Recrutement et rétention des chirurgiens orthopédistes:
Assurer la relève de la spécialité

Emil H. Schemitsch, M.D., FRCSC
Rédacteur en chef
Le Bulletin de l’ACO

L’an dernier, j’ai rédigé un certain nombre d’éditoriaux sur le thème de la fragilité de notre système de santé. Une bonne partie de ces messages portaient sur la crise de l’accès aux soins dispensés par les chirurgiens orthopédistes au Canada. L’importante pénurie de main-d’œuvre qui sévit dans la spécialité de l’orthopédie est une autre question connexe. Les longues listes d’attente et les longs délais d’attente des traitements ont d’importantes répercussions sur les patients. Les délais d’attente des traitements sont en partie reliés à la pénurie d’orthopédistes dont le nombre a chuté dans de nombreux centres hospitaliers et dont l’âge moyen a augmenté considérablement. Cette tendance n’est pas souhaitable, car la population continue de vieillir et requiert de plus en plus de soins orthopédiques et de traitement pour des fractures.

Introduction

Displaced femoral neck fractures can lead to crippling sequelae if not treated properly. Controversy has existed as to whether these injuries should be treated with internal fixation or arthroplasty. The dramatic outcomes of total hip replacement have led to increasing use of this procedure with broader indications. Each treatment alternative has included a fair proportion of failures, which have required revision. These failures and the increasing demand for normal function in all patients, regardless of age, have lead to increasing debate as to the most appropriate procedure. Our themes section will discuss this important issue in detail.

The Role Of Pinning In Subcapital Fractures

Edward J. Harvey M.D., MSc
Montreal, QC

Displaced subcapital hip fractures represent a consistent problem in orthopaedic surgery. Assorted reasons for choosing a modality of treatment include ease of surgery, cost, morbidity and mortality, risk of AVN, re-operation rates and functional disability.

The physiologically young patient has traditionally been treated with internal fixation. There is little evidence-based literature to change that treatment plan. Currently, open or closed reduction and internal fixation with three or four screws are accepted therapies. Capsulotomy does not seem to be clinically relevant. Historically, expedient surgery has been advocated to avoid osteonecrosis. However, there is probably a low rate of AVN. Also, only about 20% of patients with AVN require further surgery. However, AVN is not painless in the high-demand patient post internal fixation. Some data suggests that urgent reduction and fracture fixation within 12 hours after a displaced fracture may be associated with a reduced rate of radiographic signs of avascular necrosis¹. Pinning in the physiologically young patient is always indicated and none of the criteria such as cost, morbidity and mortality, re-operation rates and functional disability suggest otherwise.

Calgary 2004 – An Educational Meeting for the COA

James N. Powell, M.D., FRCSC Chair, Programme Committee Calgary 2004 Calgary, AB

The Program Committee of this year’s COA Annual Meeting has designed a programme that should have something of interest for absolutely everyone. Four live surgical procedures are currently planned, including a live surgery presentation of Birmingham Hip Resurfacing by Mr. Derek McMinn, implantation of an Oxford Knee, stabilization of an unstable shoulder and an ulnar shortening osteotomy. There are three symposia, one of which is dedicated to the introduction of new technology, a second on the management of distal radial fractures and finally, a symposium on the management of hip disease in young adults. Professor Reinhold Ganz will be sharing his work in periacetabular osteotomies with us at that session as the Macnab Lecturer.

There are eighteen instructional course lectures covering a broad range of topics, both medical and practice related. We’ve chosen approximately 160 of the 226 submissions for presentations either from the podium or in poster format. The submissions were superb this year and as such, I expect the open scientific sessions will be very robust.

It is my hope that you can join us in Calgary.

Exploring Research, Expanding Knowledge, Education in Motion

The Calgary 2004 Annual Meeting

F. Kelley deSouza, M.D., FRCSC
COA Local Arrangements Committee Chair
Calgary, AB

On behalf of your Local Arrangements Committee, COA Staff, the Pinnacle Group, our on-site meeting planners, and all Calgary orthopaedic surgeons, I would like to welcome you and your family to the 59^th Annual Meeting of the Canadian Orthopaedic Association (COA) combined with the 38^th Annual Meeting of the Canadian Orthopaedic Research Society (CORS), and the 27^th Annual Meeting of the Canadian Orthopaedic Nurses Association (CONA).

Dr. James N. (Jim) Powell, your local COA Programme Chair, and Dr. Kevin Hildebrand, CORS Programme Chair, along with their Programme Committees, have developed an ambitious educational programme that will incorporate live surgical demonstrations, stimulating workshops and symposia, and cutting- edge Instructional Course Lectures. As always, there will be an abundance of high-quality podium presentations. The COA has elected to present this material in a condensed three-day meeting that will keep us engaged from start to finish.

Explore Calgary & the Canadian Rockies – Host of the 59^th COA Annual Meeting

Minutes from adventure in an unspoiled mountain playground, Calgary is clean and safe; a big city without big city problems.

Adventure

Get away to a world of adventure and freedom. Spring ski in the high country and golf in green valleys on the same day. Walk, jog or bike along winding paths that follow sparkling rivers. Float over the city in a hot air balloon on a warm summer morning. Go trail riding, heli-hiking, fishing, touring or whitewater rafting under bright blue skies.

Attractions

Throughout the year, shopping, theatre, galleries, symphony, ballet, concerts and dazzling nightlife are close at hand. Chase a dragon through Chinatown. Gasp at the almost-touchable images of a giant-screen movie. Be a kid again at a children's festival, or jump to jive at a jazz festival.

Explore prairie history at a pioneer settlement, museum or fort. Spend a day at the zoo or an international-calibre equestrian facility. Tour Winter Olympic sites. Try your luck at a casino. Cheer on professional hockey, football and baseball teams.

Travel Arrangements

• Airport/Hotel Shuttle Bus is available at a charge of: $10.00 1 way or $15.00 return.
  
  • Reservations required on weekends, please call 403-531-3909 to reserve pick-up time.
    
• Parking: available on site at each hotel as well as at the Telus Convention Centre.
  
• Taxi charges from airport average $30.00

November 18, 2003

To the Editor
COA Bulletin

Subject: SARS, The COA Toronto Meeting

Dear Sir:

It was and is clear in my mind that the Executive of the COA had no choice but to cancel the Annual Meeting in Toronto in 2002. To run the risk of spreading SARS to even one patient, no matter where, by a contaminated participant returning to work in his or her own milieu would have been unthinkable.

To all those people who worked so hard, first for the Toronto Meeting and then for the transfer to Winnipeg, I say “chapeaux”.

Yours sincerely,

John V. Fowles, M.D., FRCSC

Issues in Orthopaedic Informatics #3

Integrating the Literature with the Internet

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

In 1998 the founders of the Orthogate Project (www.orthogate.com) posted the “Orthogate Project Manifesto” to explain their vision. Part of it read –

“What is the OrthoGate Project? Quite simply, the goal of this project is to make every information resource you may need as an orthopaedic surgeon, allied healthcare provider, or patient available from a web browser. This includes access to high quality electronic orthopaedic textbooks and journals - both those that exist now in the traditional sense - and those that will undoubtedly develop to take advantage of the new capabilities introduced by this new electronic medium.”

It was an enticing idea; whenever you wanted orthopaedic information, of whatever type, you could sit down at a computer anywhere in the world and with a minimum of fuss, access what you needed.

It is our pleasure to announce that John V. Fowles, M.B., B.S. (Lond.), FRCSC of Knowlton, QC was recently appointed Officer of the Order of Canada, our Country’s highest honour for lifetime achievement in important fields of human endeavour. He joins an outstanding group of orthopaedic colleagues, all members of the Canadian Orthopaedic Association, who have received this esteemed award in the past: Companion: Dr. Robert B. Salter; Officers: Dr. Richard L. Cruess, Dr. Robert W. Jackson, and Dr. Carroll A. Laurin; Members: Dr. Gordon W.D. Armstrong (see COA Bulletin #58, p. 16, August/September 2002)and Dr. Frank Gunston (see COA Bulletin # 40, p. 21, February/March, 1998).

Canadian Joint Replacement Registry Significantly Expands Coverage

Nicole de Guia, Consultant
Trauma and Joint Replacement Registries
CIHI
Toronto, ON

The Canadian Joint Replacement Registry (CJRR) has recently expanded as a national data holding, capturing surgical information on total hip and total knee replacement surgeries. For the first time, in July 2003, a subset of data from the Ontario Joint Replacement Registry (OJRR) was sent to the Canadian Institute for Health Information (CIHI), which manages the CJRR, to be incorporated into the national dataset. The data flow occurred via the Ontario Ministry of Health and Long-Term Care and through this process, updated data will be sent to CIHI on an annual basis. This addition to the CJRR is significant, as Ontario surgeons comprise approximately 34% of the estimated number of Canada’s orthopaedic surgeons performing hip and knee replacement surgeries. Also, Ontario surgeons perform 44% of all hip and knee replacement surgeries in the country (data based on Hospital Morbidity fiscal 2000-01 data). CJRR now has participating surgeons from every Canadian province and one Territory.

Bone & Joint Decade Update

James P. Waddell, M.D., FRCSC
Coordinator, Canadian National Action Network
Toronto, ON

The National Action Network for the Bone & Joint Decade in Canada continues to be very active. I am happy to report on a number of new developments since our last update in the Bulletin.

Our second newsletter has been published, which focused on osteoporosis. I would like to thank all of the contributors from the Canadian Orthopaedic Association who gave willingly of their time and expertise to make the newsletter a success. The next newsletter will be on trauma and we will have a fourth newsletter on childhood disorders. Anyone who would like to contribute to the newsletter within the four areas we have identified (arthritis, osteoporosis, trauma and childhood diseases) is very welcome. You can contact my office at Cet e-mail est protégé contre les robots collecteurs de mails, votre navigateur doit accepter le Javascript pour le voir , Ms. Hazel Wood at Cet e-mail est protégé contre les robots collecteurs de mails, votre navigateur doit accepter le Javascript pour le voir or Ms. Dot Brown at Cet e-mail est protégé contre les robots collecteurs de mails, votre navigateur doit accepter le Javascript pour le voir .

In the realm of rude awakenings, surely one of the nastiest surprises must be discovering your nest egg is gone, devoured by good intentions gone awry. That’s pretty much the situation departing COF President Dr. Hubert Labelle found himself in, when he began his term in May 2001.

Osteoarthritis of the knee can be a chronic disabling condition. Total knee arthroplasty has been the gold standard reconstructive procedure for this problem in older patients. The success of arthroscopy and the pressure to perform less invasive surgical procedures has led to a desire to attempt this procedure in many patients with osteoarthritis, prior to considering more invasive procedures. The less certain results with arthroscopy have been a source of controversy. This has prompted the current point/counterpoint debate between Dr. Litchfield and Dr. MacDonald.

Ed.

Arthroscopy of the Knee: Is it the Answer for OA?

Peter B. MacDonald, M.D., FRCSC
Professor of Orthopaedics
University of Manitoba
Winnipeg, MB

Introduction

The other day we were discussing a resident’s performance at our Postgraduate meeting when one of my spine colleagues made a suggestion about a struggling resident. “This resident,” he said, “should be encouraged to go into an easy area of orthopaedics like scoping knees” It later struck me that despite the fact that arthroscopy can be incredibly challenging and technically difficult, knee arthroscopy and debridement or “scoping for dollars”, as some refer to it, has been abused to the point of being open to ridicule. This operation, along with meniscal trimming, is regarded as easy, quick, simple, remunerative and, as such, becomes an attractive area for many general orthopaedic surgeons or marginal sports medicine specialists. Even total joint specialists are tempted to insert these cases as “fillers” into their slates for both remunerative reasons and to pacify patients on long waiting lists for knee replacement. When the operation is done poorly or for the wrong reasons, it becomes easy to dodge the scrutiny of the patient by stating: “Well, the arthritis was worse than we thought” or “We now realize that you need a knee replacement.” Occasionally, even in the face of a poorly done procedure, the patient is delighted with the outcome because of a placebo effect or limited benefit from a simple wash out of the knee. Because of a lack of clear peer-review literature-based guidelines, which result in our inability to spell out its indications, the abuse of this operation is common.

Arthritis of the Knee – Is There a Role for Arthroscopic Debridement?

Robert Litchfield M.D., FRCSC, Associate Professor
John Gallagher, FRACS
Department of Surgery, Division of Orthopaedics
Fowler Kennedy Sport Medicine Clinic
University of Western Ontario
London, ON

Arthroscopy of the arthritic knee is a most rewarding treatment modality when used selectively in the carefully chosen and well-informed patient. The role of arthroscopic debridement in the arthritic knee is to provide pain relief and functional improvement and therefore postpone (and in many cases, avoid), other major surgical interventions such as corrective osteotomies or joint arthroplasties.

Arthroscopy is a valuable part of the treatment armamentarium for arthritis of the knee, and we should not allow its important role to be undermined by recent sensationalist claims based largely on a single scientifically challenged study by Moseley et al¹.