The Canadian Orthopaedic Trauma Society:
A Jewel of Canadian Orthopaedics

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

The Canadian Orthopaedic Trauma Society (COTS) was established more than a decade ago with a view to focusing efforts on the completion of multi-centre randomized controlled trials. It has flourished under the leadership of Drs. Ross K. Leighton, Peter J. O'Brien and others and continues to establish new levels of excellence and leadership in the area of clinical research.

Nobody Owns the OR
resource allocation without turf wars

Dennis Jeanes
Special to the Canadian Orthopaedic Association

Relaxing in early April, after an afternoon round of golf in the Florida sunshine, Dr. Joe Hyndman doesn't take much prodding to air his views on a favourite topic: how to allocate OR resources in an equitable and accountable fashion. For the past five years, he and his surgical colleagues have been doing just that at the IWK Medical Centre in Halifax. Turns out "it's a very complicated problem that isn't so complicated."

Bone and Joint Canada

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

Bone and Joint Canada, part of the Bone and Joint Decade National Action Network for Canada, has convened a third meeting of orthopaedic surgeons and patient advocacy groups from across the country to address ongoing issues regarding the provision of musculoskeletal care. In addition to participation from every province and/or region of Canada in which significant orthopaedic surgery activity occurs, for the first time we also had high level government representation at this meeting to develop an exchange of ideas around the effective delivery not only of hip and knee replacement surgery but also paediatric orthopaedic surgery, non-joint replacement surgery in the adult population and osteoporosis.

Dividends, Lies and the Tape: Whither Earnings Trends?

Wilfred J. Hahn
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"Earnings for the corporate world as a whole cannot really grow faster than the economy as a whole [...]. There is a business cycle and an earnings cycle."
John Mauldin, Thoughts From the Frontline-March 2, 2007

According to widely-received market theory, stock market trends over time are highly co-related to corporate earnings. While that is certainly true over the long-term (everything else being equal) the relationship is quite variable over the shorter-term. In fact, here there is probably no correlation at all. Yet, surely, booming corporate profits over the past half decade have been a key underpinning to equity market gains. And, if earnings are a key bellwether for longer-term market trends, whither earnings trends?

Introduction

A great deal of research has attempted to answer the question of whether disc herniations should be treated operatively or nonoperatively. Technology in the operative treatment of this condition has advanced greatly over the last 20 years and yet the debate still rages. Drs. Henry Ahn and Marcel Dvorak will debate the nonoperative versus the operative treatment of this debilitating clinical problem.

Nonoperative Treatment for Disc Herniations

Henry Ahn, M.D., FRCSC
Toronto, ON

Disc herniation causing only radiculopathy and back pain (excluding cauda equina syndrome) is an elective spinal disorder. Surgery is not mandatory. Furthermore, nonoperative therapy can result in marked improvement in pain over time. The recently published multi-centre randomized Spine Patient Outcomes Research Trial (SPORT) demonstrated that patients with persistent sciatica (>6 weeks) substantially improved with nonoperative "usual care"¹. This included different combinations of education and counseling (92%), non-steroidal anti-inflammatory drugs (58%), narcotic analgesics (35%), physiotherapy (43%) and epidural steroid injections (38%) depending upon physician prescribing preferences. There was no statistical difference in outcomes between the surgical and nonoperatively treated groups for all time periods using intention-to-treat analysis.

The Case for Lumbar Discectomy

Marcel F. Dvorak, M.D., FRCSC
Head, Division of Spine
Department of Orthopaedics
University of British Columbia
Vancouver, BC

Twenty years ago, while I was a resident, patients with a disc protrusion and sciatica would be told that "based on the evidence" if they chose to have surgery, their symptoms would be about the same within a year or two as if they had simply toughed it out. Back then, an open surgical discectomy on the orthopaedic or neurosurgical services involved an incision that you could put your fist into, often a bilateral exposure, and varying degrees of curettage within the disc space. The ‘evidence' that we quoted was the Weber 1983 study⁶, which has been widely interpreted as showing no substantial long-term benefit to surgery over conservative care.

Introduction

The treatment options of supracondylar femur fractures are diverse and occasionally controversial. The introduction of new technology and the expanding indications of established technology have led to many treatment possibilities for a fracture that can be challenging. In this Themes section, Drs. Papp, Coles, Backstein and Weber will respectively discuss the options of fixed angle devices, retrograde intramedullary nailing, total knee arthroplasty and the locking plate in the treatment of these fractures.

Fixed Angle Devices

Steven Papp, M.D., FRCSC
Ottawa, ON

Supracondylar femur fractures remain a challenge for the orthopaedic surgeon. Most fractures occur as a result of a high-energy accident in young patients or in elderly patients with poor bone quality. Because of these challenges, several treatment options have evolved over time.

Retrograde Intramedullary Nail

Chad P Coles M.D., FRCSC
Assistant Professor
Division of Orthopaedics, Department of Surgery
Dalhousie University
Halifax, NS

First popularized in the 1990's, retrograde intramedullary nailing of supracondylar femur fractures remains a standard form of treatment for these fractures today. While not suited to every distal femur fracture, retrograde nailing offers certain advantages which maintain its position in the armamentarium of treatment options for these challenging fractures.

Total Knee Arthroplasty

David Backstein M.D., MEd, FRCSC
Assistant Professor, Department of Surgery
Hip & Knee Reconstruction, Mount Sinai Hospital
Director of Undergraduate Education, Department of Surgery,
University of Toronto
Toronto, ON

Do clinical scenarios exist where one might choose primary TKA as a means of treating a supracondylar fracture of the femur? The answer to this question is yes, although this is certainly not a common method of management for this problem. Complex supracondylar fractures of the femur are often difficult to manage with standard fixation techniques, particularly in the elderly with osteoporotic or osteopenic bone^1,2,3,4 and associated comorbidities. In addition, these same factors may increase the incidence of fracture nonunion⁵. Despite new and improved techniques for osteosynthesis, poor outcomes are still very common in the geriatric population⁶. An alternative option to internal fixation, which is certainly less frequently employed, includes primary total knee arthroplasty.

The Locking Plate

Don Weber M.D., FRCSC
Associate Clinical Professor
University of Alberta
Edmonton, AB

Considering the widely accepted principles of anatomic articular reduction, stable fixation, minimal soft tissue dissection, and early mobilization - the locking plate delivers in all areas. It does, however, come at a significantly higher monetary cost than more traditional fixation devices and does require some expertise to avoid documented complications.

Canadian Orthopaedic Research Legacy:
surgeons helping surgeons excel

Dennis Jeanes
Special to the Canadian Orthopaedic Foundation

When it comes to creating a truly lasting legacy for orthopaedic research, many hands indeed make light work. Or put another way: If every orthopaedic surgeon in Canada were to donate $300 per year - an hour's operating room time - resources for research would reach a million dollars within four years. The groundwork for a million-dollar legacy fund has been laid, and surgeons are now invited to help build that legacy by becoming annual donors

Medical and Scientific Review Committee:
expert advice on public and patient education

Dennis Jeanes
Special to the Canadian Orthopaedic Foundation

The Canadian Orthopaedic Foundation is pleased to announce the creation of its new Medical and Scientific Review Committee.

Staying Up To Date - Using Google Reader and RSS Feeds

Christian Veillette, M.D., M.Sc., FRCSC
Rochester, MN

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

The following article is an excerpt from a workshop on Orthopaedic Informatics conducted by Drs. Veillette and Clough for orthopaedic staff and residents at Mayo Clinic in Rochester, Minnesota.

Have You Ever Wanted to Comment on a COA Bulletin Article?

Christian Veillette, M.D., FRCSC
Rochester, MN

Now you can.

The purpose of the comment system for the online version of the COA Bulletin (COA eBulletin) is to encourage member interaction and engage in discussion on these articles. Many of the topics in the Forum and Themes sections of the COA Bulletin are purposely chosen for their current relevance and continued controversy. Editorial and Info articles are written on prominent issues facing orthopaedic surgeons in Canada. The ability to allow COA Members to augment these articles with additional viewpoints, knowledge or relevant literature provides an excellent collaborative learning opportunity.

CFBS Travelling Fellowship
Octobre - Novembre 2006

Luc Bédard, MD, FRCSC
CHA Enfant-Jésus Québec
Québec (Québec)

En partant en fellow, je doutais un peu de la valeur orthopédique de la chose, m'attendant plus à faire du tourisme que de la science... et j'ai été fort surpris. Ce fellow aura été le théâtre d'agréables rencontres et de belles découvertes, tout en étant fort intéressant orthopédiquement parlant. Je vous raconte....

Orthopaedic Surgery Residency Training Programme
Dalhousie University
Faculty of Medicine, Department of Surgery

Programme Director: William M. Oxner, M.D., FRCSC
Division Head: J. David Amirault, M.D., FRCSC

The Dalhousie University Residency Training Programme in Orthopaedics began in the late 1960's under the leadership of Dr. Reginald H. Yabsley. Since that time, the size of the programme has increased with new residents entering the programme annually. In addition to the residents selected through the CaRMS match, the programme has trained orthopaedic surgeons sponsored by rural hospitals, the Armed Forces and foreign countries. The faculty has grown to 16 members, and all the major subspecialty categories are well represented.

We regret to advise that we have lost the following members.  Our sincere condolences are extended to their families and friends.

Dr. Walter P. Bobechko
1932-2007

Dr. Roderick P. MacKenzie
1944-2007