Will Physician Extenders Improve Access to Care

Emil H. Schemitsch, M.D., FRCSC
Editor in Chief

Given the ongoing problems with access to care, it makes sense to have orthopaedic surgeons doing the work that they were trained to do. As an arthroplasty surgeon, I myself attend a busy arthritis clinic once a week where I see many patients with the diagnosis of “knee arthritis”. These patients are potential candidates for total knee replacement. Yet many actually have chondromalacia or minor meniscal pathology. They often have not received the most rudimentary conservative treatment including physiotherapy. A physician extender trained to perform some of the functions currently performed by the orthopaedic surgeon could screen these patients and begin treatment. This would allow me to see those patients who were ready for total knee replacement and thus improve access to this procedure.

A Model of Efficiency
Alberta’s optimal care experiment

Dennis Jeanes
Special to the Canadian Orthopaedic Association
Toronto, ON

During the recent federal election, as the Conservatives strategically dominated the headlines throughout December with their daily policy-platform releases, one non-partisan news item managed to break through the campaign promises, briefly capturing the national spotlight. And it’s easy to see why.

Education and Access to Care
the Bone and Joint Decade’s focus on the future

James P. Waddell, M.D., FRCSC
Coordinator, Canadian National Action Network
For the Bone and Joint Decade

The National Action Network (NAN) for the Bone and Joint Decade in Canada enters 2006 re-energized as a result of our very successful meeting in October/November 2005. By having so many people work together towards a common goal for success at the meeting, we are able to enlist the support of many people who had previously only been peripherally engaged with Bone and Joint activity.

Surgical Implant Generation Network (SIGN)
A Mission to Egypt

Myles Clough, M.D., FRCSC
Kamloops, BC

In September 2005 I was asked to attend the annual conference of the SIGN project and describe the resources on the Internet which relate to Intramedullary Nailing. This first hand look at the project was fascinating and I was provoked to volunteer for a SIGN mission to Egypt, which took place in November 2005.

Dr. Alain Jodoin, the Backbone of the Programme d’orthopédie Édouard-Samson, Completes His Tenure

Dominique Rouleau, M.D.
PGY5 POES
Montréal, QC

Residents of the Programme d’orthopédie Édouard-Samson (POES) celebrated the end of Dr. Alain Jodoin’s eight-year tenure as Programme Director at our Christmas dinner held on December 17, 2005. A compassionate mediator with vision, Dr. Jodoin was a well appreciated director for his respect for residents and their dreams. This exceptional spine surgeon practices in the Trauma Centre at Hôpital Sacré-Coeur, where he will continue to pass on his passion for surgery to residents. Thank you again!

AIOD Canada:
Setting a New Standard for
Research and Education

Mohit Bhandari M.D., MSc, FRCSC
Hamilton, ON

Dave Sanders M.D., FRCSC
London, ON

Pierre Guy M.D., MBA. FRCSC
Vancouver, BC

Emil H. Schemitsch M.D., FRCSC
Toronto, ON

For the Association Internationale pour l’ Ostéosynthèse Dynamique (AIOD) Canada

What is the Association Internationale pour l’Ostéosynthèse Dynamique (AIOD)?
AIOD was founded in 1986 in Strasbourg, France. Its founding principles focused upon research and science-based methods for dynamic osteosynthesis and closed treatment techniques for bone fracture management. As a global professional association of orthopaedic trauma surgeons, AIOD continues to deliver programmes for training and education; the publication of scientific journals and peer-reviewed papers; the sponsorship of clinical and technical studies; and the funding of research projects. The Association’s web site, www.traumacareinstitute.org, provides an overview of activities, fellowships and research funding opportunities.

Comparative Effectiveness of Kyphoplasty for Osteoporotic Insufficiency Fractures

Michael G. Johnson, M.D., FRCSC
Assistant Professor Orthopaedics and Neurosurgery
Winnipeg Spine Programme
University of Manitoba

It is estimated that age-related osteoporotic vertebral compression fractures (VCF’s) occur in more than 500,000 patients per year in the United States¹. Failed nonsurgical management may lead to persistent pain and may require surgical intervention. Minimally invasive methods of treating the symptoms of spinal compression fractures have generated considerable interest over the last two decades. Widely accepted treatment algorithms for the nonsurgical and surgical management of painful osteoporotic compression fractures have yet to be clearly established^3,4,5. The goal of this article is to examine the comparative effectiveness of kyphoplasty versus vertebroplasty and nonsurgical management of osteoporotic insufficiency fractures.

Osteoporotic Vertebral Fractures

Garth E. Johnson, M.D., FRCSC
Ottawa, ON

The spectrum of osteoporotic vertebral fractures is extremely large: ranging from asymptomatic vertebral wedging which increases with aging, to acute symptomatic fractures occurring with minimal injury. The quoted prevalence of vertebral fractures depends primarily on the criteria for diagnosis with some additional variation from one population to another^1,2,3. Generally speaking, a nine to 12 percent incidence is given for middle-aged women with a correlation between vertebral fracture prevalence and bone mineral density in the lumbar spine, height loss and chronic back symptoms. The male to female ratio also seems quite variable, varying from two to one in European population to a high of four to one in patients referred to a metabolic bone disease clinic. Several reports have shown a higher incidence in men, aged 45 to 54, in populations exposed to physically demanding activities and this may be due to occupationally-related vertebral fractures. The incidence is higher in Caucasions and Asians than in persons of dark skin colour⁴.

Introduction

John Antoniou, M.D., FRCSC
Scientific Editor

Adult orthopaedic surgeons are treating an increasing number of patients with osteoporosis. Although all surgeons are well aware of this phenomenon, most patients are discharged from the hospital or from a physician’s care without adequate evaluation and treatment of the osteoporosis. Few patients with recent fragility fractures are evaluated for low bone density or prescribed medications for osteoporosis despite the availability of therapeutic agents that effectively reduce the risk of fractures in patients who have suffered a previous fracture. It is important to remember that the responsibility of the surgeon does not end with the treatment of a fragility fracture.

The Diagnosis of Osteoporosis:
Identifying the patient at high risk of fracture

Jonathan D. Adachi M.D., FRCPC
Professor, Department of Medicine
St. Joseph's Health Care - McMaster University
Hamilton, ON

Alexandra Papaioannou, M.D., FRCPC
Associate Professor, Department of Medicine
Hamilton Health Sciences - McMaster University
Hamilton, ON

Definitions
In a 1993 consensus conference, osteoporosis was defined as “a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue with a resultant increase in fragility and risk of fracture¹.” More recently the National Institutes of Health consensus conference modified this definition to reflect that bone strength is more than just bone density and introduced the concept of bone quality². They defined osteoporosis as follows: “a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. Bone strength reflects the integration of two main features: bone density and bone quality.”

Epidemiology of Osteoporosis: Applying Relevant Figures to your Practice!

Pierre Guy, MDCM, MBA, FRCSC
Vancouver, BC

What if this article revealed:

• how much more of a problem osteoporosis is than you think?
• how much more often your total hip beds will blocked by hip fracture patients in the future?
• how much an osteoporotic fracture increases the risk of another fracture, and increases mortality risk for a patient?
• how much you could influence the occurrence of an osteoporotic fracture by adding a simple statement to your consult letter?

A Systematic Approach to the Diagnosis and Treatment of Osteoporosis in Fragility Fracture Patients

Earl R. Bogoch M.D., FRCSC
Victoria Elliot-Gibson MSc
Toronto, ON

Fragility fractures are defined as fractures of the distal radius, proximal humerus, vertebrae and proximal femur that result from minimal trauma, such as a fall from a standing height. These fractures, which are most likely the result of osteoporosis, are common injuries presenting in outpatient fracture clinics and inpatient orthopaedic wards, and represent a major portion of the work of general orthopaedic units. Up to 95% of hospitalized fracture inpatients over 75 years of age, and 80% to 90% of fractures in patients between 60 and 74 years of age can be attributed to osteoporosis¹. In this high risk population, fracture begets fracture. The risk of future fracture increases 1.5- to 9.5-fold following a fragility fracture^2-3. Moreover, mortality after hip fracture ranges from 22 to 33% within one year of hip fracture^4-5. Loss of independence results in the majority of patients who survive a hip fracture, with approximately one-quarter requiring permanent admission to a chronic care facility in the year following the fracture^6-7. The large number of fragility fractures treated by Canadian orthopaedic surgeons represents a major public health opportunity to prevent future, clinically significant, fractures of the hip.

Bisphosphonates and Fracture Healing In Orthopaedic Fracture Patients

Margaret H. Lauerman, B.S.
Paul S. Issack, M.D., Ph.D.
Joseph M. Lane, M.D.

With the increase in mean population age, there has been a rise in the number of patients who develop osteoporosis and subsequent insufficiency fractures. Up to one half of all women and one third of all men will sustain fragility fractures in their lifetime¹. The mechanism underlying this loss of bone toughness in patients with osteoporotic fractures is an abnormality of bone remodeling, with uncoupling of bone formation and bone resorption. When this highly regulated linkage is disrupted, the structural and material properties of bone diminish. An imbalance in bone formation and resorption, with excessive bone resorption, results in diminished bone mineral density and is seen in several pathologic conditions including: post-menopausal osteoporosis, prior steroid use², fibrous dysplasia³, Paget’s disease, bone metastases, and heterotopic ossification².

Message from the COA Local Arrangements Committee Chair

Stewart Wright, M.D., FRCSC
COA Local Arrangements Committee Chair

On behalf of your Local Arrangements Committee and the COA Office Staff, it is a great pleasure for me to welcome you to Toronto for the 61^st Annual Meeting of the COA, combined with the 40^th Annual Meeting of the Canadian Orthopaedic Research Society and the 32^nd Annual Meeting of the Canadian Orthopaedic Resident's Association. As you likely recall, when we last planned a COA Annual Meeting for Toronto in 2003 it was cancelled because of the SARS outbreak and ended up being rescheduled in Winnipeg later that year. We are very excited to be able to fulfill the promise we made in 2003 for an outstanding meeting in Toronto this coming June.

The 2006 Toronto Meeting Programme

Emil H. Schemitsch, M.D., FRCSC
Programme Committee Chair
Toronto 2006 Annual Meeting

The Programme Committee for this year’s COA Annual Meeting has constructed a meeting that will be of interest to all members of the Association. The meeting delivers a fantastic educational experience that includes three major symposia – one of which is dedicated to private health care in Canada, one which deals with hip and knee arthritis in the young patient and one focused on an evidence-based approach to hip fracture management. There will be continuing use of audience response systems this year at all symposia. A total of 15 instructional course lectures (ICLs) are planned, covering a broad range of topics, both medical and practice related. There will be a number of case-based ICL’s where experts in the field will discuss various difficult cases. A workshop is planned on computer-assisted hip surgery. A half-day specialty day has been put together to allow an intense and focused educational experience at the subspecialty level.

What to See

Here is an assortment of some of the exciting things going on in Toronto around the time of the Annual Meeting.

The Lord of the Rings World Premiere
Starting February 2006, the world premiere of the stage production of J.R.R. Tolkien’s classic trilogy The Lord of the Rings www.lotr.com arrives onstage at the Princess of Wales Theatre. With a thrilling score, spectacular design and featuring an ensemble of over 65 actors, singers and musicians, The Lord of the Rings is the biggest, most ambitious theatrical production ever staged. Hotel and theatre packages are available exclusively through Tourism Toronto, at www.torontotourism.com/LOTR.

Toronto Neighbourhoods
Toronto has so many different areas worth visiting. Venture into some of these neighbourhoods for a true cultural exploration!

Ask a Torontonian where they live and they won't reply with a street address or intersection. They'll name the neighbourhood. Cabbagetown. Greektown. Corso Italia. Toronto is a city of neighbourhoods. Here are some of the highlights:

Founding Contributor Target Achieved!

Debbie Gates
Communications and Education Manager
Canadian Orthopaedic Foundation

The Canadian Orthopaedic Foundation thanks all who donated to the founding endowment for the Canadian Orthopaedic Research Legacy. With your help, the target of $100,000 was reached, and the Founding Contributor category closed at $110,342. Consider how you might contribute to the Canadian Orthopaedic Research Legacy with a monthly or annual gift. Full programme details are available on the Foundation web site at www.canorth.org > Research and Grants > Research Legacy. The Canadian Orthopaedic Research Legacy programme has been established to ensure reliable long-term funding for orthopaedic research in Canada. Thank you for making that vision a reality.

The New COA Web Site

Christian Veillette, M.D., FRCSC
Toronto, ON

Myles Clough, M.D., FRCSC
Kamloops, BC

Professional associations in the 21^st century require a strong integrated on-line presence to communicate more efficiently and effectively and to increase the value of services offered to their members and the public. The COA first developed a web site in 1998 to convey the purposes of the organization, to highlight sponsored events and to provide specific information for members. However, as the COA has grown, so has its information technology needs. At the 2005 Annual Meeting in Montreal and after requesting membership input, the Communications Committee decided to redevelop the COA web site using a full featured content management system. The overall goal was to simplify the creation, management, and sharing of information across the organization using modern technology to integrate services for our members and the public.

Dr. W. Robert Harris
1922 – 2005

Robert Harris was born in Toronto December 19^th, 1922. He was educated at Upper Canada College in Toronto and graduated from the University of Toronto as an M.D. in 1945. He did his surgical training in Toronto and Boston and became a Fellow in the Royal College of Surgeons of Canada in 1953.