABC fellows who participated in the 2017 tour, as well as the visiting ABC fellows being hosted in Canada and the US this spring. The “Education Through Exchange” session will held in the Showcase Theatre in the Exhibit Hall on Thursday, June 20 from 12:45-14:00.

Vous souhaitez en savoir plus sur la Bourse de voyage ABC? Assistez au dîner-causerie où les derniers lauréats de l’ACO à avoir pris part à la tournée, en 2017, de même que les lauréats 2018 en visite au Canada et aux États-Unis ce printemps, feront des présentations sur la Bourse de voyage ABC. La séance « La formation par l’échange » aura lieu à la vitrine promotionnelle, dans la salle d’exposition, le jeudi 20 juin, de 12 h 45 à 14 h.

Dr. Garth Edward Johnson April 23, 1942 - May 8, 2018

ith heavy hearts we announce the sudden passing of Dr. Garth Edward Johnson, 76 years young, at the Ottawa Civic Hospital on Tuesday, May 8, 2018. Dad was born on April 23, 1942 in Selkirk, Manitoba, beloved son and youngest child of Dr. Edward and Eleanor (Emes) Johnson and brother of Arlene and Cynthia. He attended Winnipeg’s St Paul’s High School and graduated from the University of Manitoba Medical School in 1966. He found his calling in Orthopedics and pursued training in England, after which he returned to Canada to take a staff position at the University of Manitoba, Section of Orthopedics in 1972, then moved to the University of Ottawa and the Ottawa Civic Hospital in 1992, where he served until his retirement in 2014. Dad was gifted with a kind heart and unparalleled clinical ability. While he excelled in Orthopedic trauma and spine surgery, his greatest gift was as a teacher and mentor to many students and physicians over his long career. Dad is survived by his wife Pat (Southgate) Johnson; children Michael (Marisa), Meredith Mae (Yves), Gareth (Brittany) and Stephanie (Danny); stepsons Neil (Marie) Richardson and Colin (Robin) Richardson; first wife, Wendy MacDonald; sister

COA Bulletin ACO - Summer / Été 2018

Cynthia Webster and nephew Paul Johnson. Grandpa Garth was deeply treasured by his grandchildren: Evan, Nicholas, Julia, Daniel, Clara, Gigi, Hunter, Tristan, Jackson, Keenan, Sophie, Noah, Matthew, William and Thomas. Dad was predeceased by his parents and sister Arlene. We are grateful for the exceptional care that Dad received from Drs Sinclair, Hooper, Kubelik, Rubens and Dickie and the skilled and compassionate Civic Hospital ICU nursing team. In lieu of flowers, our family requests donations to Dad’s favourite causes, Amnesty International or the Shepherds of Good Hope. In the words of the hymn that Dad chose for his mother’s funeral, ours is a ‘Love that Will Not Let Me Go’. Published in The Ottawa Citizen on May 12, 2018

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COA Bulletin – Online Reading Tip #3

Bulletin de l’ACO – Conseil de lecture en ligne no 3

Reading the Bulletin on a Computer (desktop or laptop)? Follow these steps:

Lecture du Bulletin sur ordinateur (de bureau ou portable) – Suivre les étapes suivantes :

1) Click on DOWNLOAD and the download icon in the bottom of the viewer (make sure you aren’t viewing in full screen mode. If you can’t see the download option on your screen, exit out of full screen mode).

1) Cliquez sur la fonction « DOWNLOAD » et l’icône de téléchargement au bas du lecteur. (Assurez-vous de ne pas être en mode plein écran. Si vous ne voyez pas la fonction de téléchargement, c’est que vous êtes en mode plein écran.)

2) Save or Open the downloaded file per the prompts that appear on your screen. The Bulletin will download as a .pdf file.

2) Enregistrez ou ouvrez le fichier au choix en suivant les directives à l’écran. Le Bulletin est téléchargé en format .pdf.

3) Open up the pdf version of the Bulletin that you downloaded and select the print feature in your pdf viewer (Adobe, Microsoft Edge etc.).

3) Après avoir ouvert la version PDF téléchargée dans votre lecteur PDF (p. ex. Adobe ou Microsoft Edge), sélectionnezen la fonction d’impression.

4) Your Bulletin will print out on your home or office printer.

4) Votre imprimante lancera l’impression du Bulletin.

Look for more online reading tips in future editions of the COA Bulletin

D’autres conseils de lecture en ligne seront publiés dans les prochains numéros du Bulletin de l’ACO.

How to PRINT out an edition

refer to hold the Bulletin in your hands and read a printed version? Here’s how to print out the COA Bulletin at home.

IMPRESSION d’un numéro

ous préférez tenir le Bulletin dans vos mains et en lire la version imprimée? Voici la procédure d’impression du Bulletin de l’ACO.

COA Bulletin ACO - Summer / Été 2018

INTRODUCING

TRIATHLON TRITANIUM ®

Orthopaedics

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

FONT: Helvetica with bell curve

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

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

Concussion Management in Orthopaedic Sport Medicine Ryan Martin, M.D., FRCSC Orthopaedic Trauma and Arthroscopic Knee Surgeon Calgary, AB

gest that exposure to RBT represents the greatest risk factor for CTE features3. However, quantifying the real risk of developing CTE is difficult and likely overestimated by media headlines due, in part, to sampling bias3. Brains donated to research centres are often from those who displayed behavioural disturbances after a history of RBT12. The only way of truly defining the actual prevalence of CTE would necessitate a study of those with and without a history of RBT, and with and without neuropsychiatric symptoms. These prospective studies are currently being performed (clinical trials NCT02191267 and NCT02798185)3.

oncussions are relatively common clinical entities that have gained increased media scrutiny and public attention of late. Orthopaedic surgeons, especially those subspecialized in sport medicine, should have a conceptual understanding of the clinical features of concussions as well as their recognition, assessment techniques, and principles of management5. Orthopaedic surgeons are often asked to perform recreational, elite or professional side-line coverage, which requires There are Canadian Guidelines on Concussion in Sport and a one to be comfortable in concussion assessments and return new International Consensus statement developed to help to sport decisions. Additionally, several studies have reported guide the diagnosis and management of concussions, espeon a potential post-concussion elevated cially in athletes11. They ensure athletes risk of musculoskeletal injury because of with a suspected concussion receive persistent deficits in postural control and appropriate sideline and offsite medical neural activation patterns2,8. Thus any assessment, proper concussion manageThese vignettes are a series of articles led surgeon caring for injured athletes will ment, and appropriate return to sport by experts and thought leaders who advise encounter patients with concussions. strategies. These guidelines employ tools on how to manage clinical controversies or Being educated on concussions will presuch as the Concussion Recognition Tool address emerging treatment trends, while pare orthopaedic surgeons to provide 5 and the Sport Concussion Assessment applying evidence-based principles. With coordinated care with other health-care Tool 5 (SCAT 5)4,7. Modified versions these vignettes, we aim to help provide the professionals such as sport medicine exist for paediatric children aged < 12. best evidence-based strategies to enable physicians, athletic trainers and physical Orthopaedic surgeons, especially sport clinicians to incorporate new treatment therapists5. medicine surgeons, should be familiar and diagnostic strategies into current with these guidelines and tools referConcussions are a form of traumatic enced in the suggested reading section. practice. Although no patient or condition brain injury induced by biomechanical fits into the proverbial “box,” we often need forces11. Debate exists as to where a Learning to identify concussion is importo solve problems in “real time” and these concussion fits on the traumatic brain tant, but once identified, orthopaedic comprehensive opinions will, hopefully, injury (TBI) spectrum. It is currently not surgeons should know where to refer to. provide some useful and applicable insights. fully understood whether they result in Many cities across Canada have multidispermanent structural changes as seen ciplinary concussion care clinics that are Femi Ayeni, M.D., FRCSC in severe TBI, or if the resulting neuromedically supervised by sports medicine Scientific Editor, COA Bulletin pathological changes represent reversiphysicians, neurologists, and/or rehable functional and structural disturbancbilitation physicians. Although referrals es5. The literature distinguishes between sports-related concusshould be made on an individual basis, Canadian Guidelines sions (SRC) and non-sporting mild traumatic brain (mTBI) injusuggest that those experiencing prolonged post-concussion ries10. The rational for separating the two entities make for ease symptoms (> four weeks for youth and two weeks for adult) of guideline development. Contact sporting athletes, unlike may benefit from a referral. Persistent symptoms beyond these regular patients, also expose themselves to repetitive trauma period is called post-concussion syndrome (PCS). Such clinics before and after single event mTBI. Since orthopaedic surgeons employ multimodal treatments involving active rehabilitation care for both patient populations, it is important to point out of targeted deficit and not rest alone. Employed rehabilitathat the separation is not rooted in pathology, and lessons tion therapies include aerobic, vestibular, vision and cognitive learned from mTBI can be extrapolated to SRC and vice versa10. behavioural therapy9. Therefore, guidelines for return to sport can be extrapolated to those who injured themselves outside a sporting environment, Although orthopaedic surgeons will never be the primary medand want to return to activity (i.e. school or work)1. ical experts responsible for managing concussions, we need to have a baseline understanding of the injury. This includes The media has drawn valuable attention towards concussions being familiar with its clinical features, consensus guidelines, with significant attention being focused on the long-term and clinical assessment tools. We need to understand how coneffects of repetitive brain trauma (RBT) and the link to a neucussions can influence the care of musculoskeletal problems, rodegenerative conditions called chronic traumatic encephaand when to refer. This understanding is all the more important lopathy (CTE)3. Medical experts should be aware of the gaps now because of the increased media scrutiny influencing our and controversies associated with CTE. The gaps largely exist patients understanding of the problem. because of the reliance on a postmortem diagnosis. Although complicated by selection criteria, the available data does sug-

Evidence-based Vignettes

COA Bulletin ACO - Summer / Été 2018

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 15)

References 1. Parachute. (2017). Canadian Guideline on Concussion in Sport. Toronto: Parachute 2. Howell D.R., Osternig L.R., Chou L.-S. 2015. Return to activity after concussion affects dual-task gait balance control recovery. Med Sci Sports Exerc.;47:673-68 3. Asken, B.M. et al., 2017. Research Gaps and Controversies in Chronic Traumatic Encephalopathy. JAMA Neurology, 74(10), pp.1255–8. 4. BMJ Publishing Group Ltd, Sport, B.A.O. & Medicine, E., 2017. Concussion recognition tool 5©. British Journal of Sports Medicine, 51(11), pp.872–872. 5. Cahill, P.J. et al., 2016. Concussion in Sports. Journal of the American Academy of Orthopaedic Surgeons, 24(12), pp.e193–e201. 6. Davis, G.A. et al., 2017. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). British Journal of Sports Medicine, 39, pp.bjsports–2017–097492–3. 7. Echemendia, R.J. et al., 2017. The Sport Concussion Assessment Tool 5th Edition (SCAT5). British Journal of Sports Medicine, 33, pp.bjsports–2017–097506–3. 8. Gilbert, F.C. et al., 2016. Association Between Concussion and Lower Extremity Injuries in Collegiate Athletes. Sports Health: A Multidisciplinary Approach, 8(6), pp.561–567. 9. Leddy, J.J., Baker, J.G. & Willer, B., 2016. Active Rehabilitation of Concussion and Post-concussion Syndrome. Physical Medicine and Rehabilitation Clinics of North America, 27(2), pp.437–454.

10. McCrory, P., Feddermann-Demont, N., et al., 2017. What is the definition of sports-related concussion: a systematic review. British Journal of Sports Medicine, 51(11), pp.877– 887. 11. McCrory, P., Meeuwisse, W., et al., 2017. Consensus statement on concussion in sport—the 5th international conference on concussion in sport held in Berlin, October 2016. British Journal of Sports Medicine, 12, pp.bjsports–2017–097699–10. 12. Mez, J. et al., 2017. Clinicopathological Evaluation of Chronic Traumatic Encephalopathy in Players of American Football. JAMA, 318(4), pp.360–370. Recommended Reading for Further Information on Concussions: • Echemendia, R.J. et al., 2017. The Sport Concussion Assessment Tool 5th Edition (SCAT5). British Journal of Sports Medicine, 33, pp.bjsports–2017–097506–3. • Davis, G.A. et al., 2017. The Child Sport Concussion Assessment Tool 5th Edition (Child SCAT5). British Journal of Sports Medicine, 39, pp.bjsports–2017–097492–3. • Cahill, P.J. et al., 2016. Concussion in Sports. Journal of the American Academy of Orthopaedic Surgeons, 24(12), pp.e193–e201. • Asken, B.M. et al., 2017. Research Gaps and Controversies in Chronic Traumatic Encephalopathy. JAMA Neurology, 74(10), pp.1255–8. • BMJ Publishing Group Ltd, Sport, B.A.O. & Medicine, E., 2017. Concussion recognition tool 5©. British Journal of Sports Medicine, 51(11), pp.872–872.

Slipped Capital Femoral Epiphysis Kevin Smit, M.D., FRCSC Assistant Professor, Division of Orthopaedic Surgery, Dept. of Surgery, University of Ottawa Ottawa, ON R. Baxter Willis, M.D., FRCSC Professor, Division of Orthopaedic Surgery, Dept. of Surgery, University of Ottawa Ottawa, ON

ver the last 20 years, the treatment for slipped capital femoral epiphysis (SCFE) has evolved based on the stability classification of Loder1. There is general agreement on the initial management of mild and moderate stable SCFEs, which is by far the most common presentation. However, in recent years, there has been controversy regarding the most appropriate initial treatment of the less common unstable variety of SCFE, based on the potential complication of avascular necrosis (AVN). COA Bulletin ACO - Summer / Été 2018

Horizons The practice of orthopaedic surgery continues to evolve. We are faced with an explosion of information stemming from published cuttingedge research (bench and clinical). Likewise, an increasingly informed public has rapid access to information about novel therapies and surgical techniques. Oftentimes the best way to integrate evidence-based practice and innovative treatments is unknown or challenging. To add some perspective on how to approach emerging and/or controversial topics, we have developed this Horizons feature in the COA Bulletin. In the Horizons articles, thought leaders from various subspecialties will provide insights based on their extensive clinical experience and ongoing research. The goal of this feature is to “shed some light” on the best way forward. Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 16)

Stable Slipped Capital Femoral Epiphysis It is imperative that all physicians be able to diagnose a SCFE, as delayed referral to a paediatric orthopaedic surgeon can have devastating consequences. It is not uncommon for adolescents with stable slips to have symptoms for weeks to months, and can have multiple physician visits before the diagnosis is confirmed. SCFEs are usually diagnosed by clinical symptoms of hip, thigh or knee pain and a limp. We cannot stress enough the importance of the clinical exam of the hip in a child or adolescent with a limp or pain. These patients have limited internal rotation of the hip and have obligate external rotation when the hip is flexed. Radiographs are used to confirm the diagnosis and should include anterior-posterior (AP) and frog leg views of the pelvis which reveal the epiphysis has “slipped” posteriorly on the femoral neck. Radiographic signs include disruption of Klein’s line2 (failure of a line drawn along the superior aspect of the femoral neck to intersect a portion of the capital femoral epiphysis on the AP pelvis view), a posterior slipping or tilting of the epiphysis as visualized on the frog leg lateral view, and a widening and blurring of the physis, especially when compared to a normal opposite hip, although bilateral SCFEs are not uncommon. Once recognized, the child should be made non-weight bearing and admitted to hospital for urgent treatment or transferred emergently to a paediatric orthopaedic centre for definitive management. Surgery to stabilize the capital femora epiphysis can be done on a fracture table or radiolucent flat top table. The epiphysis is stabilized with a single central 7.0 or 7.3 mm cannulated screw placed across the physis at a right angle to the centre of the epiphysis. Ideally, four or five threads should cross the physis, and the starting point of the screw on the femoral neck is anterior to accomplish the proper trajectory. When possible, the starting point should not be more proximal than the intertrochanteric line to avoid screw head impingement on the acetabulum (Figure 1). The screw results in stabilization of the capital femoral epiphysis and eventual epiphyseodesis. Since the condition usually affects patients in the last two years of growth (girls’ peak age =12.2 years; boys’ peak age = 13.4 years)3, the epiphyseodesis results in a minimal leg length discrepancy. Recent studies of moderate and severe stable SCFE (Southwick classification: Moderate slip angle 30-50 degrees; Severe slip angle >50degrees)4 have indicated that a significant percentage of patients will develop labral and chondral damage and eventual degenerative changes in the hip joint5,6,7. These changes may occur much sooner than was previously thought. As a consequence, reconstructive procedures to remove the residual “bump” at the epiphyseal-metaphyseal junction have been proposed8. These include

Figure 1 Eleven-year-old female with chronic left hip pain has (A) AP and (B) frogleg lateral radiographs with a mild left SCFE. She had in situ pinning of her left hip and six-month postoperative radiographs (C and D) are shown.

arthroscopic osteochondroplasty, intertrochanteric osteotomy (Imhauser or Southwick – see Figure 2) plus or minus open osteochondroplasty9,10, and even a modified Dunn osteotomy to realign the femoral head to the femoral neck with careful protection of the epiphyseal blood supply11,12,13. The latter procedure requires significant understanding of the vascular anatomy to the capital femoral epiphysis and in the technical context of safe, surgical hip dislocation as advocated by Ganz12,14. The Swiss experience has shown AVN rates of only 5-7%15 but the North American experience is not as optimistic with AVN rates approaching 25-30%16.

Figure 2 (A&B) Thirteen-year-old male with left severe SCFE. (C&D) One year posteroperative radiographs after in situ pinning. (E&F) Coronal and axial CT scan images showing severe residual deformity and cam lesion. (G&H) Postoperating radiographs after Imhauser osteotomy.

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 17)

Unstable Slipped Capital Femoral Epiphysis Whereas the initial management of stable SCFE is generally in-situ stabilization, the initial treatment of unstable slips remains controversial due to the high incidence of AVN. The standard proposed treatment of in-situ pinning has significantly high rates of AVN ranging from 25-50%17,18, and therefore, many new techniques have been proposed in an attempt to minimize this dreaded complication. The timing of surgery is also controversial with some studies suggesting this type of slip is a surgical emergency requiring surgery within six to eight hours of presentation, whereas other studies with fewer patients have concluded that delayed treatment may be more efficacious19. Most studies of acute, unstable SCFE are level 4 studies with few numbers, making it difficult to draw firm conclusions. In most cases, the initial treatment of an unstable slip should be accomplished within eight hours of diagnosis. Klaus Parsch recommended an open anterior arthrotomy to both decompress the joint as well as obtain a gentle reduction of the epiphysis on the femoral neck. His AVN rate with this procedure was only five percent (two of 64 cases)20. Furthermore, Herrera-Soto has performed evaluation of intracapsular hip joint pressure and found that it is markedly elevated in patients with unstable slips undergoing a reduction manoeuvre. On this basis, he recommended a capsular decompression of the joint by arthrotomy or small capsulotomy to evacuate the haematoma and in doing so, returned the pressure to normal levels21. Recent work by the Swiss and several specialized North American centres has popularized the concept of the modified Dunn osteotomy11,13,15. This technique is accomplished by a temporary in-situ stabilization of the capital femoral epiphysis followed by surgical dislocation of the slip as outlined by Ganz13,22. The vessels to the epiphysis are then carefully preserved in a retinacular flap and the femoral neck shortened with excision of any posterior callus. The epiphysis is then gently repositioned anatomically on the femoral neck and stabilized with two or three 4.5 or 6.5 mm cannulated screws. Careful monitoring of the vascularity in the retinacular flap and the capital femoral epiphysis is carried out during the procedure. The hip is then reduced and the greater trochanter is fixed with two 4.5 mm screws and the capsule carefully repaired (see Figure 3). Early results from several North American centres have shown excellent short and mid-term results with AVN rates from 6-7% to 26%16,18. Again, these are level 4 studies with no comparative cohort, but the early results are promising in that hip joint function is improved over patients with residual deformity. This treatment strategy requires an experienced team of skilled surgeons with specialized training in surgical hip dislocation and preservation of the blood supply to the capital femoral epiphysis. In summary, initial management of the unstable SCFE remains controversial. For most treating surgeons, gentle repositioning of the capital femoral epiphysis on the femoral neck, followed by cannulated screw stabilization with one or two 7.0 or 7.3 mm cannulated screws is recommended. Avoid the posterior superior quadrant of the epiphysis with the screws so as not to compromise a consistent epiphyseal vessel. Following stabilization, it is recommended to perform a mini capsulotomy COA Bulletin ACO - Summer / Été 2018

Figure 3 Thirteen-year-old male presents with acute on chronic left hip pain. (A) AP and (B) cross table lateral radiographs show severe SCFE. (C&D) Nine-month postoperative AP and lateral radiographs of the patient after having had a Modified Dunn osteotomy with surgical realignment of the femoral epiphysis and in situ pinning of the contralateral hip.

to decrease the intracapsular pressure. Further evaluation on the role of the modified Dunn osteotomy needs to be accomplished and is probably reserved for centres with surgical expertise in this procedure. References 1. Loder T.R., Richards S.B., Shapiro P.S., Reznick L.R., Aronson D.D. Acute Slipped capital femoral epiphysis: the importance of physeal stability. The Journal of Bone and Joint Surgery. American Volume 75 (1993): 1134-1140 2. Klein A., Joplin R.J., Reidy J.A., Hanelin J. “Slipped capital femoral epiphysis; early diagnosis and treatment facilitated by normal roentgenograms” The Journal of Bone and Joint Surgery. American Volume 34 (1952): 233-239 3. Loder R.T. The demographics of slipped capital femoral epiphysis. An international multicenter study. Clinical Orthopaedics and Related Research. 322 (1996): 8-27 4. Southwick, W.O. Osteotomy through the lesser trochanter for slipped capital femoral epiphysis. The Journal of Bone and Joint Surgery. American Volume. 49(5) (1967): 807-35 5. Ganz R., Parvizi J., Beck M., et al. Femoroacetabular impingement: a cause for osteoarthritis of the hip. Clinical Orthopaedics and Related Research.417 (2003): 112-20

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

6. Leunig M., Horowitz K., Manner H., Ganz R. In situ pinning with arthroscopic osteoplasty for mild SCFE: a preliminary technical report. Clinical Orthopaedics and Related Research. 468 (2010): 3160-3167

14. Gautier E., Ganz K., Krugel N., Gill T., Ganz R. Anatomy of the medial femoral circumflex artery and its surgical implications. The Journal of Bone and Joint Surgery. British Volume 82 (2000): 679-683

7. Sink E.L., Zaltz I., Heare T., Dayton M. Acetabular cartilage and labral damage observed during surgical hip dislocation for stable slipped capital femoral epiphysis. Journal of Pediatric Orthopaedics.30 (2010): 26-30

15. Ziebarth K, Zilkens C, Spencer S, Leunig M, Ganz R, Kim Y. Capital realignment for moderate and severe SCFE using a modified Dunn procedure. Clinical Orthopaedics and Related Research 467 (2009): 704-716

8. Rab G.T. The geometry of slipped capital femoral epiphysis: implications for movement, impingement, and corrective osteotomy. Journal of Pediatric Orthopaedics 1 (1999): 419-424

16. Sankar W.N., Vanderhave K.L., Matheney T., Herrera-Soto J.A., Karlen J.W. The modified Dunn procedure for unstable slipped capital femoral epiphysis: a multi-center perspective. The Journal of Bone and Joint Surgery. American Volume. 95 (2013): 585-591

9. Kartbender K., Cordier W., Katthagen B.D. Long term follow up study after corrective Imhauser osteotomy for severe slipped capital femoral epiphysis. Journal of Pediatric Orthopaedics. 20 (2000): 749-756 10. Parsch K., Zehender H., Biihl T., Weller S. Intertrochanteric corrective osteotomy for moderate and severe chronic slipped capital femoral epiphysis. Journal of Pediatric Orthopaedics. 8 (1999): 223-230

17. Loder R., Deitz F. What is the best evidence for the treatment of slipped capital femoral epiphysis? Journal of Pediatric Orthopaedics 32 (2012): 158-165 18. Zaltz I., Baca G., Clohisy J. Unstable SCFE; review of treatment modalities and prevalence of osteonecrosis hip. Clinical Orthopaedics and Related Research. 471 (2013): 2192-2198

11. Dunn D.M. The Treatment of adolescent slipping of the upper femoral epiphysis. The Journal of Bone and Joint Surgery. British Volume 4 (1964): 621-629

19. Perry D., Monsell F., Remachandran M., Eastwood D. Management of slipped capital femoral epiphysis. Journal of Trauma and Orthopaedics 04, Issue 02 (2016): 52-55

12. Ganz R., Gill T.J., Gautier F., Ganz K., Krugel N., Berlemann, U. Surgical dislocation of the adult hip: a technique with full access to the femoral head and acetabulum without the risk of avascular necrosis. The Journal of Bone and Joint Surgery. British Volume 83 (2001): 1119-1124

20. Parsch K., Weller S., Parsch D. Open reduction and smooth Kirschner wire fixation for unstable slipped capital femoral epiphysis. Journal of Pediatric Orthopaedics, 29 (2009): 1-8

13. Leunig M., Slongo T., Kleinschmidt M., Ganz R. Subcapital correction osteotomy in slipped capital femoral epiphysis by means of surgical hip dislocation. Open Orthopaedic and Traumatology 19 (2007): 389-410

21. Herrera-Soto J.A., Duffy M.F., Birnbaum M.A. et al. Increased intracapsular pressures after unstable slipped capital femoral epiphysis. Journal of Pediatric Orthopaedics 28 (2008): 723728 22. Sucato D.J., Podeszwa D.A. Surgical dislocation with open reduction and internal fixation for unstable slipped capital femoral epiphysis: early promising results. Orthopaedic Proceedings 92-B (2010): 10.

Hand & Wrist Injuries

and and wrist problems are a common complaint and reason for referral to an orthopaedic surgeon. The general orthopaedist will be required to see these conditions on a frequent basis and needs to understand the current state of treatment and some of the controversies surrounding the pathologies themselves. The topics that will be discussed in this issue of the COA Bulletin are: basilar joint arthritis, Kienbock’s disease, fractures of the scaphoid and lastly, scaphoid non-unions. Arthritis of the basilar joint will be presented by Dr. Dave Johnston (Halifax) and focus on treatment options and the need for larger randomized trials to determine the best treatment modalities for this common condition.

Kienbock’s disease is a poorly understood condition that is a common cause of wrist pain and disability in the younger patient population. Again, there are numerous controversies concerning the epidemiology and treatment for this condition and they will be presented by Dr. Rupesh Puna (Auckland, New Zealand) and Dr. Andrew Trenholm (Halifax).

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 19)

Drs. Emanuelle Villemarie-Côté and Bertrand Perey (Vancouver) will present scaphoid fractures and Drs. Diane Nam (Toronto) and Tym Frank (Burnaby) will complete the discussion with scaphoid non-unions. These topics also contain some points of controversy in management. As we can see, all of the topics being discussed in this feature have areas of debate which has led to an exciting time in hand and wrist surgery in Canada. Like other orthopaedic subspecialty groups and societies, hand and wrist surgery is developing a multi-site research group. The goals of the group are to improve research in hand and wrist surgery, and to re-invigorate the hand and wrist presence at the COA. Thanks to the

suggestion put forward by Dr. Geoffrey Johnston (Saskatoon), this group will be called WECAN (Wrist Evaluation CANada). We look forward to sharing more information about this group and its intiatives with the membership in the near future. Andrew Trenholm, M.D., FRCSC Guest Editor, Special to the COA Bulletin Associate Professor, Dalhousie University Halifax, NS

Treatment of Basilar Joint Osteoarthritis of the Thumb David Johnston, M.D., FRCSC Halifax, NS

he basilar (trapeziometacarpal or carpometacarpal) joint of the thumb is a shallow biconcave ‘saddle’ joint which allows for multiple planes of motion. This mobility may come at the cost of stability, and multiple ligaments have been described with the anterior oblique (‘beak’) and dorsoradial ligaments as most important1,2. Given that the thumb provides 40% of hand function, osteoarthritis of the basilar joint can be debilitating for patients3. It primarily afflicts postmenopausal women with a reported incidence of over 30%4. Some evidence suggests that the female hormone relaxin may predispose to joint laxity and degeneration5. The diagnosis of basilar thumb osteoarthritis is typically suspected from the patient’s story, confirmed on clinical exam and supported by plain X-ray. The patient may present complaining of a dull ache at the base of the thumb which is worsened with daily grasping and pinching activity. On inspection, the joint may appear enlarged from hypertrophic change and subluxation (Figure 1). An adduction deformity of the metacarpal can lead to loss of the first web space, and associated hyperextension of the metacarpophalangeal joint can lead to the Z deformity. The grind test is an important provocative test that elicits palpable crepitus and pain upon applying axial compression and translation to the joint through the thumb meta- Figure1 carpal6. Typical appearance of thumb with enlargement of arthritic basilar joint.

COA Bulletin ACO - Summer / Été 2018

The Eaton-Littler classification based on PA, lateral and oblique plain radiographs of the hand is the commonest staging system of disease severity1. For early arthritic change, additional views such as the ‘Robert’s view’, which is a true AP of the joint, can be helpful. The X-rays serve a useful focal point for patient education. Eaton-Littler Classification Stage I II III IV

Description Subtle carpometacarpal joint space widening (effusion) Slight joint space narrowing, sclerosis and cystic change with osteophytes or loose bodies <2mm Advanced carpometacarpal joint space narrowing, sclerosis and cystic change with osteophytes or loose bodies >2mm Stage III plus scaphotrapezial arthritis

Non-operative Treatment Activity modification, analgesic medication and splint wear can be tried with the symptomatic patient. Commercial or custom thermoplastic splints that are palm-based can be helpful, but one randomized trial suggests that neoprene splints are cheaper and better tolerated7. Basal joint injection with steroid can provide pain relief, but the joint is a small ‘target’ and use of a small image intensifier can be reassuring for the less experienced practitioner8. In more advanced Eaton III/IV stages, the narrowed or non-existent joint space probably precludes an injection (Figure 2). One study saw no significant clinical difference between steroid, hyaluronate and placebo injection9. Operative Treatment Gervis in 1949 published his favourable results of simple trapeziectomy for osteoarthritis of the basilar thumb joint10. Over the intervening decades, a plethora of surgical solutions have been described, and evidence seems to be bringing us full circle; the critical denominator of success seems to be the ‘trapeziectomy’11-13.

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

In early disease (Eaton I/II), techniques with favourable outcomes include arthroscopic procedures, extension osteotomy of the thumb metacarpal and Eaton volar oblique ligament reconstruction with preservation of the trapezium14,. Shear forces are higher on Figure 2 the palmar aspect Plain X-ray of Eaton stage III with complete of the joint, and an loss of trapeziometacarpal joint space and extension osteotomy associated subluxation. Note subjacent scaredirects joint force photrapezial joint appears normal. to the normal dorsal articular cartilage15. The Eaton volar oblique ligament reconstruction has been promoted to treat early arthritis and marked laxity of the joint1. These surgical procedures are not widely utilized as suggested by a survey of active members of the American Society for Surgery of the Hand16. In more advanced Eaton III/IV disease, surgical choices generally include trapeziectomy with ligament reconstruction and tendon interposition (LRTI), simple trapeziectomy, arthrodesis or implant arthroplasty. Trapeziectomy with LRTI remains the most common surgical choice in North America, even though there is no substantive evidence that it is superior to other choices16. A surgeon’s choice of operation may be biased by training and/or personal choice (esteem-based rather than evidence-based medicine)6. Trapeziectomy with LRTI as popularized by Burton and Pelligrini, was designed to relieve pain with the trapeziectomy and stabilize the thumb axis against subsidence and subluxation with the ligament reconstruction. The operation (Figure 3) uses the FCR tendon placed through a bone hole at the base of the thumb metacarpal to reconstruct the ‘beak’ ligament and create a soft tissue ‘anchovy’ to fill the void following trapeziectomy. This operation has undergone many variations but the outcome is predictable, and provides very good pain relief and function over the long term17,18. Other surgeons employ a combination of FCR and/or APL to create a tendon suspensionplasty without a bone tunnel in the metacarpal19. Several studies have reported on trapeziectomy alone or, with temporary K-wire fixation of the metacarpal to maintain thumb height (haematoma- distraction arthroplasty [HDA]), and outcomes are similar to the established LRTI20,21. Mahmoudi et al. performed a systematic literature review with cost analysis (Medicare) and recommended the simpler and cheaper trapeziectomy as the logical choice over LRTI13. Arthrodesis of the basilar thumb joint has generally been chosen for younger adults, particularly males engaged in heavy, physical labour. Arthrodesis is not indicated with Eaton IV because of osteoarthritis in the subjacent scaphotrapezial joint. Non-union rates can be an issue and outcome is not proven superior to trapeziectomy and LRTI22.

Various implant arthroplasties have been used with mixed results. Silicone elastomer (Swanson) implants have fallen into disfavour because of fragmentation/subluxation and the occurrence of silicone synovitis22. The OrthosphereR, a Figure 3 ceramic sphere, led to Diagram of trapeziectomy with FCR ligasubsidence into the ment reconstruction and tendon interposition trapezium23. ArtelonR, (LRTI). From Hand Surgery Update V, American an interposition Society for Surgery of the Hand, 2012. ‘mesh’ of biodegradable polyurethaneurea, has been explanted for continued pain and there are case reports of foreign body reaction24,25. Total joint replacements of metal/polyethylene offer less predictable pain relief and loosening may lead to early failure26. Regardless of surgical choice, attention to anatomic detail is important during dissection. Loupe magnification may help in protecting the superficial radial nerve, the deep branch of the radial artery, and the EPB and FCR tendons. Following failure of non-operative treatment, surgery for basilar joint osteoarthritis is a very common upper limb procedure. Although trapeziectomy with LRTI has been regarded by many surgeons as the ‘gold standard of care’, there is no evidence to date that it is superior to simple trapeziectomy. Well-designed randomized controlled trials with standardized protocols and measures will be needed to advance the science of better patient care. References 1. Eaton R.G., Lane L.B., Littler J.W., Keyser J.J. Ligament reconstruction for the painful thumb carpometacarpal joint: a long term assessment. J Hand Surg. 1984;9A:692-699 2. Lin J.D., Karl J.W., Strauch R.J. Trapeziometacarpal joint stability: The evolving importance of the dorsal ligaments. Clin Orthop Relat Res.2014;472:1138-1145 3. Berger A.J., Meals R.A. Management of osteoarthrosis of the thumb joints. J Hand Surg (Am).2015;40(4):843-850 4. Higgenbotham C., Boyd A., Busch M., Heaton D., Trumble T. Optimal management of thumb basal joint arthritis: challenges and solutions. Orthopedic Research and Reviews.2017;9:93-99 5. Clifton K.B., Rodner C., Wolf J.M. Detection of relaxin receptor in the dorsoradial ligament, synovium and articular cartilage of the trapeziometacarpal joint. J Orthop Res. 2014;32:10611067

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 21)

6. Baker R.H.J., Al-Shukri J., Davis T.R. Evidence-Based medicine: thumb basal joint arthritis. Plastic and Reconstructive Surgery. Jan 2017;139(1):256-266

16. Wolf J.M., Delaronde S. Current trends in nonoperative and operative treatment of trapeziometacarpal osteoarthritis: A survey of US hand surgeons. J Hand Surg. 2012;37A:77-82

7. Becker S.J., Bot A.G., Curley S.E., Jupiter J.B., Ring D.A. Prospective randomized comparison of neoprene vs thermoplast hand-based thumb spica splinting for trapeziometacarpal arthrosis. Osteoarthritis Cartilage.2013;21:668-675

17. Burton R.I., Pelligrini V.D. Jr. Surgical management of basal joint arthritis of the thumb. Part I&II. Ligament reconstruction with tendon interposition arthroplasty. J Hand Surg. 1986;11A:324-332

8. Day C.S., Gelberman R., Patel A.A., Vogt M.T., Ditsios K., Boyer M.I. Basal joint osteoarthritis of the thumb: A prospective trial of steroid injection and splinting. J hand Surg (A).2004;29:247251

18. Tomaino M., Pelligrini V., Burton R. Arthroplasty of the basal joint of the thumb: long term follow-up after ligament reconstruction and interposition. JBJS (Am).1995;77(3):346-355

9. Heyworth B.E., Lee J.H., Kim P.D., Lipton C.B., Strauuch R.J., Rosenwasser M.P. Hylan versus corticosteroid versus placebo for treatment of basal joint arthritis: a prospective, randomized, double-blinded clinical trial. J Hand Surg. 2008;33A:40-48 10. Gervis W.H. Excision of the trapezium for osteoarthritis of the trapezio-matacarpal joint. JBJS (Br)1949;31(4):537-539 11. Wajon A., Vinycomb T., Carr E., Edmunds I., Ada L. Surgery for thumb (trapeziometacarpal joint) osteoarthritis. Cochrane Database Syst. Rev. 2015;2: CD004631 12. Field J., Buchanan D. To suspend or not to suspend: A randomized single blind trial of simple trapeziectomt versus trapeziectomy and flexor carpi radialis suspension. J Hand Surg (Eur). 2007;32: 462-466. 13. Mahmoudi E., Yuan F., Lark M., Aliu O., Chung K. Medicare spending and evidence-based approach in surgical treatment of thumb carpometacarpal joint arthritis: 2001 to 2010. Plastic and Reconstructive Surgery. 2016;137(6):980-989 14. Slutsky D. The role of arthroscopy in trapeziometacarpal arthritis? Clin Orthop.2014;472(4):1173-1183 15. Tomaino M.M. Treatment of Eaton stage I trapeziometacarpal disease with thumb metacarpal extension osteotomy. J HanSurgery.2000;25A: 1100-1106

19. Weilby A. Tendon interposition arthroplasty of the first carpometacarpal joint. J Hand Surg (Br)1988;13(4):421-425 20. Li Y.K., White C., Ignacy T.A., Thoma A. Comparison of trapeziectomy and trapeziectomy with ligament reconstruction and tendon interposition: a systemic literature review. Plast Reconstr Surg.2011;128(1):199-2017 21. Gray K.V., Meals R.A. Hematoma and distraction arthroplasty for thumb basal joint osteoarthritis: minimum 6.5 year follow-up evaluation. J hand Surg 20017;32A: 23-29 22. Vermeulen G., Slijper H., Feitz R., Hovius S., Moojen T.M., Selles R.W. Surgical management of primary thumb carpometacarpal osteoarthritis: A systematic review. J Hand Surg. 2011;36A:157-169 23. Adams B.D., Pomerance J., Nguyen A., Kuhl T.L. Early outcome of spherical ceramic trapezial-metacarpal arthroplasty. J Hand Surg (Am)2009;34:213-218 24. Blount A.l., Armstrong S.D., Yuan F. Porous polyurethaneurea (Artelon) joint space compared to trapezium resection and ligament reconstruction. J Hand Surg(Am). 2013;38(9):1741-1745 25. Robinson P.M., Muir L.T. Foreign body reaction associated with Artelon implant: report of three cases. J Hand Surg (Am). 2011;36(1):116-120 26. Murray P.M. Treatment of the osteoarthritic hand and thumb. Chapter 11, Green’s Operative Hand Surgery, 7th Edition. Pp.345-373

Kienbock’s Disease Rupesh Puna, MBChB, FRACS (Orth) Upper Extremity Fellow, Dalhousie University Halifax, NS Andrew Trenholm, M.D., FRCSC Associate Professor, Dalhousie University Halifax, NS

Definition and Background ienbock’s disease (KD), or osteonecrosis (ON) of the lunate was first noted 18431, but its radiographic description was not reported until 1910 by Robert Kienbock2, an Austrian radiologist. He proposed a traumatic etiology which was the “result of a contusion or sprain of the wrist”2.

COA Bulletin ACO - Summer / Été 2018

Figure 1 18-year-old male presents with dorsal wrist pain and loss of motion. Stage 3A Kienbock’s.

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

Epidemiology and Prevalence KD occurs most commonly in men, young people and manual labourers3,4. The reported prevalence is between 1.2 and 2.5%5-7.

present with boggy synovitis of the radiocarpal joint. Range of motion is usually decreased and grip strength is commonly reduced. Imaging Radiographs, bone scintigraphy, magnetic resonance imaging (MRI), and computed tomography (CT) are useful for assessment.

Etiology and Risk Factors The etiology of KD remains unclear. Mechanical, anatomic and systemic mechanisms have all been implicated.

Figure 3

Figure 2

The relationship of ulnar Confirmatory Coronal PD FSA MRI of variance and KD is contro- Kienbock’s Disease after three months versial. Gelberman et al. of failed non-operative management. noted a relationship between ulnar-negative variance and KD8. In contrast, D’Hoore et al.9, and Nakamura et al.10 found no significant relationship between ulnar-negative variance and KD. A flattened radial inclination may predispose to KD11,12. Watanabe et al.12 demonstrated the beneficial biomechanical effects associated with radial wedge osteotomy to alter the radial inclination. Thus, negative ulnar-variance and flattened radial inclination may predispose certain patients to develop KD, but neither is likely the sole factor in its etiology. The pattern of lunate blood supply has also been investigated4,8, with most cadaveric specimens receiving branches on the dorsal and palmar surface. However, Panagis et al. found the lunate to be supplied by a single palmar artery in 7%. In addition, intraosseous branching patterns varied with 31% showing a single path through without significant arborisation13. A lunate with a single vessel and minimal branching may be predisposed to ON after an injury or fracture. Increased interosseous pressure has also been suggested as a cause. Pichler and Putz14 examined the venous drainage of the lunate and found a dense plexus of venous vessels at the volar and dorsal periosteal surface that may be a site of venous outflow disruption. Schiltenwolf et al.15 also found the interosseous pressure of the lunate to be greater than the capitate by 40 mmHg in wrist extension than neutral. This could explain a predisposition to ON. KD has also been associated with conditions such as scleroderma, sickle cell anaemia, systemic lupus erythematosus, and corticosteroid use16. The etiology likely involves a complex interplay of multiple factors. Presentation and Examination Findings KD may be suspected in young males with wrist pain and stiffness. Tenderness is often reported dorsally over the lunate, and patients often experience decreased grip strength. A history of injury may be given. On examination, an effusion may be

Radiographs demonstrate Intra-operative radial shortening diffuse lunate sclerosis, cyst- osteotomy to alter height and incliic changes, fragmentation, nation of the distal radius. fracture, articular collapse and perilunate arthritic disease. They allow evaluation of ulnar variance, radial inclination, carpal height, radioscaphoid angle and lunate size. Bone scintigraphy is useful in early stages when radiographs are normal - increased uptake is usually seen. MRI has now essentially surpassed bone scintigraphy in evaluation where uniform decreased signal intensity on T1 images is seen. CT may be helpful in assessment of articular surface collapse and presence of fractures. Staging and Classification The most common method for staging was first described by Stahl17, but Lichtman et al.4 modified this to produce the most widely accepted classification based on radiographs. Table 1. Lichtman Classification of Kienbock’s Disease Stage 1 Stage 2 Stage 3 •Stage 3A •Stage 3B Stage 4

Normal X-ray, signal intensity changes on MRI Lunate sclerosis on plain X-ray, fracture lines may be present Collapse of lunate articular surface • Normal carpal alignment and height • Fixed scaphoid rotation, proximal capitate migration, loss of carpal height Lunate collapse along with radiocarpal or midcarpal arthritis

The Lichtman classification has shown good reproducibility and reliability18. One issue, noted by Goldfarb et al.19, was poor interobserver reliability for differentiating stage 3A and 3B. He proposed an additional criterion — a radioscaphoid angle of 60 degrees to subdivide stage 3. This modification has since improved interobserver reliability19. Treatment Treatment is based on symptoms, functional deficits and the stage of disease. Non-operative and operative treatment options can be considered. Most longitudinal studies evaluating conservative management have reported radiographic progression of the disCOA Bulletin ACO - Summer / Été 2018

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

ease20-22. It is controversial whether surgical intervention is superior to conservative treatment23,24. Despite disease progression, many patients remain functional, therefore a trial of conservative management is initially warranted in most.

strength remains a concern10. The lunate can also be removed and replaced with a tendon anchovy or lunate implant. Stage 4 Total wrist arthrodesis is recommended. PRC is possible provided the capitate head and lunate fossa remain free of disease. Dorsal capsular interposition can otherwise be considered in this situation. Wrist denervation is also a useful adjunct.

Surgical intervention is reserved for those who fail conservative management and procedures fall into three categories:

References

1. Lunate unloading 2. Lunate revascularisation 3. Salvage (lunate not reconstructiFigure 4 ble and arthritis exists)

Two years postop radial

1. Peste J.L. Discussion. Bull Soc Anat 18:169,1843. 2. Kienbock R., Peltier L. (trans-ed). Concerning traumatic malacia of the lunate and its consequences: Degeneration and compression fractures [classic reprint]. Clin Orthop 1980;149:4-8.

Stage 1, 2 or 3A with Ulnar-negative shortening osteotomy with no further collapse of the Variance A joint levelling procedure to unload lunate and symptom free. the lunate should be considered first — most commonly, radial shortening osteotomy. Based on biomechanical studies, the goal is to shorten the radius two to three millimetres25. Good results have been reported with radial shortening26-28. Though uncommon, ulnar lengthening is also supported biomechanically25, but requires bone grafting and there is risk of non-union29,30.

3. Kido M., Omiya K., Katai K., Kojima T. Clinical and follow-up study on Kienböck’s disease [in Japanese]. Seikei Geka. 1978; 29:1605-1609.

Several revascularisation procedures have been described, including - Vascularised transfers of the pisiform bone31 - Vascularised pedicled transfers from the distal radius32,33 - Direct implantation of the metacarpal arteries34 - Free vascularised grafts35

6. Mennen U., Sithebe H. The incidence of asymptomatic Kienböck’s disease. J Hand Surg Eur. 2009; 34:348-350.

An unloading procedure to decrease mechanical stress on the lunate may be performed concomitantly36.

8. Gelberman R.H., Bauman T.D., Menon J., et al. The vascularity of the lunate bone and Kienbock’s disease. J Hand Surg [Am] 5(3):272–278, 1980.

Stage 1, 2 or 3A with Ulnar-positive or Ulnar-neutral Variance In this group, further shortening of the radius is not likely to decrease load on the lunate. Capitate shortening alone, or combined with capitate-hamate fusion as described by Almquist37, yields revascularisation rates as high as 83% with good biomechanical support38. Other options include radial closing wedge osteotomy and radial dome osteotomy to decrease the radial inclination and reduce radiolunate contact stresses12. Core decompression of the radius and ulna has also been reported39. Stage 3B Correction of scaphoid flexion and intercarpal arthrodesis via scapho-trapezial-trapezoid (STT) or scaphocapitate (SC) fusion can decrease load on the lunate, stabilize the midcarpal joint, and prevent further collapse. STT arthrodesis has demonstrated excellent long-term results40, but SC arthrodesis is thought to be technically easier. Proximal row carpectomy (PRC) is an alternative option with proven efficacy41-44, however reduced grip COA Bulletin ACO - Summer / Été 2018

4. Lichtman D.M., Mack G.R., MacDonald R.I., Gunther S.F., Wilson J.N. Kienbock’s disease: The role of silicone replacement arthroplasty. J Bone Joint Surg Am 1977;59:899-908. 5. Kiyoshige Y., Watanabe Y. Population study of Kienböck’s disease [in Japanese]. J Jpn Soc Surg Hand. 1991; 8:299-302.

7. Tsujimoto R., Maeda J., Abe Y., Arima K., Tomita M., Koseki H., Kaida E., Aoyagi K., Osaki M. Orthopedics. 2015; 38(1):e14e18.

9. D’Hoore K., De Smet L., Verellen K., et al. Negative ulnar variance is not a risk factor for Kienbock’s disease. J Hand Surg [Am] 19(2):229–231, 1994. 10. Nakamura R., Horii E., Watanabe K., et al. Proximal row carpectomy versus limited wrist arthrodesis for advanced Kienbock’s disease. J Hand Surg [Br] 23(6):741– 745, 1998. 11. Tsuge S., Nakamura R. Anatomical risk factors for Kienbock’s disease. J Hand Surg [Br] 1993;18:70-75. 12. Watanabe K., Nakamura R., Horii E., Miura T: Biomechanical analysis of radial wedge osteotomy for the treatment of Kienbock’s disease. J Hand Surg [Am] 1993;18:686-690. 13. Panagis J.S., Gelberman R.H., Taleisnik J., Baumgaertner M. The arterial anatomy of the human carpus: Part II. The intraosseous vascularity. J Hand Surg [Am] 1983;8:375-382. 14. Pichler M., Putz R. The venous drainage of the lunate bone. Surg Radiol Anat 2003;24:372–376.

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15. Schiltenwolf M., Martini A.K., Mau H.C., et al: Further investigations of the intraosseous pressure characteristics in necrotic lunates (Kienbock’s disease). J Hand Surg [Am] 21(5):754– 758, 1996.

31. Daecke W., Lorenz S., Wieloch P., Jung M., Martini A.K. Vascularized os pisiform for reinforcement of the lunate in Kienböck’s disease: an average of 12 years of follow-up study. J Hand Surg 2005;30A:915–922.

16. Lee S. (2016). Fractures of the carpal bones. In Green’s operative hand surgery, 7th edition (pp. 588-652). Elsevier

32. Sheetz K.K., Bishop A.T., Berger R.A. The arterial blood supply of the distal radius and ulna and its potential use in vascularized pedicled bone grafts. J Hand Surg 1995;20A:902–914.

17. Stahl F.: On lunatomalacia (Kienbock’s disease): a clinical and roentgenological study, especially on its pathogenesis and the late results of immobilization treatment. Acta Chir Scand 126(Suppl):1–133, 1947. 18. Beredjiklian P.K. Kienbock’s disease Current Concepts. J Hand Surg 2009;34A:167-175.. 19. Goldfarb C.A, Hsu J., Gelberman R.H., Boyer M.I. The Lichtman classification for Kienböck’s disease: an assessment of reliability. J Hand Surg 2003;28A:74 – 80. 20. Salmon J., Stanley J.K., Trail I.A. Kienböck’s disease: conservative management versus radial shortening. J Bone Joint Surg 2000;82B: 820 – 823. 21. Beckenbaugh R.D., Shives T.C., Dobyns J.H., Linscheid R.L. Kienböck’s disease: the natural history of Kienböck’s disease and considerations of lunate fractures. Clin Orthop 1980;149:98–106. 22. Keith P.P., Nuttall D., Trail I. Long-term outcome of nonsurgically managed Kienböck’s disease. J Hand Surg 2004;29A:63– 67. 23. Delaere O., Dury M., Molderez A., Foucher G. Conservative versus operative treatment for Kienböck’s disease: a retrospective study. J Hand Surg 1998;23B:33–36. 24. Tajima T.: An investigation of the treatment of Kienbock’s disease (abstract). J Bone Joint Surg Am 48:1649, 1966. 25. Trumble T., Glisson R.R., Seaber A.V., et al: A biomechanical comparison of the methods for treating Kienbock’s disease. J Hand Surg [Am] 11(1):88–93, 1986. 26. Almquist E.E., Burns J.F., Jr: Radial shortening for the treatment of Kienbock’s disease: a 5- to 10-year follow-up. J Hand Surg [Am] 7(4):348–352, 1982. 27. Rock MG, Roth JH, Martin L: Radial shortening osteotomy for treatment of Kien- bock’s disease. J Hand Surg [Am] 16(3):454–460, 1991. 28. Weiss A.P., Weiland A.J., Moore J.R., et al: Radial shortening for Kienbock disease. J Bone Joint Surg Am 73(3):384–391, 1991. 29. Luo J., Diao E. Kienböck’s disease: an approach to treatment. Hand Clin 2006;22:465– 473.

33. Moran S.L., Cooney W.P., Berger R.A., Bishop A.T., Shin A.Y. The use of the 4 5 extensor compartmental vascularized bone graft for the treatment of Kienbock’s disease. J Hand Surg 2005;30A:50–58. 34. Tamai S., Yajima H., Ono H. Revascularization procedures in the treatment of Kienböck’s disease. Hand Clin 1993;9:455– 466. 35. Gabl M., Lutz M., Reinhart C., Zimmerman R., Pechlaner S., Hussl H., et al. Stage 3 Kienböck’s disease: reconstruction of the fractured lunate using a free vascularized iliac bone graft and external fixation. J Hand Surg 2002;27B:369–373. 36. Tamai S., Yajima H., Ono H. Revascularization procedures in the treatment of Kienböck’s disease. Hand Clin 1993;9:455– 466. 37. Almquist E.E. Capitate shortening in the treatment of Kienbock’s disease. Hand Clin 9(3):505–512, 1993. 38. Horii E., Garcia-Elias M., Bishop A.T., et al: Effect on force transmission across the carpus in procedures used to treat Kienbock’s disease. J Hand Surg [Am] 15(3): 393–400, 1990. 39. Illarramendi A.A., Schulz C., De Carli P. The surgical treatment of Kienbock’s disease by radius and ulna metaphyseal core decompression. J Hand Surg [Am] 26(2):252– 260, 2001. 40. Watson H.K., Ryu J., DiBella A. An approach to Kienbock’s disease: triscaphe arthrodesis. J Hand Surg [Am] 10(2):179–187, 1985. 41. Croog A.S., Stern P.J. Proximal row carpectomy for advanced Kien- böck’s disease: average 10-year follow-up. J Hand Surg 2008;33A: 1122–1130. 42. DiDonna M.L., Kiefhaber T.R., Stern P.J. Proximal row carpectomy: study with a minimum of ten years of follow-up. J Bone Joint Surg 2004;86A:2359 –2365. 43. De Smet L., Robijns P., Degreef I. Proximal row carpectomy in advanced Kienböck’s disease. J Hand Surg 2005;30B:585–587. 44. Lumsden B.C., Stone A., Engber W.D. Treatment of advancedstage Kienböck’s disease with proximal row carpectomy: an average 15- year follow-up. J Hand Surg 2008;33A:493–502.

30. Schuind F., Eslami S., Ledoux P. Kienböck’s disease. J Bone Joint Surg 2008;90B:133–139.

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

Evidence-based Approach to Scaphoid Fractures Emanuelle Villemaire-Côté, M.D., FRCSC Fellow, Upper Extremity Trauma and Reconstruction University of British Columbia Vancouver, BC Bertrand Perey, M.D., FRCSC University of British Columbia Vancouver, BC

he scaphoid is the most commonly-fractured carpal bone, and fractures generally occur among active young adults, many of whom are manual workers1. These patients are particularly disabled when prolonged cast immobilization is required to achieve union. The diagnosis and optimal treatment of scaphoid fractures can be challenging for the surgeon, but are essential. Late diagnosis and inappropriate treatment often lead to malunion or non-union resulting in altered wrist kinematics and arthrosis2. This article covers the most controversial issues concerning scaphoid fracture treatment. What Imaging Modality Should be Used for the Diagnosis and Evaluation of Scaphoid Fractures? An initial normal radiograph cannot accurately guarantee the absence of a scaphoid fracture3. Further imaging is required to confirm the diagnosis. MRI seems to be the study of choice for that purpose, with good evidence to support its cost-effectiveness4, but its availability may limit its application. It is also appropriate to do a second set of radiographs at two weeks. Evidence supports that immobilization in a cast during this interval is not necessary5. It is recommended by most authors to obtain at least four radiographic views to help in the diagnosis, however, there is no universally accepted radiographic series6. What is the Recommended Treatment for Acute Nondisplaced Scaphoid Waist Fracture? Cast immobilization is the standard of care for a non-displaced scaphoid waist fracture. However, there is a group of patients that could benefit from a surgical fixation of the scaphoid: the manual workers. Surgery is more cost-effective and beneficial to patients who are involved in work, sports or lifestyles incompatible with long-term immobilization. However, fixation does not show superior outcomes in the long term, and does not improve rate of union and time to union7. Surgery also exposes the patient to the risk of possible complications. A discussion with the patient is essential to reach a well-informed decision. What is the Ideal Method of Casting When Treating a Nondisplaced Scaphoid Fracture Conservatively? High-quality evidence demonstrates that inclusion of the thumb or long arm casting is not necessary for scaphoid fracture healing, and leads to greater functional impairment during the period of casting8. Therefore, wrist immobilization alone in a Colles-type of cast is the treatment of choice.

COA Bulletin ACO - Summer / Été 2018

Figure 1 Intra-operative views of a retrograde transtrapezial percutaneous screw fixation of a scaphoid fracture.

Is There an Ideal Surgical Technique When Treating Nondisplaced Scaphoid Fractures with Internal Fixation? Central placement of the screw in the scaphoid is essential as it increases the rate of union and decreases the time to union9. This can be achieved by either antegrade or retrograde transtrapezial percutaneous technique (Figure 1). Percutaneous techniques should be favoured as they decrease the risk of complications compared to an open approach. Immobilization is not necessary after scaphoid fixation. What is the Treatment of Choice for a Delayed Diagnosis of a Nondisplaced Scaphoid? When the delay in treatment exceeds four weeks from the time of injury, there is a higher risk of non-union and delayed union. However, it is unclear if surgical intervention with percutaneous fixation should be favoured over prolonged cast treatment in the absence of comminution, humpback deformity and diabetes10. What is the Ideal Treatment for a Displaced Fracture of the Waist of the Scaphoid? Cooney et al. described a displaced or unstable scaphoid fracture as greater than one millimetre offset on the

Figure 2 Lateral radiograph showing a displaced scaphoid fracture with an increased lunocapitate angle.

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

anteroposterior radiograph or oblique views, or as a lunocapitate angle greater than 15° or a scapholunate angle greater than 45° on lateral radiograph11 (Figure 2). A CT scan, with one millimetre sagittal cuts along the scaphoid axis, should be obtained to define the displacement if the plain films suggest it. A displacement, or humpback deformity, would be defined on the CT scan as an intrascaphoid angle of >35°. Only a lowquality of evidence is available on the treatment of displaced scaphoid fractures. Non-operative treatment is associated with a high risk of non-union and malunion12. Operative treatment is associated with a high rate of union using either open dorsal or open volar approach. If stable fixation is achieved, postoperative immobilization seems to be unnecessary13. What is the Ideal Treatment for a Non-displaced Acute Fracture of the Proximal Pole of the Scaphoid? Case series suggest that non-operative treatment of these fractures is associated with a high risk of delayed union or nonunion. Surgical management is therefore preferred. The dorsal approach is the ideal approach for surgical stabilization of these fractures because it allows easier exposure of the fracture site and maximizes fracture stability14 (Figure 3).

3. Mallee W.H., Henny E.P., van Dijk C.N., Kamminga S.P., van Enst W.A., Kloen P. Clinical Diagnostic Evaluation for Scaphoid Fractures: A Systematic Review and Meta-Analysis. J Hand Surg Am. 2014;39(9):1683-1691.e2. doi:10.1016/j. jhsa.2014.06.004. 4. Karl J.W., Swart E., Strauch R.J. Diagnosis of Occult Scaphoid Fractures: A Cost-Effectiveness Analysis. J Bone Jt Surg. 2015;97(22):1860-1868. doi:10.2106/JBJS.O.00099. 5. Sjølin S.U., Andersen J.C. Clinical fracture of the carpal scaphoid- Supportive bandage or plaster cast immobilization? J Hand Surg Am. 1988;13(1):75-76. doi:10.1016/02667681(88)90057-5. 6. Yin Z.-G., Zhang J.-B., Kan S.-L., Wang X.-G. Diagnostic accuracy of imaging modalities for suspected scaphoid fractures: meta-analysis combined with latent class analysis. J Bone Joint Surg Br. 2012;94(8):1077-1085. doi:10.1302/0301620X.94B8.28998. 7. Shen L., Tang J., Luo C., Xie X., An Z., Zhang C. Comparison of operative and non-operative treatment of acute undisplaced or minimally-displaced scaphoid fractures: a meta-analysis of randomized controlled trials. PLoS One. 2015;10(5):1-14. doi:10.1371/journal.pone.0125247. 8. Clay N.R., Dias J.J., Costigan P.S., Gregg P.J., Barton N.J. Need the Thumb be Immobilised in Scaphoid Fractures? J Bone Joint Surg Br. 1991;73-B(5):828-832. 9. Trumble T.E., Clarke T., Kreder H.J. Non-Union of the Scaphoid, Treatment with Cannulated Screws Compared with Treatment with Herbert Screws. J bone Jt Surg Am Vol. 1996;78A(12):1829-1837. 10. Grewal R., Suh N., MacDermid J.C. The Missed Scaphoid Fracture-Outcomes of Delayed Cast Treatment. J Wrist Surg. 2015;4(4):278-283. doi:10.1055/s-0035-1564983. 11. Cooney W.P., Dobyns J.H., Linscheid R.L. Fractures of the Scaphoid : A Rational Approach to Management. Clin Orthop Relat Res. 1980;149(June):90-97.

Figure 3 Antegrade screw fixation of a scaphoid proximal pole fracture.

References 1. Duckworth A.D., Jenkins P.J., Aitken S.A., Clement N.D., Court-Brown C.M., McQueen M.M. Scaphoid fracture epidemiology. J Trauma Acute Care Surg. 2012;72(2):41-45. doi:10.1097/TA.0b013e31822458e8. 2. Duppe H., Johnell O., Lundborg G., Karlsson M., RedlundJohnell I. Long-term results of fracture of the scaphoid. A follow-up study of more than thirty years. J Bone Jt Surg - Ser A. 1994;76(2):249-252. doi:10.2106/00004623-19940200000012.

12. Singh H.P., Taub N., Dias J.J. Management of displaced fractures of the waist of the scaphoid: Meta-analyses of comparative studies. Injury. 2012;43(6):933-939. doi:10.1016/j. injury.2012.02.012. 13. Merrell G.A., Wolfe S.W., Slade III J.F. Treatment of Scaphoid Nonunions : Quantitative Meta-Analysis of the Literature. J Hand Surg Am. 2002;27A(4):685-691. doi:10.1053/ jhsu.2002.34372. 14. Segalman K.A., Graham T.J. Scaphoid Proximal Pole Fractures and Nonunions. J Am Soc Surg Hand. 2004;4(4):233-249. doi:10.1016/j.jassh.2004.09.008.

COA Bulletin ACO - Summer / Été 2018

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

Scaphoid Non-unions Tym Frank, M.D., FRCSC Burnaby, BC Diane Nam, MSc, M.D., FRCSC University of Toronto Division of Orthopaedic Surgery Sunnybrook Health Sciences Centre Toronto, ON

Definition here is no consensus on the definition of scaphoid nonunion, but they are fractures that typically fail to show signs of radiographic healing after three months of treatment. Risk factors for developing a non-union are delayed presentation, smoking, inadequate immobilization, fracture displacement/comminution, and proximal pole involvement which carries an increased risk of avascular necrosis1.

Anatomy Over 75% of the scaphoid surface is articular cartilage. Vascularity is precarious with the dominant proximal 80% of the blood supply being retrograde from the dorsal carpal branch of the radial artery, and 20% of the distal supply from the superficial palmar arch branch of the volar radial artery.

Imaging Standard radiographic views include postero-anterior (PA), lateral wrist, scaphoid view (PA in ulnar deviation) and pronated oblique view with 45-60° of pronation. A scapholunate angle >60°, or radiolunate angle >30°, indicates the presence of a DISI deformity. Computed tomography (CT) is preferred to detect incomplete unions or for surgical planning (approach, cavitation, bone grafting). CT reformats within the sagittal plane of the scaphoid (not wrist) is used to quantify cortical bridging. Scaphoid collapse and the classic “humpback deformity” is measured as the height to length ratio >0.65, or an intra-scaphoid angle >45°. MRI can be used to detect occult fractures and assess vascularity of fracture fragments, especially in the case of proximal pole fractures. Treatment In otherwise healthy symptomatic patients, there is no role for non-operative treatment of established non-unions given the strong likelihood of eventual radiocarpal arthrosis. Surgical decision-making is dictated by fracture location, displacement, vascularity of the scaphoid (Figure 1) and the presence or absence of SNAC wrist. Scaphoid non-union operations often require bone grafting and stabilization. Indications for each of the different types of approach and bone grafting are described on the following page.

Pathogenesis and Natural History Mechanical instability and decreased perfusion, especially in proximal pole fractures, are thought to be the main causes of scaphoid nonunion. These are typically not symptomatic in the early stages and presentation is delayed. Therefore, the natural history has not been well delineated. Although progression is variable, patients with scaphoid non-union often develop a dorsal intercalated Waist segmental instability (DISI) deformity3–5. This mechanical derangement can progress to a condition known as scaphoid non-union advanced collapse (SNAC) that can result in persisAvascular tent wrist pain, stiffness, and a recognecrosis nizable pattern of degenerative radiocarpal and midcarpal arthritis secondary to abnormal post-traumatic wrist pathomechanics2,6-8. Humpback

Scaphoid non-union

Proximal pole

No avascular necrosis

Diagnosis deformity Patients often describe a remote history of trauma and may complain of vague, aching pain with a loss of wrist motion. Examination Non-vascularized VBG with dorsal findings including palpation tendervolar wedge approach ness at the anatomic snuff-box and/ bone gra or pain with pinch, axial load or pronation are generally not reliable. Investigations with radiographs are Figure 1 Scaphoid non-union treatment algorithm. required. COA Bulletin ACO - Summer / Été 2018

Avascular necrosis

No avascular necrosis

VBG with dorsal approach

Dorsal approach

No humpback deformity

Non-vascularized cancellous bone gra

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

Non-Vascularized Volar Wedge Bone Grafting with Internal Fixation For scaphoid waist fractures with deformity, and a viable proximal pole, open reduction with structural bone grafting and internal fixation with K-wires or a headless screw from a volar approach is recommended. This allows for curettage and pseudoarthrosis excision with bone grafting to reconstitute length and correct angular deformity using a wedge-shaped tricortical cancellous autograft harvested from the iliac crest. In rare situations of scaphoid waist non-unions with no collapse or deformity, a cancellous, non-vascularized bone graft can be harvested from the distal radius through a volar or dorsal approach and stabilized. Structural support with two intrascaphoid bicortical strut grafts harvested from the distal radius can also be accomplished by using the Russe method9. Vascularized Bone Grafting Vascularized bone graft (VBG) is a reasonable option for the treatment of dysvascular/avascular proximal pole scaphoid non-unions to improve union rates10. For patients with a dysvascular proximal pole failing conventional iliac crest bone grafting, a dorsal or volar approach with VBG is often indicated, with access to the proximal pole preferred through a dorsal approach. A common donor site is the 1,2 intercompartmental supraretinacular artery pedicle (1,2 ICSRA) from the distal radius as it has several distinct advantages compared to other sites. Proximity of this VBG from the distal radius to the scaphoid allows for elevation and rotation of the pedicle without microvascular anastomosis through a single approach (Figure 2). A VBG pedicled on the transverse volar carpal artery from the volar aspect of the distal radius is sometimes advantageous as it allows graft harvest and correction of a flexion deformity from a volar approach. Other options for donor sites include the medial femoral condyle, or metacarpal, yet require the technical skill of microvascular anastomosis and carry with it donor-site morbidity. The fixation of these vascularized bone grafts with K-wires or screws is surgeon dependent and the results are good11,12.

Scaphoid Non-union after Previous Surgical Fixation Infrequently, a previously operated scaphoid fracture fails to unite six months after the initial procedure. The incidence of scaphoid non-union following surgical fixation has not been well studied but management starts with delineating the potential causes of non-union. If the hardware position was appropriate, revision can proceed with introduction of a larger screw and distal radius bone graft (or VBG) with curettage. If the hardware position is inappropriate, attempts should be made to correct the fracture alignment and revise the fixation with appropriate bone grafting. Devascularizing the scaphoid with combined dorsal and volar approaches should be avoided. Summary Scaphoid non-union treatment should optimize healing potential and provide mechanical stability. The surgeon should make every effort to evaluate the cause of non-union and develop a personalized treatment for each patient based on the principles brought forth in this review.

References 1. Steinmann S.P., Bishop A.T., Berger R.A. Use of the 1,2 intercompartmental supraretinacular artery as a vascularized pedicle bone graft for difficult scaphoid nonunion. J Hand Surg Am [Internet] 2002 [cited 2017 Oct 19];27(3):391–401. Available from: http://www.ncbi.nlm.nih.gov/pubmed/12015712 2. Vender M.I., Watson H.K., Wiener B.D., Black D.M. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am [Internet] 1987 [cited 2017 Nov 20];12(4):514–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3611645

Percutaneous and Arthroscopicassisted Treatment of Scaphoid Non-union with/without Bone Graft The standard for treatment of a scaphoid non-union remains open bone grafting with internal fixation. However, percutaneous screw fixation without bone graft has been advocated in carefully selected cases of waist non-unions with minimal deformity to achieve reasonable union rates13,14. Arthroscopic-assisted debridement and bone grafting allows evaluation of associated intrinsic and extrinsic ligamentous injuries but little is known about its effectiveness and which Figure 2 intra-articular pathologies coexist 33-year-old male with proximal pole AVN non-union treated with interposition vascularized pedicled bone with scaphoid non-unions. grafting using the 1,2 intercompartmental supraretinacular artery and ORIF.

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Clinical Features, Debates & Research / Débats, recherche et articles cliniques (continued from page 29)

3. Smith D.K., Cooney W.P., An K.N., Linscheid R.L., Chao E.Y. The effects of simulated unstable scaphoid fractures on carpal motion. J Hand Surg Am [Internet] 1989 [cited 2017 Nov 23];14(2 Pt 1):283–91. Available from: http://www.ncbi.nlm. nih.gov/pubmed/2703676 4. Linscheid R.L., Dobyns J.H., Beabout J.W., Bryan R.S. Traumatic instability of the wrist. Diagnosis, classification, and pathomechanics. J Bone Joint Surg Am [Internet] 1972 [cited 2017 Nov 23];54(8):1612–32. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/4653642 5. Jupiter J.B., Shin A.Y., Trumble T.E., Fernandez D.L. Traumatic and reconstructive problems of the scaphoid. Instr Course Lect [Internet] 2001 [cited 2017 Nov 23];50:105–22. Available from: http://www.ncbi.nlm.nih.gov/pubmed/11372305 6. Vender M.I., Watson H.K., Wiener B.D., Black D.M. Degenerative change in symptomatic scaphoid nonunion. J Hand Surg Am [Internet] 1987 [cited 2017 Nov 23];12(4):514–9. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3611645 7. Ruby L.K., Stinson J., Belsky M.R. The natural history of scaphoid non-union. A review of fifty-five cases. J Bone Joint Surg Am [Internet] 1985 [cited 2017 Nov 23];67(3):428–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/3972868 8. Mack G.R., Bosse M.J., Gelberman R.H., Yu E. The natural history of scaphoid non-union. J Bone Joint Surg Am [Internet] 1984 [cited 2017 Nov 23];66(4):504–9. Available from: http:// www.ncbi.nlm.nih.gov/pubmed/6707028

10. Sunagawa T., Bishop A.T., Muramatsu K. Role of conventional and vascularized bone grafts in scaphoid nonunion with avascular necrosis: A canine experimental study. J Hand Surg Am [Internet] 2000 [cited 2017 Nov 20];25(5):849–59. Available from: http://linkinghub.elsevier.com/retrieve/pii/ S0363502300334360 11. Alluri R., Yin C., Iorio M., Leland H., Mack W., Patel K. A Critical Appraisal of Vascularized Bone Grafting for Scaphoid Nonunion. J Wrist Surg [Internet] 2017 [cited 2017 Oct 20];6(3):251–7. Available from: http://www.ncbi.nlm.nih. gov/pubmed/28725510 12. Waitayawinyu T, McCallister W V., Katolik L.I., Schlenker J.D., Trumble T.E. Outcome After Vascularized Bone Grafting of Scaphoid Nonunions With Avascular Necrosis. J Hand Surg Am [Internet] 2009 [cited 2017 Oct 20];34(3):387–94. Available from: http://www.ncbi.nlm.nih.gov/pubmed/19258134 13. Capo J.T., Shamian B., Rizzo M. Percutaneous screw fixation without bone grafting of scaphoid non-union. Isr Med Assoc J [Internet] 2012 [cited 2017 Nov 27];14(12):729–32. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23393709 14. Ikeda K., Osamura N., Tomita K. Percutaneous Screw Fixation Without Bone Graft for Cystic-Type Scaphoid Fractures. J Trauma Inj Infect Crit Care [Internet] 2008 [cited 2017 Nov 27];65(6):1453–8. Available from: http://www.ncbi.nlm.nih. gov/pubmed/19077641

9. Lee S.K., Byun D.J., Roman-Deynes J.L., Model Z., Wolfe S.W. Hybrid Russe Procedure for Scaphoid Waist Fracture Nonunion With Deformity. J Hand Surg Am [Internet] 2015 [cited 2018 Jan 29];40(11):2198–205. Available from: http://www.ncbi. nlm.nih.gov/pubmed/26362838

Massive Rotator Cuff Tear in the Young Adult Editor’s introduction to this edition’s debate

hat do you recommend for the massive rotator cuff tear in the young patient? Assuming all else has failed and surgery is the next step, which factors influence decision making the most? Is it patient expectations? Prior experience? Cost of treatment? Evidence in the literature? In this edition’s debate, experts from the University of Toronto and Université de Montréal shed some light on this burgeoning issue.

Femi Ayeni, M.D., FRCSC Scientific Editor, COA Bulletin

COA Bulletin ACO - Summer / Été 2018

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

Massive Rotator Cuff Tear in the Young Adult: The Role of Tendon Transfers Dominique M. Rouleau, M.D., FRCSC Membre CSES (Canadian Shoulder and Elbow Society) Professeure associée, Université de Montréal Chirurgienne Épaule-coude, Hôpital du Sacré-Coeur de Montréal Montréal, QC

Introduction massive rotator cuff tear in a young patient is one of the few remaining nightmares for the shoulder surgeon, since there is no perfect treatment with a predictable outcome. I have been asked to debate on the superiority of performing a tendon transfer compared to the more expensive superior capsule reconstruction (SCR). Prior to an indepth discussion of these complex surgeries, it is important to understand my humble attempt at developing an algorithm for massive cuff tear treatment (see Figures 1 and 2). Other algorithms exists; none of them are built on solid scientific evidence. Furthermore, in an emergency setting, one in five patients with suspected acute massive cuff tear would receive a diagnosis confirmation and surgery1,2. To prevent an irreparable tear and the need for complex surgery, such as tendon transfers, it is of PRIMARY IMPORTANCE to identify acute massive rotator cuff tears in patients under 60 years of age. Moreover, as for all cuff pathologies, it is also very important to optimize biology prior to surgery with tobacco cessation, normalization of vitamin D levels, proper nutrition, limiting anti-inflammatory drug intake and normalization of blood-sugar levels. This would improve healing potential, and decrease the chances of repair failure.

nition, pure massive cuff tears involve two tendons. Therefore, tendon transfer appears to be the only possible salvage procedure for most failed rotator massive cuff tears in young active patients. Further, it is supported by more than ten years of published scientific data. But, patient selection is critical…

Acute shoulder injury under 60 y.o. Normal X-ray Weakness and persistent pain at 2 weeks Imaging < 1 month Ultrasound or MRI

Physiotherapy/ Home exercises

Massive tear 2 cm +

No tear or small tear < 1 cm

3 months No success

Consider surgery Figure 1

Chronic massive rotator cuff tear < 60 y.o. (> 6 months) Osteoarthritis +

Osteoarthritis -

Physiotherapy/exercises Cortisone injection Viscosupplement injection

Debridement Partial/total repair Biceps tenotomy

When faced with this diagnosis, I always try an arthroscopic rotator cuff repair in young symptomatic patients with massive rotator cuff tear, even in chronic cases, for two reasons. First, a good debridement, biceps tenotomy and partial repair to recreate suspension bridge will achieve acceptable results in the majority of patients. Second, before the arthroscopic assessment, it is impossible to determine whether the cuff tear is repairable or not. A recent Canadian paper reported that 10/36 massive tears are repairable and showed good functional outcome3. It should be noted that this rate can vary, depending on study criteria and definitions4. A French study with a ten-year follow-up period reported 68% healing rate in large cuff tears involving two tendons5. In specific cases with severe muscular atrophy and a large tear, some authors favour tendon transfer as a primary surgery7.

Figure 2

Debate and Indications Tendon transfer and superior capsule reconstruction are salvage procedures used after failed rotator cuff tear repair in patients too active for a reverse shoulder arthroplasty. Superior capsular reconstruction is a new procedure and, consequently, has little scientific evidence to support it6, and is also very expensive. Finally, it requires persistent posterior and anterior tendons to anchor the graft. In my experience, the majority of irreparable cuff tears are not “only” superior in location. By defi-

Tendon transfer is contraindicated in7,8: √ Low-demand older patients √ Patients who want to resume heavy labour √ Patients with good range of motion and no pain after physiotherapy √ Pseudoparalytic shoulders (active anterior elevation less than 60°-90°) and antero-superior escape of the humeral head

Failure after 6 - 12 months PO Debridement Partial/total repair Biceps tenotomy

Consider Reverse arthroplasty for sedentary lifestyle

Superior cuff

Superior Caps. recon.

Superior and posterior cuff

Post Latissimus trans. Inf. Trapezius trans.

Superior and anterior cuff

Ant. Latissimus trans. Pectoralis transfer

Full anterior/ superior and posterior tear

COA Bulletin ACO - Summer / Été 2018

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

√ Deltoid palsy √ Antero-posterior (four tendons) AND failed repair; tendon transfers are not recommended as we cannot transfer the anterior and posterior tendons √ Osteoarthritic shoulders The choice of tendon transfer is guided by tear anatomy for patients, while considering the previous exhaustive list of contraindications. Another relative contraindication would be a patient who cannot afford to lose the use of the operated shoulder for a long period of time. This is because rehabilitation is a very long and slow process. In all transfer surgeries, range of motion is initiated after four to six weeks of immobilization. Strengthening of the transferred muscle is started only at six months postoperatively, and optimal results are expected 12-18 months after surgery. The satisfaction rate is of 60% to 80%7. In the long term, pain is decreased, but a pain free shoulder is present in 19% of patients10. Transfers for Posterosuperior Irreparable Cuff Tear In cases where the supraspinatus and infraspinatus are involved, a latissimus dorsi transfer (LDT) can be performed. There is also the possibility of a lower trapezius transfer (LTT), to restore active external rotation. A biomechanical study suggested that LDT is more effective in 90° of abduction and LTT with the arm alongside the body11. Latissimus dorsi transfer (LDT) This is a complex procedure and can be performed using different techniques. An excellent paper written by P. Valenti from Paris describes a mini incision technique assisted by arthroscopy8,9. In this technique, the latissimus is harvested by a small (seven centimetre) posterior approach along the lateral border of the scapula. Great care must be taken to protect the axillary and radial nerves during tendon removal from the humerus between teres major and pectoralis major, by working in maximal internal rotation. The neurovascular pedicle within the muscle then needs to be identified and mobilized. The muscle should also be released from the angle of the scapula and the subcutaneous tissue. The tendon can then slide under the deltoid by blunt dissection, and be retrieved in the subacromial space with the help of the arthroscope. The fixation on the greater tuberosity should be done as superiorly and anteriorly as possible on the rotator cuff footprint, with suture anchors or a cortical button. Using a longer posterior incision is probably safer for surgeons who are not familiar with the posterior shoulder anatomy. The shoulder is maintained in a brace with abduction and neutral rotation for six weeks. Lower trapezius transfer (LTT) This transfer is suggested to improve external rotation of the arm alongside the body in patients with normal subscapularis function12. The benefits of this transfer include: it is an agonist that is used in co-contraction for the external rotation of the arm, the line of pull is similar to the infraspinatus, as well as excursion and tension8. A five centimetre horizontal incision is made over the medial aspect of the scapula’s spine, over the spine tubercle. The inferior trapezius is separated from the middle trapezius and mobilized. The trapezius nerve is located two centimetres medial to the spinal border of the scapula. The tendon will be extended with an Achilles tendon allograft or a double-stranded semitendinosus. A blunt dissection is COA Bulletin ACO - Summer / Été 2018

made between the posterior deltoid and the injured infraspinatus. The graft is retrieved using arthroscopic assistance and attached on the infraspinatus footprint with anchors or a cortical button. The graft is then sutured to the lower trapezius tendon with the arm in external rotation. The shoulder is maintained in a brace in 20 degrees of external rotation for six weeks. Transfers for Anterosuperior Irreparable Cuff Tear In patients with maintained external rotation activity of the infraspinatus, and an irreparable subscapularis, anterior tendon transfers could be considered. The previously mentioned contraindications still need to be followed. A pectoralis major tendon transfer can be done as well as a latissimus dorsi transfer. Pectoralis major transfer This transfer can be done using the standard deltopectoral approach. There have been reports that the sternal head is superior for restoring internal rotation from a biomechanical point of view13, however, this has yet to be confirmed in a clinical setting14. The pectoralis major is located under the clavicular head and superiorly on the humerus. The tendon can then be rerouted under or over the conjoint tendon. Either way, this transfer does not respect classic transfer principles as it comes from the anterior chest wall. In more muscular patients, I prefer to reroute the pectoralis major tendon under the conjoint tendon after identification of the axillary nerve and the musculocutaneous nerve. The coracoacromial ligament should be preserved. Remnant fibers of the subscapularis can be repaired more medially on the lesser tuberosity. The pectoralis major is then fixed on the lesser tuberosity with anchors or a cortical button. The shoulder is immobilized in neutral rotation for six weeks. Gentle passive external rotation can be started at four weeks. Latissimus dorsi anterior transfer (LDAT) This transfer can be performed by open surgery or assisted by arthroscopy12. I prefer the open technique, as I feel more comfortable when it comes to protecting the axillary nerve; however, this is a personal preference and not based on scientific evidence. Using the deltopectoral approach, the LD tendon can easily be identified on the medial aspect of the proximal humerus. Sometimes, it is necessary to release the first third of the pectoralis major to properly see the LD tendon. After minimal blunt mobilization, the tendon is easily transposed to the lesser tuberosity and sutured over the residual subscapularis, repaired medially. Postoperative care is similar to a pectoralis transfer. Conclusion Tendon transfers have been well described in the literature for several years, and the procedure is more inclusive than the novel superior capsule reconstruction. A variety of techniques can help tailor the surgery to specific tendon deficits in carefully selected patients. Anterior transfers are more familiar to shoulder surgeons, since they are used to this surgical approach. Posterior transfers are technically demanding, but can be easily done after proper surgical preparation. Expectations should be realistic: a long rehabilitation, decreased but persistent pain, and improved but not perfect function need to be clearly understood by the patient.

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

References 1. Callaghan M.J., Baombe J.P., Horner D., Hutchinson C.E., Sandher D., Carley S. A prospective, observational cohort study of patients presenting to an emergency department with acute shoulder trauma: the Manchester emergency shoulder (MESH) project. BMC Emerg Med. 2017 Dec 22;17(1):40. doi: 10.1186/s12873-017-0149-y. PubMed PMID: 29273012; PubMed Central PMCID: PMC5741868. 2. Bateman M., Davies-Jones G., Tambe A., Clark D.I. Implementation of a Shoulder Soft Tissue Injury Triage Service in a UK NHS Teaching Hospital Improves Time to Surgery for Acute Rotator Cuff Tears. BMJ Qual Improv Rep. 2016 Jun 6;5(1). pii: u211254.w4531. doi: 10.1136/bmjquality.u211254.w4531. eCollection 2016. PubMed PMID: 27335643; PubMed Central PMCID: PMC4915307. 3. Holtby R., Razmjou H. Relationship between clinical and surgical findings and reparability of large and massive rotator cuff tears: a longitudinal study. BMC Musculoskelet Disord. 2014 May 26;15:180. doi: 10.1186/1471-2474-15-180. PubMed PMID: 24884835; PubMed Central PMCID: PMC4039058. 4. Henry P., Wasserstein D., Park S., Dwyer T., Chahal J., Slobogean G., Schemitsch E. Arthroscopic Repair for Chronic Massive Rotator Cuff Tears: A Systematic Review. Arthroscopy. 2015 Dec;31(12):2472-80. doi: 10.1016/j.arthro.2015.06.038. Epub 2015 Sep 11. Review. PubMed PMID: 26364549. 5. Agout C., Berhouet J., Bouju Y., Godenèche A., Collin P., Kempf J.F., Favard L. Clinical and anatomic results of rotator cuff repair at 10 years depend on tear type. Knee Surg Sports Traumatol Arthrosc. 2018 Feb 6. doi: 10.1007/s00167-0184854-1. [Epub ahead of print] PubMed PMID: 29411080. 6. Wall K.C., Toth A.P., Garrigues G.E. How to Use a Graft in Irreparable Rotator Cuff Tears: A Literature Review Update of Interposition and Superior Capsule Reconstruction Techniques. Curr Rev Musculoskelet Med. 2018 Mar;11(1):122-130. doi: 10.1007/s12178-018-9466-3. Review. PubMed PMID: 29327176; PubMed Central PMCID: PMC5825347.

8. Valenti P. Joint-preserving treatment options for irreparable rotator cuff tears. Orthopade. 2018 Feb;47(2):103-112. doi: 10.1007/s00132-017-3516-1. Review. PubMed PMID: 29380001. 9. Grimberg J., Kany J., Valenti P., Amaravathi R., Ramalingam A.T. Arthroscopic-assisted latissimus dorsi tendon transfer for irreparable posterosuperior cuff tears. Arthroscopy. 2015 Apr;31(4):599-607.e1. doi: 10.1016/j.arthro.2014.10.005. Epub 2014 Dec 10. PubMed PMID: 25498458. 10. El-Azab H.M., Rott O., Irlenbusch U. Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. J Bone Joint Surg Am. 2015 Mar 18;97(6):462-9. doi: 10.2106/JBJS.M.00235. PubMed PMID: 25788302. 11. Hartzler R.U., Barlow J.D., An K.N., Elhassan B.T. Biomechanical effectiveness of different types of tendon transfers to the shoulder for external rotation. J Shoulder Elbow Surg. 2012 Oct;21(10):1370-6. doi: 10.1016/j.jse.2012.01.026. Epub 2012 May 8. PubMed PMID: 22572399. 12. Clark N.J., Elhassan B.T. The Role of Tendon Transfers for Irreparable Rotator Cuff Tears. Curr Rev Musculoskelet Med. 2018 Mar;11(1):141-149. doi: 10.1007/s12178-018-9468-1. Review. PubMed PMID: 29411320; PubMed Central PMCID: PMC5825349. 13. Jennings G.J., Keereweer S., Buijze G.A., De Beer J., DuToit D. Transfer of segmentally split pectoralis major for the treatment of irreparable rupture of the subscapularis tendon. J Shoulder Elbow Surg. 2007 Nov-Dec;16(6):837-42. Epub 2007 Nov 1. PubMed PMID: 17936023. 14. Valenti P., Boughebri O., Moraiti C., Dib C., Maqdes A., Amouyel T., Ciais G., Kany J. Transfer of the clavicular or sternocostal portion of the pectoralis major muscle for irreparable tears of the subscapularis. Technique and clinical results. Int Orthop. 2015 Mar;39(3):477-83. doi: 10.1007/s00264-0142566-9. Epub 2014 Oct 24. PubMed PMID: 25341950.

7. Burkhart S.S., Ricchetti E.T., Levine W.N., Galatz L.M. Challenges and Controversies in Treating Massive Rotator Cuff Tears. Instr Course Lect. 2016;65:93-108. PubMed PMID: 27049184.

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 - Summer / Été 2018

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

Massive Rotator Cuff Tear in the Young Adult: The Role of Superior Capsular Reconstruction Ryan Paul, M.D., FRCSC Fellow, Orthopaedic Sports Medicine University of Toronto Toronto, ON Patrick Henry, M.D., FRCSC Assistant Professor, Department of Surgery University of Toronto Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre Holland Musculoskeletal Program Toronto, ON

Introduction assive rotator cuff tears in the young adult represent a significant treatment dilemma for orthopaedic surgeons. While many cases are straightforward, with complete repair being the procedure of choice, there remains a subset of patients with tears that are irreparable by traditional techniques. The ideal management in such patients continues to be controversial, with no single treatment established as the gold standard. Surgical options may include debridement, partial repair, biceps tenotomy/tenodesis, bridging rotator cuff reconstruction with graft, tendon transfers, or the emerging technique of superior capsular reconstruction1.

Anatomy When discussing the role of superior capsular reconstruction, it is essential to review the anatomy of this structure, which until recently, was given little attention. Ishihara et al. demonstrated the relevant anatomy and function of the superior capsule2 through a series of cadaveric and biomechanical experiments. Medially, the superior capsule exists below the supraspinatus and above the glenoid in the sub-supraspinatus recess, and may be seen as a synovial fold in this area3. Laterally, it blends with the undersurface of the rotator cuff insertion and attaches to the rotator cable/crescent. It inserts on the greater tuberosity, taking up a substantial 30 to 60% of the insertional footprint. Biomechanically, Mihata et al. demonstrated, in cadaveric models, that a full thickness superior capsule defect results in increased translation of the humeral head4. Reconstruction of the superior capsule was shown to restore humeral translation and subacromial contact pressure back to intact levels, however, the glenohumeral joint reaction force remained decreased. Given these results, the superior capsule is thought to function as a static stabilizer of the glenohumeral joint, resisting humeral translation and maintaining a stable fulcrum for motion. In addition, it may help to re-establish a bridge between the anterior and posterior rotator cuff, allowing for more efficient recreation and function of the axial force couple. Table 1 COA Bulletin ACO - Summer / Été 2018

Clinical Experience The first clinical series reported by Mihata’s group demonstrated excellent results with superior capsular reconstruction using fascia lata autograft5. ASES score improved from 24 to 93 and the healing rate on postoperative MRI was 83%; results not matched by other treatment options in this patient population. For example, the best published results of latissimus dorsi tendon transfer for massive cuff tears demonstrated improvement in ASES scores from 27 to 686-8. Results of attempting arthroscopic repair on chronic massive rotator cuff tears have also been mixed. A systematic review in 2016 by Henry et al. found that pooled ASES scores improved from 40 to 84, and the re-tear rate on follow-up MRI was 79%9. Since the original description of autograft fascia lata SCR by Mihata, two North American case series have been published using a modified technique with human dermal allograft10,11. The results have shown improvements in clinical outcomes, however not to the extent of Mihata’s original series (Table 1). There are several potential reasons for this including a surgical learning curve and a change in graft composition. These studies highlight that graft features and surgical technique (including rotator cuff management) are important factors to consider while using this modified allograft technique12. As experience and evidence grows, we may see optimization of results that rival the index description using fascia lata autograft. Additionally, early experience with SCR has not demonstrated significant complications (such as neurologic injury, inflammatory reaction, or accelerated degenerative changes). There has been one documented infection requiring debridement of the 98 patients published thus far11. This low rate of major complications highlights the safety of the procedure (at least in the short term). Furthermore, since bone and surrounding soft tissue are preserved, patients who clinically fail SCR are still able to undergo revision procedures which may include tendon transfer or conversion to reverse shoulder arthroplasty. As such, when a complete rotator cuff repair cannot be performed, initial treatment with SCR does not “burn bridges” for subsequent procedures, and patients may be readily converted intra-operatively with standard equipment and positioning. Discussion When comparing SCR to tendon transfer, one must consider the risks and benefits of each procedure, the goals of the operation, and potential morbidity. One benefit of superior capsular reconstruction is that it is an all-arthroscopic procedure, and is subject to no or mini-

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

mal donor site morbidity depending on the graft chosen. Comparatively, latissimus dorsi tendon transfer is subject to morbidity from the harvest site and potential injury to the deltoid and surrounding shoulder girdle musculature when performing an open transfer. In addition, the latissimus is normally involved Figure 1 in glenohumeral internal Arthroscopic image of a right shoulder rotation, adduction and viewing from lateral portal. A massive extension and as such retracted superior rotator cuff tear is functions as a secondary demonstrated. After mobilization the stabilizer. Therefore, when tear was not amenable to complete considering reconstruc- repair. tion options, particularly when results are thought to be equal, a less invasive operation that preserves intact shoulder anatomy may be preferable. One disadvantage of performing SCR is the associated cost, particularly when using dermal allograft. Fixation of the graft may require up to six or more suture anchors. The combined cost is significant and must be justified going forward. The final decision should be made in conjunction Figure 2 with the patient, and Arthroscopic image of the same patient be based on their clini- viewing from posterolateral portal. cal symptoms and overall Completed superior capsular recongoals. Given that SCR acts struction with dermal allograft and as a static stabilizer and posterior margin repair is shown. likely helps re-centre the shoulder, it may be more applicable to patients who have primary complaints of pain and clinical signs of impingement/ proximal humeral migration. In contrast, given that tendon transfers provide a potentially active muscle unit, they may be more effective at improving significant weakness, particularly when lag signs are present. In these situations, tendon transfer may be a more reasonable index procedure. Further research, ideally comparative in design, is needed to fully characterize the appropriate indications for these procedures. Final Statement In conclusion, superior capsular reconstruction is still early in its evolution and application. Biomechanical and early clinical evidence does support its use. It has not been associated with significant complications, and leaves options open for revision or salvage procedures as necessary. For these reasons, SCR has seen a relatively strong interest and proliferation across North America. In appropriately selected patients, SCR may prove to be a valuable technique in the orthopaedic surgeon’s armamentarium. Certainly, if reproducible results can be obtained

to match those of Mihata’s original series, it may become the procedure of choice in this difficult patient population. Further research is needed in this area, as surgeons become more familiar with the technique and longer-term clinical results are published. References 1. Green, A., Chronic massive rotator cuff tears: evaluation and management. Journal of the American Academy of Orthopaedic Surgeons, 2003. 11(5): p. 321-31. 2. Ishihara, Y., et al., Role of the superior shoulder capsule in passive stability of the glenohumeral joint. Journal of Shoulder & Elbow Surgery, 2014. 23(5): p. 642-8. 3. Bouliane, M., et al., The sub-supraspinatus recess and superior labral motion: an arthroscopic analysis. Shoulder & Elbow, 2018. 4. Mihata, T., et al., Superior capsule reconstruction to restore superior stability in irreparable rotator cuff tears: a biomechanical cadaveric study. American Journal of Sports Medicine, 2012. 40(10): p. 2248-55. 5. Mihata, T., et al., Clinical results of arthroscopic superior capsule reconstruction for irreparable rotator cuff tears. Arthroscopy, 2013. 29(3): p. 459-70. 6. El-Azab, H.M., O. Rott, and U. Irlenbusch, Long-term follow-up after latissimus dorsi transfer for irreparable posterosuperior rotator cuff tears. Journal of Bone & Joint Surgery - American Volume, 2015. 97(6): p. 462-9. 7. Ersen, A., et al., Time-dependent changes after latissimus dorsi transfer: tenodesis or tendon transfer? Clinical Orthopaedics & Related Research, 2014. 472(12): p. 3880-8. 8. Namdari, S., et al., Latissimus dorsi tendon transfer for irreparable rotator cuff tears: a systematic review. Journal of Bone & Joint Surgery - American Volume, 2012. 94(10): p. 891-8. 9. Henry, P., et al., Arthroscopic Repair for Chronic Massive Rotator Cuff Tears: A Systematic Review. Arthroscopy, 2015. 31(12): p. 2472-80. 10. Hirahara, A.M., W.J. Andersen, and A.J. Panero, Superior Capsular Reconstruction: Clinical Outcomes After Minimum 2-Year Follow-Up. American Journal of Orthopedics (Chatham, Nj), 2017. 46(6): p. 266-278. 11. Denard, P.J., et al., Preliminary Results of Arthroscopic Superior Capsule Reconstruction with Dermal Allograft. Arthroscopy, 2018. 34(1): p. 93-99. 12. Leroux, T.S., Editorial Commentary: Superior Capsule Reconstruction With Dermal Allograft: Effective Marketing or the Real Deal? Arthroscopy, 2018. 34(1): p. 102-104.

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

Not Even in the Former Soviet Union Brian Day, M.D., FRCSC Vancouver, BC

e have been involved in litigation to determine the constitutionality of Canada’s health system since well before the Chaoulli decision of 2005. Our own action – in which the majority of plaintiffs are patients – was launched over nine years ago. I have gained some insight into the workings of our legal system, and it’s not always pretty. Medicine and the law really are two of the oldest professions although, according to Kipling, neither is as old as prostitution. Hippocrates (460 – 370 BC) is typically credited with being the founder of medicine, while the ancient orators of Athens are often cited as the first lawyers in history. However, King Imhotep of Egypt was practising both law and medicine over 2000 years before Hippocrates and the orators. Our professions’ ancient origins mean we share some significant flaws and traditions that have been exposed repeatedly during our current trial. I alluded to this in a previous commentary, “Trials and Tribulations”. We both have a strange respect for the views of “experts” that is unearned and illogical. Government lawyers have taken that reverence to a new level. In one of many similar examples, a patient witness wrote in an affidavit that she was taking so many antiinflammatory drugs that she became nauseated. Government lawyers spent considerable court time arguing for the sentence to be deleted. “She can state how many pills, but the diagnosis of nausea requires “expert medical opinion” by a physician expert witness (not just any physician). As noted in my earlier report, because they were treating doctors rather than experts, an ophthalmologist was not permitted to define glaucoma nor was a colon surgeon allowed to explain colonoscopy. Government demanded we bring in experts if we wanted to do that. Evidence presented shows BC is failing to meet its own maximum benchmarks for all priority levels in most procedures. They have taken the position that pain and suffering while waiting is not relevant. The recently announced new funding for hip and knee replacements is welcome, but the latter represent just 2-3% of surgeries in BC. It does not address patients languishing on stretchers in ER’s for days, nor for those without access to a family doctor, nor those needing mental health services. A monopoly can survive, yet underperform, because there is no yardstick by which to compare performance. The problem with private clinics and hospitals is that they expose our system’s deficiencies. Newly received government documents, reluctantly disclosed, after many months of courtroom pressure, expose the recent announcements on new funding for what they represent: too little, too late. The following are a few examples of the many categories in which between 40 and 70 per cent or more of patients are forced to wait and longer than the government recommended maximum (beyond which harm is clinically proven):

• Vascular patients with severe claudication. • Cataract patients unable to function without assistance. • Biliary colic with severe daily pain. • Bladder cancer awaiting fulguration. • Prostate cancer with high risk of progression. A soon to be published study will reveal that many BRAC gene positive patients are developing breast cancer while waiting for mastectomies (Angelina Jolie procedure). The March 2018 internal Vancouver Coastal Health Authority report card reveals only 49% of their surgical patients meet maximum medically accepted wait times. This is an unequivocal admission of patients being harmed.

In editions of the COA Bulletin, Dr. Brian Day will be contributing trial updates from the Constitutional Challenge to B.C.’s ban on the purchase of private health insurance for medically necessary services that are already covered by the public system, led by the Cambie Surgery Centre. The outcome of this trial is important to orthopaedic surgeons across Canada as the decision in British Columbia will likely set a precedent for other provinces. Improving access will be beneficial to patients, to the economy of Canada, is comGovernment lawyers con- passionate, and will provide resources so that our orthopaedic graduates tinue to reiterate outland- will have jobs in the future.

ish statements, such as: “So the plaintiffs’ argument Regardless of how you feel about the that evidence of harms … trial and its outcome, the debate on is somehow relevant …is access and funding of care is critical simply wrong”; “Not all rel- to the future care of our patients – Ed. evant evidence is admissible”; “Statements made by the Premier or Health Minister cannot constitute admissions that can be relied on”; “Harms caused by current legislation are not relevant”. Clinics in BC are falsely accused of “extra billing” by deliberately distorting the Canada Health Act definition: “Extra-billing means the billing for an insured health service rendered to an insured person by a medical practitioner or a dentist in an amount in addition to any amount paid or to be paid for that service by the health-care insurance plan of a province.” The fact is that private clinics in BC don’t extra bill patients. In contrast, evidence has been submitted that shows many examples of public hospitals doing so. We were initially presented with the task of obtaining rebuttals for 40 government expert reports. After making us go to that expense, government withdrew half of them. So far we estimate they have wasted well over $25 million in fighting to preserve the status quo. Governments’ highly paid rejected experts included many that, under cross examination, would have helped our case: “Parallel private insurance funding does add to the net resources availCOA Bulletin ACO - Summer / Été 2018

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able for the health system, and does provide some care that would otherwise be a charge on the public system”, wrote one. Another, a former Alberta health executive, was solicited as an expert even though he has left the country and was ruled by a judge to have caused an unnecessary enquiry and wasted over $10 million dollars. Another had written, “Medicare is being put on trial, and will likely be found wanting in many regards”. No wonder they have been withdrawn. We the taxpayers remain on the hook for their high fees. Like most provincial governments, BC has a web site to guide patients to available surgeons. I followed up with a BC Children’s Hospital surgeon whose profile on the government site showed just a handful of patients waiting a very short time. I asked the surgeon to check their records. In truth there were over 1200 waiting. A recent physician witness testified he had been asked to stop seeing patients, since it made wait lists longer. The Ministry had also ordered that patients in moderate pain be re-classified as being in mild pain, so as to improve the provincial statistics and benchmarks. In a recent ten-day period of court time, the government demanded eight days to argue about striking, rather than hearing evidence. Key words in applications to strike – a hand me down from ancient legal traditions – are hearsay, relevance, opinion, argument and expert. If you state your place and date of birth that’s inadmissible hearsay, except for the few of us who personally remember being born, and checking the calendar to confirm the date. The court is not credited by government lawyers with the ability to differentiate and apply weight to “relevance”, “opinion”, hearsay and “argument”. As government lawyers waste precious court time, criminals go free because of delays in the court system. In a demonstration of fiscal stupidity, our BC government volunteered to the federal government that they believed private clinics in BC were billing 16 million dollars a year. In response, the federal government deducted that amount from transfer payments. Other provinces that allow private MRI’s have not volunteered their estimated private clinic revenues and have suffered no deductions.

Our current NDP Health Minister, Adrian Dix, made a statement, ‘’The consequences of the failure of the previous government to enforce the law has cost patients millions of dollars”, ignoring the fact that private clinics operated without harassment for many years under the last NDP government (in which he was involved). Arithmetic is not a strong point with politicians, but it is estimated that private clinics in BC save the government $300 million a year by removing that burden of funding from the public system. As the delays continue, government lawyers who are unwilling or unable to argue the case on its legal merits, have been assisted in their filibuster strategy by a BC NDP government that appears to take its orders from public sector union leaders. They have altered the Act we are challenging in mid-trial, which will require another parallel costly court action before a different judge. I agree with them that their only chance of victory is through fiscal bullying and stretching us financially. We feel vindicated by the fact that public support is on our side. A March 2018 Ipsos poll, (see our supporting Canadian Constitution Foundation1) shows that 81% of BC residents support us. Further updates on the trial, which recommenced in April 2018, will be posted at www.charterhealth.ca and www.yourhealthcantwait.ca. Newly announced measures are even much more authoritarian, and include fines of $10,000 to $20,000 per patient treated in a private BC clinic. Just over a month ago, I spoke to an international group of international senior health executives. They were from countries as diverse as New Zealand, Holland, UK, Switzerland, Germany, Zimbabwe and Russia. None could believe that laws that make private health insurance illegal could possibly exist in Canada. The Russian delegate remarked, “This could not even happen in the former Soviet Union, where I was raised”. References 1. http://theccf.ca/wp-content/uploads/2018/03/2018-Constitution-Day-healthcare.pdf

Resident Morale is ‘Cautiously Reasonable’ While Graduate Underemployment Remains at the Forefront of COA Efforts Trinity Wittman, MSc, COA Advocacy and Development Manager Kevin Orrell, M.D., FRCSC, COA President Emil H. Schemitsch, M.D., FRCSC, COA Human Resources Committee Chair Bogdan A. Matache, M.D., C.M., FRCSC, PGY5, University of Ottawa David Stockton, BSc, M.D., PGY4, University of British Columbia

n 2016, the COA reported on the job crisis, sharing our profound frustration at the unacceptably high rate of underemployment among Canadian orthopaedic graduates. Surgeon underemployment poses a threat to patient access to care as highly-specialized skills are underutilized and eroded while

COA Bulletin ACO - Summer / Été 2018

aging patient populations are underserviced in many regions. Graduates unable to find full-time employment in Canada are faced with chronic locum experiences, serial fellowships and continued studies, and some are still turning to job opportunities abroad, particularly in the United States. However, the versatility of the profession allows for a different path to entering practice than in the past, with the majority of surgeons able to make an interim living while looking for full-time employment, albeit sometimes for a longer time period than they had hoped. While the COA is limited in its ability to enforce certain practice changes, the Board of Directors will continue to take all possible actions within our purview to address this complex issue.

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Resident Morale and Training Choices: Are We Still in Crisis Mode? Collaboration and open communication between residents/ fellows, job seekers and COA decision-makers is crucial. At each COA Board of Directors meeting, the Canadian Orthopaedic Residents’ Association (CORA) Chairs are invited to present on behalf of their colleagues. Over the last two years, Board discussions were led by Dr. Bogdan Matache, R5, University of Ottawa (on behalf of Co-Chair Lisa Lovse) and Dr. David Stockton, R4, University of British Columbia (on behalf of Co-Chair Amar Cheema). They highlighted residents’ interest in continued partnership with the COA as well as a number of trends (some of them troubling) related to the underperforming job market. What follows are excerpts from their presentations: • “Residents are seeking ways to identify early on where the potential opportunities will be. They often arrange electives at community hospitals where they hope to one day find a job or where surgeons are nearing retirement age, perhaps at the expense of filling an educational need or advancing their orthopaedic knowledge and skills. Residents in Toronto, for example, invited hospital chiefs from around the GTA together for a dinner and networking event to enable residents to see where potential opportunities might lie and in what specialties. • Most residents who aspire to have academic careers either expect to do a master’s degree at the start of their practice, or complete a surgeon-scientist program during training. Many of us now see a master’s degree as more of a prerequisite to an academic post than simply a competitive advantage. • The unofficial requirement for a community job, at least in some regions, appears to be two fellowships, despite the fact that many smaller community centres restrict surgeons from performing some advanced procedures. Combined with the opportunity cost of sacrificing a year of full-time practice, this sense of “overqualification” has led to dissatisfaction and cynicism among residents looking to transition into community practice. • This comes back to the issue of mentorship and transition to practice. There appear to primarily be two current models: • First model - Graduates pursue two fellowships and receive highly subspecialized training, in order to market themselves as the most qualified applicant in their subspecialty. However, if/when they are hired, they are often not required (and may even be advised against) performing some of the procedures they have gained proficiency in, depending on the needs of their respective hiring group. • Second model - Involves early identification of a potential new hire, guidance towards a fellowship by a ‘mentor’ surgeon, and potential job sharing for the first couple of years as the young surgeon starts, and the senior surgeon ends practice. • Only in certain centres is the second model the preferred hiring method. Other centres unfortunately see a large pool of unemployed labour and in some cases, are still abusing the ‘locum’ position. We applaud groups who, for example, have stated that as soon as a member begins to take a sustained lower share of the call burden, they are expected to retire within a reasonably short time period and allow time to find a replacement. The COA Guidelines on Late

Career Transition should be promoted as much as possible to encourage this model of practice transition. We would ideally like to see the COA expand its influence with regards to recommendations around transitioning out of, and into practice. • Overall, however, residents are indeed seeing the efforts that the COA is making to address the job crisis, but more effort can be made to communicate this to junior members. One of our colleagues hit the nail on the head in describing resident morale as ‘cautiously reasonable’, which seems to be an improvement compared to a few years ago. ‘Reasonable’ meaning that most residents understand the realities of the current job market. All residents are aware of the very high unemployment rate, and are taking steps to ensure that they are able to move and work abroad if necessary.” Understanding the Numbers 2017 Employment Snapshot A detailed collection of employment data is gathered annually by the COA Human Resources Committee, chaired by Dr. Emil Schemitsch and made up largely of the Canadian Program Directors. This annual snapshot is akin to a “where are they now?” update of all orthopaedic graduates over the last eight years and provides an important tool for advocating for further resources. We are pleased to report a 100% response rate from the 17 training programs since the inception of this initiative in 2014. The 2018 data will further differentiate for gender. Key findings from the most recent data based on Canadian orthopaedic graduates from 2010-2017, or “recent grads” (current at July 1, 2017): • 165 recent grads are currently seeking full-time employment (“Looking for work”), including those completing locum, fellowship or research, representing a 9% decrease from 2016. Surgeons completing a fellowship have historically been included in this category given that they are competing for upcoming jobs in the market, however future iterations of this survey will include results both including and excluding fellows. • 73 recent grads are currently working full-time outside of Canada. From 2015 to 2016, there was a 53% increase in grads working outside of Canada, whereas from 2016 to 2017, there was only a 20% increase. This hopefully indicates that while recent grads are still turning to U.S. and international positions, this trend is decreasing. • Underemployment (“Looking for work” category) is most pronounced among recent grads from British Columbia (39%), followed by the Prairies (33%) and Ontario (32%), while rates in Atlantic Canada (19%) and Quebec (12%) are still concerning. 2017 National Orthopaedic Hiring Survey The COA Practice Management Committee has collected data over the last year outlining the demographic of orthopaedic surgeons, as well as anticipated orthopaedic hiring trends, via input from each of the provincial presidents. Key findings across Canada: COA Bulletin ACO - Summer / Été 2018

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• There are 1322 full-time orthopaedic surgeons employed across Canada. • 148 of 1322 full-time orthopaedic surgeons are women (11.2%). Interestingly, COA Active membership is comprised of 15% women. • 110 full-time orthopaedic surgeons are over the age of 65. • 81 orthopaedic surgeons currently have operating privileges but only work part-time hours (<70% of a “normal” orthopaedic practice; excludes locums) • In Quebec, locum positions are exceptional, with one or two per year, and usually for less than a year. In all other provinces, the percentage of hospitals which allow locum work ranges from 15% in Saskatchewan to 81% in British Columbia. • In 2016, 69 full-time orthopaedic surgeons were hired across Canada, which is arguably a positive result, as it is greater than the number of residency positions currently offered annually (54 in 2017). • In the next five years, 175 orthopaedic surgeons are expected to be hired across Canada. • In the next five years, if more resources were available in an ideal scenario, 287 orthopaedic surgeons would be hired in order to serve the population. • 24 orthopaedic surgeons will retire in the next year. • 147 orthopaedic surgeons will retire in the next 5 years. • Job sharing examples currently exist in British Columbia, Ontario, and Manitoba. Complete data will be available via the COA web site in July 2018. Government Advocacy and Promoting Access to Care: Arguably the most significant way that the COA can make a difference is by advocating for improved access to MSK care, which not only improves patient care and satisfaction, but ultimately leads to a more efficient system and further job creation. The COA believes that hospital-based resources should be allocated more effectively to better serve Canadian patients. Board members continue to advocate accordingly at various levels of government and the COA has partnered with provincial orthopaedic associations to promote various advocacy initiatives. The COA strongly supports growing provincial initiatives such as the Ontario MSK Strategy as a means for improved access to MSK care. Over the last two years, the COA Access to Care Steering Committee enlisted member support in developing an inventory of dozens of local and provincial innovations which have improved access to timely and appropriate MSK care. Important themes were brought forward such as improved surgical screening and centralized intake of referrals, use of digital innovations and improved flow of communications. We continue to build this database of models of care and share them with members through the COA Bulletin. Steering Committee members met with several federal agencies including Health Canada to promote Canadian MSK innovations and offer our members as collaborative resources to the government. We are continuing our advocacy efforts this year by further partnering with champions from the provincial orthopaedic associations, to encourage provincial Ministry collaboration on piloting improvements in access to care, drawing on models that are successful locally. This initiative will be further develCOA Bulletin ACO - Summer / Été 2018

Full-time Orthopaedic Surgeons 69 Hired in 2016 40

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oped at the June 2018 Board meeting, including a call for provincial champions and revision of the COA Access to Care Position Statement. Direct patient and citizen advocacy directed towards governments and health authorities will also be an important tool in the future of the COA’s advocacy platform. Education: The COA leadership encourages all members to remain aware of the impact of underemployment and to initiate steps throughout various career stages and in local settings to contribute to solutions. Inappropriate use of locums is of paramount importance. Trauma work performed by new graduates in locum positions should be linked to scheduled surgical resources. The COA strongly encourages orthopaedic surgeons to prohibit locum positions that do not allow for safe and highquality continuity of patient care, and to acknowledge the risks to new graduates that serial fellowships and chronic locum positions pose to skillset and practice readiness. For the Board’s complete list of recommendations, please refer to the Orthopaedic Graduate Unemployment Position Statement. Late Career Transition Planning and Job Sharing: The COA encourages senior members to consider job-sharing models and the addition of junior surgeons to a group practice, when moving towards retirement. Decreased surgical activities could be linked to meaningful participation in other aspects of surgical practice, including patient assessment, mentoring, assisting, teaching, research and administration. Please refer to the COA Guidelines for Late Career Transition. Reduction in residency spots: At the COA’s recommendation, orthopaedic residency positions nationwide have decreased from 81 in 2011 to 54 in 2017. Given the lengthy training process required to recruit and train orthopaedic surgeons, the COA Board must continue to monitor these changes. We recognize that the needs of the population and the training programs are not necessarily best met by reduction in resident numbers, but the unfortunate reality is that public funding for new permanent positions, as well as the hospital-based resources required to support them, are inadequate in many regions. Free Job Board for Members: The password-protected membership portal offers a Job Board, where members can post and seek available locum and full-time positions at no charge. We encourage all hospitals to maintain a transparent hiring process by widely circulating opportunities. To post a position, please email cynthia@canorth.org.

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Nationwide Projections Retiring & Hiring in 5 Years

Full-time Orthopaedic Surgeons 175 Projected to be Hired in 5 Years 300

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Free Services: COA membership is offered free of charge to residents, fellows and job seekers (including those doing locums and part-time work). Newly-hired surgeons are offered a 50% rebate on their membership dues for the first year in practice. This initiative translates to 6-10 years of free membership benefits. Click here for membership benefits.

24 RETIRING 1 YEAR

RETIRING 5 YEARS

HIRING 5 YEARS PROJECTED

HIRING 5 YEARS IDEAL SCENARIO

We Value Your Input: Given the limitations in our ability to intervene directly in finding jobs for graduates, how can the COA further address graduate employment? Please contact policy@canorth.org with any suggestions. Insufficient patient access to care coupled with underemployment is a complex and challenging paradox facing our profession, and the COA will continue to seek ways to best serve our members.

Le moral des résidents est « raisonnablement prudent » tandis que le sous-emploi des diplômés demeure au cœur des priorités de l’ACO Trinity Wittman, M.Sc., directrice du développement et des activités de défense des droits de l’ACO Kevin Orrell, MD, FRCSC, président de l’ACO Emil Schemitsch, MD, FRCSC, président du Comité sur les ressources humaines en orthopédie de l’ACO Bogdan A. Matache, MD, CM, FRCSC, R5, Université d’Ottawa David Stockton, B.Sc., MD, R4, Université de la Colombie-Britannique

n 2016, l’ACO faisait état de la crise de l’emploi, exprimant sa grande frustration par rapport au sous-emploi chez les diplômés en orthopédie au Canada, qui atteignait des proportions inacceptables. Le sous-emploi des orthopédistes compromet l’accès aux soins, car il entraîne une sous-utilisation et une érosion de compétences ultraspécialisées, et ce, alors même que la population vieillissante est mal servie dans bien des régions. Les diplômés incapables de trouver un emploi à temps plein au pays enfilent les formations spécialisées et les suppléances et prolongent leurs études; certains se tournent encore vers les emplois offerts à l’étranger, plus particulièrement aux États-Unis. Par contre, la polyvalence de la profession offre aujourd’hui à la majorité des orthopédistes une nouvelle façon de commencer à exercer en attendant de trouver un emploi à temps plein, même si cette période intérimaire dure parfois plus longtemps qu’ils ne l’auraient espéré. Enfin, même si la capacité de l’ACO d’instaurer des changements dans la façon d’exercer est limitée, son conseil d’administration continue de faire tout en son pouvoir pour faire progresser ce dossier complexe.

Moral des résidents et choix de formation : Sommes-nous toujours en situation de crise? La collaboration et des communications ouvertes entre les résidents et boursiers, les chercheurs d’emploi et les décideurs de l’ACO sont essentielles. À chaque réunion du conseil d’administration de l’ACO, les présidents de l’Association canadienne des résidents en orthopédie (ACRO) viennent présenter un rapport au nom de leurs collègues. Ces deux dernières années, les discussions avec le conseil ont été menées par le Dr Bogdan Matache, résident de cinquième année de l’Université d’Ottawa (au nom de la Dre Lisa Lovse, coprésidente), et le Dr David Stockton, résident de quatrième année de l’Université de la Colombie-Britannique (au nom du Dr Amar Cheema, coprésident). Ils ont souligné l’intérêt des résidents pour le partenariat avec l’ACO et un certain nombre de tendances – parfois troublantes – liées au sous-emploi. Voici quelques extraits de leurs rapports : • Les résidents cherchent des moyens de cerner rapidement où seront les possibilités d’emploi. Ils prévoient souvent leurs stages optionnels dans des hôpitaux communautaires où ils espèrent trouver un emploi ou encore où des orthopédistes approchent de l’âge de la retraite, et ce, parfois aux dépens de leurs besoins en matière de formation ou de la progression de leurs connaissances et compétences. Les résidents de Toronto, par exemple, ont invité les chefs de département d’hôpitaux du Grand Toronto pour un souper de réseautage afin de permettre aux résidents de cerner où étaient les possibilités et dans quelles spécialités. COA Bulletin ACO - Summer / Été 2018

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• La plupart des résidents qui aspirent à une carrière universitaire s’attendent soit à faire une maîtrise en début d’exercice, soit à suivre un programme de chirurgienchercheur en cours de formation. Bon nombre d’entre nous considérons maintenant la maîtrise davantage comme un prérequis pour un poste universitaire que comme un simple avantage concurrentiel. • Officieusement, le prérequis pour un poste en hôpital communautaire, du moins dans certaines régions, semble deux formations supérieures, même si bien des petits centres communautaires empêchent les orthopédistes d’effectuer certaines procédures avancées. Si on ajoute à cela le coût d’opportunité associé au sacrifice d’une année d’exercice à temps plein, ce sentiment de « surqualification » cause de l’insatisfaction et du cynisme chez les résidents souhaitant travailler en milieu communautaire. • Ce qui nous ramène à la question du mentorat et de la transition vers l’exercice. Il semble y avoir grosso modo deux modèles actuellement : • Premier modèle – Un diplômé suit deux formations supérieures et obtient une formation hyperspécialisée afin de se vendre comme le candidat le plus qualifié dans sa sous-spécialité. Par contre, s’il obtient éventuellement un poste, souvent, il n’a pas besoin de certaines des procédures qu’il a appris à maîtriser, selon les besoins de son employeur, et on lui conseille même parfois de ne pas les utiliser. • Deuxième modèle – Un candidat potentiel est repéré très tôt, on lui conseille une formation supérieure auprès d’un orthopédiste « mentor », puis on lui propose parfois un partage des tâches les premières années de sa carrière, pendant que l’orthopédiste chevronné fait la transition vers sa retraite. • Ce n’est que dans certains centres que le deuxième modèle d’embauche prévaut. Dans d’autres centres, malheureusement, il y a un vaste bassin de main-d’œuvre au chômage et, dans certains cas, on abuse encore des postes de suppléance. Nous saluons les groupes qui, par exemple, affirment que dès qu’un membre commence à assumer une moins grande part du temps de garde, on s’attend à ce qu’il prenne sa retraite dans un délai raisonnablement court et à ce qu’on ait le temps de lui trouver un remplaçant. Il faut faire la promotion des Lignes directrices sur la transition en fin de carrière de l’ACO autant que possible afin de favoriser ce modèle de transition vers l’exercice. Nous aimerions idéalement voir l’ACO élargir son influence en ce qui a trait aux recommandations sur la transition vers l’exercice et vers la retraite. • Globalement, les résidents voient bien les efforts déployés par l’ACO pour lutter contre la crise de l’emploi; il est toutefois possible de mieux les faire connaître aux jeunes membres. Un de nos collègues a tapé dans le mille en qualifiant le moral des résidents de raisonnablement prudent, ce qui semble une amélioration par rapport à il y a quelques années. On dit « raisonnablement », parce que la plupart des résidents comprennent les réalités du marché de l’emploi actuel. Tous les résidents sont conscients du taux de chômage très élevé et prennent les mesures nécessaires pour s’assurer de pouvoir déménager et travailler à l’étranger au besoin.

COA Bulletin ACO - Summer / Été 2018

Comprendre les statistiques La situation d’emploi en orthopédie en 2017 Le Comité sur les ressources humaines en orthopédie de l’ACO, présidé par le Dr Emil Schemitsch et principalement composé de directeurs de programmes canadiens, procède chaque année à la collecte de données détaillées sur la situation d’emploi des diplômés en orthopédie des huit dernières années, à la manière des articles « Que sont-ils devenus? ». Il s’agit d’un outil important lorsque vient le temps de demander davantage de ressources. Nous sommes heureux de signaler que, depuis le début de cette initiative, en 2014, nous obtenons un taux de réponse de 100 % auprès des 17 programmes de formation. En 2018, les données tiendront compte du sexe. Voici les principales constatations tirées des dernières données sur les diplômés canadiens en orthopédie de 2010 à 2017, ou « jeunes diplômés » (au 1er juillet 2017) : Actuellement, 165 jeunes diplômés cherchent un emploi à temps plein (« diplômés à la recherche d’un emploi »), ce qui comprend ceux qui effectuent des suppléances, une formation spécialisée ou de la recherche, soit une baisse de 9 % par rapport à 2016. Les orthopédistes qui effectuent une formation spécialisée sont traditionnellement inclus dans cette catégorie, car ils seront bientôt à la recherche d’un emploi, mais les prochaines versions du sondage présenteront les résultats avec et sans ce groupe d’orthopédistes. • En tout, 73 jeunes diplômés travaillent à temps plein à l’extérieur du Canada. De 2015 à 2016, on a constaté une hausse de 53 % des diplômés travaillant à l’extérieur du Canada; de 2016 à 2017, la hausse a été de seulement 20 %. Cela indique, espérons-le, que même si les jeunes diplômés se tournent toujours vers les États-Unis et l’étranger pour trouver un emploi, la tendance est à la baisse. • Le sous-emploi (qui touche les « diplômés à la recherche d’un emploi ») est particulièrement élevé chez les jeunes diplômés de la Colombie-Britannique (39 %), suivis de ceux des Prairies (33 %) et de l’Ontario (32 %), tandis que les taux au Canada atlantique (19 %) et au Québec (12 %) demeurent préoccupants. Sondage national sur l’embauche en orthopédie en 2017 Au cours de la dernière année, le Comité sur la gestion de l’exercice de l’ACO a recueilli des données démographiques sur les orthopédistes, de même que sur les embauches prévues en orthopédie, auprès de chacun des présidents des associations provinciales d’orthopédie. Voici les principales constatations de ces travaux : • En tout, on compte 1 322 orthopédistes à temps plein au Canada. • De ces 1 322 orthopédistes à temps plein, 148 sont des femmes (11,2 %). Fait intéressant, les femmes représentent 15 % des membres actifs de l’ACO. • Au total, 110 orthopédistes à temps plein ont plus de 65 ans. • En tout, 81 orthopédistes ont accès au bloc opératoire, mais travaillent seulement à temps partiel (moins de 70 % d’un exercice orthopédique « normal », à l’exclusion des suppléances).

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• Au Québec, les postes de suppléance sont exceptionnels; on en compte un ou deux par année, et ils durent généralement moins d’un an. Dans toutes les autres provinces, la proportion des hôpitaux qui autorisent les suppléances va de 15 % en Saskatchewan à 81 % en Colombie-Britannique. • En 2016, 69 orthopédistes à temps plein ont été embauchés au Canada, ce qui est sans aucun doute positif, car ce nombre est plus élevé que le nombre de places en résidence disponibles chaque année (54 en 2017). • Au cours des 5 prochaines années, 175 orthopédistes devraient être embauchés au pays. • Au cours des 5 prochaines années, dans un contexte idéal où davantage de ressources seraient disponibles, 287 orthopédistes seraient embauchés pour répondre aux besoins de la population. • En tout, 24 orthopédistes prendront leur retraite au cours de la prochaine année. • En tout, 147 orthopédistes prendront leur retraite au cours des 5 prochaines années. • On trouve actuellement des modèles de partage des tâches en Colombie-Britannique, en Ontario et au Manitoba. Les données complètes seront publiées sur le site Web de l’ACO en juillet 2018. Relations gouvernementales et promotion de l’accès aux soins : Militer pour l’amélioration de l’accès aux soins de l’appareil locomoteur est assurément la meilleure façon pour l’ACO de changer les choses; non seulement on améliore ainsi les soins et la satisfaction des patients, mais, au bout du compte, on rend le système plus efficace et on favorise la création d’emploi. L’ACO croit qu’on doit veiller à une allocation plus efficace des ressources hospitalières afin de mieux répondre aux besoins de la population canadienne. Les membres du conseil d’administration poursuivent leurs activités de défense des droits et intérêts auprès des divers ordres de gouvernement, et l’ACO a conclu des partenariats avec les associations provinciales d’orthopédie afin de promouvoir différentes initiatives connexes. L’ACO soutient fermement des initiatives provinciales comme la stratégie de transformation des soins musculosquelettiques en Ontario à titre de moyens d’améliorer l’accès aux soins de l’appareil locomoteur. Ces deux dernières années, le comité directeur de l’ACO sur l’accès aux soins orthopédiques a demandé aux membres de l’aider à dresser l’inventaire de dizaines d’innovations locales et provinciales qui ont permis d’améliorer l’accès aux soins de l’appareil locomoteur appropriés en temps opportun. Des

C.-B.

ALB.

SASK.

MAN.

ONT.

QC.

N.-B.

N.-É.

Î.-P.-É.

T.-N.-L.

Prévisions nationales

300

Retraites et embauches au cours des 5 prochaines années 287

250

200

175

150

147 100

24 RETRAITES 1 AN

RETRAITES 5 ANS

EMBAUCHES PRÉVUES 5 ANS

EMBAUCHES IDÉALEMENT 5 ANS

thèmes importants en sont ressortis, comme un meilleur triage chirurgical et une admission centralisée, le recours aux innovations numériques et une amélioration des communications. Nous continuons de nourrir cette banque de modèles de soins et de les partager avec les membres par l’intermédiaire du Bulletin de l’ACO. Les membres du comité directeur ont rencontré les représentants de plusieurs organismes fédéraux, y compris Santé Canada, afin de promouvoir les innovations canadiennes dans les soins de l’appareil locomoteur et de proposer au gouvernement de collaborer avec nos membres. Nous continuons nos efforts de défense des droits et intérêts cette année en poursuivant nos partenariats avec des champions des associations provinciales d’orthopédie de sorte à favoriser la collaboration avec les ministères provinciaux dans le cadre de projets pilotes d’amélioration de l’accès aux soins grâce à des modèles qui connaissent du succès à l’échelle locale. Cette initiative sera abordée plus en détail à la réunion du conseil d’administration de juin 2018; on y lancera en outre un appel aux champions provinciaux et on y reverra l’Énoncé de position sur l’accès aux soins orthopédiques au Canada. La défense des droits et intérêts des patients et de la population en général directement auprès des gouvernements et des autorités sanitaires constituera également un outil important dans les efforts de l’ACO en matière de défense des droits et intérêts. Formation : La direction de l’ACO invite tous les membres à rester conscients de l’incidence du sous-emploi et à prendre des mesures, peu importe l’étape de leur carrière et leur milieu, pour trouver des solutions. L’utilisation inappropriée des suppléances est un enjeu primordial. Le travail en traumatologie COA Bulletin ACO - Summer / Été 2018

Advocacy & Health Policy / Défense des intérêts et politiques en santé (continued from page 43)

effectué par les nouveaux diplômés occupant des postes de suppléance doit être reflété dans les ressources chirurgicales planifiées. L’ACO recommande fortement aux orthopédistes d’interdire les postes de suppléance qui ne permettent pas d’assurer la qualité et la continuité des soins aux patients pour des raisons de sécurité, et d’être conscients des risques que posent les formations spécialisées et les postes de suppléance à la chaîne pour le maintien des compétences et la capacité à exercer des nouveaux diplômés. Pour connaître les recommandations du conseil d’administration, consultez l’Énoncé de position de l’ACO sur le sous-emploi des diplômés en orthopédie. Planification de la transition en fin de carrière et partage des tâches : L’ACO incite les orthopédistes chevronnés à envisager des modèles de partage des tâches et l’intégration de jeunes orthopédistes à un groupe de pratique dans la planification de leur transition vers la retraite. Une diminution des activités chirurgicales pourrait être associée à une participation significative à d’autres aspects de l’exercice de la profession, dont l’évaluation des patients, le mentorat, l’entraide, l’enseignement, la recherche et l’administration. Pour en savoir plus, consultez les Lignes directrices sur la transition en fin de carrière de l’ACO. Réduction du nombre de places en résidence : Sur recommandation de l’ACO, le nombre de places en résidence au pays est passé de 81 places en 2011 à 54 en 2017. Vu la durée du processus de recrutement et de formation des orthopédistes, le conseil d’administration de l’ACO doit continuer de faire le suivi de ces changements. Nous admettons que ce n’est pas en réduisant les places en résidence qu’on répond le mieux

aux besoins de la population et des programmes de formation, mais la triste réalité est que les fonds publics pour de nouveaux postes permanents, et les ressources de soutien en milieu hospitalier connexes, sont insuffisants dans bien des régions. Babillard des possibilités d’emploi gratuit pour les membres : Le portail des membres, auquel ces derniers accèdent par mot de passe, propose un babillard des possibilités d’emploi. Les orthopédistes peuvent y afficher les postes de suppléance et à temps plein et y chercher un emploi gratuitement. Nous recommandons à tous les hôpitaux de maintenir un processus d’embauche transparent en diffusant massivement les possibilités d’emploi. Pour annoncer un poste, écrire à cynthia@canorth.org. Services gratuits : L’adhésion à l’ACO est gratuite pour les résidents, boursiers et chercheurs d’emploi (y compris ceux qui font des suppléances et travaillent à temps partiel). De plus, les orthopédistes qui viennent d’obtenir un poste bénéficient d’un rabais de 50 % sur la cotisation pour leur première année d’exercice. Grâce à cette initiative, il est possible de profiter des avantages offerts aux membres gratuitement pendant six à dix ans. Cliquez ici pour connaître les avantages de l’adhésion. Vos commentaires sont importants pour nous : En tenant compte de sa capacité limitée à intervenir directement dans les efforts de recherche d’emploi des diplômés, l’ACO aimerait savoir ce qu’elle pourrait faire d’autre, selon vous, pour améliorer la situation d’emploi des diplômés. Si vous avez des suggestions, écrivez à policy@canorth.org. L’accès inadéquat aux soins et le sous-emploi sont un paradoxe complexe qui touche notre profession, et l’ACO poursuit sa quête de moyens de mieux servir ses membres.

Gain Practice-Changing Skills in Just 1 Hour:

Intimate Partner Violence (IPV) Educational Program for Fracture Clinics The EDUCATE Program is an IPV educational program for all fracture clinic staff who see patients (i.e. orthopaedic surgeons, residents, non-physician HCPs, and non-HCP staff ). The program is evidence-based and takes 1-hour to complete. The COA and the EDUCATE team are looking for Champions across Canada to bring the EDUCATE program to their fracture clinic. Champions will receive specialized training on the program curriculum as well as how to identify, and respond to, IPV in the orthopaedic context. Champion training will take place at the COA 2018 Annual Meeting in Victoria, BC on Friday, June 22 from 1:45 to 3:30 pm.

Bring the EDUCATE Program to Your Fracture Clinic!

CLICK HERE to sign up to become a champion COA Bulletin ACO - Summer / Été 2018

CLICK HERE to learn more about the EDUCATE program

Drs. Sheila Sprague and Mohit Bhandari from McMaster University developed the EDUCATE Program along with their team of investigators

www.IPVeducate.com

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

Five New Choosing Wisely Orthopaedic Recommendations

Cinq nouveaux énoncés liés à l’orthopédie pour la campagne Choisir avec soin

n April 16, 2018, the COA, in collaboration with the Arthroscopy Association of Canada (AAC) and the Canadian Arthroplasty Society (CAS), partnered with Choosing Wisely Canada to launch five new orthopaedic recommendations of tests, treatments or procedures for patients and health care professionals to question. The new guidelines have been added to the existing list launched in 2014, for a total of 10 orthopaedic recommendations.

e 16 avril 2018, l’ACO, en collaboration avec l’Arthroscopy Association of Canada (AAC) et la Société canadienne d’arthroplastie (CAS), s’est associée à la campagne nationale Choisir avec soin afin de publier cinq nouveaux énoncés sur des tests, traitements et procédures liés à l’orthopédie que les patients et professionnels de la santé doivent considérer. Ces nouvelles recommandations s’ajoutent aux énoncés publiés en 2014, pour un total de dix recommandations en orthopédie.

Thank you to members of the COA Standards Committee, the AAC Executive and the CAS Executive for their dedicated work on this initiative.

Merci aux membres du Comité sur les normes nationales de l’ACO, de la direction de l’AAC et de la direction de la CAS pour leur immense travail dans le cadre de cette initiative.

See Ten Things Physicians and Patients Should Question to view the full list, including rationale and references for each recommendation. We encourage you to share broadly and thank you for your continued engagement in the Choosing Wisely Canada campaign!

Pour la liste complète des énoncés, avec les explications connexes et les sources, voir les « Dix énoncés que les médecins et leurs patients doivent considérer ». Nous vous invitons à partager abondamment cette liste. Merci de votre participation soutenue à la campagne nationale Choisir avec soin!

Ten Things Physicians and Patients Should Question

Dix énoncés que les médecins et leurs patients doivent considérer

1. Don’t use arthroscopic debridement as a primary treatment in the management of osteoarthritis of the knee. 2. Don’t order a knee MRI when weight-bearing X-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis as the MRI rarely adds useful information to guide diagnosis or treatment. 3. Don’t order a hip MRI when X-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis as the MRI rarely adds useful information to guide diagnosis or treatment. 4. Don’t prescribe opioids for management of osteoarthritis before optimizing the use of non-opioid approaches to pain management. 5. Don’t routinely request pathological examination of tissue from uncomplicated primary hip and knee replacement surgery undertaken for degenerative arthritis. 6. Avoid performing routine postoperative deep vein thrombosis ultrasonography screening in patients who undergo elective hip or knee arthroplasty. 7. Don’t use needle lavage to treat patients with symptomatic osteoarthritis of the knee for long-term relief. 8. Don’t use glucosamine and chondroitin to treat patients with symptomatic osteoarthritis of the knee. 9. Don’t use lateral wedge insoles to treat patients with symptomatic medial compartment osteoarthritis of the knee. 10. Don’t use postoperative splinting of the wrist after carpal tunnel release for long-term relief.

1. Ne pas utiliser le débridement arthroscopique comme traitement primaire de l’arthrose du genou. 2. Ne pas demander d’IRM du genou lorsque des signes d’arthrose sont visibles à la radiographie avec mise en charge et en présence de symptômes d’arthrose, car l’IRM apporte rarement un complément d’information utile pour orienter le diagnostic ou le traitement. 3. Ne pas demander d’IRM de la hanche lorsque des signes d’arthrose sont visibles à la radiographie et en présence de symptômes d’arthrose, car l’IRM apporte rarement un complément d’information utile pour orienter le diagnostic ou le traitement. 4. Ne pas prescrire d’opioïdes pour la prise en charge de l’arthrose avant d’avoir optimisé l’utilisation des approches non opioïdes de gestion de la douleur. 5. Ne pas demander d’emblée une anatomopathologie à la suite d’une arthroplastie primaire de la hanche ou du genou sans complications effectuée en raison d’une arthrite dégénérative. 6. Éviter de demander d’emblée une échographie de dépistage postopératoire d’une thrombose veineuse profonde chez les patients qui ont subi une arthroplastie élective du genou ou de la hanche. 7. Éviter le lavage articulaire pour un soulagement de longue durée de l’arthrose symptomatique du genou. 8. Ne pas utiliser la glucosamine et la chondroïtine dans le traitement de l’arthrose symptomatique du genou. 9. Ne pas utiliser les orthèses plantaires à correction latérale pour traiter l’arthrose symptomatique du compartiment médial du genou. 10. Ne pas utiliser d’attelle au poignet en traitement postopératoire pour un soulagement de longue durée après le relâchement du tunnel carpien.

COA Bulletin ACO - Summer / Été 2018

The Canadian Orthopaedic Foundation is pleased to have awarded the following research grants for 2017: J. Edouard Samson Award Dr. Kishore Mulpuri (Vancouver, BC) – “A Prospective, International Hip Dysplasia Registry with Follow-up to Skeletal Maturity: An Analysis of Risk Factors, Screening Practices and Treatment Outcomes” Carroll A. Laurin Award Dr. Paul E. Beaulé and Dr. Stéphane Poitras (Ottawa, ON) – “Efficacy of a non-surgical treatment protocol for patients with symptomatic femoro-acetabular impingement: a randomized controlled trial” Robert B. Salter Award Dr. Michael J. Monument (Calgary, AB) – “rhBMP-2 in bone sarcoma surgery: Does BMP-2 signalling in mouse models of osteosarcoma influence tumour biology?” Inaugural Dr. Cy Frank Award Dr. Bas A. Masri, Dr. David R. Wilson and Dr. David J. Stockton (Vancouver, BC) – “Reliability of Cartilage Mapping Using Upright Open MRI in Patients with ACL Injuries” Canadian Orthopaedic Research Legacy (CORL) Awards Dr. Ryan Degen (London, ON) – “A kinematic analysis of the hip following injury and repair of the capsule and labrum” Dr. Laurie A. Hiemstra (Banff, AB) – “SHould You transFer the Tubercle? (The SHYFT Trial) - A Randomized Clinical Trial comparing Isolated MPFL Reconstruction to MPFL combined with Tibial Tubercle Osteotomy – A Pilot Study” Dr. Moin Khan (Hamilton, ON) – “Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE)” Dr. Ian Lo (Calgary, AB) – “Graft reconstruction for irreparable rotator cuff tears: superior capsule reconstruction vs. tendon repair with graft interposition” Dr. Peter MacDonald and Dr. Jeff Leiter (Winnipeg, MB) – “Number One Overall Graft Pick? Hamstrings versus Bone-Patellar-Tendon-Bone versus Quadriceps Tendon Graft for ACL Reconstruction: A Prospective Cohort Study” Dr. Prism S. Schneider (Calgary, AB) – “Validation of a Self-Administered Outcome Measure for Young Patients With Hip Trauma” For research summaries, see the Research Impact Report at www.whenithurtstomove.org/annual-report. 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

The Canadian Orthopaedic Foundation Announces a New Research Award Geoffrey Johnston, M.D., MBA, CHE President and Chair, Canadian Orthopaedic Foundation

his year, the Canadian Orthopaedic Foundation (COF), in conjunction with the Canadian Orthopaedic Research Society (CORS), is delighted to introduce a new research award honouring Dr. Cy Frank and his legacy. Members of the CORS executive and the COF collaborated to propose the new award as a tribute to the memory of Dr. Cy Frank, one of Canada’s foremost orthopaedic clinician-scientists. As a result, the Cy Frank Award for Innovation in Orthopaedic Research was hatched. Cy Frank was the epitome of a clinician-scientist, an orthopaedic surgeon and researcher, who passed away too soon, in May 2015. He was a staunch supporter of orthopaedic research, and at the time of his passing was a member of the COF’s Board of Directors. His orthopaedic legacy was limitless, having fulfilled leadership roles in the Division of Orthopaedic Surgery in Calgary, in The COF introduces a the Province of Alberta, nationally in new research award the Canadian Orthopaedic Association honouring the late and in the Canadian Institutes of Health Dr. Cy Frank Research, to name but a sampling of his many talents. Dr. Frank received many awards and honours, including the Order of Canada, recognizing a lifetime of distinguished contribution to advancing orthopaedic health-care services and for his scientific contributions to bone and joint repair research. The COF’s Cy Frank Award specifically recognizes orthopaedic research which demonstrates innovation, a passion near and dear to Dr. Frank’s heart. The COF’s Research Review Panel, which includes CORS reviewers, was unanimous in its selection of the first recipients of this special award: Drs. Bas Masri, David Wilson and David Stockton from Vancouver, BC, for their research project entitled Reliability of Cartilage Mapping Using Dr. Bas Masri Upright Open MRI in Patients with ACL Injuries. Drs. Masri, Wilson and Stockton summarize their research project in this way: ”Anterior cruciate ligament (ACL) rupture is a common injury that disrupts the biomechanics of the knee and is associated with the early degeneration of knee cartilage (i.e. knee osteoarthritis). Surgery to reconstruct the torn ACL is supposed to restore normal joint biomechanics. Why then, does

it not reduce the risk of future arthritis? To address this question, we will use a new Upright Open MRI that is able to measure cartilage tissue biomechanics in standing, loadbearing positions. If we can prove that this new technology is a reliable ‘functional’ imaging technique for injuries Dr. David R. Wilson that affect cartilage, we can begin to understand how surgeries designed to restore normal biomechanics might be improved.” The Cy Frank Award for innovation in orthopaedic research is a prestigious addition to the COF’s cadre of named awards, honouring the titans of Canadian orthopaedic research. Three others awarded this year include: • The J. Edouard Samson Award, presented annually in recognition of the best career orthopaedic research over a period of five years. Dr. Samson was the first Francophone Canadian surgeon in Dr. David Stockton Quebec to devote himself solely to orthopaedics. At Montreal’s l’Hôpital du Sacré-Coeur for 30 years, Dr. Samson conducted an enormous orthopaedic practice and trained a large group of orthopaedic surgeons. He was a founding member of the COA. • The Carroll A. Laurin Award, recognizing excellence in clinical research. Dr. Laurin was director of orthopaedics at the University of Montreal and at McGill University. A former president of the Canadian Orthopaedic Association, Dr. Laurin was invested as an officer of the Order of Canada in 1996. • The Robert B. Salter Award, recognizing excellence in basic science research. Dr. Salter was a pioneer in the field of paediatric orthopaedic surgery and cartilage research. His textbook of orthopaedic surgery is used throughout the world. Among his many other awards and honours, Dr. Salter was invested as an officer of the Order of Canada in 1977 and promoted to Companion in 1997. The COF is proud to honour these legendary orthopaedic researchers by presenting awards in their names and is pleased to add the Cy Frank Award for innovation in orthopaedic research, in conjunction with CORS, to this distinguished group of awards. The COF research awards program is made possible thanks to the donations of individuals and industry leaders. We are especially grateful to Zimmer Biomet and to DePuy Synthes for generous support of the COF research program.

COA Bulletin ACO - Summer / Été 2018

La Fondation Canadienne d’Orthopédie est heureuse d’accorder les prix et bourses de recherche suivants pour 2017 : Prix J.-Édouard-Samson r D Kishore Mulpuri (Vancouver, C.-B.) – A Prospective, International Hip Dysplasia Registry with Follow-up to Skeletal Maturity: An Analysis of Risk Factors, Screening Practices and Treatment Outcomes Bourse Carroll-A.-Laurin rs D Paul E. Beaulé et Stéphane Poitras (Ottawa, Ont.) – Efficacy of a non-surgical treatment protocol for patients with symptomatic femoro-acetabular impingement: a randomized controlled trial Bourse Robert-B.-Salter r D Michael J. Monument (Calgary, Alb.) – rhBMP-2 in bone sarcoma surgery: Does BMP-2 signalling in mouse models of osteosarcoma influence tumour biology? Premiers lauréats du Prix Cy-Frank rs D Bas A. Masri, David R. Wilson et David J. Stockton (Vancouver, C.-B.) – Reliability of Cartilage Mapping Using Upright Open MRI in Patients with ACL Injuries Bourses de l’Héritage de la recherche orthopédique au Canada (HROC) r

D Ryan Degen (London, Ont.) – A kinematic analysis of the hip following injury and repair of the capsule and labrum re

D Laurie A. Hiemstra (Banff, Alb.) – SHould You transFer the Tubercle? (The SHYFT Trial) – A Randomized Clinical Trial comparing Isolated MPFL Reconstruction to MPFL combined with Tibial Tubercle Osteotomy – A Pilot Study r

D Moin Khan (Hamilton, Ont.) – Shoulder instability Trial comparing Arthroscopic stabilization Benefits compared with Latarjet procedure Evaluation (STABLE) r

D Ian Lo (Calgary, Alb.) – Graft reconstruction for irreparable rotator cuff tears: superior capsule reconstruction vs. tendon repair with graft interposition rs

D Peter MacDonald et Jeff Leiter (Winnipeg, Man.) – Number One Overall Graft Pick? Hamstrings versus BonePatellar-Tendon-Bone versus Quadriceps Tendon Graft for ACL Reconstruction: A Prospective Cohort Study re

D Prism S. Schneider (Calgary, Alb.) – Validation of a Self-Administered Outcome Measure for Young Patients With Hip Trauma Pour le sommaire de ces projets de recherche, consultez le Rapport d’incidence de la recherche 2017 à https://whenithurtstomove.org/fr/rapport-annuel. 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 :

Parrain :

DePuy Synthes Canada

Contributeur :

Foundation / Fondation

La Fondation Canadienne d’Orthopédie lance un nouveau prix de recherche Geoffrey Johnston, MD, MBA, CHE Président du conseil de la Fondation Canadienne d’Orthopédie

ette année, la Fondation Canadienne d’Orthopédie a l’immense plaisir de lancer, en partenariat avec la Société de recherche orthopédique du Canada (SROC), un nouveau prix de recherche en l’honneur du Dr Cy Frank et de sa contribution durable à l’orthopédie. Les membres du comité de direction de la SROC et de la Fondation ont œuvré de pair afin de proposer le nouveau prix à la mémoire du Dr Frank, l’un des plus grands clinicienschercheurs en orthopédie que le Canada ait compté. C’est ainsi qu’est né le Prix Cy-Frank pour l’innovation en recherche orthopédique. Le Dr Frank était la quintessence du clinicien-chercheur, un chirurgien orthopédiste et chercheur qui est parti trop tôt, en mai 2015. Grand champion de la recherche orthopédique, il était, à son décès, membre du conseil d’administration de la Fondation. Sa contribution à l’orthopédie est incommensurable. Il a assumé des rôles de leadership à la division de l’orthopédie de l’Université de Calgary, en Alberta, et, à l’échelle nationale, au sein de l’ACO et La Fondation lance des Instituts de recherche en santé du un prix de recherche Canada (IRSC), pour ne citer que quelques à rla mémoire du exemples des organismes qui ont bénéficié D Cy Frank de ses nombreux talents. Le Dr Frank a reçu de nombreux prix et autres distinctions; il a entre autres été fait membre de l’Ordre du Canada en reconnaissance de son rôle dans l’avancement des services de soins orthopédiques en Alberta et de sa contribution scientifique à la recherche sur les réparations osseuses et articulaires. Le Prix Cy-Frank souligne plus particulièrement l’innovation en recherche orthopédique, une véritable passion pour le Dr Frank. Le comité d’examen de la Fondation, qui comprend des représentants de la SROC, a choisi à l’unanimité les premiers lauréats de ce prix spécial : les Drs Bas Masri, David Wilson et David Stockton, de Vancouver, en Colombie-Britannique, pour leur projet de recherche intitulé Reliability of Cartilage Mapping Using Upright Open MRI in Patients Le Dr Bas Masri with ACL Injuries. Les Drs Masri, Wilson et Stockton résument leur projet de recherche : « La rupture du ligament croisé antérieur (LCA) est une blessure courante qui perturbe les fonctions biomécaniques du genou et est associée à une dégénérescence précoce de son cartilage (arthrose du genou). Si la chirurgie de reconstruction du LCA est censée restaurer les fonctions biomécaniques de l’articulation, pourquoi ne réduit-elle pas les risques d’arthrite? Pour répondre à cette question, nous utiliserons un nouvel appareil d’imagerie

par résonance magnétique (IRM) à grande ouverture qui permet d’évaluer les fonctions biomécaniques des cartilages chez un patient en position debout et en charge. Si nous pouvons prouver que cette nouvelle technique d’imagerie est “fonctionnelle” et fiable pour l’examen des bles- Le Dr David R. Wilson sures aux cartilages, nous pourrons commencer à comprendre la façon dont les chirurgies de restauration des fonctions biomécaniques pourraient être améliorées. » Le Prix Cy-Frank pour l’innovation en recherche orthopédique est un ajout prestigieux aux prix et bourses commémoratifs de la Fondation, créés en hommage aux géants du milieu de la recherche orthopédique au Canada. Les trois autres prix et bourses de recherche commémoratifs remis cette année sont les suivants : • Le Prix J.-Édouard-Samson, remis chaque année, reconnaît la meilleure r recherche en orthopédie menée sur Le D David Stockton r une période de cinq ans. Le D Joseph-Édouard Samson a été le premier chirurgien canadien-français au Québec à se consacrer exclusivement à l’orthopédie. Pendant 30 ans, à l’Hôpital du Sacré-Cœur de Montréal, le Dr Samson a dirigé un énorme service d’orthopédie et formé un nombre imposant d’orthopédistes. Il est l’un des membres fondateurs de l’ACO. • La Bourse Carroll-A.-Laurin souligne l’excellence en recherche clinique. Le Dr Laurin a été directeur de la chirurgie orthopédique à l’Université de Montréal et à l’Université McGill. Ancien président de l’ACO, le Dr Laurin a été investi Officier de l’Ordre du Canada en 1996. • La Bourse Robert-B.-Salter souligne l’excellence en recherche fondamentale. Le Dr Robert Salter a été un pionnier dans le domaine de l’orthopédie pédiatrique et dans la recherche sur les cartilages. Son ouvrage sur la chirurgie orthopédique est utilisé partout dans le monde. Entre autres prix et distinctions, il a été investi Officier de l’Ordre du Canada en 1977, puis promu Compagnon de l’Ordre du Canada en 1997. La Fondation est fière de rendre hommage à ces légendes de la recherche orthopédique en remettant ces distinctions commémoratives, et heureuse d’y ajouter, en partenariat avec la SROC, le Prix Cy-Frank pour l’innovation en recherche orthopédique. Les programmes de financement de la recherche de la Fondation Canadienne d’Orthopédie ne seraient pas possibles sans les dons de particuliers et de chefs de file de l’industrie. Nous souhaitons remercier tout spécialement Zimmer Biomet et DePuy Synthes pour leur généreux soutien aux programmes de financement de la recherche de la Fondation.

COA Bulletin ACO - Summer / Été 2018

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

Using the CanMEDS Roles in Your Practice Great Leaders: The CanMEDS Leader Role

One only has to look to the Canadian Medical Association’s physician education subsidiary, Joule, to identify numerous Physician Leadership Institute courses on topics relevant to leadership in medicine3. Some examples include “Leading Change”, “Dollars and Sense”, and “Engaging Others”.

Jason Werle, M.D., FRCSC Program Director, University of Calgary Calgary, AB

s we reflect on the word “Leader”, names from historical events often come to mind: Sir Winston Churchill in the Battle of Britain during the Second World War, or John F. Kennedy during the 1962 Cuban Missile Crisis. These world-renowned leaders possessed skills and intangible qualities that set them apart from their peers. They were able to lead their nations through some of the darkest and most uncertain moments in human history.

The CanMEDS framework is a tool used for teaching and for our continuing medical education. It is well established, benefits our profession and has been integrated into the Royal College’s programs including Maintenance of Certification. The seven roles of the CanMEDS are: Medical Expert (the integrating role) Communicator Collaborator Leader Health Advocate Scholar Professional Over the next few editions of the COA Bulletin, I will be asking

The Royal College of Physicians and Surgeons of Canada has established “Leader” as an important CanMEDS role. This role transitioned from “Manager” to “Leader” in 2015 to better reflect the professional activities of Royal College members in all disciplines4. As leaders, physicians engage with others to contribute to a vision of a high-quality health-care system, and take responsibility for the delivery of excellent patient care through their activities as clinicians, administrators, scholars, and teachers5.

In Canada, we are fortunate to various members of the COA to define each of the roles and how have superb leaders in orthothey can be used in day to day practice and education. This series paedic surgery that have led us, will provide guidelines on how to use the CanMEDS roles to their full and the Canadian Orthopaedic advantage in your orthopaedic practice. Dr. Jason Werle has kindly Association forward. Names agreed to examine the role of Leader in this edition’s feature. like Cy Frank, Ross Leighton, The key competencies of the and Mo Bhandari come to CanMEDS Leader role as idenEnjoy! – Ed. mind. By the nature of our protified by the Royal College5 fession, orthopaedic surgeons include: are leaders whether we are delivering patient care by leading a team in the operating room, in the clinic, or in the emergency 1. Improvement of Health-care Delivery in Teams, room. We are leaders as we advocate for our patients at comOrganizations, and Systems mittee meetings. We are leaders as we teach medical students, 2. Stewardship of Health-care Resources residents, and fellows the art and science of our profession. We 3. Leadership in Professional Practice are leaders as we measure our surgical performance and focus 4. Managing Career Planning, Finances, and Health Human on quality improvement and patient safety. We are leaders as Resources in Practice we carry out research to improve the lives of current and future generations. As orthopaedic surgeons, we are uniquely positioned to apply the science of quality improvement to improving systems of But what truly makes a great leader? Can leadership skills and patient care5. Numerous examples exist in current Canadian abilities be learned? orthopaedic practice. Many COA members in British Columbia, Alberta, Ontario, and Quebec participate in the American Great leaders often possess particular qualities. They have College of Surgeons-National Surgical Quality Improvement a high level of emotional intelligence1 which is the ability to Program (NSQIP) at their respective hospitals. All orthopaemonitor one’s own and others’ feelings and emotions, to disdic patients have benefited from the COA’s “Operate Through criminate among them, and to use this information to guide Your Initials” program introduced in 19946 and the American one’s thinking and actions. Great leaders are usually great Academy of Orthopaedic Surgeons’ “Sign Your Site” initiative communicators. They can identify important issues for their established in 19986. The widespread adoption of the World constituents and convey thoughts, ideas, and solutions with Health Organization’s Safe Surgery Checklist has improved surcoherent messaging. Great leaders have insight and foresight. gical care delivery around the world7. Orthopaedic surgeons They are altruistic as they make decisions that are selfless and that participate in these activities contribute to a culture that intended to improve circumstances for the common good. promotes safety and excellence in patient care. This is true Great leaders respect all members of the teams that they lead. leadership. Many authors believe that leadership skills can be learned2.

COA Bulletin ACO - Summer / Été 2018

Training & Practice Management / Formation et gestion d’une pratique (continued from page 50)

Given limited provincial health-care budgets in Canada, orthopaedic surgeons must engage in the stewardship of these finite resources. We can demonstrate leadership by advocating for our orthopaedic patients to ensure that a fair allocation is achieved. We can demonstrate leadership by applying evidence and management processes to achieve cost-appropriate surgical care. We can demonstrate leadership by finding efficiencies in care delivery that others cannot.

5. Dath D., Chan M.-K., Anderson G., Burke A., Razack S., Lieff S., Moineau G., Chiu A., Ellison P. Leader. In: Frank J.R., Snell L., Sherbino J., editors. CanMEDS 2015 Physician Competency Framework. Ottawa: Royal College of Physicians and Surgeons of Canada; 2015 6. Wong D.A., Lewis B., Herndon J., Martin C., Brooks R.: Patient safety in North America: beyond “Operate Through your Initials” and “Sign Your Site”. J Bone Joint Surg Am; 2009: Vol 91.1534-41.

Leadership in professional practice is also a key competency for this CanMEDS role5. Leading 7. Haynes A., Weiser T., Berry W., Lipsitz S., through change is an important aspect of Breizat A., Dellinger E.P., Herbosa T., Joseph S., orthopaedic practice. We all know that change Kibatala P., Lapitan M., Merry A., Moorthy K., A can be difficult for us and for other members of Surgical Safety Checklist to Reduce Morbidity and the health-care team. But change is necessary. As Mortality in a Global Population. N Engl J Med; 2009: we strive for efficiency, enhanced patient safety, 360.491-499 and improved access, we will all be required Copyright © 2015 to lead through change in our hospitals and The Royal College of Physicians clinics. As we do this, maintaining our focus and Surgeons of Canada. on the patient experience and patient outReproduced with permission comes will ensure that we are following the correct path. Finally, we must lead as we manage our career and practice. We must set priorities and manage time effectively to integrate our practice and personal life. This is often a challenging task as we balance the many demands on our time. However, our own health (physical, mental, and spiritual) is a critical component in our ability to deliver care to our patients safely and effectively.

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

As Canadian orthopaedic surgeons, we practice in an environment that requires the key competencies of the CanMEDS Leader role. As leaders in our surgical communities, we should embrace them. Our patients and the care of their musculoskeletal injuries and illnesses are depending on it. References 1. Salovey P., Mayer J., Emotional Intelligence. Imagination, Cognition and Personality; 1990: Vol. 9(3) 185-211 2. Kouzes J., Posner B., The Leadership Challenge, 5th Edition, 2012 3. Physician Leadership Institute 2018 Courses, Joule, A CMA company 4. Dath D., Chan M.-K., Abbott C. CanMEDS 2015: From Manager to Leader, Ottawa: The Royal College of Physicians and Surgeons of Canada; 2015

2018

June 20-23 juin CORA Meeting/Réunion de l’ACRO June 20 juin Victoria, BC www.coa-aco.org

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

June 3-6 juin CORA Meeting/Réunion de l’ACRO June 3 juin Halifax, NS COA Bulletin ACO - Summer / Été 2018

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

Accumulating MOC Credits in Section 3

ecently, the COA Office has seen a marked increase in the number of member inquiries regarding how to earn MOC Section 3 (self-assessment) credits. With the December 2019 deadline looming where Royal College Fellows need to have accumulated and reported 25 credits in each Section 1, 2 and 3, the concern is understandable. Section 1 group learning credits are easy – attending the COA Annual Meeting can net you as high as 28 credits, depending on how many sessions you attend. Section 2 self-learning credits are also fairly straight forward, some of the activities in this section earn two credits per hour invested. Participation in some COA committees can earn you 15 credits per year, per committee. From the Royal College web site, “the purpose of the committee must be to improve or enhance the quality, safety, or effectiveness of the health-care system.” Section 3 assessment opportunities are also numerous and varied. And important. Numerous studies have established the important role of feedback in identifying areas where competence or performance can be improved. When basing future learning activities on an assessment of how you are doing in practice, you are truly identifying needs that are relevant to your roles and responsibilities. There is considerable continuous professional development literature on self-assessment. - Eva and Regehr in 2005 (https://fhs.mcmaster.ca/ceb/docs/ Featured_paper_Eva.pdf ) discuss the flaws in how selfassessment has been considered. - A review by Davis et al. (http://jama.jamanetwork.com/ article.aspx?articleid=203258) concluded that the accuracy of physicians’ self-evaluation in comparison to external measures of performance was poor. Generally, physicians who were performing well, underestimated their performance and the greatest disconnect was among physicians who were the least skilled and most confident. And if you are not yet convinced that assessment is critically important, there is an increasing expectation of the profession (http://fmrac.ca/professional-revalidation-of-physicians/) for the privilege of self-regulation. Since 2007, the implementation of Physician Revalidation programs across multiple Canadian provinces requires licensed physicians to “participate in a recognized [CPD process] in which they demonstrate their commitment to continued competent performance” in their practice. There are several ways to integrate assessment into your learning plan: - Some provinces have Physician Achievement Review programs. Doing one of these assessments counts for three credits per hour in Section 3. - Many peer-review programs that are available in some provinces qualify you for Section 3 credits. - If you teach, annual teaching evaluations count.

COA Bulletin ACO - Summer / Été 2018

- If you participate in performance appraisals, 360 degree assessments or any other types of workplace assessments related to your practice domains, including communication, leadership or managerial ability, these count for Section 3 credits. - If you write peer-reviewed journal articles, the time you spend reviewing the feedback you receive from your peers counts for Section 3 credits. - Chart audits or other practice performance-based assessments count. - The Royal College has several accredited self-assessment programs for free. The Bioethics modules are available on the Royal College web site and since they address ethics in medicine, they are applicable to anyone. - The Canadian Medical Protective Association (CMPA) also has accredited medico-legal self-assessment programs available on their web site. - Purchase from the American Academy of Orthopaedic Surgeons (AAOS), and complete one of the COA-accredited AAOS self-assessment exams(SAE) (go to http://www.royalcollege.ca/portal/page/portal/rc/ common/documents/cpd_accreditation/section3/ orthopedic_e.html to see which AAOS SAE programs have been accredited by the COA). Only COA-accredited SAE courses can be claimed for Section 3 credits. Completing just one SAE can net you more than the required 25 Section 3 credits (three credits per hour). For bonus credits, consider establishing a personal learning project (PLP) based on your SAE results. You would claim your PLP hours (two credits per hour) under Section 2 (self-learning). Don’t hesitate to contact the COA office with any questions.

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

Obtention de crédits dans la section 3 du programme de MDC

écemment, les bureaux de l’ACO ont constaté une hausse marquée des demandes de renseignements sur l’obtention de crédits dans la section 3 (Évaluation) du programme de Maintien du certificat (MDC). Comme la date limite de décembre 2019 pointe tranquillement à l’horizon et que, d’ici là, les Associés du Collège royal doivent avoir consigné 25 crédits dans chaque section (1, 2 et 3) du programme de MDC, on peut comprendre que beaucoup soient préoccupés. Section 1 (Apprentissage collectif) – Pour ces crédits, c’est simple : on peut obtenir jusqu’à 28 crédits simplement en participant à la Réunion annuelle de l’ACO, selon le nombre de séances auxquelles on assiste. Section 2 (Auto-apprentissage) – Ces crédits sont aussi relativement simples à obtenir, et pour certaines activités, on obtient deux crédits par heure consacrée à l’activité. La participation aux activités de certains comités de l’ACO peut permettre d’obtenir 15 crédits par année, par comité : « l’objectif ou l’activité du comité, du groupe de travail, ou un titre semblable, doit avoir pour objectif d’améliorer la qualité, la sécurité ou l’efficacité du système de soins de santé. » (Site Web du Collège royal) Section 3 (Évaluation) – Ici, les possibilités sont aussi nombreuses que diversifiées. Et importantes. De nombreuses études ont établi l’importance de la rétroaction dans la détermination des points à améliorer sur les plans des compétences ou de la performance. En planifiant nos activités d’apprentissage en fonction d’une évaluation de notre exercice, on peut véritablement cerner nos besoins par rapport à nos rôles et responsabilités. Le rôle de l’autoévaluation est abondamment étudié dans la littérature sur le perfectionnement professionnel : - Eva et Regehr (2005 – https://fhs.mcmaster.ca/ceb/docs/ Featured_paper_Eva.pdf ) abordent les lacunes dans la façon dont l’autoévaluation est considérée. - Dans une revue systématique, Davis et al. (2006 – http:// jama.jamanetwork.com/article.aspx?articleid=203258) concluent que l’autoévaluation des médecins par rapport aux évaluations externes de leur performance manque de justesse. En général, les médecins qui avaient une bonne performance sous-estimaient celle-ci, et les médecins chez qui les compétences laissaient le plus à désirer étaient les plus confiants. Et si vous n’êtes pas encore convaincu que l’évaluation est d’une importance capitale, dites-vous qu’elle est de plus en plus une attente de la profession (http://fmrac.ca/wp-content/uploads/2014/02/ FINAL_Revaluation_Position_FR.pdf) en retour du privilège de l’autoréglementation. Depuis 2007, en raison de la mise en œuvre de mécanismes de revalidation des médecins dans bien des provinces canadiennes, les médecins autorisés doivent « participer à un [processus de perfectionnement professionnel] reconnu dans lequel ils et elles démontrent leur engagement envers le maintien d’une performance compétente » dans leur exercice. Il existe plusieurs façons d’intégrer l’évaluation dans notre plan d’apprentissage : - Certaines provinces ont des programmes d’évaluation de la performance des médecins. Faire l’une de ces évaluations permet d’obtenir trois crédits dans la section 3 par heure.

- Beaucoup des programmes d’évaluation par les pairs offerts dans certaines provinces permettent d’obtenir des crédits dans la section 3. - Si vous enseignez, les évaluations annuelles d’enseignement comptent. - Si vous participez à un processus d’évaluation du rendement, d’évaluation à 360° ou à tout autre type de démarche d’évaluation en milieu de travail en lien avec les domaines d’exercice de la profession, y compris la communication, les capacités de leadership ou de gestion, les heures que vous y consacrez comptent pour des crédits dans la section 3. - Si vous écrivez des articles pour des revues examinées par des pairs, le temps passé à prendre connaissance des commentaires reçus de vos pairs ouvre droit à des crédits dans la section 3. - Les vérifications de dossiers et autres formes d’évaluation de l’exercice de la profession axées sur le rendement comptent pour des crédits dans la section 3. - Le Collège royal offre plusieurs programmes d’auto-évaluation agréés gratuitement. Les modules de bioéthique sont disponibles sur le site Web du Collège royal, et puisqu’ils abordent l’éthique en médecine, ils sont pertinents pour tout le monde. - L’Association canadienne de protection médicale (ACPM) offre aussi des programmes d’autoévaluation médicolégale agréés sur son site Web. - Certaines autoévaluations (Self-Assessment Exams ou SAE) payantes de l’American Academy of Orthopaedic Surgeons (AAOS) sont agréées par l’ACO (rendez-vous à www.royalcollege.ca/portal/page/portal/rc/common/ documents/cpd_accreditation/section3/orthopedic_f. html pour voir lesquelles). Seules les SAE agréées par l’ACO peuvent compter pour des crédits dans la section 3. Une seule SAE peut permettre d’obtenir plus que les 25 crédits requis dans la section 3 (3 crédits par heure). Pour quelques crédits supplémentaires, vous pouvez également envisager de créer un projet de formation personnel (PAP) en fonction des résultats de votre SAE; les heures consacrées à un PAP donnent droit à deux crédits par heure dans la section 2 (Auto-apprentissage). N’hésitez pas à communiquer avec les bureaux de l’ACO si vous avez des questions. COA Bulletin ACO - Summer / Été 2018

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

National Fee Comparator: Practice Management Committee Tool for Provincial Billing Negotiations Greg Clarke, M.D., FRCSC Chair, COA Practice Management Committee Kentville, NS

n the early years of the new millennium, there was a sentiment that we should have a sense of how orthopaedic services were compensated across the Provincial Authorities that make up our national health-care system. The task of developing and implementing a system of data collection fell to the COA’s Practice Management Committee (formerly known as COPEF) under the leadership of Dr. Ken Hughes from Richmond, British Columbia. Initially, data was collected for only the top billing codes. However, it was soon recognized that this rather simplistic approach did not offer the full picture. In many jurisdictions, there were multiple items that might be billed in the course of managing a specific MSK problem. This led to the development of sessions of care data which was designed to include any fees billable over a six-week course of care for a diagnosis. This allowed the capture of fees for preoperative assessment or consultation, operative procedures, postoperative care fees in and out of hospital, and any discharge fees. This seemed to further clarify those interprovincial comparisons. Over the past decade, many settlements seem to have focused on value-added items rather than fee increases. The most recent data collection has attempted to garner information on these items such as CMPA rebates, CME rebates, rural incentives and BMI premiums.

This data collection continues as part of the mandate of the Practice Management Committee. A focused data collection is carried out approximately every two years. Between the formal collection surveys, presidents of the provincial orthopaedic societies are encouraged to forward revised data that may occur as the result of any negotiated settlement. It is hoped that COA members can draw on this data to inform fee negotiations at the provincial level, and to assist in negotiating upgrades to existing fees or the development of new fee items by the provincial bodies. Although not published on the COA web site, this data is available to any member either through your provincial orthopaedic society or by contacting the COA head office. The National Fee Comparator remains fluid. The Practice Management Committee regularly discusses how we might improve the data collection or analyze it in a way that may be more helpful. The committee invites any input from the membership as to how this resource might be enhanced. Please contact policy@canorth.org with any feedback or to request a copy of this working document.

Orthopaedic Surgery Residency – Is the Juice Worth the Squeeze? Snapshot of the Residency Training Experience Ryan Degen, M.D., MSc, FRCSC Western University, Department of Orthopedic Surgery Fowler Kennedy Sport Medicine Clinic London, ON

urgical residency is a challenging period for any trainee. There is a significant increase in responsibility compared to medical school that many are inadequately prepared for. The pressures of this responsibility, coupled with continual study and long clinical work-hours, have often been associated with resident dissatisfaction or “burnout”. Orthopaedic surgery has been identified as one of the highest risk specialties for burnout among trainees3. While it is important to recognize burnout, the presence of physician burnout and depression is not unique to orthopaedics. Studies have shown increasing rates among medical students and residents across all specialties COA Bulletin ACO - Summer / Été 2018

Orthopaedic training is long, challenging and at times, exhausting. To that, some would say, “tough times don’t last, but tough people do.” The reality is that in order to train and retain the best and brightest, we, as an orthopaedic community, should look to understand what current and recent graduates identify as potential areas to improve and enhance the residency and training experience. Fortunately, Drs. Ryan Degen and Simon Adams offer their insights using recent literature, data collection, and their past experiences to provide a “snap shot” of the residency training experience, and what may come afterwards. Femi Ayeni, M.D., FRCSC Scientific Editor

Training & Practice Management / Formation et gestion d’une pratique (continued from page 54)

when compared to the general population3,5, demonstrating that it may be a cultural problem within medicine, rather than a specific surgical field. Emphasizing high burnout rates in orthopaedics, as done by Ames et al.3, may come with negative connotations. Medical students and junior residents may become concerned about their future in the field and ultimate career satisfaction, leading them to pursue other options. This may impact trainees from pursuing a field they may have otherwise had a fulfilling career in.

students. While this could take some time, residents should be reassured, in the meantime, that the grass is indeed greener on the other side.

While many of the studies referenced above are from institutions in the United States, the high rates of burnout and depersonalization among orthopaedic residents identified in these studies should not be ignored. Adams et al. recently performed a similar study, surveying residents in nine different surgical specialties in Canadian programs1. They identified comparably high rates of resident dissatisfaction, particularly in orthopaedics as well. It’s unfair to turn a blind eye to this, and assume everyone will persevere with the same “nose to the grindstone” attitude instilled upon us during our training. There is sufficient literature identifying factors associated with reduced career satisfaction and higher burnout that we are compelled to consider, and make appropriate changes to our training programs. The simplest variables appear to relate to social supports and mentorship, where regularly scheduled social outings5,7 and structured mentorship programs6,8 have demonstrated the ability to reduce resident burnout. Other variables, such as a perceived work-life imbalance, and threatened underemployment, may not be as easy to address at this time. However, these should remain on the agenda to improve upon within our association. After all, it may have a lasting impact on current and future generations of surgeons-in-training.

2. Balch C.M., Shanafelt T.D., Sloan J.A., Satele D.V., Freischlag J.A. Distress and career satisfaction among 14 surgical specialties, comparing academic and private practice settings. Ann. Surg. 2011;254:558–568.

Another consideration, one that is commonly overlooked, is that the rate of burnout and emotional exhaustion significantly declines once training is complete. In a systematic review, Pulcrano et al. reviewed six studies that evaluated emotional exhaustion and depersonalization, as well as career satisfaction in orthopaedic residents and attending surgeons4. They found that both emotional exhaustion and depersonalization rates were significantly higher in residents, while career satisfaction was significantly higher in attending surgeons (85%) compared with residents (69%). Interestingly, one of the studies even identified orthopaedics as a specialty with the lowest rates of burnout among practicing attending surgeons, compared with 13 other surgical specialties2. Furthermore, they reported orthopaedic surgeons as having the highest career satisfaction and lowest depression screening rates among all surveyed surgical specialties. Finally, they also identified that orthopaedic surgeons have the highest mental quality of life, and lowest rates of home/work conflict compared to other specialties. These studies are important as they highlight that there truly is “light at the end of the tunnel”, with a high probability of having a fulfilling career after residency training is complete. While I am early in my career, I can confidently say that the path taken to get here was worth it. Could it have been easier? Certainly. Going forward, I think it’s important to critically evaluate our training process. Simple adjustments, based on the referenced studies above, can improve the resident experience to lessen attrition and improve recruitment of medical

References 1. Adams S., Ginther D.N., Neuls E., Hayes P. Attitudes and factors contributing to attrition in Canadian surgical specialty residency programs. Can. J. Surg. 2017;60:247–252.

3. Ames S.E.., Cowan J.B., Kenter K., Emery S., Halsey D. Burnout in Orthopaedic Surgeons: A Challenge for Leaders, Learners, and Colleagues. J. Bone Jt. Surg. - Am. Vol. 2017;99:1–6. 4. Pulcrano M., Evans S.R.T., Sosin M. Quality of life and burnout rates across surgical specialties: A systematic review. JAMA Surg. 2016;151:970–978. 5. Rogers E., Polonijo A.N., Carpiano R.M. Getting by with a little help from friends and colleagues: Testing how residents’ social support networks affect loneliness and burnout. Can. Fam. Physician. 2016;62:e677–e683. 6. 6. Strelzow J., Petretta R., Broekhuyse H.M. Factors affecting orthopedic residency selection: A cross-sectional survey. Can. J. Surg. 2017;60:186–191. 7. Sullivan M.C., Bucholz E.M., Yeo H., Roman S.A., Jr R.H.B, Sosa J.A. “Join the Club.” 2012;147:408–414. 8. Zhang H., Isaac A., Wright E.D., Alrajhi Y., Seikaly H. Formal mentorship in a surgical residency training program: a prospective interventional study. J. Otolaryngol. - Head Neck Surg. 2017;46:1–6.

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

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

COA Bulletin ACO - Summer / Été 2018

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

Potential Attrition in Canadian Orthopaedic Residency Programs Simon T. Adams MBChB, M.D. D. Nathan Ginther, M.D. Evan D. Neuls, M.D. Paul Hayes M.D., FRCSC University of Saskatchewan, Department of General Surgery, Royal University Hospital Saskatoon, SK

issatisfaction with residency programs and potential attrition of residents has been extensively investigated in the United States but until a recent study by Ginther et al., little was known about the equivalent impression of those training in Canadian programs1. This study focused specifically on general surgery residents in Canada and its key finding was that almost a third of respondents reported that they were “somewhat” or “seriously” considering a career change. This prompted the authors to consider how this group compared to residents enrolled in other Canadian surgical specialty programs. To this end, the authors adapted the questionnaire used in the original study to make it more generic and applicable to the fields of orthopaedic surgery, urology, neurosurgery, plastic surgery, otolaryngology, cardiac surgery, ophthalmology and vascular surgery prior to distributing it to the program directors and coordinators for all such residency programs in Canada, in addition to the relevant specialist societies. The full method and results of this study were recently published in the Canadian Journal of Surgery2. Specific to orthopaedics, the study showed a response rate of 42.8% (117 completed responses out of 414 orthopaedic residents registered in Canada according to the CAPER web site), of whom 48 (27.1%) reported that they were either “somewhat seriously” or “seriously” considering leaving their program – a figure close to the average of the nine specialties involved (26.8%) but behind only urology (29.4%) and general surgery (32.7%) for the highest rates of dissatisfaction and potential attrition. The orthopaedic respondents were in keeping with the other specialties in that their PGY-status, gender, age and relationship status were not significantly associated with a desire to switch careers, whereas an intent to pursue post-residency fellowship training was associated with a lower level of dissatisfaction (p=0.004). Where the orthopaedic respondents differed from the other specialties, was in the fact that although an overall desire to pursue an academic practice (rather than a community-based one) was also associated with a significantly reduced risk of wanting to switch careers (p=0.005), this was not true for the orthopaedic residents (p=0.262). Data collected as part of the adaptations for the follow-up study, but not included in the original general surgery study and therefore not appearing in the CJS paper, showed that although length of training was not felt to be a factor for residents when initially applying for orthopaedics at the CaRMS stage, respondents did feel that they would be more likely to COA Bulletin ACO - Summer / Été 2018

pursue alternative specialties if the training were to be extended by one year (p=0.003). In addition, in the follow-up study, residents were asked about their degree of satisfaction with regard to their exposure to operative experience, academia/ research, formal teaching, informal teaching and outpatient clinics. Those that were not considering changing specialties were significantly more satisfied with their exposure to the first four of these (p=0.000, p=0.028, p=0.005 and p=0.000 respectively) but there was no difference between the two groups with regard to outpatient experience (p=0.699). In keeping with the responses from the other eight specialties, the most common reasons given for why orthopaedic residents would consider changing careers were poor work/life balance during residency (51.2% vs 55.5% overall) and fear of un/ underemployment post-residency (47.6% vs 40.8% overall) with excessive work hours during residency coming in third (33.4% vs 27.6% overall). The primary reasons why residents would choose to persevere in their current programs were also similar to those of the other eight specialties, and showed a statistically significant difference between those considering a career change and those who were not. 78.0% of orthopaedic residents taking part in the study stated that they would choose to stay in their current program because they enjoy the work (80.6% for those not considering switching programs and 54.2% for those who were). The overall figure for the nine specialties was 87.5%. Conversely, 45.8% of orthopaedic residents felt that they had already invested too much time in their current program for switching to be a viable option (38.0% for those not considering switching programs vs. 66.7% for those who were). The overall figure was 56.3%. This study has provided some insight into the levels of satisfaction and security felt by orthopaedic residents in Canada, and has provided a means of comparison to residents in other surgical specialty programs with similar post-training employment prospects and lifestyles. Although the majority of trainees in these specialties appear to be satisfied with their career choices, a not-insignificant number appear to be harbouring a serious intent to switch career paths. References 1. Ginther D.N., Dattani S., Miller S., Hayes P.: Thoughts of Quitting General Surgery Residency: Factors in Canada. Journal of surgical education 2016, 73(3):513-517. 2. Adams S., Ginther D.N., Neuls E., Hayes P.: Attitudes and factors contributing to attrition in Canadian surgical specialty residency programs. Canadian journal of surgery Journal canadien de chirurgie 2017, 60(4):247-252.

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

Think Your Will and POAs are Valid? (There’s a good chance they might not be) Adam O’Neill, BSc, MBA, CLU, CHS

ne of the most important, if not the most important, legal documents in an orthopaedic surgeon’s life is their will and powers of attorney. These documents determine that your desires are carried out upon your death, or in the event that you can no longer make decisions yourself regarding your assets or personal health. And yet, many Canadians (and by extension, many Canadian orthopaedic surgeons) either don’t have valid wills and powers of attorney written, or have documents which may have become invalid due to life events, changes in the legal landscape, or other reasons. Dying with No Will According to recent surveys, somewhere around 63% of Canadians do not have a valid will in place1. Surgeons will almost certainly have nowhere near this rate of lack, but I still come across individuals who have delayed or ignored this need long after it should have been attended to. Many Canadians think that if they haven’t prepared these documents, they don’t have a will or powers of attorney. In fact, they do. If you die intestate (with no will in place), your province of residence, in its infinite wisdom, has ever-so-helpfully anticipated that situation and written a “default” will for you. It is this set of “default” rules which will be applied if you do not take it upon yourself to write out and codify your own directions. While some may feel this provides some level of security, it very rarely, if ever, results in an outcome which would be desired. If minor children are the beneficiaries, without specific instructions, all funds are received at age 18. Using myself as an example, I can confidently say that if I had inherited a large sum of money at that age, there is a very good chance that I may have made less-than-ideal decisions on its use. If powers of attorney are not laid out, your spouse (whom you may intend to have that power) may very well end up being approved and appointed as your power of attorney. However, the court may also (reasonably) assume that there were valid reasons which led you to refuse to appoint them while you had the chance. This, in turn, may then lead them to require your spouse to report to the court (on a regular basis) their actions, and seek approval and permission to continue in this role. While that action may be imminently reasonable, imagine the stress and strain that this would subject your spouse to in the event of your being in a coma (having to return to court to access assets, approve medical treatments, or determine the future of business shares). This situation is so distasteful and easily avoidable, that the only thing I am forceful about in my financial practice is that clients have (or immediately begin the process of putting into place) a valid will and powers of attorney.

Invalid Documents Most orthopaedic surgeons will have had the foresight to put proper documentation in place. However, despite responsible and timely efforts, many individuals’ best efforts may have been rendered invalid by changes in their lives or in the legal environment. The birth of a new child or a new marriage can invalidate previous wills. Changes in the legal environment (such as the 2014 Wills, Estates and Succession Act in BC), can also affect previously valid legal documents. Additionally, in my practice I have reviewed numerous very poorly-written wills which are either too vague to be effective, or which are rendered outright invalid, in part or in whole. Corporate Wills and POAs For those surgeons who have incorporated (either a professional corporation or any other type of corporation), a separate set of documents is required to determine the direction and intent for your corporate assets. Incomplete Documents One common oversight is appointing backups for key positions such as executor or power of attorney. In far too many cases, an individual who was your first choice may no longer be suitable, willing, able, or even alive to execute those duties. Ensuring appropriate backups as a failsafe ensures those duties will be attended to by individuals whom you’ve chosen. Changes in society and technology can also present a need to review your documents. For example, is there any language in your will detailing your online or digital assets? Who can access and control your Facebook or other online accounts? For many families this has become a de facto family photo album, the loss of which would be devastating. Out-of-date Documents Has your executor moved overseas? Have your children proved maturity, or had their situation and needs change? Have you sold any of the assets specifically named in your will? Have any of your intentions or desires changed at all since you wrote your will? Even if the laws haven’t changed, there may have been significant changes to the individuals, assets, or desires covered in those documents. One common error is to neglect the will and powers of attorney once written. As a best practice, documents should be reviewed at every life event and regularly (for example, every five years) to ensure that your wishes remain accurately reflected. For Your Loved Ones As a Financial Advisor whose practice focuses on medical professionals, I see the effects of invalid, poorly constructed, or outright non-existent wills and POAs far too often. The damage and pain it can cause can be both truly catastrophic and easily avoidable. If you do not yet have these documents in place,

COA Bulletin ACO - Summer / Été 2018

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

(continued from page 57)

I strongly urge you to make an appointment with an estates lawyer to do so. If you have them in place (or think you do), then please review them to make sure they are still valid and representative of your current wishes.

mended to seek independent advice related to your particular circumstances as necessary.

The information in the article has been provided to the COA by O’Neill Financial Inc. and COAplan Inc. It is always recom-

1. http://www.lawpro.ca/news/pdf/Wills-POAsurvey.pdf

References

Operate Through Your Initials

The history of the “Wrong-sided Surgery” initiative in Canada Paul Wright, M.D. Whistler, BC

n the mid 1990’s, Canadian orthopaedic surgeons forever changed the safety of surgical procedures in Canada, and in the rest of the world. They created a paradigm shift in the way that we recognize medical errors and assure the safety of patients as their “rights”. Most significant, was the fact that this new era of operating room safety was built by Canadian orthopaedic surgeons from the ground up. The initiative came about from the recognition by COA members that we can make our surgical activity even safer for our patients. It was not imposed or directed from above, but created and executed from within our own ranks.

Ross Leighton, as Chair, spearheaded statements on operating room minimum requirements, retirement and manpower. Brendan Lewis successfully championed areas of patient safety. Most noticeably, definitive identification of the correct level in spinal Pioneers and leaders of various initiatives surgery became recognized worldwide that are now considered integral parts of because of his efforts. I looked into our our practice will be contributing to the COA medical protective insurance, evaluating Bulletin as part of our history and legacy the relevance and wisdom of staying series. In this edition, I have invited Dr. Paul with the Canadian Medical Protective Wright, an original champion for the Operate Association. By 1993, we had risen to the Through Your Initials program, to provide most expensive level of insurance at that some background behind the development time. We needed to identify the cause and how we could alter our practices and execution of this important initiative. to lower our collective risk rates. It was during this liaison with the CMPA that Dr. Paul Wright is a retired orthopaedic I was privileged to see just where we surgeon from Whistler, British Columbia. He were having our greatest exposure to is Emeritus UBC, Department of Orthopaedics litigation. and worked in Burnaby, British Columbia.

He was on numerous COA committees from 1983 to 2007, was Chair of the Canadian Orthopaedic Foundation from 2002 to 2007, and a member of their Board from 1991 to 2007. - Ed.

By embracing, endorsing and enacting the Operate Through Your Initials initiative in Canada, the safety and medical errors recognition era commenced nationally.

Most currently trained Canadian orthopaedic surgeons would not know that there ever was a time when we did not identify the site of surgery, and undertake a checklist before initiating a procedure. To a recently trained graduate, the way that we historically prepared for a surgical undertaking would be identified as deviant surgical behavior. For years, we had not questioned this “normalization of deviance”1. All of the hard working members of the COA’s former Committee on Orthopaedic Practice and Economics (COPE) need to be congratulated for their significant contributions. In the 1980’s and 90’s, there were three “Amigos” that produced most of the Position Papers directed towards patient safety and the wellbeing of orthopaedic surgeons: Drs. Ross Leighton, Brendan Lewis and I were members of the COPE for decades. COA Bulletin ACO - Summer / Été 2018

Operating on the wrong limb with the successful litigation, and the harm to our orthopaedic patients, jumped off the page.

With rates of 13 successfully litigated suits per year for wrong-sided surgeries2, I knew that we could do better, and possibly eliminate the problem completely. The actual rate of wrong-sided surgery is not known, as many go unreported. A confidential survey of members of the Arthroscopy Association of North America revealed that during the lifetime of an orthopaedic surgeon, 8.5% had operated on the wrong knee during their careers3. While the statistical significance may be low, the impact on the patient and the surgeon is enormous. I felt we could eliminate this error. Changing Surgeons Behaviour Altering a professional’s behaviour is not easy4. I knew a protocol for wrong-sided surgery needed to be short, simple and quick to be executed preoperatively. Recognizing that surgeon buy-in was paramount, I also knew that I needed to engender ownership of this policy from the surgeons. I used the model employed by Canadian pilots for a checklist, and incorporated a timeline of execution.

Training & Practice Management / Formation et gestion d’une pratique (continued from page 58)

In June of 1994, I personally presented the draft of this Position Paper to the COA’s Board of Directors. They enthusiastically endorsed the paper, and tasked the COPE to execute it5,6,7 .

Within five years of the roll out of the Canadian initiative, most orthopaedic associations or health-care authorities in the world had established their own protocols for wrong-sided surgery.

Summary of Position Paper – Surgeon Checklist

By 2001, almost all health authorities and hospitals in Canada had taken ownership of the Operate Through Your Initials concept, and had extended it to cover a broader range of procedural issues.

1. Have your office chart with you in the operating facility. If this is not possible then review the hospital chart. 2. The responsible surgeon should visit the patient preoperatively and mark the limb or location with his or her INITIALS. 3. Have the patient identify the site and side to be operated upon. 4. Mark the specific area to be operated upon with your INITIALS using a permanent marking pen. 5. Do not drape our your initials before surgery. You must see your INITIALS while you are operating. 6. DO NOT OPERATE UNLESS YOU SEE YOUR INITIALS BEFORE MAKING YOUR INCISION. OPERATE THROUGH YOUR INITIALS

There were many individual crusaders who took this initiative up as their own, and contributed to its success. Dr. Don Johnson (University of Ottawa) significantly popularized it through his international arthroscopy publication. Originally, the COPE also had developed a Position Paper on “Pause for the Patient”, however, the Committee felt that it was best to focus on the wrong side/wrong level issues first. As it turned out, most of the background work for this paper was applied to the “Time Out” concept used now extensively in Canada and across the world. Results Hard data remains difficult to assemble, as the true incidence is not really reported. The numbers are also so small on a percentage basis - going from 13 to 0 cases is not statistically significant. It does however represent a healthy trend.

The timeline was followed with acceptance by the Board in June 1994 and fully rolled out in June 1995. Small Change-Big Impact8 I was contacted by Health Canada, the National Steering Committee on Patient Safety (formed in 2002), fourteen international organizations, multiple Canadian and American hospitals, and many health regions throughout the world. All wanted the “formula” and were curious as to how we enacted it so quickly. As Canadians, we are always happy to share our experiences, as it represents safety for the patients. I genuinely feel that the key to the quick execution in Canada (pre-Internet!) was the endorsement and teaching of the protocol in training programs. Canada immediately had an army of the brightest and most enthusiastic orthopaedic surgeons ensuring that it was carried forward. I remain indebted to the directors of the training programs for their universal acceptance and standardized training protocols.

In the early 90’s, 13 cases were litigated yearly by the CMPA. By the early 2000’s, we experienced several years with 0 cases. This significant “trend” meant that we dropped one category in the CMPA risk level. Between 1996 and 2006, COA members cumulatively paid out 64 million dollars less in CMPA dues. It was projected that 136 million dollars less was paid for malpractice cases. Most importantly, it was projected that 70 fewer orthopaedic patients were subjected to this error of wrong-sided surgery. Canadian orthopaedic surgeons made a difference. The number of wrong-sided surgeries litigated has remained low. While the preoperative protocols are now mandated by hospitals and regions, Canadian orthopaedic surgeons can proudly enjoy their success at creating the programs from within.

Image of a promotional pamphlet with a “Free Pen” 1995. In the pre-Internet days, slide presentations, written articles and personal contacts were the modes of informing orthopaedic surgeons of “Operate Through Your Initials”.

International Application Dr. Jesse Delee (San Antonio, Texas) listened to my standardized presentation on Operate Through Your Initials in June of 1995. He immediately approached me to share this with American counterparts. By September 1997, he had a task force in place with the AAOS that rapidly developed their own tailored program of “Sign Your Site”. Acceptance and adoption proved to be more challenging in the US, as they did not experience the same rapid deployment and enthusiastic cohesion that we enjoyed within the COA.

Small Actions-Big Change8 Future Challenges Current orthopaedic surgeons can most influence the safety of their patients. By recognizing and acting upon “Normalization of Deviance”1, big changes can be made with small actions. When you see that something is wrong, and can make things safer – act upon it. Use the committees of the COA to help you achieve these changes. COA Bulletin ACO - Summer / Été 2018

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

(continued from page 59)

This initiative is an example of how the COA, working as a cohesive group, was able to significantly improve patient safety for Canadians and the world. (Authors Note: I remain greatly indebted to my colleagues Drs. Ross Leighton and Brendan Lewis for their tireless work and input on this project, and to all COA members who so wholeheartedly endorsed this initiative and really made it their own personal crusade.)

4. Serdalis, N., Hull, L., Birnback, D.J., Improving Patient Safety in the Operating Theatre and perioperative care: obstacles, interventions and priorities for accelerating progress. British Journal of Anaesthesia, Vol 109, Suppliment 1, Dec 2012, p 3-16. 5. Wright, P.H., Operate Through Your Initials: Position Paper on Wrong-Sided Surgery in Orthopaedics. Presented to the COA Board. June 1994.

References

6. Lewis, B.D., Initial Evidence, reduced levels of wrong-sided surgery. COA Bulletin, 2002:10.

1. Banja J., The normalization of deviance in healthcare delivery. Bus Horiz Tab. 2010;53:139–148.

7. Meakins, J.L., Site and Side of Surgery: Getting it right. Editorial. Canadian Journal of Surgery. Vol 46. No. 2. April 2003

2. Canadian Medical Protective Association, Cases of Litigation, 1993-1997.

8. Dutton,Jane E., Spreitzer, Gretchen M., 2014. How to be a positive leader: Small Actions, Big Impact. Berrett-Koehler Publications Inc. San Francisco.

3. Albright, Daniel. J, MacDavid Jr., Jason, The Incidence of Wrong-Site Surgery in Knee Arthroscopy. Confidential Survey. The Arthroscopy Association of North America, 2000.

Your COA in Review

Coup d’œil sur l’ACO

a Séance de travail de l’ACO a été transformée en séance de consultation où les membres peuvent poser des questions ou formuler des suggestions au Comité de direction et au conseil d’administration.

Thursday, June 21 16:30-17:30 Saanich – Level 1, Victoria Conference Centre Town hall session brings together leadership & membership he COA Business Meeting has been revamped into a town hall session where members can address the Executive and Board of Directors with any questions or suggestions.

This open forum gives all members the opportunity to: - learn about recent projects, programs and initiatives carried out by COA committees and staff - provide feedback, input, and the chance to direct any questions to the leadership - vote on bylaw changes - find out who this year’s Nominating Committee has selected as the 2nd President Elect - select the next Nominating Committee who will elect the 2021 COA President

All COA members are invited to participate

COA Bulletin ACO - Summer / Été 2018

Le jeudi 21 juin, de 16 h 30 à 17 h 30 Salle Saanich, 1er étage, Victoria Conference Centre Séance de consultation réunissant la direction et les membres

Cette assemblée générale permet à tous les membres : - d’en savoir plus sur les projets, initiatives et programmes récents des comités de l’ACO; - de formuler de la rétroaction, de partager leurs idées et de poser des questions à la direction; - de se prononcer sur les modifications au Règlement général; - d’élire les membres du prochain comité des candidatures; - de découvrir qui sera le prochain président élu.

Tous les membres de l’ACO sont invités.

More possibilities

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

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

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ICORS

2nd Meeting of the

International Combined Orthopaedic Research Societies (ICORS) Deuxième réunion des

International Combined Orthopaedic Research Societies (ICORS)

Montréal 2019 June 19-22 Du 19 au 22 juin www.2019icors.org