Issue 67
November/December 2004 
In this issue:
- Now or Never - the political wait time exists to reduce wait times
- Hip Resurfacing - an implant whose time has come again
- The Line Forms Here - e-activist channells patient frustration to politicians
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A Note Of Optimism - Better times are on the way
Alain Jodoin, M.D., FRCSC
President, Canadian Orthopaedic Association
By the time you read this letter, Christmas and the holiday season will be upon us. Time certainly passes quickly when you're busy!
In recent weeks, the COA has been focusing on enhancing its communication strategy with political leaders and distributing information on the work of its committees. The report from the National Standards Committee was of particular interest to us.
With the support of Doug Thomson, CEO of the COA, and Hans Kreder, Co-Chair of the National Standards Committee, I wrote to Prime Minister Paul Martin on behalf of the COA to congratulate him on the health care agreement negotiated with the provinces. I also offered him our assistance in determining evidence based benchmarks for medically acceptable wait times for primary orthopaedic procedures.
In addition, I asked Mr. Martin to consult with the COA when the time comes to discuss implementation methods for the resulting benchmarks once these have been finalized.
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Last Updated ( Wednesday, 21 March 2007 )
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New Technology – A Blessing and A Curse
Emil H. Schemitsch, M.D., FRCSC
Editor in Chief
Toronto, ON
As I sit here thinking about the arrival of the holidays, I wonder if the New Year will allow my holiday wish list to be filled. New technologies are often thought of by many as expensive new toys. Yet these new technologies have the potential to fundamentally change how we practice our specialty. The introduction of new technology is both a blessing and a curse. As we develop new methods to look after our patients, we feel pressure to deliver these costly new technologies to our patients. In many instances, this pressure is rightfully justified. Work is being done with minimally invasive surgery, robotics, computer-assisted surgery, bone substitutes, and bone imaging which will revolutionize the field of orthopaedic surgery. Canadian orthopaedic surgeons have always been international leaders. We must embrace, understand and train with this new technology if we are to maintain our position as leaders and innovators.
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Last Updated ( Monday, 11 February 2008 )
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Hip Resurfacing – An Implant Whose Time Has Come Again
James N. Powell, M.D., FRCSC
Guest Editor
Calgary, AB
At this year’s Canadian Orthopaedic Association Annual Meeting held in Calgary, a symposium was held on the assessment of new technologies including one that has recently reappeared: hip resurfacing. I believe that this is currently one of the most contentious topics in arthroplasty surgery. Dr. Steven J. M. MacDonald organized the symposium on resurfacing and he was one of four speakers - three of whom have agreed to summarize their presentations for publication in this issue of the COA Bulletin. I am certain that you will enjoy reading the articles by Drs. Paul E. Beaulé, James P. Waddell and Steven J. M. MacDonald.
Following this symposium and case presentation, we polled the attendees. Thirty-six per cent (36%) of the attendees who were not performing resurfacing were prepared to consider it after appropriate training. Seventy-percent of the attendees felt that metal ion release was a significant issue in hip resurfacing arthroplasty. Ninety-percent that felt that each orthopaedic surgeon trained in the technique should be able to undertake resurfacing arthroplasty. Interestingly, 90% also felt that it should be reserved for the domain of the high volume arthroplasty practitioner. It was almost an even split as to whether this operation should be available in a publicly funded system with 55% voting yes on this issue and 45% voting no. Almost 90% of surgeons felt that patients having hip resurfacing should be in a clinical trial and 95% felt that patients should be followed in the Canadian Joint Replacement Registry.
I trust you will enjoy reading the articles and I anticipate much more debate on this topic over the next two or three years.
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Last Updated ( Wednesday, 21 March 2007 )
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Surface Arthroplasty of the Hip:
Does it Have a Role in the 21st Century?
Paul E. Beaulé, M.D., FRCSC
Assistant Clinical Professor
David Geffen School of Medicine at UCLA
Joint Replacement Institute at Orthopaedic Hospital
Los Angeles, CA
Introduction
In recent years, there has been resurgence of interest in metal-on-metal surface arthroplasty of the hip1 as an alternative to total hip replacement for the young and active adult2. Concomitantly, ceramic-on-ceramic bearings and new polyethylenes are being introduced as promising technology to improve the longevity of standard total hip replacements. Although these technologies are being embraced3,4by many, the 10-year survivorship of ceramic-on-ceramic total hips is relatively low at 79-85%5,6, and the new polyethylenes have only two-year data7.
Similarly, the renewed interest in the clinically proven low wear of the metal-on-metal bearing8,9combined with the capacity of inserting a thin wall cementless acetabular component10, has fostered the reintroduction of surface arthroplasty of the hip. As in other forms of conservative hip surgery. i.e. pelvic osteotomies11 and surgical dislocation with head-neck contouring 12,13, patient selection will help minimize complications14 and the need for early reoperation. Currently there are two applications for hip resurfacing: 1) hemi-resurfacing in the early stages of osteonecrosis and 2) full surface arthroplasty in presence of advanced arthritis. Both will be discussed in terms of indications and results.
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Last Updated ( Wednesday, 21 March 2007 )
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Hip Resurfacing: A Good Idea?
Steven J.M. MacDonald, M.D, FRCSC
London, ON
Hip resurfacing implants enjoyed a brief period of popularity 25-30 years ago. The results at that time, however, were clearly inferior to conventional total hip replacements and most, but not all, centres abandoned these implants.
Over the last five years or so there has been a growing interest in the newer generation of resurfacing implants and, clearly, a resurgence in their use. The Australian Orthopaedic Association National Joint Registry1 reported that resurfacing implants accounted for 6.7% of all primary hip arthroplasties performed in 2003. In areas of Europe, and particularly in the United Kingdom, the popularity of this implant grows at a rapid pace.
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Figure 1 An anteroposterior radiograph of a resurfacing implant functioning well at one-year follow-up.
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Last Updated ( Wednesday, 21 March 2007 )
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Hip Resurfacing Arthroplasty
James P. Waddell, M.D., FRCSC
Toronto, ON
The first successful hip arthroplasty to be widely used was a surface replacement known as cup or mould arthroplasty. In this procedure, a single shell was placed between a shaped femoral head and a prepared acetabulum and movement was used to try and develop fibrocartilage on the two bony surfaces. This operation was supplanted by stemmed total hip replacement using a polyethylene cup and a stainless steel or cobalt-chrome stem - both components being held in position by methylmethacrylate. This total hip replacement was reliable and the results were reproducible.
Over time, conventional total hip replacement was recognized as having a number of problems including wear of the polyethylene component, loosening of the femoral and acetabular components with accompanying attritional bone loss. In addition, activity reduction was recommended for patients and dislocation remained a persistent problem. Resurfacing arthroplasty was a very attractive option for the young active patient. Large head size made dislocation virtually impossible and because of the increased stability and decreased potential for wear, activity reduction for the patient would not be necessary.
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Last Updated ( Wednesday, 21 March 2007 )
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The Orthopaedic Surgery Training Programme at Queen’s University
David Yen, M.D., FRCSC
Kingston, ON
Queen’s University is located in Kingston, Ontario which is found where the Rideau Canal meets Lake Ontario at the mouth of the St. Lawrence River. Kingston was the first capital of the united Upper and Lower Canadas before the national seat of government was moved to Ottawa in the 1840’s. The School of Medicine at Queen’s was established in 1854. Post graduate training in orthopaedic surgery began in the mid 1960’s. Initially, the Royal College granted Queen’s recognition for one year of training in orthopaedic surgery with the second year taking place at the University of Toronto. Within three years, after an on-site review by the Royal College, accreditation for full training at Queen’s was granted, with teaching taking place under the supervision of Drs. Michael Simurda and Charles Sorbie at the Kingston General Hospital and Dr. John Hazlett at the Hotel Dieu Hospital.
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Last Updated ( Wednesday, 21 March 2007 )
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The Bone and Joint Decade Nears the Half Way Mark
James P. Waddell, MD, FRCSC
Coordinator, Canadian National Action Network
For the Bone and Joint Decade
Toronto, ON
We are now moving up to the five year mark of the Bone and Joint Decade. We are fortunate that Canada will be able to host the Bone and Joint Decade Conference in 2005 – marking the half way point of the Decade. The decision has been made to now hold this meeting in the last week of October. The venue has changed from Toronto to Ottawa in order to allow more participation by a wider variety of individuals.
ACAP (Alliance for Canadian Arthritis Programme) is holding a Standards of Care Conference which will involve members of all disciplines involved in delivering musculoskeletal care; they are going to partner with the Bone and Joint Decade International Steering Committee (ISC) and coordinators from National Action Networks from around the world to work on standards of care for a number of conditions in countries outside of Canada.
We will be requesting participation in this meeting from individual members of the Canadian Orthopaedic Association (COA) with expertise in different aspects of health care delivery both at home and abroad.
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Last Updated ( Wednesday, 21 March 2007 )
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Now or Never
the political will exists to reduce wait times
Doug Thomson
CEO, Canadian Orthopaedic Association
When the First Ministers reached their $41-billion accord on long-term health care funding last September, the federal government specifically pledged $4.5 billion for a Wait Times Reduction Fund. These new monies would be dedicated to training and hiring human resources, clearing backlogs, building capacity, expanding community care and developing tools to manage wait times. All this activity would be directed at five clinical areas deemed to be priorities: cancer, heart, diagnostic imaging, sight restoration and joint replacement.
In return for its largesse, the federal government finally got what it had sought for so long. For the first time ever, the provinces and territories committed themselves to performance evaluations on wait-time reduction. And lest anybody develop cold feet, a very tight timeline was imposed on the whole process. By December 2005, all provinces and territories must have developed “comparable indicators of access to health care” and “evidence based benchmarks for medically acceptable wait times.” By December 2007, each jurisdiction must establish target dates to achieve priority benchmarks.
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Last Updated ( Wednesday, 21 March 2007 )
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Informing the Process
the OOA has government’s attention
Dennis Jeanes
Special to the Canadian Orthopaedic Association
Toronto, ON
For better or worse, federal and provincial governments have zeroed in on total joint replacements as one of the “big five” clinical areas where wait times must diminish and access to service must increase (see “Now or Never” on p. 12 of this issue of the COA Bulletin). And there’s $4.5 billion of new money to back up the initiative. If the Ontario Orthopaedic Association’s (OOA) government-relations efforts with the ministry of health were ever at a critical phase, it’s now. The whole, confounding, tangled mess — not enough beds, not enough OR time, not enough ORs, not enough surgeons, not enough nurses and, especially, not enough anaesthiologists — is about to be straightened out, and on the double.
“One way or another, this government initiative has to translate into more time in the operating room for orthopaedic surgeons,” says Dr. Peter Schuringa, the newly appointed President of the Ontario Orthopaedic Association. “The first and most crucial need is to create more OR resources."
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Last Updated ( Wednesday, 21 March 2007 )
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Improving Orthopaedics with Digital Imaging
Jason Knox
Marketing Manager
AGFA Health Care
Toronto, ON
Traditionally reserved for a few departments in the hospital, PACS (Picture Archiving and Communications System) is growing to become an integral piece of information technology throughout the health care institution. One area that has relatively low PACS penetration is the orthopaedics department. Although orthopaedic surgeons are no strangers to digital technology, relatively few have embraced it and even fewer have integrated a digital planning workstation into their department. Despite the access to on-demand imaging with traditional PACS workstations, the reluctance to use this technology in orthopaedics exists largely due to feature sets that were not robust enough to meet the demands of planning.
PACS has evolved and its range of capabilities now extends beyond the traditional confines of radiology. Recently unveiled, PACS workstations have been enhanced with specialized orthopaedic tools to enable the orthopod to prepare for surgery at a new level of efficiency and precision.
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Last Updated ( Wednesday, 21 March 2007 )
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The Line Forms Here
e-activist channels patient frustration to politicians
Dennis Jeanes
Special to the Canadian Orthopaedic Foundation
Toronto, ON
All too often, orthopaedic surgeons and clinic staff are on the receiving end when patients decide to vent their pent-up feelings about lengthy wait times and poor access to medications and medical devices. So COA members will be relieved to know that a new service on the Foundation’s web site should take some of the pressure off.
Thanks to a license for E-Activist, donated by AstraZeneca, you now have somewhere to send irate and upset patients that’s positively therapeutic. Just direct them to the Foundation’s new home page.
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Last Updated ( Wednesday, 21 March 2007 )
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Best Face Forward
Web site brings new resources to patients and professionals
Dennis Jeanes
Special to the Canadian Orthopaedic Foundation
Toronto, ON
The web site address may be familiar — www.canorth.org — but, as of October 12, once you arrive at the Foundation’s home page, all is new. Murky blue has been replaced by bright white-space, defined by the Foundation’s new visual identity (which we announced last issue) and upbeat portraits of people of all ages. The site’s basic architecture has been laid out, and there are information streams for patients and professionals, fund-raisers and donors, volunteers and advocates. Resources are easily available to visitors looking for information, arranged in a vertical menu on the left. The format is maintained throughout, so that as new services and content come on-line in the future, users will intuitively know where to find them.
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Last Updated ( Wednesday, 21 March 2007 )
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2004 Canadian Orthopaedic Foundation Financial Report
Kevin G.S. Orrell, M.D., FRCSC
Secretary/Treasurer, Canadian Orthopaedic Foundation
Halifax, NS
The Board of the Canadian Orthopaedic Foundation reviewed and approved the audited statements for the period ending March 31, 2004, at its recent teleconference meeting.
The Foundation had a strong fund-raising result for the year, with totals up four percent over prior year. Sponsorships and other donations increased by $201K, resulting in an overall increase in revenue of 18%.
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Last Updated ( Wednesday, 21 March 2007 )
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Report from the First Canadian ASG Fellow
Ross Leighton M.D., FRCSC
2004 Canadian ASG Fellow
Halifax, NS
In 1978, a Travelling Fellowship was jointly established and sponsored by the Austrian, Swiss and German Orthopaedic Societies. Since then, fellows have been visiting centres in Britain, Canada and the USA. The original intention was also for a reciprocal fellowship, and in 1998, two orthopaedic surgeons from the USA visited the German-speaking countries in Europe. This year saw the first fellows from Britain and Canada joining with two others from the USA. I am very grateful to the Canadian Orthopaedic Association for selecting me as this first Canadian representative.
The ASG Fellowship is highly regarded in Europe, and a large alumnus association has developed promoting dialogue and collaboration. Many people worked hard to make our trip a great success, but particular thanks should go to Prof. Hans-Werner Springorum from Bad Mergentheim, and Prof. Jochen Eulert, and Dr Christian Hendrich and Dr Dirk Boehm from Würzburg, of the ASG Alumnus Association who perfectly coordinated all of the arrangements for our visits and travel.
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Last Updated ( Monday, 11 February 2008 )
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Dr. Donald Edward Sweet
Orthopaedic Educator
Thomas V. Smallman, M.D., FRCSC
Director, COA Annual Basic Science Course
Syracuse, NY
Unexpectedly, on the 2nd of August 2004, Dr. Don Sweet died of complications related to renal failure. His contribution to the orthopaedic community in Canada, and the impact of his loss is best summarized by Dr. Alain Jodoin’s note of condolence to Dr. Sweet’s widow, Elizabeth, and his family and friends:
“Please accept our sincere condolences on the passing of Dr. Don Sweet from his many Canadian friends and colleagues. We consider Don Sweet an icon in the world of orthopaedic education – he will be sorely missed.
His voluntary participation as the principle speaker at the Canadian Orthopaedic Association Annual Basic Science Course for the past 17 years has allowed more than one thousand orthopaedic residents to experience his unique, powerful and inimitable style of teaching. His words and his thoughts touched all. At the recent meeting of the COA Board of Directors, it was unanimously decided to honour Dr. Sweet’s enormous contributions to the education of Canadian orthopaedic residents with the COA Award of Merit. This award was scheduled to be presented at the 2005 Annual Meeting in Montréal. Sadly, this presentation will now be made “à titre post-hume” as we say in French.
We wish, through this message to you who shared his life, to acknowledge the passing of a great man. We give thanks for his short presence in our lives.”
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Last Updated ( Wednesday, 21 March 2007 )
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