A Fine Balance
juggling workplace and family

Dennis Jeanes
Special to the Canadian Orthopaedic Association

Doug Thomson
CEO
Canadian Orthopaedic Association

"How do you have a life and still do your job?" For Dr. Tracy Wilson, the question wasn't merely rhetorical, it was imperative to find an answer. She and her husband, Dr. David Puskas, are both full-time practising orthopaedic surgeons at the Thunder Bay Regional Health Sciences Centre in northwestern Ontario: "We decided that if we were going to have kids - and we now have three young children - we had an obligation to get to know them. So I try to be home every night at five."

Delivering on the Value Equation
for staff, membership satisfaction is job one                                                         

Dennis Jeanes
Special to the Canadian Orthopaedic Association

"We're small but mighty," says Doug Thomson, who as CEO of the Canadian Orthopaedic Association, comprises one third of its full-time staff. "At the last Annual Meeting in Halifax, some COA members saw Cynthia, Trinity and me and assumed that there were a bunch more of us back at the office holding down the fort. They were quite surprised to find that, no - there's only the three of us."

Update from Bone and Joint Decade Canada

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

Rhona McGlasson, RPT, MBA
Project Coordinator for the Bone and Joint Health Network
Sunnybrook, Holland Centre

Hazel Wood, BSc OT, MBA
Executive Director
Bone and Joint Decade Canada

For the past two years, Bone and Joint Canada has been working with orthopaedic surgeons across Canada to develop a strategy to address wait times for hip and knee replacement surgery. This initiative is being led by the provinces that have implemented successful models of care over the last few years. These initiatives include Alberta, where a randomized control trial was implemented that proved it possible to improve access to care while improving the quality of care. In Ontario, a model was launched in Toronto which resulted in reducing the average wait time from surgeon to surgery down to two months, while improving consistency of care. This model uses advanced practice therapists in an effort to better coordinate care as well as reduce the cost. Through the implementation of central intake, coordinated care and OR efficiencies, BC has reduced wait times and improved consistency of care. Other models across the country which have begun more recently have also started to improve care for patients requiring hip and knee replacement surgery. Furthermore, the programmes in Alberta, Ontario and BC have started to expand their concepts to other areas of MSK where wait times for care continue to be an issue.

Introduction 

To fuse or not to fuse? That has been the ongoing question in the treatment of odontoid fractures. Drs. Albert J.M. Yee and Joel A. Finkelstein will debate the advantages and technical aspects of one versus the other.

Odontoid Fractures: Anterior Odontoid Screw Fixation

Albert J.M. Yee, M.D., MSc, FRCSC
Assistant Professor, Department of Surgery
University of Toronto

Fractures of the odontoid account for approximately 20% of all cervical fractures with many (~70%) being Type II fractures (ie. fracture crossing the base of the odontoid process at the junction with the axis body)¹. The optimal treatment of Type II fractures remains controversial and evidence suggests no standards or guidelines, but rather presents options in care^2-4. The decision as to whether or not to operate and if so, what type of procedure to perform, is subject to much discussion.

Odontoid Fractures: Surgical Management by Fusion

Joel Finkelstein, M.D., FRCSC
Section Head, Orthopaedic Sunnybrook Spine Programme
Sunnybrook Health Sciences Centre, University of Toronto
Toronto, ON

Approximately fifty percent of axial rotation of the cervical spine occurs at the C1-C2 articulation. Instability at this level occurs most commonly as a result of fractures of the odontoid or bursting injuries of the atlas with disruption of the transverse ligament. The goal in the treatment is 1) to reestablish the normal anatomic relationships at the level or the ring of C1 and 2) to maintain them either through osteosynthesis of the dens or through a solid fusion of C1 and C2. The theoretical advantage of osteosynthesis of the dens is to maintain this motion. However, due to scarring of the transverse ligament related to the injury itself and with anything less than anatomical alignment of the odontoid process, there may be loss of C1-C2 motion despite one's best efforts. Inability to achieve anatomical alignment also precludes direct fixation of the dens. This technique is also contraindicated in patients with osteoporosis, nonunion, os odontoideum or thoracic kyphosis. The role of fusion for odontoid fractures is well established and a number of techniques are available to achieve the goals of treatment in a safe and effective manner.

Introduction
Total knee arthroplasty is considered the gold standard for tricompartmental knee arthritis. By contrast, unicompartmental knee arthritis has many treatment alternatives that have advantages and disadvantages. Drs. Backstein, Winemaker, Bohm, Turgeon and Gandhi will discuss patellofemoral arthroplasty, unicompartmental arthroplasty, total knee arthroplasty, high tibial osteotomy and knee bracing respectively.

Unicompartmental Knee Arthritis

Patellofemoral Arthroplasty

David Backstein M.D., MEd, FRCSC
Toronto, ON

It is now recognized that isolated patellofemoral (PF) arthritis is a clinical entity of significant frequency, which is considerably disabling to those who suffer from it. Davies et al¹ found a 9% (19/206 knees) prevalence of isolated PF arthritis in 174 consecutive patients over 40 years old and 13.6% in women over 60 years old. In a radiographic study of 273 symptomatic knees in women, McAlindon² found an 8% prevalence of isolated PF arthritis. These data clearly indicate that this condition is worthy of some attention.

Unicompartmental Knee Arthritis

Unicompartmental Knee Arthroplasty

Mitchell J. Winemaker, M.D., FRCSC
Hamilton, ON

Unicompartmental knee arthroplasty (UKA) is one of several options in the treatment of unicompartmental knee osteoarthritis. Initial interest in UKA has been curtailed by the inferior long-term survivorship in comparison to total knee arthroplasty (TKA)^1-4. Some interest in UKA persisted because of the purported functional superiority⁵ to TKA in terms of range of motion and ease of rehabilitation and revision^6-8. A reduced risk of serious complications and infections when compared to TKA has also supported UKA as an attractive alternative⁹. The improved cost effectiveness of UKA relative to TKA has further been claimed in recent literature^10,11.

Unicompartmental Knee Arthritis

Total Knee Arthroplasty

Eric R. Bohm, BEng, M.D., MSc, FRCSC
Assistant Professor
University of Manitoba Joint Replacement Group
Winnipeg, MB

Introduction
Total knee arthroplasty (TKA) is indicated for the management of symptomatic knee arthritis when nonoperative management has failed and the well-informed patient feels that the potential benefits outweigh the risks. While many consider TKA to be the arthroplasty standard of care when there are significant arthritic changes involving two or more compartments, the recent resurgence of interest in patellofemoral arthroplasty and unicompartmental arthroplasty has given the patient and surgeon more options to choose from when only one compartment is involved. Patient satisfaction following knee replacement surgery is related primarily to relief of pain and restoration of function; the other important consideration of course is durability, since the results of revision surgery rarely match those of the primary surgery¹. When considering surgical options, the surgeon and patient must therefore balance the competing interests of pain relief, functional result and durability.

Unicompartmental Knee Arthritis

High Tibial Osteotomy

Thomas Turgeon, M.D., FRCSC
Assistant Professor, University of Manitoba
Winnipeg, MB

High tibial osteotomy (HTO) has been a long-standing treatment for osteoarthritis of the medial compartment of the knee. In recent decades, advances in arthroplasty have shifted the focus of knee arthritis procedures away from joint preserving osteotomies. Despite this trend, HTO continues to play an important role in the treatment of appropriately selected patients.

Unicompartmental Knee Arthritis

Knee Bracing

Rajiv Gandhi, M.D., FRCSC
Nizar Mahomed, M.D., FRCSC
Toronto, ON

The knee is the joint most affected by osteoarthritis and varus alignment is its most common deformity¹. Conservative treatment options include weight loss, pain medicines, intra-articular injections, lateral heel wedges, and bracing. Bracing options include valgus-unloader braces or simple neoprene sleeves.

Foundation Appoints Honorary Members

Debbie Gates
Special to the Canadian Orthopaedic Foundation

The Canadian Orthopaedic Foundation recently added the role of Honorary Member to its Board of Directors. This special appointment is intended to engage distinguished individuals meaningfully, without taxing their already demanding schedules. While there is no restriction on the number of Honorary Members, this honour is bestowed with care, reserved for accomplished community members, and is only extended at the request of the Board of Directors. Four distinguished individuals who share the Foundation's passion for excellence in bone and joint health have been appointed Honorary Members: Dr. Cy Frank, Dr. Gary Mooney, Dr. Frank Sim, and Dr. Paul Wright. In this issue, the Foundation presents Dr. Cy Frank.

Information Technology and Orthopaedic Education

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

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

The arrival of computers has not materially changed the way in which medical students and orthopaedic trainees learn the subject. Indeed the teaching of musculoskeletal medicine has been the recent subject of severe criticism and reform of the educational process is a major goal of the Bone and Joint Decade¹. This article is an entry to the literature on the use of information technology (IT) both in orthopaedic trainee education and in CME, as well as a brief review of useful Internet resources.