Brochure - Division of Orthopaedic Surgery

Transcription

Division of Orthopaedics
U n i v e r s i t y o f T oront o Gra d u at ion D ay
April 6, 2011
Richard H. Gelberman, M.D.
D
r. Gelberman is the Fred C. Reynolds Professor
and Chairman, Department of Orthopaedic
Surgery at Washington University Medical
School in St. Louis, Missouri. He completed his
undergraduate education at the University of North
Carolina and graduated from the University of Tennessee
Medical School. He did his internship at University
of Southern California, Los Angeles, his residency at
University of Wisconsin, Madison, and was a fellow in
hand and microvascular surgery at Duke University, and
in pediatric orthopaedics at Harvard/Children’s Hospital
of Boston.
Dr. Gelberman has been an active member of many
medical organizations including being Past President of
the American Academy of Orthopaedic Surgeons and
Past-President of the American Society for Surgery of
the Hand. He is currently a member of the Journal of
Bone and Joint Surgery Board of Trustees.
Dr. Gelberman is the recipient of numerous research
awards and honors including the Kappa Delta Award
for orthopaedic research in 1985; author of over 250
scientific papers and editor of three books and 25 book
chapters. He was elected to the Institute of Medicine of
the National Academy of Sciences in 2003. He also serves
on the editorial boards of eight medical publications.
Dr. Gelberman is married to Sarah and has three
children and five grandchildren. He enjoys golf, music,
history, baseball, and spending time with his border
terrier, Morris.
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D i v i s i o n o f O r t h o p a e d i c S G RA D U ATI O N D AY
Division of Orthopaedic
Surgery Graduation Day
– Agenda
1015-1045
Coffee break and Group Picture
1045-1100
Dr. Om Sharma
Perioperative Complications of Combined Anterior/
Posterior Spinal Fusion compared to Posterior Fusion
with the Use of Skull-Skeletal Traction in the Correction
of Adolescent Idiopathic Scoliosis Curves Greater than 75
Degrees
Wednesday April 6, 2011
0830-0900
Welcome Reception – coffee, tea and snacks
1100-1115
Dr. Ali Zahrai
What Do Patients Want to Know? Determining the
Information Needs of Patients Undergoing Lumbar
Microdiscectomy
0900-0910
Introduction and Welcome - Dr. Ben Alman
0910-0915
Residents’ Introduction – Dr. Peter Ferguson
1115-1130
Dr. Olanrewaju Okusanya
Measuring the Benefit of Hip Surgery in Non-Ambulant
Children with severe Cerebral Palsy. A Prospective Cohort
Study
0915-0930
Dr. Harsha Malempati
Surgery for the Degenerative Lumbar Spine: A
Population-Based Study of Recent Trends and Evaluation
of Outcomes in Current Surgical Practice
1130-1200
Dr. Shayne Keetbaas
Posterior Tibial Tendon Transfer For Treatment Of
Peroneal Nerve Palsy: A Novel Technique With Use Of A
Metallic Button
0930-0945
Dr. Syndie Singer
Ankle Arthroplasty and Ankle Arthrodesis - Prospective
Gait Analysis Compared to Controls
0945-1000
Dr. Richard Hurley
Training Femoral Neck Screw Insertion Skills to Surgical
Trainees:
Computer-Assisted Surgery Versus Conventional
Fluoroscopic Technique
1200-1300
Lunch for all Present
1300-1315
Dr. Michael Blankstein
Balancing surgical inequities around the globe: The role
of academic partnerships
1000-1015
Dr. Ali Farno
A Modified Cement Spacer Technique for Infected Total
Hip Arthroplasties with Significant Bone Loss
1315-1330
Dr. Nicholas Yardley
Patellar Tendon and Hamstring Tendon Autografts in ACL
Reconstruction – An Assessment of the Methodological
Quality of Published Randomized Control Trials
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1330-1345
Dr. Dawi Amariyen
Cementless Total Hip Arthroplasty in Patients 75 Years of
Age and Older
1415-1435
Coffee break
1435-1450
Dr. Ben Alman
“What is the evidence that the evidence is right”
1345-1415
Presentations from new faculty starting since July 2010
1450-1545
Salter Lecture:
Dr. Richard Gelberman
“Nerve Repair”
1345-1400
Dr. Richard Jenkinson
1400-1415
Dr. Simon Kelley
1545-1600
Awards Presentation and Closing Remarks
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DIVISION OF
ORTHOPAEDIC
SURGERY ANNUAL
REPORT 2009/2010
In the clinical realm, we
formalized
our
sports
program, and Darrel Ogilvie
Harris was selected as its
interim head. This program
united
clinicians
from
several of our hospitals and
developed shared clinical
resources for outpatient care
at Women’s College Hospital
towards the development of
an innovative comprehensive
sports clinical, education, and research program. Sports
now join Spine, Foot and Ankle, and Hand as formal
programs within our University framework.
summer 2010
O
ur divisional faculty members identified
a focus on working together to develop
innovations in research, education, and
clinical care, as our priorities during our divisional
strategic planning session four year ago. I am delighted
to report that this past year saw concrete results from our
focus on these priorities.
Our academic footprint is a measure of how we impact
orthopaedics internationally. It is a measure of the impact
of our publications, the number of our trainees who
have developed successful academic careers outside of
Toronto, and how our work improves the outcome for
the patients we treat. We have one of the world’s largest
academic footprints, having ranked third in the world in
peer reviewed publications last year. This accomplishment
is in no small part due to our strong focus on research.
In the education realm, we completed the first year of
our competency-based curriculum. This pilot program,
approved by the Royal College of Physicians and
Surgeons of Canada, and funded by the Ontario Ministry
of Health and Long Term Care is the only entirely
competency-based residency training program that we
are aware of in the world. Peter Ferguson, our associate
program director, Bill Kraemer, our program director,
Connie Johnson, the administrative coordinator, as well
as all of the module leaders for the program have done
a phenomenal job in running this for its inaugural year.
By all measures this program has been a phenomenal
success, with residents in the program achieving levels
of competency in a single year that would have taken
several in the traditional stream. Some of the components
have been so overwhelming successful, such as the initial
module that we are planning to incorporate this into our
training program for all residents. Our second cohort of
trainees entered the program this year, and we are looking
forward to reporting our results of this very innovative
educational program.
Sevan Hopyan and Cari Whyne, as co-chairs of our
research committee have done a fabulous job overseeing
and mentoring the residents who entered their integrated
research and clinical year. Their participation in this novel
combined clinical and research training program has
facilitated the ability of our trainees to participate in high
level research, resulting in an overall increase in our research
productivity.As evidence of this,Ali Zahrai received the JA
Nutter award for best paper presentation at the Canadian
Orthopaedic Residents Association meeting. His paper
was titled “Quality of life and educational benefit among
orthopedic surgery residents: a prospective, multi-centre
comparison of the night float and the standard call systems”
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The past several years have seen the development of new
technologies and research paradigms that have improved
the quality and clinical applicability of our research
work. These developments are associated with growth
in the size of the biomedical research community and
the expense of undertaking high quality research studies.
Indeed there has been tremendous growth in the Toronto
research community over the past decade. Unfortunately,
national research funding has not kept pace with the
increased costs associated with undertaking this high
quality research. Despite these challenges, we continue
to maintain research fining at a high level, with our
funding this year totaling more than $6,000,000.
to teaching and learning in the Surgical Skills Centre
over the past year.
We welcomed two new recruits this past academic year,
Kellie Leitch and Lucas Murnaghan. Both are pediatric
orthopaedists. Lucas has a clinical practice focused on
pediatric sports and an academic focus on education.
Kellie has a general pediatric practice, but a special
interest in cerebral palsy, and an academic focus on
medical leadership development and public service, and
advocacy.We all welcome Kellie and Lucas to our faculty.
The Lawson award for best academic resident, as
adjudicated by a committee, went to Isaac Moss, and
the Meisami award for most compassionate resident, as
selected by the faculty, went to Rashid Jinnah. The R.I.
Harris award for the best presentation at the Graduation
Day went to Isaac Moss and the Bob Jackson (for the
best sports medicine talk) and Canadian Back Institute
(for the best spine talk) went to Jas Chahal and Mehdi
Sadoughi respectively. The James Waddell award for the
best PGY 4 resident was awarded to Om Sharma. Danny
Whelan received the Divisional Award for Best Teacher
as selected by the residents.
Our Graduation Day Visiting Professor was John Healey,
Chief of Orthopaedic Oncology Service at Memorial
Sloan-Kettering Cancer Center and Professor of
Orthopaedic Surgery and Vice-Chair, Department of
Surgery Weill Medical College of Cornell University.
He gave a fabulous and very insightful “Oncologic
and Functional Treatment of Osteogenic Sarcoma: An
Orthopaedic Success Story” talk as his Salter lecture.
Graduating residents presented their research work
during the main Graduation Day activities.
Congratulations to our faculty who were successful at
academic promotion this year at the university. Nizar
Mahomed was promoted to full professor; and Steve
Lewis was promoted to associate professor. Also thanks
to our division member, Robin Richards, who chairs the
departmental promotions committee.
Bill Maloney (Stanford University School of Medicine),
Brian Snyder (Boston Children’s Hospital), Jed Davies
(Faculty of Dentistry U of T), Paul Tornetta (Boston
Medical Center), Mark Myerson (Mercy, Mercy Medical
Center, Baltimore, MD), John Healey, Arlen Hanssen
(Mayo Clinic Rochester, MN) and Dave Williams
(McMaster University and Canadian Space Agency
astronaut) all visited Toronto this year and gave University
wide grand rounds.
Our members received a number of awards on Gallie
Day this year. Ali Zahrai (supervised by Valerie Palda,
Aileen Davis, and Albert Yee) received the Gallie
Award – 3rd prize for his work on The development
of a preliminary preoperative education tool for patients
undergoing lumbar microdiscectomy utilizing multiple
stakeholder interviews. Rashid Jinnah received the D R
Wilson award, for the surgical resident who is rated by
undergraduate students as being an outstanding teacher.
Richard Holtby received the Surgical Skills Centre
Distinguished Educator Award, which recognizes an
individual who made exemplary, innovative contributions
Our faculty members received three University wide
education awards: Bill Kraemer: the Award for Excellence
in Postgraduate Medical Education; Peter Ferguson the
W. T. Aikins for Individual Teaching Performance (Small
Group); and David Backstein, the Dean Chute Silver
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Shovel Award for excellence in overall clinical teaching
in the undergraduate medical program.
Our division lost two members who were icons in
orthopaedics this year. Robert Salter, past divisional
chair, and faculty member for more than 50 years was
the world’s most well known orthopaedic surgeon. He
revolutionized the treatment of childhood dislocated hips,
and pioneered the concept of applying basic science to
improve clinical care. His classification system of children’s
fractures is universally used worldwide. His support for the
University and the Hospital for Sick Children, where he
spent his entire career, was unwavering. He was still active
in teaching and research up until a few weeks before his
death. In addition to his academic achievements, Bob was
known for doing his best to help anyone who came to
him with a problem. Bob Jackson was a pioneer in the
use of arthroscopy for intrarticular procedures, and in
the development of sports medicine. He worked at the
Western and then became head of the Orthopaedic and
Arthritic hospital (now part of Sunnybrook). He played a
critical role establishing the Special Olympics in Canada
and supporting this endeavor worldwide. He was the only
physician that Sport Illustrated named as one of the most
influential figures in sports. Although he did move to
Dallas towards the end of his career, he had returned to
Toronto after he retired from active clinical practice. We
will miss both of these individuals, who were exceptional
role models, and gave so much to our division, Toronto,
Orthopaedics, and to the world.
The University of Toronto’s Division of Orthopaedic
Surgery is continuing in its long history of excellence
in clinical care, teaching, and research. Our faculty’s
renewed focus on innovation and integration has resulted
in new education, research, and clinical advances. I am
proud of how well our division members are working
together to develop innovative new programs, which will
undoubtedly increase our division’s academic footprint.
Ben Alman
A.J. Latner Professor and Chair
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Hospital for Sick Children
This past year we recruited Simon Kelley to the
faculty at Sickkids. Simon’s clinical focus will be on
complex limb deformity and his research focus will
be on understanding the fundamental biology of
musculoskeletal regeneration, with a long-term goal of
developing improved techniques to treat limb deformity.
With the arrival of Simon, we now have faculty covering
every clinical aspect of pediatric orthopaedics.
The faculty continues to be active clinically
and academically. Last year we saw roughly 20,000
outpatients, had over thirty publications, and held close
to two million dollars in yearly research funding.
Our fellowship continues to be strong, and we currently
adopted the strategy of select fellows from around the world
in each year. Our most recent graduates all have gone on
to strong academic positions. Two of our graduates, Anna
Cuomo and Kathryn Doughty, have taken positions at
the Shriners Hospital in Los Angeles (USA). Dominique
Knight has taken a position at the Royal infirmary of
Edinburg (UK), Stephen Cooke has a position at University
Hospitals Coventry and Warwick (UK), and Thomas
Palocren returned to the Christian Medical College Vellore
Department of Otrthopaedics (India). Our current fellows
are David Wright who completed his MBBS at Liverpool
University (UK), Walter Truong from the University
of Minnesota (USA), David Lebel from Ben-Gurion
University (Isreal), Talal Ibrahim from the University of
Leicester (UK), and Emily Dodwell from the University of
British Columbia (Canada). In addition, Cristina Alves has
stayed on to complete a Master’s degree while continuing
to help out with clinical work. She is from the Hospital
Central Do Funchal in Madeira in Portugal.
We were saddened by the passing of Robert Salter,
who had been a member of our division for over
fifty years. Our Salter Society (Sickkids orthopaedic
fellowship alumni), held a special meeting in Toronto this
year, and we invited all of the Sickkids and University
of Toronto Orthopaedic Alumni to return. Over fifty of
Bob’s trainees returned for this event in his memory.
In the upcoming year, we plan to strengthen our
collaborative academic output by starting work translating
fundamental science to clinical care in collaboration with
the recently established Bone Health Centre at Sickkids.
We are hopeful that this new endeavor will help rapidly
bring new innovations to patient care.
Ben Alman,
Head of Orthopaedics, Hospital for Sick Children
Mount Sinai Hospital
The 2009-2010 academic year was particularly
productive for the Division of Orthopaedic Surgery at
Mount Sinai Hospital. The division is subdivided into
three clinical services: Orthopaedic Oncology, Hip and
Knee Reconstruction and Sports Medicine.
In total, 33 peer reviewed publications emanated out
of our unit during the course of the year and we held
nearly 5 million dollars in grants. In addition, our faculty
attended 29 invited speaking engagements at national
and international Orthopaedic educational conferences.
The Orthopaedic Oncology service continues to be the
pre-eminent unit in Canada for the treatment of bone and
soft tissue sarcoma. Approximately 450 cases are performed
annually by Drs. Jay Wunder and Peter Ferguson. These
patients seek out the expertise of our Oncology surgeons
from all corners of the country. Jay’s research is focused
on investigating the genetic causes of bone and soft
tissue tumours while Peter works on tissue engineering
techniques to enhance impaired wound healing.
The Hip and Knee Reconstruction service, consisting
of Drs. David Backstein, Allan Gross and Oleg Safir,
performed approximately 650 hip and knee replacements
in 2009-10. The focus of our unit is revision surgery
performed on patients who have already had joint
replacements which have failed due to causes such
as wear or infection. Approximately 30% of all joint
replacements performed at Mount Sinai are complex
revision reconstructions.
Dr. John Theodoropoulos is a Sports Medicine surgeon
operating out of both Mount Sinai and the Women’s
College Hospital as part of the University of Toronto
Sports Program. John had 3 peer reviewed publications
in the realm of cartilage restoration during 2009-10.
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Finally, excellence in education remains a primary focus
of the Division of Orthopaedic Surgery at Mount Sinai
Hospital. Our unit trained and supervised 19 clinical and
2 research fellows over the course of the academic year
in addition to numerous residents and medical students.
These fellows originated from countries including
Israel, USA, France, Italy, UK and Canada. Drs. Safir
and Backstein continue to work on research in Surgical
Education and had two peer reviewed publications in
this area in 2009-10. Additionally Dr. Backstein was the
recipient of the Dean A.L. Chute teaching award and was
an Aikens Award nominee. Dr. Ferguson was the winner
of the Aikens Award for outstanding teaching in a small
group setting and Dr. Safir won outstanding poster at the
2009 Wilson Centre Research Day.
produced numerous grants and publications. Recent
accomplishments include: Dr. Schemitsch, President Elect
Canadian Orthopaedic Association and Deputy Editor
Journal of Orthopaedic Trauma; Dr. McKee, Associate
Editor Journal of Orthopaedic Trauma; Dr. Daniels, Chair
Research Committee Foot and Ankle Society, Dr.Whelan,
Sports Medicine Society traveling fellow; Dr. Waddell,
Chair Expert Panel in Orthopaedic Surgery in Ontario.
Emil Schemitsch,
Head of Orthopaedics, Saint Michael’s Hospital
Sunnybrook Hospital
CLINICAL
General
• Phramacy Kiosk: Sunnybrook has introduced an
David Backstein,
Head of Orthopaedics, Mount Sinai Hospital
outpatient pharmacy kiosk that allows patients to have
their prescriptions filled via a vending machine like
interface with remote video link to a pharmacist.
• ISOC: Sunnybrook is the only Canadian centre to
date to be invited as a member of the prestigious
International Society of Orthopaedic Centres.
• E-Referral Tracking System: This system was designed
by the Sunnybrook’s Information Services team
in collaboration with the Holland MSK program.
It is an innovative electronic system for managing
and tracking patient referrals, and has served as the
Provincial pilot for tracking Wait Times from referral
to first appointment with a specialist. The system is
currently being adapted for use in the Odette Cancer
Centre, and has been adopted in several other LHIN’s
across the Province.
• UofT Musculoskeletal Extra-departmental Unit: The
vision for this recently established Unit is international
leadership in interdisciplinary musculoskeletal
research and education that drives improvements in
musculoskeletal care and health.The Unit is University
wide in scope with two hubs and leadership positions
located at Sunnybrook and at Mount Sinai Hospital
Saint Michael’s Hospital
The Division of Orthopaedic Surgery at St Michael’s
Hospital had a successful year in 2009/10. Current clinical
focus is on advanced hip and knee reconstruction (Dr.
James Waddell, Dr. Earl Bogoch, Dr. Emil Schemitsch);
upper extremity reconstruction (Dr. Michael McKee and
Dr. Jeremy Hall); foot and ankle reconstruction (Dr. Tim
Daniels and Dr. James Waddell); spine (Dr. Henry Ahn)
and sports medicine (Dr. Daniel Whelan). St Michaels
Hospital is a level I trauma centre and areas of expertise
include polytrauma, complex upper and lower extremity
trauma, foot and ankle trauma, pelvis and acetabulum and
nonunions and malunions. The Division is internationally
recognized in these areas as a quatenary referral centre and
has a thriving fellowship and education program.
Current research is focused in the Martin Orthopaedic
Biomechanics Laboratory (Implant evaluation, mechanics
of hip resurfacing and fracture fixation, computer assisted
surgery), Musculoskeletal Research Laboratory (Biology
of fracture repair and cell based and gene therapy
approaches to fracture healing) and in clinical trials (more
than 30 ongoing studies: foot and ankle, trauma, hip and
knee, sports, spine, fragility fractures). The division has
Trauma
• Pelvic and Acetabular Trauma: Sunnybrook is the
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largest trauma centre in Canada with particular
expertise in pelvic and acetabular trauma. We run the
only Canadian international pelvic course (every two
years) and educate pelvic fellows and visitors from all
over the world.
• Hip fracture Management: We have focused on
achieving better access to surgery for hip fracture
patients by working with our OR management
team to ensure that all hip fractures are done within
48 hours (priority is bumped up if not done within
24 hours). Our team, which includes an advanced
practice nurse, has also developed a comprehensive
patient, family educational package and standardized
care pathways to help smooth the transition back into
the community after hip fracture.
• Outpatient Fracture Care: Most patients with ankle
fracture, distal radius fractures and other similar
bone or soft tissue injuries are now managed on an
outpatient basis via a designated outpatient fracture
operating room (once list per week). This allows
inpatient resources to be reserved for more complex
tertiary and quaternary care cases.
• Spine: Through a funded spine chair, a number of
clinical initiatives are planned including a voice
controlled bed for paraplegics, an educational package
including a video for patients and families, and
refinement of spine clinical care pathways.
also cited as a “Leading Practice” in Sunnybrook’s
recent Accreditation Survey
• Hip & Knee Joint Replacement - Care Pathways – The
Holland Centre care pathways represent evidencebased best practice and an inter-professional model of
care that both ensures quality and consistent patient
care but also efficient use of system resources. The
Care Pathways have been instrumental in continuing
to reduce length of stay and reliance on inpatient
resources. They have recently served as the model for
the new Stroke Care Pathway and the Hip Fracture
Care Pathway.
EDUCATION
• Chair in Education: Through the generosity of the
Holland family, the Holland MSK program has a
partially funded chair in education that will eventually
be used to attract an individual to lead a program of
education research and excellence.
• Computer Navigation as an Educational Tool: Dr.
Nousiainen’s research is focused on the potential
benefit of computer simulation in learning surgical
skills. Dr. Nousiainen is the Associate Director of
the University of Toronto’s Competency Based
Curriculum.
• Competency Based Curriculum. The Holland Centre
is the Pilot site for introduction to Arthroplasty
rotation for innovative Orthopaedic Competency
Based Curriculum. This program is designed to
shorten the time required to acquire surgical skills by
using a combination of skills acquired in the Surgical
Skills Laboratory and quickly applying them in the
operating room. Ongoing research on competency
based MSK training for rheumatology and family
practice residents will help to optimize MSK training
modules that can be transferred across disciplines.
• Spine Research in Education. Research on the
evaluation of spine clinical fellowship training in
Canada is driving the development of enhanced
programs for clinical spine fellowship by identifying
opportunities to enhance cross-disciplinary training
in spine care as well as focused expertise in complex
Arthroplasty
• Central Intake & Assessment Centre – Hip & Knee
Arthritis Program: Patients referred for management
of their Hip & Knee Arthritis now have a single point
of contact across the TC LHIN. They are given an
appointment in an Assessment Centre within two
weeks of their referral, and are seen, assessed, and receive
education from an Advanced Practice Physiotherapist.
If a patient is confirmed to be a surgical candidate,
they have the option of choosing the first available
appointment with an orthopaedic surgeon or waiting
for a specific surgeon.This team approach has reduced
wait times, improved the quality of care and is being
adopted across the Province.This model of care was
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Ford, C Whyne, M Akenss and D Cole involvement
in the Bone Metastasis Clinic and clinical care
efforts in transdisciplinary surgical oncology care.
Bone Metastases Research Group – long standing
(over 10 years) collaboration between scientists and
clinicians in the HMSK and cancer programs aimed
at better diagnosis, treatment and management of
skeletal metastases. Includes multiple basic science/
bioengineering, preclinical and translational clinical
research initiatives. Funding for this research has been
obtained through multiple agencies including CIHR,
NSERC, CBCRA, USDOD CDMRP Breast Cancer
Research Program
• Photodynamic therapy (PDT)– translational research
to treat vertebral metastasis with extensive pre-clinical
work (Whyne, Yee, Akens – supported through
CIHR, CBCF, OICR) in collaboration with the
Wilson Group (OCI, UHN) and Shane Burch, UCSF.
New work examining the role of PDT in fracture
healing motivated by findings is supported by the US
Army Department of Defense DOD Peer Revewed
Orthopaedic Research Program, Congressionally
Directed Medical Research Programs (CDMRP)
• Radiofrequency (RF). In conjunction with Baylis
Medical and supported by the Ontario Centres of
Excellence, DrsWhyne,Yee and Akens are evaluating a
new bipolar cooled RF device for ablation of skeletal
metastases through a series of preclinical research
studies.
• Development of a pedicle screw simulator. A CT based
simulator for pedicle screw and other screw bone
simulation (i.e sacroiliac screws) has been developed in
the Orthopaedic Biomechanics Lab (OBL) at SRI in
conjunction with a neurosurgeon (Dr Ginsberg) at St
Mikes. Positive evaluation of the simulator for resident
and fellowship training has been demonstrated through
integration at U of T spine courses. The simulator is
being further developed as a stand alone “freeware”
program. This will allow wide access to the training
possible for the device in developed and developing
nations. AO has indicated an interest in the simulator
for their international training programs.
spine care for both neurosurgeons and orthopaedic
surgeons.
• UT Spine Program city-wide initiative with
establishment of an educational committee to look
at enhancing fellowship, residency training in spine.
At the fellowship level, the UT Spine Program will
explore the new Royal College of Physician and
Surgeon’s Diploma Program as a multi-site initiative.
• SHOTE (Sunnybrook Haddasah Orthopaedic Trauma
Exchange) - The continued fellowship training of
Israeli orthopaedic surgeons on a yearly basis was
initiated by the Sunnybrook Hadassah Orthopaedic
Trauma Exchange and now includes many hospitals
in Israel.
RESEARCH
General
• Chairs: The Holland Musculoskeletal Program at
Sunnybrook has 7 partially and fully funded chairs
to support bench to bedside research activities and
infrastructure.
Bench to Bedside to the Policy Table
• Bone Healing: Dr. Nam’s work is focused on
understanding the role of the immune system and
possibly enhancing bone healing through various
manipulations. Dr. Nam and her graduate student
were awarded the best basic science paper at the
department of orthopaedic surgery research day on
their research focused on the immunology of fracture
healing.
• Biomarkers: Dr. Cole has been investigating the role
of biomarkers in certain types of cancer with skeletal
metastasis potential.
• Bone Stabilization: A new initiative is underway
toward development of a novel method to stabilize
thin bone fractures in conjunction with investigators
in plastic surgery at SHSC and IBBME at the
University of Toronto (funding by the US DOD
PROP CDMRP NSERC). We are also exploring
innovative techniques to stabilize bone metastases in
the periacetabular region.
• Bone/Vertebral Metastasis – A Yee, J Finkelstein, M.
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• Spine Disc Tissue-Engineering – An emerging city-wide
spine initiative includes innovation in development of a
spine disc tissue-engineering approach to the degenerating
disc. Supported by ARTEC funding, Drs. Yee, Whyne,
and Kim Woodhouse are working to develop innovative
tissue engineered cell and hydrogel based scaffold for
the treatment of early stage degenerative disc disease
at the fundamental and pre-clinical level. New citywide collaborations will extend this tissue engineering
research further with collaborations at UHN though the
U of T spine program (support requested from CHRP
and AO Spine – pending)
• SPILNE fusion. A new posterior fusion device has been
developed in the OBL at SRI in conjunction with Dr
Ginsberg at St Mikes (as above) Patent Pending.
• New advances for spinal cord injury evaluation and
treatment. Through the new centre for spinal trauma
a multidisciplinary group has been assembled at SRI
focused on a pilot preclinical project to locally deliver
therapeutics to the spinal cord using state of the art image
based (MR focused high intensity focused ultrasound)
and viral delivery technology and to evaluate spinal cord
damage and therapeutic effects through MR imaging.
• Open Fracture Treatment: Ongoing research by Dr.
Jenkinson and Kreder is utilizing primary data and
population data to delineate parameters around what is
acceptable as a delay to definitive treatment for specific
types of open injuries, which will have profound
implications for the management of open fractures.
• Access to care: Ongoing research by Jenkinson, Kreder,
Webster and others is evaluating the consequences
of delay to treatment for pelvic, acetabular and hip
fractures with an aim to developing networks of care
and to inform policies to improve patient flow.
• Trauma RCTs: We are involved as PI, co-PI, collaborators
and coinvestigators in eight trauma related RCTst hat
seek to define best practice for various types of injuries.
Many of these are national and international studies. Dr.
Jenkinson and Kreder are leading a study on the postoperative management of ankle fractures to evaluate
the safety and potential benefit of early weight bearing,
motion and return to function. Dr. Kreder is a co-PI on
a study to determine whether function and outcome
after isolated humerus fractures is improved by open
reduction and internal fixation versus standard care (splint
immobilization). Dr. Kreder is a co-PI on a cross Canada
study comparing various fixation options for distal radius
fractures building on his previous work in this area.
Hans Kreder,
Head of Orthopaedics, Sunnybrook Hospital
Toronto Western Hospital
1.We are building a Personalized Arthritis research
programme consisting of a comprehensive arthritis
biobank and integrated bioinformatics platform. This
will allow for integration of data capture on human
tissues, diagnostic imaging and clinical data of all
patients at UHN.
This world first resource will allow for banking of
blood for DNA and disease biomarkers, as well as
collection of cartilage, synovium, and synovial fluids
over longitudinal intervals. Integrated with the
clinical data, this will allow for systematic evaluation
of disease course and predicting disease progression
in arthritis patients. The integrated research team
consists of research coordinators as well as a PhD
cartilage biology scientist with expertise in genomic
and proteomic analysis.
2. In the fall of 2010 Dr. J. Rod Davey along with an
international design team of surgeons from the United
States and England launched the Arcos Modular
Femoral Revision System manufactured by Biomet.
The Arcos Modular Femoral Revision System is a
comprehensive, press-fit revision femoral component
consisting of three proximal and five distal stem bodies
with multiple designs for reconstruction of various
defects associated with femoral revision surgery.
Auxillary implants are available to aid in fixation
and include trochanter reattachment claws, bolts and
interlocking screws. Components are available in a
variety of designs and sizes to offer 117 proximal/
distal combinations for various femoral defects. The
12
Toronto East General
Hospital
new system addresses many deficiencies observed in
current systems on the market and is being introduced
into Canada, United States, England, Australia and
Europe at this time.
Toronto East General Hospital - 2009/2010
Our hospital continues to provide general orthopaedics
to our local community and beyond.
Peter Weiler continues as Chief of the Division, since
2008 and has an active practice in General Orthopaedics,
with an emphasis on hip and knee extremity arthroplasty.
Much of his spare time is spent representing the division
at various meetings within the hospital, at the University
and within the Toronto Central LHIN.
Bill Kraemer continues to enjoy a thriving practice in
Spine and general orthopaedics. Bill has worked tirelessly
the last 5 years as Program Director for the Orthopaedic
Residency Training Program. He has spearheaded the
development of a new approach to residency training the Competency Based Curriculum (CBC) in which 3
residents each year approach their learning in a module
based fashions as opposed to the traditional apprenticeship
model. Bill has just step down from his post and will no
doubt have some extra time on his hands for family.
Paul Wong continues at East General with a very busy
practice in General Orthopaedics, specializing in lower
hip and knee arthroplasty.
Mel Catre has been busy in his Orthopaedic Practice
with a special interest in Sports Medicine including
arthorscopic shoulder surgery.
Frank Mastrogiacomo,our most junior member has been
busy growing his practice in Hip and Knee arthroplasty.
He frequently enjoys going up north to Kirkland Lake
amongst other North venues where he, along with several
other Toronto surgeons provide orthopaedics.
Gianni Maistrelli continues to work mostly in hip and
knee arthroplasty.
Our other senior members Tom Barrington and Ian
Harrington no longer take call or operate but provide
much needed orthopaedic service in our outpatient
clinics each week.
All of our surgeons continue to participate as teachers in
the Division of Orthopaedics with University of Toronto.
3.Johnny Lau has been working for 10 years on a
design for a total ankle replacement. This year we are
launching the Zimmer total ankle replacement.
4. Through the Ontario Specialty Committee we
have developed a patient information and self
management website entitled “Back Care Canada”,
(BackCareCanada.ca) which has also become the
National website for The Canadian Spine Society of
which Dr. Raja Rampersaud is the President.
5.This is the inaugural year of the Sports Medicine
Program. This is a new program has been set up by
the Division of Orthopedic Surgery at the University
of Toronto. It is headed by Dr. Ogilvie-Harris. He
will engage an active recruitment program of new
staff and scientists. The five year goal is to establish
fully integrated Sports Medicine clinical programs,
well funded research, and teaching excellence
including patients, residents, fellows and community
physicians. This will pave the way for leadership in
Sports Medicine as part of U of T MSK Program.
This is an important part of the UHN Osteoarthritis
Program. As part of the personalized arthritis care, it
involves early treatment, early diagnosis and part of
the range of treatment options. Specifically, it will
deal with areas of sports injuries which, if untreated,
lead to the subsequent development of osteoarthritic
change. Care is provided for early osteoarthritis
... where minimally invasive surgery would be
of benefit especially future options for cartilage
transplantation and stem cell technology. This is part
of the regenerative technology thrust which offers
great future potential for osteoarthritis treatments.
Nizar Mahomed,
Head of Orthopaedics, Toronto Western Hospital
Peter Weiler,
Head of Orthopaedics, Toronto East General Hospital
13
ABSTRACT
Harsha Malempati
Background: Degenerative disease of the lumbar spine
is a very common of cause of lower back and leg pain,
and is one of the most common reasons for patients
visiting their family physicians [1]. Also, with our aging
population, it is a disease that is increasing in prevalence.
Of surgical procedures performed by a spinal surgeon,
lumbar spinal decompressive surgery and spinal fusion
surgery are the most common procedures realizing that
there is variance in practice which may reflect surgical
background training, physician-specialty referral patterns,
and surgeon experience [2]. The purpose of this study
is to assess trends volumes, surgeon characteristics, and
outcomes for surgery of the degenerative lumbar spine.
Harsha grew up in Windsor,
Ontario where he was a
nationally ranked junior
tennis player. He completed
his medical school training
and his orthopaedic residency
at the University of Toronto.
During his residency, Harsha
entered the Surgeon Scientist
Program and completed a
Masters of Science degree in
spine fellowship education
and outcomes research under the supervision of Dr.
AlbertYee. Harsha has had a very busy final year including
successfully defending his Masters thesis, studying for
“The Quiz”, and getting married. He would not have
been able to accomplish all of this without the support
of his loving wife, Amy. He looks forward to moving to
Seattle this summer for his fellowship training in spine
surgery at the University of Washington.
Methods: Using administrative databases, a longitudinal
population-based retrospective study was performed
including all patients aged 50 years and older who
underwent surgery for degenerative disease of the
lumbar spine in Ontario between 1995 and 2001.
Data was collected on surgeon characteristics (specialty,
volume), index procedures (decompressions, fusions),
and outcomes (reoperations, complications).
Surgery for the
Degenerative Lumbar
Spine: A PopulationBased Study of Recent
Trends and Evaluation
of Outcomes in Current
Surgical Practice
Results: Between 1995 and 2001, 6128 patients were
identified who underwent surgery for the degenerative
lumbar spine (4200 had decompressions and 1928 had
fusions). Neurosurgeons performed significantly more
overall index procedures, and more decompressions,
while orthopaedic surgeons performed more fusions
(p<0.05). Using our definition of a ‘spine expert’, the
low volume spine surgeons operated on a combined total
average of 749 (87.5 percent) degenerative lumbar spine
cases per year while the high volume surgeons operated
on a combined total average of 160 (12.5 percent). The
reoperation rate was higher for decompressions than
fusions at two years (5.4 percent vs. 3.9 percent, odds
ratio 1.4, p<0.004), but not over the long-term. Patient
outcomes (mortality, complication rates, readmissions,
etc.) were significantly affected by patient factors such as
age and co-morbidities (p<0.05).
Harsha Malempati1, Samuel Bederman5,Veronica Wadey1,2,3,
David Backstein1,4, Hans Kreder1,2,3, and Albert Yee1,2
1
Division of Orthopaedic Surgery, Department of Surgery, University
of Toronto; 2Division of Orthopaedic Surgery, Sunnybrook Health
Sciences Centre; 3Holland Orthopaedic and Arthritic Centre;
4
Division of Orthopaedic Surgery, Mt. Sinai Hospital; 5Department of
Orthopaedic Surgery, University of California-Irvine
14
Conclusions: There is a trend of increasing lumbar spinal
to be lowest among surgeons who were less than two
years removed from their fellowship training. On the
other hand, when comparing fellowship-trained trauma
surgeon mortality rates at Level One trauma centers, there
is a significant correlation between years of experience
as a surgeon at the institution and improved outcomes
for severely injured patients with surgeons requiring
an average of 7.9 years of experience at major trauma
centers to reach expertise when gauged by benchmark
mortality rates [4].
A comparison of surgical volume as it relates to
clinical outcomes for scoliosis surgery between spine
and pediatric orthopaedic fellowship-trained surgeons
in New York and California showed that higher-volume
surgeons had better clinical outcomes for their patients
[5]. Another study found that patients of low-volume
surgeons have a greater risk of hip arthroplasty revision
at six months but no greater risk of revision at the time
of longer-term follow-up. The authors observed that
there appeared to be no significant association between
hospital volume and the rate of revisions of total hip
arthroplasties [6]. Furthermore, it was noted that the
majority of total hip arthroplasties in the Medicare
population, from 1997 to 2004, were not performed by
the highest-volume hospitals or surgeons. For rotator
cuff repair, patients operated on by low-volume surgeons
had significantly lower mean operating room times and
significantly higher likelihood for an extended length of
stay when compared with those operated on by highvolume surgeons. The authors observed that there was
a linear trend for a higher proportion of routine patient
discharge with increasing surgeon volume [7]. It could
be suggested that high-volume providers may use health
care resources more efficiently.
A study of mortality in trauma patients at academic
Level One trauma centers found that the structure and
organization of trauma programs and senior surgical
mentoring overpowered any influence of individual
surgeon experience on mortality rates [8]. Higher
hospital volumes, more so than individual surgeon
volumes, have been associated with lower mortality rates
for Medicare patients in the United States undergoing
fusion rates for degenerative disease of the lumbar spine
in Ontario. There are differences between orthopaedic
surgeons and neurosurgeons with respect to the type of
procedures performed: neurosurgeons have higher rates
of decompressions while orthopaedic surgeons have
higher fusion rates. Patient factors (age, co-morbidities)
play a greater role in determining outcomes for
degenerative lumbar spine surgery compared to surgeon
factors (specialty, volume).
INTRODUCTION
Degenerative disease of the lumbar spine is a very
common of cause of lower back and leg pain, and is one
of the most common reasons for patients visiting their
family physicians [1]. Over 75 percent of individuals
during their life will experience an episode of chronic
low back pain related symptoms, chronic referring to
symptoms lasting over three months. Also, with our aging
population, it is a disease that is increasing in prevalence.
Of surgical procedures performed by a spinal surgeon,
lumbar spinal decompressive surgery and spinal fusion
surgery are the most common procedures realizing that
there is variance in practice which may reflect surgical
background training, physician-specialty referral patterns,
and surgeon experience [2].
As technology progresses and the complexity of
surgical techniques expand, it is clear that surgical
fellowship training has become an important component
to training future surgeons. However, there are many
other factors that can affect clinical outcomes. Some
examples of such factors include: characteristics of
the surgeon, hospital-dependent variables, and patient
demographics and co-morbidities.
Surgeon experience can also vary among surgeons
who have completed fellowship training, and this can
have a direct effect on outcomes for patients. A study
of perioperative complication rates for lumbar disc
microsurgery among fellowship-trained neurosurgeons
found that intraoperative complication rates were highest
for surgeons who were between their second and sixth
years of practice [3]. Also, reoperation rates were found
15
major orthopaedic surgery such as hip and knee
arthroplasty, other hip and femur procedures, and spine
procedures [9].
From this review of literature, it appears that both
surgeon volumes and hospital volumes may have a
significant impact on patient outcomes. A study of knee
arthroplasty in all acute care hospitals in Taiwan between
2000 and 2003 found that a surgeon’s patient volume has
a more significant effect than a hospital’s patient volume
on clinical outcomes; however, patient volumes for both
surgeon and hospital are equally important when gauged
by the authors vis-à-vis economic outcomes [10]. In
the treatment of hip fractures, there is evidence that
surgeon volume, but not hospital volume, is associated
with decreased mortality for fracture fixation [11]. Both
surgeon and hospital volume seem to be associated with
nonfatal morbidity and length of stay. Finally, a systematic
review of orthopaedic procedure volume and patient
outcomes found that surgeon volume had a greater
effect on patients than hospital volume for primary and
revision joint arthroplasties, whereas hospital volume was
more strongly related to outcome than surgeon volume
for the other procedures examined [12].
Another important factor to consider is the timing
of a surgery. For example, it has been shown that bile
duct injury repairs done by hepatobiliary surgeons have
better outcomes, with lower risk of failure, when done
electively rather than emergently [13]. The aspect of
timing of surgery in spinal care, particularly for emergent
spinal conditions and neurologic impairment remains
very controversial.
Patient factors also play a critical role in clinical
outcomes. Spinal fusion is performed on a wide range of
patients for a variety of spinal conditions. Patient factors
such as poor body habitus and high body mass index
have been show to increase inpatient complications,
increase transfusion requirements, and utilize more
resources during thoracolumbar and lumbar spine
fusion procedures [14]. Indeed, obese patients do require
greater surgical care and effort in order to achieve
optimal outcomes. A study of perioperative outcomes in
anterior retroperitoneal lumbar disc procedures found
that obese patients had significantly longer duration of
anterior exposure, duration of entire anterior surgery,
longer length of anterior incision, and more depth from
skin to fascia and from fascia to spine compared to nonobese patients [15].
For posterior lumbar fusion surgery for acquired
spondylolisthesis, older patients and those with three
or more comorbidities are 79 percent more likely to
experience an in-hospital complication and five times as
likely to have a complex discharge disposition compared
to younger patients with no comorbidities [16].
Patient outcomes are not only associated with
patient age and comorbidities, but with the primary
diagnoses and surgical procedures being performed. For
degenerative disease of the cervical spine, complications
and mortality are more common in the elderly, after
posterior rather than anterior fusions, and for a primary
diagnosis of cervical spondylosis with myelopathy [17].
In this study, we assess recent trends in surgery for the
degenerative lumbar spine. Specifically, we determine the
relationship between surgical specialty background and
expertise on the volumes and types of surgical procedures
performed. Furthermore, we determine the effects of
surgeon factors (specialty background, surgical expertise)
as well as patient factors (age, co-morbities, etc.) on
MATERIALS AND METHODS
A longitudinal retrospective study of patients who
underwent surgery for the degenerative lumbar spine
was performed using administrative databases. The
Canadian Institute for Health Information (CIHI)
contains data from all patient-hospital encounters and
includes specialist designation (i.e. orthopaedic surgeon,
neurosurgeon) for all physicians in province of Ontario
[18]. Medical care for patients in the Ontario is covered
by the Ontario Health Insurance Plan (OHIP) which
assigns unique identifiers to patients, hospitals, and
physicians that can be linked to the CIHI database [19].
All data is stored in a secure facility and access to data
was administered through the Institute for Clinical
Evaluative Sciences (ICES).
16
The work presented in this paper is an extension
of prior work [18] where re-operation rates following
spinal surgery were compared based on surgical
background specialty training and surgeon volume.
We were additionally interested in characterization of
an expert surgeon and reviewing additional outcome
metrics beyond patient reoperation rates. Data for
index procedures of the degenerative lumbar spine
was collected from April 1, 1995 to December 31,
2001, using International Classification of Diseases,
Ninth Revision (ICD-9) diagnostic and Canadian
Classification of Procedures (CCP) procedural codes.
Fiscal years for the data run from April 1 to March 31,
and coding systems changed after December 31, 2001
to the new ICD-10 version. Also, we used a two-year
look-back window (April 1, 1993 to March 31, 1995)
of index procedures in order to ensure that we were
capturing index procedures and not reoperations of
previous recent surgical procedures. Our outcomes
included complication rates, reoperation rates, mortality,
readmission rates, postoperative imaging rates (CT
scan and MRI), and mean hospital length of stay and
were captured to June 30, 2005. A more recent patient
cohort was challenged by administrated changes to the
OHIP coding of procedures circa 2003, in additional to
consideration of follow-up length in gauging metrics of
interest.
Patients included in our study were aged 50 or older,
and had diagnoses and procedures consistent with
degenerative disease of the lumbar spine (Appendix 1).
We excluded those patients with neoplastic conditions,
inflammatory conditions, primary disc disorders,
infections of the spine, and fractures of the vertebral
column (Appendix 2).There is varying opinion regarding
age guidelines in ‘degenerative’ etiologies. Some studies
have limited inclusion to patients aged 65 years and
older although spinal pathology related to degenerative
instability can frequently be seen in patients as young
as 50 years [20,21]. We classified index patients as
receiving either a surgical decompression procedure or a
fusion procedure (instrumented and non-instrumented,
referring to the use of spinal surgical devices) as these
are the most commonly used coded procedures for
degenerative lumbar spine surgery (Appendix 3). As
previously stated, we used a two-year look-back window
to ensure that optimize the capture of index procedures,
recognizing the limitation that patients may have had
a more remote spinal surgical procedures. The rate of
reoperation for surgery of the degenerative lumbar spine
has been estimated to be 23 percent over ten years [22].
For each patient, baseline demographic information
(age, gender) and co-morbidity were collected. Comorbidity was quantified using the Charlson-Deyo
index. This validated measure uses ICD-9 diagnostic
information within the CIHI database and assigns a score
from zero to five for 17 different co-morbid conditions
[1]. Patients were categorized into two groups according
to the Charlson-Deyo index: (1) zero or (2) greater than
or equal to one.
For each patient, the surgeon performing the
procedure was identified using a unique OHIP number.
The specialty background of a surgeon (i.e. orthopaedics,
neurosurgery) was also determined by unique specialty
codes. There are varying definitions of expertise in a
spinal surgeon. Metrics that could be considered include
the number and intensity of post-residency fellowship
training, the number of years in clinical spine surgical
practice, and surgeon volume. The Canadian Spine
Society defines a spine surgeon as one who spends at
least 80 percent of their elective practice doing spinal
surgery [23]. However, the definition of ‘elective’ time in
surgical practice is controversial with many considering
the denominator of access to operating room time. In
Canada, there remains a strong need for orthopaedic
and neurosurgeons, despite their subspecialty interests in
spinal care, to contribute towards general orthopaedic
and neurosurgical care. There are increasing demands
for orthopaedic surgeons to contribute towards joint
arthroplasty and musculoskeletal trauma care and
neurosurgeons to contribute towards cranial trauma care.
As such, most spine surgeons practicing in Canada possess
blended clinical practices (personal correspondence, Dr.
Hamilton Hall, Executive Director, Canadian Spine
Society).
17
The work of Bederman et al. [18] defined expertise
by surgeon volume. In our current work, we were
additionally interested in evaluating expertise in the
proportion of spinal cases over the denominator of all
surgical cases performed. This approach conceptually
would favor individuals spending more of their surgical
time performing spinal procedures versus surgeons that
are involved in ‘busy’ surgical practices. A limitation
of existing administrative databases is that it does not
currently capture whether an identified surgeon has
spent an additional post-residency year or more in
spinal surgical fellowship training. For each surgeon,
the number of index procedures over the prior two
fiscal years up until the date of the index procedure was
determined. Also, the number of all other spine surgery
procedures performed over the prior two fiscal years up
until the date of the index procedure was determined
using ICD-9 procedural codes for orthopaedic surgery
and neurosurgery. Lastly, the number of the all nonspine surgical procedures performed over the prior two
fiscal years up was determined using ICD-9 procedural
codes for orthopaedic surgery and neurosurgery. We
then calculated a ratio of ‘Spine Expert Volume’ in order
to better differentiate between surgeons who perform
spinal surgery as the majority of their surgical practice
to those that did not. The ‘Spine Expert Volume’ is
calculated as follows:
Spine Expert Volume = A + B / A + B + C
where: A equals the total number of index procedures
performed;
B equals the total number of all other spine procedures
performed; and,
C equals the total number of all non-spine procedures
performed.
We then dichotomized the surgeons based on having
a spine expert volume ratio of either less than 0.50 (i.e.
less than 50 percent of their surgical cases is devoted to
spinal surgery) or greater than or equal to 0.50 (i.e. at
least 50 percent of their surgical cases are devoted to
spinal surgery). This was based on a preliminary review
of the distribution of surgeons by their volume ratio. Our
outcome measures included not only reoperation rates (as
was evaluated by Bederman et al. [18]), but was extended
to review complication rates, mortality, length of hospital
stay, rates of readmission, and postoperative imaging
rates. Outcome measures were captured prospectively
for each patient until June 30, 2005. Reoperation rates
were evaluated at six weeks, one and two years, and
over the full study period. Complications and mortality
were evaluated at three months, and one year after index
procedure. Readmissions were evaluated up to three
months after the index procedure. Postoperative imaging
was evaluated over the entire study period.
Statistical Analysis
Univariate statistics (frequency) of all outcome data
including reoperations, complications, hospital length of
stay, and mortality was performed. Bivariate analysis was
used to compare provider data (specialty background,
spine expert volume ratio) with index procedures.
Multivariate analyses were performed using multiple
logistic regression for binary outcomes and multiple
linear regression for continuous outcomes adjusting
for other dependent variables (provider characteristics
including both specialty background and spine expert
volume ratio, demographics, and index procedure).
Frequency tables for count data were analyzed by Chisquare statistics. Binary outcomes include reoperation
rates, complications, postoperative imaging, readmission,
and mortality. The continuous outcome was the hospital
length of stay. Survival analysis was performed for time
to reoperation as explained by provider characteristics
(specialty background, spine expert volume ratio),
demographics, and index procedures.
RESULTS
From April 1, 1995 to December 31, 2001, we identified
7585 patients who underwent surgery for degenerative
disease of the lumbar spine. Of these, 6128 patients met
our inclusion criteria and these cases were analyzed. Of
these 6128 patients, 4200 underwent decompression
procedures only while 1928 underwent fusions, with
or without decompression (Table 1). For our purposes,
the non-instrumented (i.e. without insertion of surgical
18
devices, for example, metal alloy pedicle screws and
rods) fusion procedures were grouped together with
the instrumented fusions for the remainder of the
analysis.There were not many non-instrumented fusions
performed and, for degenerative disease of the lumbar
spine, the overall purpose and surgical decision-making
behind a non-instrumented fusion and an instrumented
fusion are the same. Also, for the year 2001, we have
included both the actual number of cases performed
as well as extrapolated data that was calculated by
multiplying by a correction factor of 4/3. This was done
to reflect the three of 12 incomplete months for that
year since annual volumes are collected from April 1 to
March 31. The mean age of all patients was 67.7 (range
50-94) years, there were 3360 women (54.8 percent),
and the majority of patients had no significant comorbidities (72.7 percent).
There was an average of 111 surgeons in Ontario
per year performing surgery for degenerative disease
of the lumbar spine (Table 2). When the surgeons were
dichotomized by spine expert volume ratio (i.e. the
relative calculated over the previous two years) into low
volume and high volume, there were an annual average
of 101 (90.6 percent) low volume surgeons and ten (9.4
percent) high volume surgeons. The low spine volume
surgeons operated on a combined total average of 749
(87.5 percent) degenerative lumbar spine cases per year
while the high volume surgeons operated on a combined
total average of 160 (12.5 percent) degenerative lumbar
spine cases per year.
Over the study period,2687 (43.8 percent) degenerative
lumbar spine cases were performed by surgeons with a
neurosurgical background, and 3441 (56.2 percent) cases
were performed by surgeons with an orthopaedic surgical
background (Table 3). Also, 5078 (82.9 percent) cases
were done by low spine expert volume surgeons while
1050 (17.1 percent) cases were done by high spine expert
volume surgeons. Neurosurgeons averaged performing
42.0 index operations (index decompressions and index
fusions) per year while orthopaedic surgeons averaged
performing 27.3 index operations per year (Table 4).This
is a significant difference (p=0.0002). Neurosurgeons
performed significantly more decompressions per year
than orthopaedic surgeons (p<0.0001). It is recognized
that denovo or adjunctive fusion surgery is, in general,
a longer procedure when compared to decompressive
surgery alone. Fusion surgery is also associated with
greater morbidity and surgical complication rates [18].
Orthopaedic surgeons performed significantly more
fusions per year than neurosurgeons (p=0.003). All
together, neurosurgeons performed a higher percentage
of decompressions compared to fusions for degenerative
disease of the lumbar spine than their orthopaedic
counterparts (p<0.0001). Orthopaedic surgeons did
operate on 7.2 percent more females than neurosurgeons
but there was no significant difference between the
two groups with respect to other demographics or comorbidities of their patients.
Outcomes
As reported by Bederman et al. [18], from 1995 to
2005, there were 649 reoperations (10.6 percent). Of
these, 343 were decompressions (5.6 percent; Table
5) and 306 were fusions (5.0 percent; Table 6). The
reoperation rate was higher for decompressions than
fusions at two years (p=0.0036). The Odd’s ratio for
reoperation at two years for a decompression compared
to a fusion index procedure is 1.4 (95 percent CI 1.11.8). Also, reoperations were more likely to be required
in younger patients (p<0.0001) and in patients with
no co-morbidities (p=0.01). We found no significant
differences in long-term reoperation-free survival for
index procedures, surgeon specialty, or spine expert
volume.
Extending beyond prior work [18], current work
observed that within three months of identified index
procedures, there were 285 complications (4.6 percent;
Table 7). These included surgical complications, medical
complications, and surgical treatment of complications
by reoperation. These surgical reoperations are
different than those reoperations discussed above.
What we mean by reoperations for complications are
procedures such as irrigation and debridement of wound
infections, replacement for hardware failure, and so
19
forth. Logistic regression analysis showed an increased
risk of complications with increased age (p=0.02)
and with increased co-morbidities (p<0.0001). Index
decompressions are significantly less likely lead to
complications than fusions (OR 0.7; 95 percent CI 0.50.9), a finding consistent with literature.
In current work, we also observed that within 90
days of the index procedure, 743 (12.1 percent) patients
required readmission to the hospital (Table 8). This was
more common in older patients (p<0.0001), males
(p=0.02), and patients with co-morbidities (p<0.0001).
The average length of stay for a patient operated on by a
neurosurgeon was 6.8 days while the average length of stay
for a patient operated on by an orthopaedic surgeon was
7.9 days. This may reflect, in part, orthopaedic surgeons
performing more index fusion procedures while the
neurosurgeons performed more index decompression
procedures.The average length of hospital stay for patients
of low spine expert volume surgeons was 7.2 days while
the average length of hospital stay for those of high spine
expert volume surgeons was 8.2 days. Increased length
of hospital stay was significantly more likely for patients
of high spine expert volume surgeons (p=0.007), older
patients (p<0.0001), female patients (p=0.01), patients
with at least one co-morbidity (p=0.0001), and index
fusion procedures (p<0.0001).
In current work, mortality was evaluated by in-hospital
mortality, as well as mortality three months, and one year
after hospital discharge (Table 8). In-hospital mortality
was significantly increased with increasing patient age
(p=0.0008) and in patients with at least one medical comorbidity (p=0.02). One-year mortality was significantly
higher with increased patient age (p<0.0001), in males
(p=0.02), and in patients with at least one medical comorbidity (p<0.0001).
Finally, we found that 2893 (47.2 percent) patients
had imaging performed after their index procedure
(Table 9). Postoperative imaging was significantly more
likely in younger patients (p<0.0001), female patients
(p<0.0001), and patients with no co-morbidities
(p=0.04). Postoperative imaging is much more likely
after a decompression procedure compared to a fusion
(p=0.0004). The Odd’s Ratio of having postoperative
imaging completed after decompression for degenerative
disease of the lumbar spine compared to a fusion is 1.3
(95 percent CI 1.1-1.4).
DISCUSSION
The purpose of our study was to understand the
relationship between surgeon factors, patient factors,
and surgical procedures, and their relative influence on
We observed that, in general, surgeons with background
neurosurgical training performed more surgeries per year
for the treatment of degenerative lumbar spine than their
orthopaedic counterparts. Furthermore, neurosurgeons
performed a higher rate of decompressions compared
to fusions while orthopaedic surgeons performed more
fusion surgeries. This observation likely has various
variables that are contributors to the observed findings.
Firstly, decompression surgery may take a shorter
period of time to perform than fusion procedures, or
procedures with adjunctive fusion. As such, a higher
rate of procedures may be completed if considering a
finite time period. Secondly, the trend towards a greater
fusions being performed by individuals with orthopaedic
experience may also reflect surgeon comfort and also
referral patterns by referring primary care physicians.
Orthopaedic surgical residency trainees tend to be
exposed to greater musculoskeletal conditions relating
to bony and joint disease, whereas neurosurgical trainees
have a broader exposure to the general care of neural
systems and tissues. Differences in training and decisionmaking surrounding spinal surgery (an area where
surgery transcends several connective tissue types) may
be important to clinical practice [2]. Thus, patients with
similar problems associated with degenerative disease
of the lumbar spine may receive different treatment
recommendations based on the specialty of the surgeon
that they visit. Despite the differences in approach, there
were in the current work no significant differences
between neurosurgeons and orthopaedic surgeons in
terms of reoperation rates, complications, and mortality
using our metrics described.
20
We attempted to assess variations in practice and
outcomes in degenerative lumbar spine surgery based
on spine expert volume. We calculated this based on
the total number of spine surgeries performed over
the total number of all surgeries performed in a two
period for each surgeon. As discussed previously, we
then dichotomized into high volume surgeons and low
volume surgeons with high volume surgeons being
those whose surgical practice is at least 50 percent spine
surgical cases. We did not find any significant differences
between the low and high volume groups in terms of
reoperations, mortality, or complications when using
this specific approach.There were far fewer high volume
surgeons than there were low volume surgeons.Although
this approach more accurately gauges those individuals
spending a greater proportion of their operative cases in
spine surgery when compared to absolute spine volume
indices that Bederman et al. [18] utilized, one must also
recognize a limitation of existing administrative databases
in that it does not identify those individuals that have
either received a year or more of fellowship training
specific to spine surgery. An interesting observation in
our current work is that individuals with higher ‘surgeon
expert volume’ also recorded a longer length of hospital
stay. This may reflect, in part, surgical experts being
referred and participating in complex spine surgical
care with technical procedural aspects that may lend to
longer hospital stays given the relative lack of differences
observed when specifically looking a patient medical
co-morbidities versus the complexity of the anatomical
bony and neural spinal condition.
We observed in our current work that if we utilized
a suggested definition of a spinal surgeon as one who
spends at least 80 percent of their elective time performing
spine surgery (Canadian Spine Society definition), the
surgeon number, at least in the Province of Ontario over
the study period, would not lend itself to a meaningful
evaluation of data given the small numbers that would
be categorized as a spine surgeon. Our approach in
classifying ‘spine surgeon expert volume’ would also
overestimate the number of spine surgeons by the CSS
definition as a limitation of the administrative database
lies in the clarity of segregating an elective versus nonelective procedure with both included in our definition
of ‘spine surgeon expert volume’. Conducting this work
over a longer period of time, or additional efforts to
tease our elective versus non-elective procedures locally
may additionally strengthen observed findings. Another
means may include focusing on surgeons performing the
more complex, or uncommon, procedures.
In our current work, we observed several patient
factors that appear to play a significant role in determining
outcomes for surgery for degenerative lumbar spine
conditions. Complication rates were greater for older
patients and those with associated medical co-morbidities.
Increased hospital length of stay and increased readmission rates to hospital following discharge were also
observed for older patients and those with associated
medical co-morbidities. Reoperations were less likely
in older patients and those with medical co-morbidities.
This is an interesting observation that may be explained
by several factors. Patient age and associated medical
co-morbidities may be more important variables in a
surgeon considering a patient eligible or likely to benefit
from an additional spinal surgical procedure (i.e. revision
spine surgery). It is recognized that revision spine surgery
has poorer outcomes when compare to individuals
undergoing their first spine surgical procedure. Younger
individuals may be more likely to articulate ongoing
concerns relating to bodily pain, especially aspects in
physical functioning, that strongly influence patient
perceptions of their quality of life. Additionally, in our
work, both in-hospital and one-year post discharge
mortality, were also greater for older patients and those
with medical co-morbidities. Such discussion in presurgical counseling may be important in patient decision
making vis-à-vis informed consent for revision surgery.
Postoperative imaging (CT scan and MRI) and
reoperation rates were observed at higher rates for
decompressive procedures when compared to fusion
procedures. The purpose of postoperative imaging is
usually to assess the spine for further pathology if the
patient experiences continued symptoms postoperatively
Decompressions do not address the instability often
21
present in degenerative disease of the lumbar spine.
Patients may experience symptoms of instability
after a decompressive procedure (as iatrogenic postsurgical instability is a known condition that can result
following extensive bony and soft tissue resection that
may be required for adequate neural decompression).
Additionally, in the context of ongoing symptomatic
neural anatomical compression following decompressive
surgery, consideration of revision decompressive surgery
often includes the inclusion of resecting additional bony
and soft tissues that play an important role in the static
and dynamic stabilizers of the spine and vertebral column
from a physical perspective.
There are several limitations to this aspect of our
current work. First, as with any study using administrative
databases, there is the possibility of coding inaccuracies.
However, procedural and demographic data from the
databases we used have been shown to be accurate [19].
Second, by using a two-year “look-back” window we
may have wrongly classified some reoperations as being
index procedures as patients may have had a more
remote spinal surgical operation that was not captured.
Third, patients included in our study and in followup were limited to those who received care in the
Province of Ontario. We cannot directly extrapolate to
the general Canadian experience as there are recognized
differences in health care delivery models, physician
referral pathways, patient triage, and access. It is possible
that some patients received their index procedure in
Ontario and then may have experienced reoperations,
complications, and other outcomes elsewhere. Fourth,
this study is observational and is susceptible to inherent
biases, including its retrospective nature. For example,
patients may have had a particular preference regarding
which surgeon or hospital they wanted to be referred
to. Lastly, some surgeons may be improperly categorized
in the low spine expert volume group. This would be
case for surgeons who may have recently retired or
approached retirement, taken a leave of absence during
the study period, or be in their early years of spinal
surgical practice following several years of respected
spine fellowship training. Such surgeons may arguably be
considered experts, but would not have been classified
according to our approach aforementioned.
In conclusion, this study demonstrated that there
are differences in surgical practice for the degenerative
lumbar spine, and that these differences are related to
factors such as surgical specialty training and surgical
expertise. Furthermore, outcomes in surgery for the
degenerative lumbar spine are related mainly to patient
factors such as age and co-morbidities.
Table 1. Number of procedures performed in Ontario for degenerative
disease of the lumbar spine from Apr. 1, 1995 to Dec. 31, 2001.
Adapted from Bederman et al. [12]
TABLES AND FIGURES
Decompression
Noninstrumented
Fusion
Instrumented
Fusion
Total
1995
600 (72.0)
39 (4.7)
194 (23.3)
833
1996
706 (78.3)
39 (4.3)
157 (17.4)
902
1997
633 (71.2)
30 (3.4)
226 (25.4)
889
1998
625 (69.6)
34 (3.8)
239 (26.6)
898
1999
594 (66.4)
41 (4.6)
259 (29.0)
894
2000
619 (61.9)
59 (5.9)
322 (32.2)
1000
2001
423 (59.4)
564* (59.4)*
47 (6.6)
63* (6.6)*
242 (34.0)
323* (34.0)*
712
(949)*
*Numbers and rates adjusted by 4/3 to reflect the three of 12
incomplete months for 2001 since annual volumes are collected
from April 1 to March 31.
22
Table 2. ‘Spine Expert’ volumes for surgeons who treated patients in Ontario with degenerative disease of the lumbar spine between Apr. 1,
1995 to Dec. 31, 2001
No. (%) of surgeons
Annual surgical
volume
No. (%) of patients
Year
Low volume
High volume
Total
Range
Low volume
High volume
Total
1995
114 (93.4)
8
(6.6)
122
1-85
702 (84.3)
131 (15.7)
833
1996
114 (92.7)
9
(7.3)
123
1-89
783 (86.8)
119 (13.2)
902
1997
106 (92.2)
9
(7.8)
115
1-100
767 (86.3)
122 (13.7)
889
1998
96 (88.9)
12 (11.1)
108
1-91
736 (82.0)
162 (18.4)
898
1999
93 (91.2)
9
(8.8)
102
1-95
771 (86.2)
123 (13.8)
894
2000
99 (90.0)
11 (10.0)
110
1-85
821 (82.1)
179 (17.9)
1000
2001
85 (85.0)
15 (15.0)
100
1-89
498
664* (69.9)
214
285*
(30.1)
712
949*
*Numbers and rates adjusted by 4/3 to reflect the 3 of 12 incomplete months for 2001 since annual volumes are collected from April 1 to
March 31.
Table 3. Demographics of patients in Ontario who underwent surgery for degenerative disease of the lumbar spine between Apr. 1, 1995 to Dec.
31, 2001, by surgeon specialty and ‘spine expert volume’
Surgeon specialty
Spine Expert Volume
Characteristic
Neurosurgery
Orthopaedic
Low volume
High volume
No. of patients
2687
3441
5078
1050
Age, mean (range) yr
68.3 (50-92)
67.2 (50-94)
67.7 (50-94)
67.5 (50-91)
Female, no. (%)
1365 (50.8)
1995 (58.0)
2782 (54.8)
578 (55.0)
Charlson ³ 1, no. (%)
744 (27.7)
929 (27.0)
1346 (26.5)
327 (31.1)
Low volume – ‘spine expert’ volume ratio < 0.50; High volume – ‘spine expert’ volume ratio ³ 0.50
Table 4. Surgical procedures performed on patients in Ontario who underwent surgery for the degenerative lumbar spine between Apr. 1, 1995
to Dec. 31, 2001, by surgeon specialty and spine expert volume
Decompressions, no.
Spine Expert Volume
Fusions, no.
Neurosurgeons
Orthopaedic
Surgeons
Total
Neurosurgeons
Orthopaedic
Surgeons
Total
Low volume
1999
1609
3608
82
1388
1470
High volume
487
105
592
119
339
458
Total
2486
1714
4200
201
1727
1928
23
Table 5. Decompression-type reoperations among patients in Ontario who underwent surgery for degenerative disease of the lumbar spine
between Apr. 1, 1995 and Dec. 31, 2001, by demographics and surgeon factors
Decompression-type Reoperation; no. (%)
Characteristics
6 weeks
1 year
2 years
Overall
No. of patients
24 (0.4)
96 (1.6)
175 (2.9)
343 (5.6)
66.8 (52-81)
67.2 (50-87)
66.7 (50-87)
66.6 (50-87)
Female sex
12 (0.4)
50 (1.5)
89 (2.6))
164 (4.9)
Male sex
12 (0.4)
46 (1.6)
86 (3.1)
179 (6.5)
Charlson = 0
17 (0.4)
72 (1.6)
136 (3.1)
271 (6.1)
Charlson ³ 1
7 (0.4)
24 (1.4)
39 (2.3)
72 (4.3)
Index operation
Decompression
19 (0.4)
80 (1.9)
141 (3.4)
278 (6.6)
Fusion
5 (0.3)
16 (0.8)
34 (1.8)
65 (3.4)
Low volume
18 (0.4)
75 (1.5)
142 (2.8)
289 (5.7)
High volume
6 (0.6)
21 (2.0)
33 (3.1)
54 (5.1)
Neurosurgery
10 (0.4)
55 (2.0)
87 (3.2)
176 (6.6)
Orthopaedic Surgery
14 (0.4)
41 (1.2)
88 (2.6)
167 (4.8)
Spine Expert Volume
Surgeon specialty
Table 6. Fusion-type reoperations among patients in Ontario who underwent surgery for degenerative disease of the lumbar spine between Apr.
1, 1995 and Dec. 31, 2001, by demographics and surgeon factors
Fusion-type Reoperation; no. (%)
Characteristics
6 weeks
1 year
2 years
Overall
No. of patients
12 (0.2)
46 (0.8)
122 (2.0)
306 (5.0)
65.7 (50-80)
66.2 (50-81)
66.6 (50-83)
65.1 (50-83)
Female sex
8 (0.2)
27 (0.8)
76 (2.3)
190 (5.6)
Male sex
4 (0.1)
19 (0.7)
46 (1.7)
116 (4.2)
Charlson = 0
7 (0.2)
36 (0.8)
91 (2.0)
235 (5.3)
Charlson ³ 1
5 (0.3)
10 (0.6)
31 (1.8)
71 (4.2)
Decompression
4 (0.1)
28 (0.6)
82 (2.0)
171 (4.1)
Fusion
8 (0.4)
18 (0.9)
40 (2.1)
135 (7.0)
Low volume
11 (0.2)
39 (0.8)
103 (2.0)
265 (5.2)
High volume
1 (0.1)
7 (0.7)
19 (1.8)
41 (3.9)
Neurosurgery
2 (0.1)
18 (0.7)
47 (1.8)
103 (3.8)
Orthopaedic Surgery
10 (0.3)
28 (0.8)
75 (2.2)
203 (5.9)
Index operation
Spine Expert Volume
Surgeon specialty
24
Table 7. Early complications (within 3 months) among patients in Ontario who underwent surgery for degenerative disease of the lumbar spine
between Apr. 1, 1995 and Dec. 31, 2001, by demographics and surgeon factors
Types of Complications; no. (%)
Characteristics
Surgical
Medical
Surgical Reoperations
Overall
No. of patients
158 (2.6)
172 (2.8)
55 (0.9)
285 (4.6)
68.3 (50-87)
70.5 (50-88)
66.0 (50-82)
69.1 (50-88)
Female sex
88 (2.6)
90 (2.7)
25 (0.7)
150 (4.5)
Male sex
70 (2.5)
82 (3.0)
30 (1.0)
135 (4.9)
Charlson = 0
100 (2.2)
94 (2.1)
30 (0.7)
165 (3.7)
Charlson ³ 1
58 (3.5)
78 (4.7)
25 (1.5)
120 (7.2)
Decompression
89 (2.1)
110 (2.6)
34 (0.8)
174 (4.1)
Fusion
69 (3.6)
62 (3.2)
21 (1.1)
111 (5.8)
Low volume
125 (2.5)
134 (2.6)
43 (0.8)
221 (4.4)
High volume
33 (3.1)
38 (3.6)
12 (1.1)
64 (6.1)
Neurosurgery
62 (2.3)
69 (2.6)
17 (0.6)
113 (4.2)
Orthopaedic Surgery
96 (2.8)
103 (3.0)
38 (1.1)
172 (5.0)
Index operation
Spine Expert Volume
Surgeon specialty
Surgical reoperations – includes incision and drainage of subcutaneous tissue, excisional debridement of wound/infection/burn, etc. Low volume
– ‘spine expert’ volume ratio < 0.50; High volume – ‘spine expert’ volume ratio ³ 0.50
Table 8. Readmissions and Mortality among patients in Ontario who underwent surgery for degenerative disease of the lumbar spine between
Apr. 1, 1995 and Dec. 31, 2001, by demographics and surgeon factors
Characteristics
Readmissions within 3
months
In-hospital mortality
Mortality at
3 months post-discharge
Mortality at
1 year post-discharge
No. of patients
743 (12.1)
21 (0.3)
20 (0.3)
95 (1.6)
69.7 (50-94)
74.7 (59-88)
72.8 (57-87)
73.5 (53-94)
Female sex
336 (10.9)
10 (0.3)
11 (0.3)
40 (1.2)
Male sex
377 (13.6)
11 (0.4)
9 (0.3)
55 (2.0)
Charlson = 0
470 (10.6)
9 (0.2)
10 (0.2)
41 (0.9)
Charlson ³ 1
273 (16.3)
12 (0.7)
10 (0.6)
54 (3.2)
Decompression
512 (12.2)
13 (0.3)
16 (0.4)
73 (1.7)
Fusion
231 (12.0)
8 (0.4)
4 (0.2)
22 (1.1)
Low volume
599 (11.8)
17 (0.3)
16 (0.3)
81 (1.6)
High volume
144 (13.7)
4 (0.4)
4 (0.4)
14 (1.3)
Neurosurgery
338 (12.6)
10 (0.4)
10 (0.4)
48 (1.8)
Orthopaedic Surgery
405 (11.8)
11 (0.3)
10 (0.3)
47 (1.4)
Index operation
Spine Expert Volume
Surgeon specialty
25
Table 9. Postoperative Imaging among patients in Ontario who underwent surgery for degenerative disease of the lumbar spine between Apr. 1,
1995 and Dec. 31, 2001, by demographics and surgeon factors
Postoperative Imaging; no. (%)
Characteristics
CT
MRI
Overall
No. of patients
2125 (34.7)
1632 (26.6)
2893 (47.2)
66.9 (50-89)
65.8 (50-89)
66.8 (50-89)
Female sex
1247 (37.1)
897 (26.7)
1651 (49.1)
Male sex
878 (31.7)
735 (26.6)
1242 (44.9)
Charlson = 0
1575 (35.4)
1243 (27.9)
2297 (51.2)
Charlson ³ 1
550 (32.9)
389 (23.2)
938 (56.1)
Decompression
1457 (34.7)
1211 (28.8)
2045 (48.7)
Fusion
668 (34.6)
421 (21.8)
848 (44.0)
Low volume
1754 (34.5)
1352 (26.6)
2380 (46.9)
High volume
371 (35.3)
280 (26.7)
513 (48.9)
Neurosurgery
928 (34.5)
813 (30.3)
1335 (49.7)
Orthopaedic Surgery
1197 (34.8)
819 (23.8)
1558 (45.2)
Index operation
Spine Expert Volume
Surgeon specialty
26
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27
APPENDICES
Appendix 2: Exclusion Criteria (ICD-9)
Appendix 1: Patient Identification(ICD-9-diagnostic codes;
CCP-procedural codes)
• 170.2 Malignancy of bone and articular cartilage (vertebral
column)
• 213.2 Benign neoplasm of bone and articular cartilage (vertebral
column)
• 720 Inflammatory spondylopathies
• 722 Disc disorders
• 730 Infection
• 805-806 Fracture of vertebral column
Spinal stenosis, degenerative spondylolisthesis
• 721.3 Lumbosacral spondylosis without myelopathy (lumbar or
lumbosacral: arthritis, osteoarthritis, spondylarthritis)
• 724.0 Spinal stenosis, other than cervical
• 724.00 Spinal stenosis, unspecified region
• 724.02 Spinal stenosis, lumbar region
• 724.2 Lumbago (low back pain, low back syndrome, lumbalgia)
• 724.3 Sciatica (neuralgia or neuritis of sciatic nerve)
• 724.4 Thoracic or lumbosacral neuritis or radiculitis, unspecified
(radicular syndrome of lower limbs)
• 724.5 Backache, unspecified (vertebrogenic pain syndrome NOS)
• 724.6 Disorders of sacrum (ankylosis or instability, lumbosacral or
sacroiliac)
• 724.9 Other unspecified back disorders (ankylosis of spine NOS,
compression of spinal nerve root NOS, spinal disorder NOS)
• 738.4 Acquired spondylolisthesis (degenerative spondylolisthesis,
spondylolysis acquired)
• 738.5 Other acquired deformity of back or spine (deformity of
spine NOS)
Appendix 3: Classification of Index Surgical Procedures
Procedure Designation
• OHIP Procedure codes
• Decompression (N185)
• Decompression and non-instrumented fusion (N185 + E567)
• Decompression and instrumented fusion (R371)
Instrumented fusion:
Any code with R371
R371 – instrumentation – deformities – segmental procedure –
with fusion
Noninstrumented fusion:
Any code with E567 and no R371
E567 – arthrodesis – fusion with other procedure(s)
Procedures (CCP)
• 16.09 Other explorations and decompression of spinal canal
(decompression: laminectomy, laminotomy; exploration of spinal
nerve root; fomraminotomy)
• 92.31 Excision of intervertebral disc
• 93.03 Dorsal spinal fusion
• 93.04 Dorsolumbar spinal fusion with Harrington rod
• 93.05 Other dorsolumbar spinal fusion
• 93.06 Lumbar spinal fusion
• 93.07 Lumbosacral spinal fusion
Decompression:
Any code with N185 without R371 or E567
N185 – decompression – posterior – posterior laminectomy 1 or
2 levels, cervical, thoracic, lumbar
28
Syndie Singer
Materials and Methods: Prospective preoperative and
one-year postoperative gait analyses were performed
on patients with isolated ankle arthritis that underwent
either ankle arthrodesis or arthroplasty during a sevenyear period. Validated outcome questionnaire data were
obtained. Sixteen patients with arthroplasty and eight
patients with arthrodesis were included; ten matched
control subjects were included. Statistical analysis using
the Kruskal-Wallis test and Wilcoxon scores were used
to determine how much ankle arthrodesis and ankle
arthroplasty patients deviate from each other as well as
from control group values.
Results: There is a trend for arthroplasty patients to
Syndie was born in Montreal and raised in Thornhill.
She moved to Montreal for her undergraduate degree
in Anatomy & Cell Biology at McGill where she played
ice hockey for the Martlets. Syndie then returned to
Toronto and completed medical school at the University
of Toronto in 2006. Syndie and her husband, Roni, are
now the proud parents of baby Talia, born in December
2010. Syndie is looking forward to getting back to work
with her fellowship in Foot & Ankle Surgery with Dr.
Daniels in July at St. Michael’s Hospital.
walk faster and have increased ranges of motion when
compared to arthrodesis patients, though neither groups’
gait patterns were completely normalized. Arthroplasty
patients showed a trend towards normalizing dorsiflexion
but not plantarflexion. Varus/valgus range of motion
was similar for both arthroplasty and control groups,
which differed significantly from arthrodesis. The ankle
moments and power in both treatment groups remained
significantly lower compared to controls. Questionnaire
data indicated that both treatments provided a similar
magnitude of improvement with a trend towards greater
improvement with arthroplasty.
Ankle Arthroplasty
and Ankle Arthrodesis
- Prospective Gait
Analysis Compared to
Controls
Conclusion: Gait patterns of patients following three-
component mobile bearing total ankle arthroplasty
more closely resembles normal gait as compared to
arthrodesis. Motion in both the coronal and sagittal
planes is primarily responsible for the differences.
Reasons why patients are not using the plantarflexion
range of motion in the terminal stance phase needs
further investigation. Results obtained from this study
can add to the clinicians’ ability to inform patients of
predicted functional outcomes prior to treatment of
end-stage ankle osteoarthritis.
Authors: Syndie Singer, Sue Klejman, Ellie Pinsker,
Timothy Daniels
ABSTRACT
Background: This study compares patients with isolated
end-stage ankle osteoarthritis, after undergoing either
arthroplasty or arthrodesis, using gait analysis and outcome
measures to elucidate differences between the two
treatment options, compared to a healthy control group.
Keywords: Ankle arthritis; Ankle arthrodesis; Ankle
arthroplasty; Gait analysis; Control group
29
INTRODUCTION
patients with isolated end-stage osteoarthritis of the
ankle, undergoing either arthroplasty or arthrodesis,
using three-dimensional gait analysis to reveal objective
differences between the groups, as well as to contrast
these findings with outcome measure questionnaire data.
The patient groups are also compared to healthy age-,
weight- and sex-matched controls.
Surgical management of patients with end-stage ankle
arthritis has traditionally involved both ankle arthrodesis
and shoe modification. Ankle arthrodesis effectively
relieves pain and improves functional outcome; however,
comparative studies have demonstrated that the patients
functional outcomes remain significantly lower than
normal and there are measurable abnormalities in their
gait parameters1. Long term retrospective clinical studies
have identified a high incidence of ipsilateral hindfoot
arthritis with an associated deterioration in outcomes1-3.
Ankle arthroplasty was introduced in the 1970s.
Although initial results were poor, this was largely due
to early loosening4,5. Newer studies suggest that implant
survival rates are 70 to 95 percent for follow up from two
to 12 years6-9. A recent systematic review of intermediate
and long-term outcomes comparing arthroplasty to
arthrodesis indicates that the risk of early complications
and long-term failure associated with either procedure
is comparable10. With the continued refinement of
prosthetic design and surgical technique, the use of
arthroplasty has resurged during the last decade; the
results from newer implants look promising, with
improved durability, functional outcomes and implant
longevity6-9,11,12.
Both arthrodesis and arthroplasty are able to improve
pain and function in patients with significant ankle
pathology. Nonetheless, surgeons continue to strive to
restore patients’ joints to a near-normal state, since it is
hypothesized that restoring ankle motion can improve
patient satisfaction and function, as well as delay the onset
of subtalar joint arthritis. While assessing differences in
outcomes on the basis of subjective questionnaires is
problematic, gait analysis can help elucidate objective
differences between arthroplasty and arthrodesis.
In spite of the increasing prevalence of total ankle
replacements, research on the effect of this surgical
intervention on gait mechanics is limited. Early gait
studies following arthroplasty revealed poor outcomes13-15,
while more recent studies show a general trend towards
normalization of gait patterns16-21.
The purpose of this study is to compare groups of
MATERIALS AND METHODS
The present study was performed with approval of the
Research Ethics Board of our institutions; all participants
signed an informed consent form prior to inclusion.
Prospective preoperative and one-year postoperative gait
analysis was planned for all patients undergoing either
ankle arthrodesis or total ankle arthroplasty between
2000 and 2007. Patients also completed outcome data
questionnaires. Only those patients with isolated ankle
arthritis and minimal or no subtalar arthritis were
included. Strict exclusion criteria were applied in order
to ensure that gait pattern differences could be attributed
to treatment alone (see Figure 1). Gait analysis was
compared to a healthy sex and age-matched control
group of ten subjects.
A total of 24 patients were included: 16 with isolated
ankle arthroplasties (Scandinavian [STAR] or Hintegra)
and eight patients who underwent ankle arthrodesis.
All surgical procedures were performed by the senior
author. Healthy controls with painless joints were
recruited in order to obtain a group of ten age-, weight-,
and sex-matched controls (see Table 1). Sample size
was limited by the availability of patients undergoing
these procedures during the study period; however, this
number is comparable to similar gait studies18,22,23.
Gait Analysis
Bilateral barefoot gait data were collected for the patient
sample. Patients wore T-shirts and tight-fitting shorts
during the examination to allow for accurate marker
placement. Gait data were collected at a frequency of
60 Hertz using a seven-camera Vicon motion capture
system (Vicon Peak, Oxford, UK). Ground reaction
forces were recorded with two Bertec force platforms
30
(Bertec Corporation, Columbus, OH, USA), sampling
at 1200 Hertz frequency, located in the center of the
walkway.
Three-dimensional kinematics of the foot were
obtained using an adapted two-segment foot model to
describe the motion of (i) the forefoot relative to the
hindfoot and (ii) the hindfoot relative to the shank, as
adapted from Wu et al.24; data were also analyzed using
a one-segment foot model22 for comparison. Thirty-five
spherical reflective markers were used to define the rigid
body model1; marker positions are shown (see Figure 2).
Reflective markers were manually identified using Vicon
Workstation (Vicon Peak, Oxford, UK). Local dynamic
and bone-embedded coordinate systems were defined for
the forefoot (metatarsals, cuneiforms and cuboid), hindfoot
(calcaneus, talus and navicular), shank, thigh and pelvis.
The motion of the distal segment relative to the proximal
segment was obtained using Euler angles. A rotation
sequence from sagittal plane to coronal plane to transverse
plane was used to define the relative forefoot and hindfoot
angles to allow for comparisons with previously published
data24.The remaining segment rotations were defined using
an Euler sequence of coronal, followed by transverse and
then sagittal plane rotations1. All trajectories were filtered
using a generalized cross-validated spline technique25.
Gait trials were performed along a ten-meter walkway.
Participants were instructed to walk at their regular, selfselected walking speed.At least three complete trials were
captured per subject. For a trial to be considered complete
it was required that markers were not obstructed allowing
for their accurate three-dimensional reconstruction, and
that complete force plate data from the affected side
were collected. In all cases, an average of three trials was
used to obtain a single representative stride. Measures
of velocity and percentage of time in stance & swing
phases were calculated on the basis of the posterior heel
marker trajectories. Heel-off was determined from the
sagittal trajectory of the heel marker, adapted from the
method described by Beyeart22. At heel-off, the following
variables were measured: anterior tilt of the tibia defined
as sagittal plane rotation of the tibia with respect to the
global coordinate system, knee flexion defined as sagittal
plane rotation of the tibia with respect to the femur, and
tibia/hindfoot angle defined as coronal plane rotation
of the hindfoot with respect to the tibia. Data were
processed to determine temporal kinematic and kinetic
parameters using BodyBuilder software (Vicon Peak,
Oxford, UK).
Questionnaire Data
Patients completed preoperative, one-year and two-year
postoperative functional outcome scores including the
Ankle Osteoarthritis Scale (AOS) and the American
Academy of Orthopaedic Surgeons (AAOS) Foot and
Ankle Questionnaire (includes Short Form-36 Standard
Version 2.0 Health Survey). As well, they completed
two general questions regarding satisfaction with the
procedure. Two year questionnaire data were used
for one patient who did not complete the one year
questionnaire.
Statistical Analysis
Statistical analyses were performed to compare ankle
arthrodesis to ankle arthroplasty, as well as to determine if
each group deviates from normal values. For each group,
means, standard deviations, medians, and box-plots were
used to describe gait parameters. Given the small sample
sizes in each group and presence of outliers, the nonparametric Kruskal-Wallis test was used to compare the
three groups. For variables statistically significant, the
non-parametric Wilcoxon rank-sum test was performed
to determine which pair of groups was statistically
different. Two-tailed p-values <0.05 were considered
significant in all tests. Analyses were performed with SAS
9.1 statistical software (SAS Institute Incorporated, Cary,
NC, USA). Due to the small sample size, p-values were
used to indicate trends rather than absolute statistical
significance. The absolute difference between pre and
postoperative outcome scores for both arthroplasty
and arthrodesis patients were compared using the t-test
for normally distributed data sets. The Social Function
and Role-Emotional components of the SF-36 were
not normally distributed and thus, the nonparametric
Wilcoxon rank-sum test was used instead.
31
Source Funding
significant differences between the groups were found
with the number of patients available. The control group
had the largest range of motion (27.9+/-5.3 degrees),
while arthroplasty showed an intermediate outcome
at (17.7+/-3.6 degrees; p<0.01 compared to control)
and arthrodesis resulted in the least amount of motion
(13.4+/-4.1 degrees; p<0.01 compared to control).
Interestingly, the main difference between the two patient
groups came exclusively from improved dorsiflexion.
For arthroplasty patients, dorsiflexion was 10.9+/-4.0
degrees, compared to dorsiflexion of only 6.4+/-4.2
degrees in the arthrodesis patients, however, the p-value
did not reach significance between the three groups
(p=0.052). Conversely, neither patient group was using
normal plantar flexion range of motion (arthroplasty
7.0+/-4.8 degrees; p<0.01 compared to control,
arthrodesis 7.0+/-4.9 degrees; p=0.01 compared to
control).This motion was significantly limited compared
to controls (16.0+/-5.6 degrees; see Figure 3).
Ranges of ankle varus/valgus were similar in
arthroplasty (14.1+/-6.1 degrees) and control (14.4+/4.0 degrees) groups, but restricted in the arthrodesis group
(9.3+/-3.0 degrees; p=0.04 compared to arthroplasty).
The range of tibial tilt followed a similar pattern to the
coronal motion. Further, tibial tilt at heel off was not
shown to be different between the three groups; p=0.20.
External funding from granting agencies and industry
were utilized in this study to obtain the gait analysis on
both the patient and control group.
RESULTS
Gait analysis data and outcome data for the two patient
groups are presented (16 arthroplasty patients and eight
arthrodesis patients). Gait analysis was compared to a
healthy control group of ten subjects.
Gait Analysis – Temporal Parameters:
Temporal-spatial gait parameters for postoperative
arthrodesis, postoperative arthroplasty and control
groups include velocity, cadence, step length, symmetry
of stride length, stance phase as a percentage of gait cycle
and heel rise as a percentage of gait cycle. The results are
summarized in Table 2.
The average walking speed was fastest in the control
group (1.22±0.17m/s), intermediate in the arthroplasty
group (1.09±0.18m/s) and slowest in the arthrodesis
group (1.00±0.21m/s). A similar trend was found for the
cadence.The trend towards reduced walking speed of the
arthrodesis group compared to the arthroplasty group
was a result of a reduction in cadence but not stride
length. The duration of stance phase as a percentage of
the gait cycle was similar for all three groups. Heel rise
occurred at within one percent of the gait cycle for both
arthroplasty and arthrodesis groups, however, there was
a trend for the control group to heel rise slightly earlier.
With the number of patients available, no significant
difference in symmetry of stride length was found
between groups.
Gait Analysis – Kinetic Parameters
Ankle kinetic variables showed significant differences
between the groups and are summarized in Table 4
(see Figure 4). Ankle power was greatest in the control
subjects (2.2+/-0.5 W/kg) and significantly less for the
patient groups (arthrodesis 0.8+/-0.7 W/kg, arthroplasty
1.1+/-0.5 W/kg). This difference was statistically
significantly different between control and patient
groups, (arthroplasty vs control p<0.01, arthrodesis
vs control p<0.01), but not between patient groups
(p=0.30; see Figure 5). Similar to ankle power, the same
pattern was seen for peak ankle extension moment and
ankle moment at heel rise (see Figure 6).
Gait Analysis – Kinematic Parameters
Kinematic gait parameters for postoperative arthrodesis,
postoperative arthroplasty and control groups include:
range of ankle dorsi/plantarflexion, range of ankle varus/
valgus, tibial rotation and tibial tilt at heel off. Results are
summarized in Table 3.
Inspection of maximum ankle dorsiflexion and
plantarflexion revealed a strong trend but no statistically
32
Outcome Questionnaire Data
group over the arthrodesis group; however, neither
groups’ parameters were normalized to those of the
control group. Improvements in parameters such as
velocity, ankle dorsiflexion range of motion, ankle varus/
valgus range of motion, tibial rotation, and sagittal plane
ankle power indicated that arthroplasty yields a more
normal gait pattern than arthrodesis. This also represents
a marked improvement over gait patterns observed
following first-generation ankle arthroplasties5,15.
In contrast to other measures which only showed
slight improvements, the coronal ankle range of motion
for the arthroplasty group was similar to that of the
controls, while the arthrodesis group was substantially
stiffer. Maintaining normal motion in the coronal plane
is crucial for balance as the subjects progress from heeloff to toe-off, which would allow for normal locking
of the chopart joints, thereby conferring additional gait
stability.
Maximal plantarflexion occurs at toe off.The fact that
both patient groups are limited compared to controls and
that the arthroplasty patients are not using any increased
plantar range of motion compared to arthrodesis patients
is a significant discovery that could help in the design
of future implants. Neither of the arthroplasty designs
used in this study effectively reproduces the posterior
malleolus of the ankle. This is a common design of most
modern day ankle arthroplasties. It is possible that the
lack of posterior support is preventing the patients from
using their functional range of ankle plantarflexion
during the terminal portion of the stance phase.
Only a single comparative gait study has been
published23. Piriou’s group compared two equallysized groups of arthroplasty and arthrodesis patients,
and concluded that the arthroplasty group has a slower
but more symmetrical gait, with ground reaction
forces approaching that of normal controls. However,
the study is limited by the short six-month follow-up
period for some subjects, unmatched controls, limited
kinetic analysis, and kinematic results from the sagittal
plane only. These results differ somewhat from our
findings where arthroplasty patients walked faster than
arthrodesis patients by 0.09 m/s and we found no
There was a general trend for arthroplasty outcome scores
show slightly greater absolute improvement; however,
these improvements were not shown to be statistically
significantly different.
The AOS score is a self-assessment instrument that
rates pain and disability related to ankle arthritis. A lower
score is better. For the arthroplasty patients, the pain
portion of the scores decreased an average of 26.9 points
compared to 21.8 points in arthrodesis (p=0.54). The
disability score component decreased by 33.7 points in
arthroplasty compared to only 24.5 points for arthrodesis
(p=0.30; see Figure 7).
The AAOS foot and ankle self-assessment form
investigates pain and function (core scores), as well as
shoe comfort. A higher score is better. Arthroplasty
and arthrodesis patients core scores improved for the
standardized mean by 28.3 and 22.5 points respectively
(p=0.45), as well as the normative score by 22.9 and 18.1
points (p=0.44). The shoe comfort score was the only
parameter where the trend was reversed, with arthrodesis
patients showing greater improvement, however not
statistically significant.
For shoe comfort core scores, arthroplasty improved
by 10.7 points and arthrodesis by 26.2 points (p=0.36).
The shoe comfort normative scores improved similarly
by 3.9 and 9.0 points respectively (p=0.34; see Figure 8).
The SF-36 is general health scale that examines two
components of well-being. The eight score areas are
combined to give two summary scores including the
physical component score and mental component score.
A higher score is better. Arthroplasty patients showed an
improvement of 10.3 points in the physical component
score where as arthrodesis patients improved 7.1 points
(p=0.47). Mental component scores showed limited
change in both patient groups. Scores decreased by 0.9
points for arthroplasty and 0.2 for arthrodesis (p=0.91).
DISCUSSION
A one-year functional outcome analysis using gait
analysis demonstrated temporal, kinematic and kinetic
improvements in function for the ankle arthroplasty
33
difference in symmetry of step. However, both studies
demonstrated that ankle motion and forces were not
completely normalized by either procedure, but were
closer to normal with arthroplasty.
Other studies have not yet compared kinetic data
(moments and power) amongst study groups and controls.
Our study demonstrated that ankle moments and power
did not detect any significant differences between patients
after ankle arthritis surgery; however, there is a slight
trend towards improved power for arthroplasty when
compared to arthrodesis. The failure of arthroplasty to
improve ankle joint power generation during late stance is
interesting and worthy of future studies.The ankle plantar
flexor moments improved in both groups, however, in the
arthroplasty group this was not accompanied by greater
plantar flexion, resulting in no increase in ankle power.
Future studies, may consider methods to improve ankle
plantarflexion during late stance and hence, ankle power.
It has been theorized that the development of
ipsilateral arthritis in the subtalar and midtarsal joints
following ankle arthrodesis is the result of abnormal
gait kinematics postoperatively22. The normalization
of coronal motion and improvement in ankle sagittal
movement observed following arthroplasty suggests
that more normal hindfoot / midfoot kinematics are
restored. It has not been established whether this will
decrease stresses on adjacent joints, thereby slowing the
progression of arthritis.
The gait data can be contrasted with the outcome
questionnaire data. According to our outcome data
questionnaires, the arthroplasty patients had slightly
higher initial scores compared to arthrodesis patients.
To account for this difference, we examined absolute
improvements in the scores. Both groups’ scores
improved, and we noted a slight general trend for
larger gains in arthroplasty patients; this difference was
not statistically different. Subjective questioning about
satisfaction with the procedure revealed that arthroplasty
patients seemed to be more satisfied, perhaps due to the
more normal feel of the ankle replacement conferred
by the objective improvements in motion compared to
arthrodesis. Both patient groups were likely to choose
the same procedure again, which is likely reflective of
the patients’ knowledge of the limited surgical treatment
options for their condition.
Limitations and Bias
Although our study only included 24 of a possible 171
patients who had ankle arthritis surgery; we wanted
to ensure that the arthroplasty and arthrodesis groups
were comparable. Consequently, we designed our
exclusion criteria to identify patients whose alterations
in gait pattern could be solely attributed to this surgical
procedure. Although this design necessarily limits our
sample size and power, it was essential to ensuring the
reliability of our conclusions.
Measurements between individual subject trials
were more variable using the two-segment foot model
compared to the one-segment model.This variability was
attributed to small differences in placement or movement
of closely spaced markers, which can translate to larger
differences in measured values. Recognizing that the
one-segment foot model provides a more reproducible
pattern with decreased measurement error, the onesegment foot was used in majority of the data analysis.
Similarly, given the proximity of the markers used
to determine coronal and transverse plane movement,
substantial variability in the measured forces in
these directions are found throughout the gait cycle.
Consequently, only sagittal plane data were utilized for
kinetic parameters to minimize measurement error.
Generalizability
Our results can be generalized to patients with endstage ankle arthritis who are between forty and eighty
years of age, and are choosing between ankle arthroplasty
and arthrodesis. Arthroplasty is rarely performed on
patients under the age of forty, and patients over the
age of eighty were excluded from this study. Although
we employed strict exclusion criteria, it was necessary
to isolate differences in gait patterns due to the surgical
procedure alone; the relative expectations of patients
who have other joint replacements and/or other lower
limb trauma can likely be extrapolated.
34
CONCLUSION
10. Haddad, S.; Coetzee, J.; Estok, R.; Fahrbach, K.; Banel, D.;
and Nalysnyk, L.: Intermediate and long-term outcomes of total
ankle arthroplasty and ankle arthrodesis. A systematic review of the
literature. J Bone Joint Surg Am., 89(9): 1899-905, 2007.
11. Buechel, F. F., Sr.; Buechel, F. F., Jr.; and Pappas, M. J.:
Eighteen-year evaluation of cementless meniscal bearing total
ankle replacements. Instr Course Lect, 51: 143-51, 2002.
12. Anderson, T.; Montgomery, F.; and Carlsson, A.:
Uncemented STAR total ankle prostheses. J Bone Joint Surg Am,
86-A Suppl 1(Pt 2): 103-11, 2004.
13. Michelson, J. D.; Schmidt, G. R.; and Mizel, M. S.:
Kinematics of a total arthroplasty of the ankle: comparison to
normal ankle motion. Foot Ankle Int, 21(4): 278-84, 2000.
14. Mazur, J.; Schwartz, E.; and Simon, S.: Ankle arthrodesis.
Long-term follow-up with gait analysis. J Bone Joint Surg., 61:
964-75, 1979.
15. Stauffer, R.; Chae, E.; and Brewster, R.: Force and motion
analysis of the normal, diseased and prosthetic ankle joint. Clin.
Orhtop., 127: 189 - 196, 1977.
16. Benedetti, M. G.; Leardini, A.; Romagnoli, M.; Berti,
L.; Catani, F.; and Giannini, S.: Functional outcome of
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Am Podiatr Med Assoc, 98(1): 19-26, 2008.
17. Houdijk, H.; Doets, H. C.; van Middelkoop, M.; and
Dirkjan Veeger, H. E.: Joint stiffness of the ankle during
walking after successful mobile-bearing total ankle replacement.
Gait Posture, 27(1): 115-9, 2008.
18. Doets, H. C.; van Middelkoop, M.; Houdijk, H.; Nelissen,
R. G.; and Veeger, H. E.: Gait analysis after successful mobile
bearing total ankle replacement. Foot Ankle Int, 28(3): 313-22, 2007.
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D.; Goepfert, B.; and Hintermann, B.: Gait analysis in ankle
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the agility total ankle during gait. Foot Ankle Int, 27(11): 980-4, 2006.
In summary, the current investigation demonstrates that
ankle arthroplasty normalizes gait mechanics to a greater
extent than arthrodesis. It is important to keep in mind that
neither procedure is able to replicate normal ankle function.
Although ankle powers and moments did not show
differences between patient groups, significant maintenance
of joint motion was observed in the arthroplasty group.
It is our impression that this normalization explains
patients’ perceived improved satisfaction with arthroplasty
as compared to arthrodesis. A longitudinal evaluation will
determine if these changes will conclusively result in a
decreased incidence of ipsilateral hindfoot arthritis and give
us insight into long term patient satisfaction.
The results of this study will help with the design of
future implants as well as help clinicians predict outcomes
and educate patients on the expected gait improvements
following ankle arthroplasty and ankle arthrodesis.
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J. M.: The effect of tibio-talar arthrodesis on foot kinematics
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35
FIGURES & TABLES
Figure 4 – Comparison of maximum ankle power generation and
ankle extension moment.
Figure 1 – Inclusion/Exclusion Diagram
Figure 5 – Comparison of ankle power during gait cycle.
Figure 2 – Reflective marker placement diagram.
Figure 6 – Comparison of sagittal plane ankle moment during gait
cycle.
Figure 3 – Comparison of ankle range of motion during gait cycle.
36
Figure 7 – Comparison of pre to post operative changes in AOS
scores.
Figure 8 – Comparison of pre to post operative changes in AAOS
scores.
Table 1 - Demographic Data
Group Averages
Arthrodesis
Table 2 - Temporal Gait Parameters
Arthroplasty
Control
Arthrodesis
Arthroplasty
Control
1.00+/-0.21
1.09+/-0.18
1.22+/-0.17
104.0+/-7.4
111.7+/-11.6
114.2+/-6.1
1.16+/-0.21
1.16+/-0.15
1.27+/-0.12
1.3+/-1.6
2.1+/-1.6
1.7+/-1.8
60.1+/-2.5
61.5+/-2.0
62.2+/-0.9
47.1+/-3.8
48.0+/-2.2
45.4+/-1.8
Velocity Kruskal-Wallis;
Total in group
8
16
10
Female/Male
3/5
9/7
5/5
Right/Left
2/6
10/6
5/5
Age (years)
50.6 +/- 16.5
61.3 +/- 10.9
51.0 +/- 21.3
range
(20.1 to 71.3)
(39.4 to 77.9)
(24.0 to 77.0)
(steps/s)
Weight (kg)
88.8 +/- 18.3
89.3 +/- 32.8
80.8 +/- 11.2
Stride Length
range
(62.5 to 109.5)
(46.5 to 164.0)
(67.5 to 98.5)
(meters)
Height (cm)
172.5 +/- 8.1
167.4 +/- 13.2
167.4 +/- 7.8
range
(164 to 185)
(151 to 187)
(155 to 180)
Symmetry Stride
Length
BMI (kg/m2)
29.9 +/- 6.1
31.4 +/- 8.8
29.0 +/- 5.1
range
(20.8 to 36.8)
(17.1 to 49.8)
(22.6 to 41.0)
Time to Gait
Analyisis (years)
1.31 +/-0.47
1.12 +/- 0.27
n/a
range
(0.89 to 2.1)
(0.91 to 2.04)
p=0.067
(m/s)
Cadence KruskalWallis; p=0.068
(%difference)
Stance Phase
(% gait cycle)
Heel Riseb; p=0.01
(% gait cycle)
Significant difference between arthrodesis and control groups
Significant difference between arthroplasty and control groups
c
Significant difference between arthrodesis and arthroplasty groups
a
b
c
a
b
c
a
b
37
Table 3 - Kinematic Gait Parameters
Measurements in degrees
Arthrodesis
Arthroplasty
Control
13.4+/-4.1
17.7+/-3.6
27.9+/-5.3
7.0+/-4.9
7.0+/-4.8
16.0+/-5.6
Ankle Dorsiflexion Kruskal-Wallis; p=0.52
6.4+/-4.2
10.9+/-4.0
11.9+/-3.9
Ankle ROM Varus/Valgus
9.3+/-3.0
14.1+/-6.1
14.4+/-4.0
Tibial Rotation
8.8+/-3.0
10.0+/-2.4
10.7+/-2.2
18.8+/-4.3
22.5+/-4.2
20.2+/-3.7
Total Sagittal Ankle ROM
a; p=0.003, b;
p=0.0002, c; p=0.052
Ankle Plantarflexion
a; p=0.01, b; p=0.003
a; p=0.02, c; p=0.04
Tibial Tilt at Heel Off
Table 4 - Kinetic Gait Parameters
Power
a; p=0.006, b; p=0.002
Arthrodesis
Arthroplasty
Control
0.8+/-0.7
1.1+/-0.5
2.2+/-0.5
0.8+/-0.3
0.9+/-0.2
1.1+/-0.1
0.8+/-0.3
0.9+/-0.2
1.1+/-0.1
(Watts/kg)
Ankle extension momenta; p=0.04, b; p=0.007
(Nm/kg)
Ankle moment at heel risea; p=0.04, b;
p=0.009
(Nm/kg)
38
Training Femoral Neck
Screw Insertion Skills to
Surgical Trainees:
Computer-Assisted
Surgery Versus
Conventional
Richard Hurley
Richard
was
born
in
Christchurch, New Zealand.
He graduated in medicine
from the University of Otago
(Dunedin, New Zealand) in
2002. Shorty following this he
began surgical training with
the Royal Australasian College
of Surgeons in Orthopaedics
at Wellington Hospital.
In 2005 Richard was introduced to the University
of Toronto Orthopaedic Resident exchange program
by his mentor Dr. Geoffrey Horne, an ex-Toronto
Orthopaedic trainee and colleague of Dr. James Waddell.
Over a six-month period Richard obtained valuable
experiences working as a resident at the Toronto Western
Hospital and Sunnybrook Health Sciences Centre.
While in Toronto he also met his future wife Adrienne, a
neurosurgery resident.
In 2006 Richard became a permanent resident of
Canada. His career took a brief hiatus as a product
manager for DePuy Inc. of Johnson & Johnson Medical
Products Canada. He managed computer-assisted surgery
products in alliance with Brainlab AG and also oversaw
DePuy’s industry sponsored clinical trials.
In 2007 Richard was accepted into the University of
Toronto Orthopaedic Residency program. During his
residency he was elected the divisional chief resident for
2010.
Richard is the proud father of four-year-old son
Jackson and two-year-old daughter Kennedy. Next year
he will be completing a trauma fellowship with Dr. Hans
Kreder and Dr. David Stephen at the Sunnybrook Health
Sciences Centre.
Richard T. Hurley, MBChB (Otago 2002)
Supervisor:
Markku T. Nousiainen, B.A.(Hons.), M.S., M.Ed., M.D.,
FRCS(C)
Assistant Professor, Department of Surgery,
University of Toronto
Principle Authors:
Nousiainen MT, Zingg P, Omoto D, Carnahan H,
Weil YA, Kreder HJ, and Helfet DH
ABSTRACT
Background: The purpose of this study was to determine
the effect of computer navigation on the learning of a
basic orthopaedic surgical procedure in the medical
trainee, performing internal fixation of a femoral neck
fracture. As conventional training for this procedure
already relies on continuous extrinsic feedback provided
by fluoroscopy and computer-assisted fluoroscopic
techniques have been shown to provide significantly
more accurate and precise placement of cannulated
screws in expert surgeons, it was hypothesized that
computer-based navigation would not compromise the
learning of hardware placement in the surgical trainee.
In addition, it was hypothesized that those trained with
computer navigation would be able to transfer their
skills in properly performing the task with conventional
fluoroscopic guidance.
39
A prospective, randomized, controlled
study was conducted. Thirty-nine senior medical
students or first-year surgical residents that had not yet
performed the surgical procedure of internal fixation
of a femoral neck fracture were recruited to participate.
Twenty participants were randomly assigned into the
conventional fluoroscopy-guided technique while the
remaining nineteen participants were assigned to the
computer-based navigation technique. Upon completion
of a video and expert training session, each participant
performed the surgical task on the simulated hip fracture.
Four weeks later, the participants returned to perform
a retention test of performance using the technique
they were originally trained with. A transfer test then
followed – each group of students repeated the surgical
task but instead used the other technique to guide them
(i.e. those trained with the conventional fluoroscopyguided technique used the computer-based navigation
technique and vice versa). The primary outcome
measure for the study was placement of the hardware in
the femoral head; secondary outcome measures included
number of attempts taken to perform the task, number
of times the subchondral bone of the femoral head was
penetrated, the total radiation time and dosage during
the procedure, and the total time taken to perform the
procedure.
Methods:
Results: The primary outcome measure, hardware
positioning (distance of guide wire to subchondral
bone of femoral head), improved after the training
session, whether the surgical novices used fluoroscopy
or computer navigation. The positioning of hardware
reached that of expert surgeons, as each group was able
to place the guide wire within the goal of five mm.
of subchondral bone. The participants maintained this
level of skill during retention and transfer testing, as no
significant difference was seen within or between the
groups from the post-test period onward. Participants
trained with computer navigation minimized the number
of attempts to place the hardware, and used significantly
less total radiation time and dosage after training.
Conclusions: The findings of this study suggest that the
training module we developed will improve hardware
placement to near expert levels in immediate and
delayed testing whether computer navigation is used
or not. But when computer navigation is used, less
total radiation time and dosage is used by the trainee
and fewer attempts are taken to perform the procedure.
In addition, no compromise in learning occurs when
the surgical novice trained with computer navigation
transfers to using conventional fluoroscopy to perform
the task. This study suggests that computer navigation
may be safely used to train surgical novices in this basic
surgical procedure. Nevertheless, the task is complex and
further studies are required to show how novices can
learn to improve all aspects of performing this procedure
to expert levels.
40
Training Femoral Neck
Screw Insertion Skills to
Surgical Trainees:
Computer-Assisted
Surgery Versus
Conventional
that the use of computer navigation to train medical
trainees to perform basic surgical procedures such as
hip fracture fixation may be detrimental. A number of
motor learning studies have demonstrated that while
the concurrent augmented feedback provided by
computer navigation enhances performance during
practice, it does not contribute to learning, as measured
on delayed retention or transfer tests.8,9,10,11 As such, it
may be detrimental to learning.This is due to the learner
either developing a dependence on the continuous
additional feedback provided from extrinsic cues during
the learning process (guidance hypothesis) or due to
the learner deferring to the more readily available or
interpretable extrinsic feedback over intrinsic feedback
(attentional processes hypothesis).18 It has been suggested
that the concurrent augmented feedback provided by
technology such as computer navigation needs to be
appropriately diminished over time in order to avoid the
development of learner dependence. 21
There have been few studies that have examined
how computer-assisted surgery affects the skills of
surgical trainees when learning how to perform
routine orthopaedic surgical procedures. However, an
investigation by Mayman et al. compared the use of
conventional fluoroscopy versus computer navigation
in the placement of Dynamic Hip Screw guidewires in
a sawbone model by a fifth-year orthopaedic surgery
resident.5 This study found that placement of the
guidewire was significantly more accurate and precise
when the computer-assisted technique was used
immediately after training. It also required fewer drill
tracks through the femur and exposed the patient and
the surgical team to significantly less ionizing radiation.
No assessment of retention of skill performance after the
training session was provided.
The impact of computer-assisted surgery on the
learning curve associated with hip resurfacing has
been reported in three studies.13,14,15 All of these studies
have shown that when medical trainees use computer
navigation, component positioning equals that of expert
surgeons. However, the longer term retention of this skill
was not evaluated. (Performance on retention and transfer
Nousiainen MT, Zingg P, Omoto D, Carnahan H,
Weil YA, Kreder HJ, and Helfet DH
Introduction
Femoral neck fractures are among the most common
orthopaedic injuries that impact the healthcare system,
costing over six billion dollars annually in the United
States alone. The surgical management of such fractures
with cannulated screws is among one of the most
common orthopaedic procedures performed. Proper
surgical technique in obtaining appropriate guidewire
and hardware placement is known to be one of the most
important factors in predicting outcome.1,2
The acquisition of the surgical skills necessary to
perform this task is mandatory during the residency
training process and typically involves learning on real
patients with fluoroscopic guidance. Recent publications
involving experienced orthopaedic surgeons have shown
that when compared with conventional fluoroscopic
guided techniques, computer-assisted fluoroscopic
techniques provide significantly more accurate and
precise placement of the guidewires and cannulated
screws, with fewer drill tracks through the femur and
less exposure to ionizing radiation.3.4,16,17 In addition,
after using computer navigation in the operating
room, experienced orthopaedic surgeons demonstrate
improved accuracy in freehand component placement
during subsequent procedures performed without
computer navigation.7
Despite its success with expert surgeons, there is
evidence from the kinesiology and psychology literature
41
tests is regarded as the only true test of learning – changes
in performance during practice, while often referred to
as learning curves, are felt to represent temporary effects
related directly related to the practice session).18,21 An
accurate determination of how computer navigation
affects the learning of surgical skill is difficult due to
limitations in study design. None of the studies present
evidence of whether they were sufficiently powered to
determine their primary outcome, have mentioned how
the type of training their participants underwent at the
beginning of the study was standardized, or have had any
mention of participant performance on a retention test
of performance and knowledge after the training/study
session. In addition, two of the study designs were nonrandomized.13,15
Some of these limitations were overcome by Gofton
et al. who compared computer navigation-guided
training to conventional training in the placement
of a total hip arthroplasty acetabular cup in surgical
trainees.6 Participants were randomized to three training
conditions: conventional training with expert feedback;
computer navigation training; and knowledge of results
training (this group initially self-determined cup
position and then had access to computer navigation
to independently correct cup position thereafter).
Outcomes were assessed in a pretest session and in ten
minute, and six week retention and transfer tests. The
concurrent augmented feedback provided by computerassisted orthopaedic surgery was found to improve
early performance and lead to equivalent learning in
component positioning during the immediate and
delayed retention and transfer tests compared to the
conventional training and knowledge of results training
groups.Thus, it was concluded that there is no detriment
to learning when trainees are exposed to computerassisted surgery. Despite these results, the authors pointed
out that further investigation was required to ensure that
computer-assisted surgery does not comprise trainees’
learning in more complex tasks.
The placement of three cannulated screws across
a reduced femoral neck fracture provides a different
technical challenge from implanting an acetabular cup
during a total hip arthroplasty and may be considered
to be a more complex task. While the ideal position
of a total hip arthroplasty cup must be determined in
the axial and coronal planes, the three guidewires and
subsequent screws used in femoral neck fracture fixation
must (i) be placed parallel to each other in the coronal
and sagittal plane, (ii) have their insertion point located
proximal to the lesser trochanter, (iii) be in the form of
an inverted triangle, (iv) be within five millimeters of
the subchondral bone of the femoral head, and (v) have
appropriate spread between the screws.
What also makes this procedure more complex than
total hip arthroplasty acetabular component positioning
is that, in addition to responding to cues obtained from
the operative site, the surgeon must respond to cues
provided from the fluoroscopy unit that is used to guide
hardware placement. The continuous extrinsic feedback
visual cues shown on the fluoroscopy monitor screen
provide immediate knowledge of hardware placement
(knowledge of results), allowing the surgeon to adjust
hardware placement any time.
Computer navigation software enhances the surgeon’s
capability to improve hardware placement in two ways.
First, it provides information on the anticipated trajectory
of the hardware before it is even placed in bone. Second,
it shows the necessary orthogonal fluoroscopic views
simultaneously on a monitor screen, allowing the surgeon
to determine the appropriate placement of hardware in
all necessary planes.
This study attempted to determine if the form of
feedback provided by computer navigation affected the
learning of the basic orthopaedic surgical task of the
placement of hardware across a femoral neck fracture
in the surgical trainee. As conventional training already
relies on continuous extrinsic feedback provided
by fluoroscopy and computer-assisted fluoroscopic
techniques have been shown to provide significantly
more accurate and precise placement of cannulated
screws in expert surgeons, it was hypothesized that
computer-based navigation would not compromise the
learning of hardware placement in the surgical trainee.
In addition, it was hypothesized that those trained with
42
computer navigation would be able to transfer their skills
in effectively performing the task with conventional
fluoroscopic guidance.
requiring internal fixation. Fluoroscopic images were
taken with a Phillips C-arm and fluoroscopy screen.
Computer navigation was provided by a BrainLab
system which was linked to an infrared camera under
stable tripod. Passive arrays were attached to a Shantz
pin in the greater trochanter of the proximal femur
model. The proximal femur was registered with standard
anteroposterior and lateral fluoroscopic images taken by
a certified radiology technician. Appropriate protective
lead gear was worn by all participants. A radiation
docimeter was worn underneath the lead gown.
After viewing an instructional video on the
principles of how three cannulated screws are placed
across an undisplaced femoral neck fracture using
both fluoroscopic and computer navigation guidance,
the participants underwent a pretest by performing
the surgical task of placing the three 2.8 millimeter
guide wires (Synthes, Westchester, Pennsylvania) in the
proximal femur model. In order to minimize time taken
to perform the procedure, participants did not insert any
cannulated screws as would typically be done during a
surgical procedure.
Immediately after the pretest, twenty participants were
randomly assigned into the conventional fluoroscopyguided technique (Group 1) while the remaining
nineteen participants were assigned to the computerbased navigation technique (Group 2). This training
session involved viewing the instructional video once
again. A thirty-minute practice session with an expert
instructor then followed. Immediately upon completion
of the training session, each participant performed
the surgical task on the simulated hip fracture – this
comprised the immediate post-test.
Four weeks later, the participants returned to perform
a retention test of performance using the technique
they were originally trained with. A transfer test then
followed – each group of students repeated the surgical
task but instead used the other technique to guide them
(i.e. those trained with the conventional fluoroscopyguided technique used the computer-based navigation
technique and vice versa).
Performance during the pre-, post-, retention, and
Materials and Methods
A prospective, randomized, controlled study was
conducted. Ethics approval was obtained from the
Research Ethics Board at the University of Toronto.
Thirty-nine senior medical students or first-year surgical
residents that had not yet performed the surgical
procedure of internal fixation of a femoral neck fracture
were recruited to participate.
The primary outcome measure for the study was
placement of the hardware in the femoral head; secondary
outcome measures included number of attempts taken to
perform the task, number of times the subchondral bone
of the femoral head was penetrated, the total radiation
time and dosage during the procedure, and the total time
taken to perform the procedure.
Power analysis indicated that a minimum of seventeen
participants in each group were needed to provide 80
percent power to detect clinically significant differences
in screw position in the femoral neck. This was based
on an earlier study by Liebergall et al. who showed that
the difference in angle deviation of screws was about
four degrees between the navigational and conventional
group.4 This difference yields an effect size larger than
one (Cohen’s d) for a two-tailed student t test. Therefore
a minimum of 17 per sample for a power of 80 percent
and significance of 0.05 was required. Power analysis was
done using a power analysis calculator (Center Space
Software, Corvallis, OR).
A custom-designed, left proximal femur model
(Sawbones; Pacific Research Laboratories, Vashon,
Washington) was affixed in the supine position to a rigid
mounting device that placed the model at the same
height that is used during surgical fixation of a fractured
hip. A surgical drape was then placed over the construct
to prevent the study participant from using visual cues
to determine the exact location for hardware placement.
As the proximal femur model was not osteotomized,
it simulated an undisplaced femoral neck fracture now
43
transfer tests was determined by radiographic analysis of
hardware placement. On standardized anteroposterior
and lateral radiographs of the hip, the distance of the
tip of the guidewires to the subchondral bone of the
femoral head, guidewire parallelism, and the distance of
the guidewire insertion point from lesser trochanter was
measured. Secondary outcome parameters included (i)
the total number of attempts required to perform the
procedure, (ii) the number of times the subchondral
bone of the femoral head was penetrated, (iii) the total
radiation exposure during the procedure, (iv) the total
radiation time required to perform the procedure, and
(v) the total time taken to perform the procedure.
For all participants, standard anteroposterior and
lateral fluoroscopic images were taken at the end of each
task by a certified radiology technician.The fluoroscopic
images were then digitally transferred as DICOM
(Digital Imaging and Communications in Medicine)
files and measured by a single, non-blinded evaluator in
their original format using compatible software. Each
radiograph was calibrated according to a 15 millimeter
diameter ball bearing visible in the bone model image.
Parallelism was measured as an “Average Screw
Deviation” as described in a previous study4. The shaft
guidewire angle (), defined as the angle between
the femoral shaft axis and the axis of the wire, was
measured for each guidewire. The average difference
((|1-2|+|1-3|+|2-3|)/3) between the three
angles of the guidewires was calculated and recorded
as “parallelism”. Only the anteroposterior images were
used to determine parallelism.
The distance from the guidewire tip to subchondral
bone was measured directly as the shortest distance from
the tip of the wire to the outer border of the femoral
head along the axis of the wire. For each wire (anterior,
posterior, inferior), the distance in anteroposterior and
lateral views was compared and the smallest value was
recorded. Finally, the average of the determined values
of each wire was calculated and defined as the “distance
from subchondral bone”.
All dependent variables were analyzed using separate
repeated measures analysis of variance (ANOVA) models.
Each model looked at the effect of group (conventional,
computer assisted), time of test (pre-, post-test, transfer
test), as well as the interaction between group and
time. For ANOVA effects significant at p<.05, pairwise
comparisons of means were carried out using Tukey’s
test. All analyses were carried out using SAS Version 9.1
(SAS Institute, Cary, NC, USA).
Results
An analysis of the two randomized study groups did
not demonstrate any significant difference in the pretest
with respect to all measured variables (distance of tip
of guidewire to subchondral bone, guidewire parallelism,
number of attempts required to perform the procedure,
number of times the subchondral bone of the femoral
head was penetrated, total radiation exposure during
the procedure, total radiation time required to perform
the procedure, and the total time to perform procedure
(Figs. 1 A to G).
With regards to the primary outcome, distance of
tip of guidewire to subchondral bone, all participants
improved their accuracy of hardware placement at posttest (p< 0.001) (Fig. 1 A). This skill was retained at the
same level at retention and transfer testing. There was no
significant difference between groups at any point.
No significant change was seen in guidewire
parallelism or the total time to perform the procedure in
either group at any time point (Figs. 1 B and D).
For the outcome, number of attempts required to
perform the procedure, the group that underwent
computer navigation training showed a significantly
reduced number of attempts at post-test (p < 0.001),
(Fig. 1 C). This skill level was retained at retention
test and transfer testing. Participants that trained with
fluoroscopy took fewer attempts (p = 0.03) to position
hardware only when they used computer navigation
during transfer testing (Fig. 1 C).
The total radiation time and dosage required to
perform the procedure diminished significantly in the
computer navigation group from pre- to post-test (p
< 0.001 and p < 0.003, respectively). This skill level
remained unchanged in the retention test (Figs. 1E
44
and F). Participants trained with fluoroscopy did not
demonstrate a change in total radiation time or dosage
from pre- to post-test to retention test (Figs. 1E and F).
During transfer testing, participants that trained with
fluoroscopy used less radiation time (p < 0.001) and
radiation dose (p < 0.003) when they subsequently used
the navigation to perform the task, whereas participants
that trained with computer navigation used more
radiation time (p = 0.003) and radiation dose (p < 0.02)
(Figs. 1 E and F).
Neither of the groups showed significant changes
in the number of times the subchondral bone of the
femoral head was penetrated at any time point in the
study; there was no difference between training groups
either (Fig. 1 G).
between the groups from the post-test period onward.
This finding is consistent with that reported by Gofton
et al., who reported that computer navigation training
did not comprise the learning of surgical novices in the
positioning of a total hip arthroplasty acetabular cup at
retention or transfer testing.
Despite the improvement in this aspect of hardware
placement, neither guidewire parallelism nor the number
of times the subchondral bone of the femoral head was
penetrated improved in either group during the study.
At best, the group trained with both fluoroscopy and
computer navigation achieved parallelism within three
degrees of what expert surgeons achieve. (4) Although it
is recommended that the three guidewires/screws should
be inserted in a parallel manner, the literature does not
provide data that would support that suggestion. In two
clinical studies, no relationship between the angulation
of the screws and the occurrence of fracture non-union
was found.19,20 Therefore, it remains unknown how much
degree of angulation is critical for a fracture healing
complication.The increased parallelism values seen in the
participants in this study may not be of clinical relevance.
Both groups of participants penetrated the
subchondral bone of the femoral head at a mean of up to
two times. Although no published literature exists on this
component of hip fracture fixation, it is reasonable to
assume that the majority of experts rarely penetrate the
subchondral bone of the femoral head when performing
this procedure. Why no improvement was seen with
these parameters in any group (despite the training
module that explained the importance of obtaining
completely parallel guidewires and not penetrating the
subchondral bone of the femoral head) may be due to a
weakness in the training module – it is possible that the
participants’ attention was focused more on other aspects
of guidewire placement or learner exhaustion occurred,
producing a ceiling effect.
In keeping with the literature on expert and novice
surgeons (5), this study found that participants trained
with computer navigation minimized the number of
attempts to place the hardware. In their study comparing
femoral neck screw positioning using either computer
Discussion
The purpose of this study was to determine the effect
of computer navigation on the learning of a basic
orthopaedic surgical procedure in the medical trainee,
performing internal fixation of a femoral neck fracture.As
conventional training for this procedure already relies on
continuous extrinsic feedback provided by fluoroscopy
and computer-assisted fluoroscopic techniques have been
shown to provide significantly more accurate and precise
placement of cannulated screws in expert surgeons, it
was hypothesized that computer-based navigation would
not compromise the learning of hardware placement in
the surgical trainee. In addition, it was hypothesized that
those trained with computer navigation would be able
to transfer their skills in properly performing the task
with conventional fluoroscopic guidance.
This study showed that the primary outcome
measure, hardware positioning (distance of guidewire
to subchondral bone of femoral head), improved after
the training session, whether the surgical novices used
fluoroscopy or computer navigation. The positioning
of hardware reached that of expert surgeons, as each
group was able to place the guidewire within the goal
of five millimeters of subchondral bone.The participants
maintained this level of skill during retention and transfer
testing, as no significant difference was seen within or
45
navigation or fluoroscopy, Hamelinck et al. found that
expert surgeons used significantly less attempts with
the computer assisted technique (mean 3.8 +/- 0.6
attempts with computer assistance versus mean 13.3
+/- 4.4 attempts with fluoroscopy). Our study showed
that in comparison to the pre-test an improvement
was seen during the post-, retention and transfer tests,
with no significant improvement between these times.
In contrast, those trained with fluoroscopy did not
show any decrease in attempts until they transfer tested
with computer navigation. The decrease in attempts
seen whenever computer navigation was used is
likely due to the technological advantage inherent to
computer navigation. As computer navigation provides
information of the anticipated trajectory of hardware
in bone in both the coronal and sagittal planes when
the navigated guide wire sleeve is placed in the surgical
field, adjustments can be made by the surgeon to ensure
correct hardware positioning in both planes even before
the hardware is introduced into bone. This is in contrast
to the information provided by fluoroscopy. Fluoroscopy
provides real time imaging of where the hardware is at
any one time in one plane – the surgeon has to imagine
where the final trajectory of the hardware will be in both
planes before inserting it into bone and uses fluoroscopy
to confirm the final position of the hardware. If changes
have to be made, the hardware has to be removed from
bone and then re-inserted.
The fact that those trained with computer navigation
in this study used significantly less total radiation time
and dosage after training is also in keeping with the
literature.17 Why those trained with fluoroscopy did
not minimize the total time and amount of radiation
until they transferred over to using computer navigation
may again be explained by the fact that the use of
computer navigation alone provides an advantage in
these parameters. This is further supported by the fact
that when those trained with computer navigation used
fluoroscopy in the transfer test, the time and amount
of radiation used significantly increased. Although the
participants in this study used significantly less radiation
time and dosage with computer navigation, they still used
more than what an expert would use by approximately
seven seconds.17 This lack of improvement to expert
levels may again be due to the fact that functional task
difficulty was high for this level of (novice) learner.
While the participants were able to show learning to
expert levels in the instance of hardware placement, it is
possible that the task was too difficult to show learning
to expert levels in other parameters.
Although many publications have shown that expert
surgeons use less time to perform navigated cases,3,4,16
the only study that has looked at the effect computer
navigation has in experts placing three cannulated screws
in a simulated hip fracture model similar to this study
has shown that experts require a similar amount of time
whether they use navigation or not.17 Hamelinck et al.
showed that the mean time to place three cannulated
screws in with computer navigation was 23.7 +/- 6.5
minutes; when fluoroscopy was used, the mean time was
22.4 +/- 5.6 minutes.17 The participants in this study
performed at a similar level as expert surgeons. The
participants took approximately 17.4 +/- 7.1 minutes
to perform the procedure – no improvement in time
occurred at any time point during the study.The current
study did not have the participants place the cannulated
screws in bone, thus making a direct comparison to the
data from Hamelinck et al. difficult. Nevertheless, the
time taken by the novices to place the guidewires in
the bone model in this study can be considered to be
comparable to that taken by expert surgeons.
Basic motor theory suggests that while concurrent
augmented feedback enhances the performance of
novices during practice, it does not contribute to
learning, as measured on delayed retention or transfer
tests.8.9.10.11 Despite the basic motor theory, Gofton et
al. found that the augmented feedback provided by
computer navigation in training surgical novices how to
position a total hip arthroplasty acetabular cup did not
compromise learning.6
This study similarly observed that the concurrent
augmented feedback provided by computer navigation
did not compromise the learning of a new surgical task.
Instead, it improved many aspects of task performance
46
that were maintained at immediate and delayed retention
testing and transfer testing. Not only was the primary
outcome measure of hardware placement improved to
a level exhibited by expert surgeons but so were the
secondary outcome measures of decreased attempts
taken to perform the procedure and minimized total
radiation dose and time.
Why a compromise in learning was not seen may be
due to the fact that the concurrent augmented feedback
provided by computer navigation may not be all that
different from the feedback provided by conventional
fluoroscopy to this level of learner. It may be that the
feedback perceived by the surgical novices as they
underwent training with either fluoroscopy or computer
navigation provided a similar amount of information
that was used to manage the functional task.
The reason why we saw no improvement in the
outcome parameters of guidewire parallelism or time
taken to perform the procedure in either training group
may be due to a number of factors. The functional task
difficulty of the study may have been too high for this
level of (novice) learner; although they were able to
improve their skills in some outcome measures, they
were unable to successfully learn other skills that were
reflected in other outcome measures. In addition, learner
exhaustion from the training video\expert instruction
session may have occurred, causing a ceiling effect. It is
possible that with more practice, the participants’ skill
would have improved in these parameters.
Should computer navigation be used in the training
of basic surgical skills in surgical novices? The findings of
this study suggest that the training module we developed
will improve hardware placement to near expert levels
in immediate and delayed testing whether computer
navigation is used or not. But when computer navigation
is used, less total radiation time and dosage is used by
the trainee and fewer attempts are taken to perform
the procedure. In addition, no compromise in learning
occurs when the surgical novice trained with computer
navigation transfers to using conventional fluoroscopy
to perform the task in terms of hardware placement,
although total radiation time and dosage increases
(consistent with the technology used). Conversely,
if a surgical novice is trained with fluoroscopy, the
novice will use more total radiation time and dosage
and have a higher number of attempts to perform the
procedure during immediate and retention testing. But
these parameters will improve in transfer testing with
computer navigation.
This study suggests that computer navigation may be
safely used to train surgical novices in this basic surgical
procedure. Nevertheless, the task is complex and further
studies are required to show how novices can learn to
improve all aspects of performing this procedure to
expert levels.
References
1. Selvan VT, Oakley MJ, Rangan A, Al-Lami MK. Optimum
configuration of cannulated hip screws for the fixation of
intracapsular hip fractures: a biomechanical study. Injury. 2004
Feb;35(2):136-41.
2. Lindequist S, Tornkvist H. Quality of reduction and cortical
screw support in femoral neck fractures. An analysis of 72
fractures with a new computerized measuring method. J Orthop
Trauma. 1995;9:215–221.
3.
Hamelinck HK, Haagmans M, Snoeren MM, Biert J, van Vugt
AB, Frölke JP. Safety of computer-assisted surgery for cannulated
hip screws. Clin Orthop Relat Res. 2007 Feb;455:241-5.
4. Liebergall M, Ben-David D, Weil Y, Peyser A, Mosheiff R.
Computerized navigation for the internal fixation of femoral
neck fractures. J Bone Joint Surg Am. 2006 Aug;88(8):1748-54.
5.
Mayman D,Vasarhelyi EM, Long W, Ellis RE, Rudan J, Pichora
DR. Computer-assisted guidewire insertion for hip fracture
fixation. J Orthop Trauma. 2005 Oct;19(9):610-5.
6. Gofton W, Backstein D, Tabloie F, Dubrowski A. The effect of
computer-assisted surgery on the learning of surgical skills. J
Bone Joint Surg Am. 2007 Dec:89(12):2819-2827.
7. Leenders T, Vandevelde D, Mahieu G, Nyuts R. Reduction in
variability of acetabular cup abduction using computer assisted
surgery: a prospective and randomized study. Comput Aided
Surg. 2002;7:99-106.
47
Figure 1. Line graphs with standard deviation bars with means and p-values for
all measures as a function of the four tests: pre-, post-, retention and transfer: (A)
distance of tip of guidewire to subchondral bone, (B) parallelism of guide wires,
(C) total time to perform procedure, (D) total attempts to perform procedure, (E)
total fluoroscopy time, (F) total fluoroscopy dosage, and (G) number of times the
subchondral bone of the femoral head was penetrated. Group 1 = fluoroscopy training;
Group 2 = computer navigation training.
8. Patrick J, Mutlusoy F. The relationship between types of
feedback, gain of a display, and feedback precision in acquisition
of a simple motor task. Q J Exp Psychol A. 1982;34(Pt 1):17182.
9.
Annett J. Learning under conditions of pressure: immediate and
delayed knowledge of results. Q J Exp Psychol. 1959;11:3-15.
10. Annet J. Feedback and human behavior. Baltimore, MD:
Penguin;1969.
11. Kohl RM, Shea CH. Augmenting motor responses with
auditory information: guidance hypothesis implications. Hum
Perf.. 1995;8:327-43.
12. Guadagnoli MA, Lee TD. Challenge point: a framework for
conceptualizing the effects of various practice conditions in
motor learning. J Mot Behav. 2004;36(2):212-224.
13. Seyler TM, Lai LP, Sprinkle DI, Ward WG, Jinnah RH. Does
computer-assisted surgery improve accuracy and decrease the
learning curve in hip resurfacing? A radiographic analysis. J
Bone Joint Surg Am. 2008;90 Suppl 3:71-80.
14. Cobb JP, Kannan V, Brust K, Thevendran G. Navigation reduces
the learning curve in resurfacing total hip arthroplasty. Clin
Orthop Relat Res. 2007;463:90-97.
A
15. Hodgson A, Helmy N, Masri BA, Gredianus NV, Inkpen KB,
Duncan CP, Garbuz DS, Anglin C. Comparative repeatability
of guide-pin axis positioning in computer-assisted and manual
femoral head resurfacing arthroplasty. Proc Inst Mech Eng [H].
2007;221:713-724.
16. Implementation of a new navigated parallel drill guide for
femoral neck fractures. Kendoff D, Hufner T, Citak M, Geerling
J, Maier C, Wesemeier F, Krettek C. Comput Aided Surg.
2006;11(6):317-321.
17. Hamelinck HK, Haagmans M, Snoeren MM, Biert J, van Vugt
AB, Frolke JP. Safety of computer-assisted surgery for cannulated
hip screws. Clin Orthop Relat Res. 2007;455:241-245.
18. Schmidt RA, Lee TD. Motor control and learning: a behavioral
emphasis. 3rd ed. Champaign, IL: Human Kinetics;1999. Motor
learning concepts and research methods; p 263-284.
B
19. Gurusamy K, Parker MJ, et al. The complications of displaced
intracapsular fractures of the hip: the effect of screw positioning
and angulation on fracture healing. J Bone Joint Surg Br; 2005;
87(5):632-4.
20. Spangler L, Cummings P, et al. Biomechanical factors and failure
of transcervical hip fracture repair. Injury. 2001;32(3):223-8.
21. Schmidt RA,Wulf G. Continuous concurrent feedback degrades
skill learning: implications for training and simulation. Hum
Factors. 1997;39:509-25.
48
C
F
D
G
E
49
Ali Farno
factors such as duration from the index arthroplasty to
infection diagnosis, organism virulence and the patient
co-morbidities. An articulating antibiotic impregnated
cement spacer used for two-stage revision for prosthetic
hip infections delivers antibiotic directly to the source of
the infection. In addition, maintenance of joint mobility
reduces scar formation, soft tissue contractures and
facilitates exposure during reimplantation of definitive
prostheses [6]. However the complications associated
with dynamic cement spacers such as spacer dislocation
or fracture and periprosthetic femur fracture may be
further magnified in the context of significant bone loss.
In the following study, the authors present their
experience with techniques aimed at ameliorating
the risk of the complications associated with dynamic
spacers in the context of significant bone loss.
Extended Trochanteric Osteotomy (ETO) facilitates
the removal of cemented or fully-porous stems and
reduces the risk of iatrogenic, uncontrolled fracture of
the femur during the first stage [8]. In some cases, an
ETO greater length than 15 centimeters is required.
Prefabricated cement spacers may not be long enough
to bypass the ETO in such circumstances, predisposing
the femur to fractures during the interval between the
first and second stages. The risk of femoral fractures
may be furthered when the ETO can not be fully
reduced to restore the cylindrical shape of the femur
following removal of the infected implants and thorough
debridement of the femur. When the remaining femoral
bone stock does not provide adequate mechanical
support for the spacer, the ETO fixation may benefit
from augmentation with plates [7].
Additional risk of dynamic spacer dislocation may
occur when removal of the acetabular component leaves
segmental defects in zone one [9]. In addition, medial wall
defects may be present, predisposing to protrusion of the
spacer into the pelvis. Dislocation or protrusion causes
substantial discomfort and dysfunction for the patient,
and prevents ambulation in the period between spacer
insertion and definitive revision surgery. A management
alternative for medial wall defects or pelvic discontinuity
includes protection by a reconstruction cage, while
Ali obtained his Medical
Degree from Tehran University
of Medical Sciences. He worked
as a General Practitioner for
five years before moving to
Canada and joining the U of T
Orthopaedic Surgery Program.
He is planning to do one year
of Trauma and Arthroplasty
fellowship at SBK that will be followed by another year
of fellowship of Lower Extremity Reconstruction and
Revision Arthroplasty in MSH.
Ali is grateful to all of his clinical supervisors and the
well organized administration staff that have been vital to
his successful completion of his residency training.
He would especially like to thank the staff surgeons
who took a personal interest in his education.
A Modified Cement
Spacer Technique
for Infected Total Hip
Arthroplasties with
Significant Bone Loss
A.E. Gross MD, FRCSC, D. Backstein MD, Med,
FRCSC, O.Safir MD, FRCSC
A.Farno MD, O. Ben Lulu MD,Y. Kosashvili MD,
MHA D.Walmsley MD,
Background
Infection is a devastating complication with an
incidence ranging from 0.2 percent - 0.7 percent [1–
5] for primary total hip arthroplasty (THA) and 0.95
percent to 22 percent for revision THA [1–5]. Treatment
regimes include antibiotic suppression, irrigation and
debridement, single stage revision THA, two-stage
revision THA and resection arthroplasty, depending on
50
segmental roof defects can be protected by either a
reinforcement ring or cement and screws, depending on
the size of the defect [7]. Implanted hardware is certainly
at risk of being colonized, and thus any plate or cage
should be covered with antibiotic loaded-cement due
to the risk of re-infection. The goal of this study was to
evaluate these surgical techniques, the risk of mechanical
failure and re-infection rates when these methods are
utilized.
performed preoperatively, and at six weeks after the first
stage (prior to the reimplantation), six weeks after the
reimplantation, six months and annually post surgery.The
preoperative radiograph was used in order to determine
the necessary length of the trochanteric osteotomy to
allow safe femoral component removal. The initial
radiograph following the second stage revision served as
the baseline to which all subsequent radiographs were
compared. Radiographs were evaluated by two of the
authors (A.E.G and O.S) for evidence for component
migration or loosening.
Methods
Eleven patients treated for infected THA at a tertiary
care, university centre were included in the study. An
ETO was utilized for the surgical approach in all cases
[8].There were seven males and four females.The average
age of patient at time of first stage revision was 73.9 years
(range 65-82 years). Seven patients had infection of their
primary hip arthroplasty and four patients of a revision
THA. Of the seven patients with primary hip arthroplasty,
two had cementless prostheses, one cemented, three had
failed cement spacer in situ (referred from other centers)
and one cemented bipolar hemiarthroplasty. Of the
four patients with revision THAs, two had cementless
components, one had cemented components and one
had a proximal femoral allograft (Table 1).
In all cases, joint fluid was aspirated for culture and cell
count and serum erythrocyte sedimentation rate (ESR)
and C-reactive protein (CRP) were obtained.Tissue was
sampled for pathologic evaluation for all cases at the time
of surgery. In the situation of negative cultures, a diagnosis
of infection was made if both laboratory values were high
(ESR>30 and CRP>10) and acute inflammation (more
than 10 poly morphonuclear cells per power field) was
recorded in the pathological examination. Two of the 11
patients had negative cultures, yet they were regarded as
infected due to positive laboratory parameters (Table 2).
Clinical evaluation in each patient included Harris
Hip Scores (HHS) [10], preoperatively, at 6 weeks; 6
months post op and at annual follow up visits (Table 2).
Radiological evaluation included routine hip
radiographs (anterior-posterior view of the pelvis as well
as anterior-posterior and lateral view of the affected hip)
Surgical Technique
Using an extended trochanteric osteotomy, all
components including cement when applicable, were
carefully removed while minimizing damage to the
remaining bone stock. Thorough debridement of the
surgical field (femur and acetabulum) was performed
to remove infected and nonviable tissue. Acetabular and
Femoral Bone defects were categorized intraoperatively
based on the classification of the Gross [11, Table 2].
Acetabulum
When medial wall defects or pelvic discontinuity were
identified (two patients), an ilio-ischial cage was placed
to bridge the defect (Figure 1b). The inferior flange of
the cage was slotted into the ischium and the superior
flange was fixed to the ilium with screws. The cage
was then covered with antibiotic impregnated cement.
Segmental defects larger than 50 percent at Zone One
(two patients) were protected by a roof ring covered with
antibiotic impregnated cement, while defects smaller
than 50 percent (one patient) were treated with cement
secured with screws to the ilium. The reinforcement of
Zone One was performed to improve the stability of
the articulating spacer. The cement was molded into
acetabulum to accommodate a femoral cement spacer.
Femur
In order to extend the length of a prefabricated antibiotic
impregnated femoral spacer a spacer mold with a metal
endoskeleton (Biomet, Warsaw, Indiana) was assembled
51
and press-fit into a pre-cut reamed intramedullary nail
(Synthes, Solothurn, Switzerland ). The nail itself was
coated and filled with antibiotic impregnated cement.
This extended construct was then inserted into the
femoral canal allowing bypass of the distal end of the
femoral osteotomy and thus provided more stability.
Following reduction, the osteotomy was secured with
cerclage wires. When the integrity of the femur could
not be adequately restored by the osteotomy reduction
alone, a femoral dynamic compression plate (Synthes,
Solothurn, Switzerland) coated with antibiotic loaded
cement was used. In some cases the plate was placed on
femoral bone distally and was in direct contact with the
spacer proximally, where the femoral bone was deficient.
The cement coated plate was secured with the circlage
wires and served as a lateral buttress to the construct and
also provided superior rotational stability for the spacer
as well as the osteotomy (Figures 1b, 2c, 2d, 2f, 3b, 4b).
Antibiotic loaded cement contained two grams of
Vancomycin, and either 3.6 grams of Tobramycin, or
two grams of Ceftazidime per 40 gram package for each
spacer technique depending on sensitivities. All patients
received tailored intravenous therapy determined by the
infecting organism for at least six weeks until their CRP
and ESR levels were normal or trending towards normal
values. If wound and soft tissue healing were adequate,
antibiotics were discontinued for a two week antibiotic
holiday. Following the holiday period, ESR and CRP
levels were re-examined, and if they remained within
normal levels or they did not begin trending back up,
the reimplantation was scheduled. In the second stage,
the spacer was removed and intraoperative frozen
section was performed. When no evidence of persistent
infection was present (less than five polymorphonuclear
cells under high powered field microscopy), definitive
re-implantation of components was performed. In the
present study, the second stage procedure was performed
at a mean of 3.5 months (range, two to eight months)
following first stage.
Patients were permitted to ambulate with toe-touch
weight-bearing between the first and second stage
surgery. In all but three cases where the osteotomy had
fully healed, the second stage revision was performed
using the previous ETO. In those three cases, a modified
trochanteric slide was used for the second stage revision
[12]. Patients were permitted toe-touch weight bearing
for six weeks following the second stage.Active abduction
exercises were initiated at eight weeks after the second
stage revision, after radiographic evidence of osteotomy
union was present.
Results
Eleven patients at an average age of 73.9 years (range
65-82 years) were treated with this technique. In ten
patients (90.9 percent), infection was eradicated within
a mean of 3.5 months (range two to eight months). In
one patient, there was dissociation of the spacer from the
nail noted at 15-week follow up. The patient underwent
second stage revision at 24 weeks following first stage
revision without dislocation or fracture, possibly due to
the support of the plate. At the second stage revision, the
nail was removed using the osteotomy without difficulty.
None of the patients had spacer fracture, periprosthetic
fracture, or dislocation.
One patient had recurrent dislocations following his
second stage revision for which he was treated with a
constrained liner. He died six months after the second
stage revision (three months after his conversion to a
constrained liner) for reasons unrelated to his surgery,
without clinical or radiographic evidence for infection
at latest follow up.
Harris Hip Scores at an average of 1.25 years (range
1-1.5) following second stage revision was 73.2 points
(range 66-86), which represent an improvement of 27.3
points compared to pre-operative scores.
Discussion
Two-stage reimplantation after infection of THA remains
the gold standard to which other forms of treatment
should be compared, with infection eradication rates
exceeding 90 percent [13-15]. ETO allows a relatively
safe removal of femoral components and a good exposure
of the acetabulum [8] while causing a limited, repairable
damage to the femur and hip abductors. Several studies
52
advised performing the ETO to the distal end of the
component’s fixed surface, so that the component can
be removed with relative ease without exerting torsional
forced on the femur to avoid inadvertent fractures [8].
There are several inherent complications associated
with the use of dynamic spacers including dislocation
and femoral fracture. Leunig et al. analyzed the geometry
of their cement spacers, concluding that a larger headto-neck ratio reduced the risk of spacer dislocation
[17]. A second factor associated with failure was an
insufficiently deep anchorage in the intramedullary canal.
These authors found a depth of anchorage of 22±33
millimeter in the failure group, while complication-free
spacers were on average attached to a depth of 57±41
millimeter. In the same study, there were five reported
dislocations in 12 patients treated with hand-formed
cement spacers [17]. Two other studies have noted one
dislocation in ten patients, and three dislocations in 13
patients, emphasizing the incidence of this problem [18,
19]. The two primary types of spacer dislocation which
have been described are due to loss of fixation in the
proximal femur leading to rotation within or dislocation
from the femoral canal and secondly dislocation of the
spacer head from the acetabulum [7].
Another complication associated with cement
spacer use is fracture, both of the spacer itself and of
the native bone. Biring et al. noted that out of 135
patients treated with their cement spacer technique,
eight had intraoperative bone fractures, five developed
postoperative bone fractures, six experienced dislocation
or subluxation, and two experienced cement fractures
[20].
When a long (more than 15 centimeter) ETO is
required for removal of infected THA implants, the
prefabricated cement spacer requires augmentation. The
pre-cut nail provides for distal fixation resisting coronal
and sagital deforming forces while the plate enhances
the rotational stability and protects both the femur and
the osteotomy from fractures.
In this study, acetabular bone stock was protected by
an ilio-ischial cage for pelvic discontinuity and medial
wall defects, while a reinforcement ring was used
for segmental defects at the dome. These acetabular
augmentations prevented medial and lateral dislocations,
respectively, optimizing the potential benefits of the
spacer discussed above.
A dilemma persists regarding the cost-benefit of
the added hardware. Although we did not experience
dislocations, the plate and cages may become a sanctuary
for bacteria, leading to re-infection. It has been shown
that antibiotic impregnated cement continues to elute
antibiotics for four months postoperatively [21]. Thus,
the combination of thorough mechanical debridement
together with protection of the hardware with antibiotic
impregnated cement may enhance the benefits of the
added hardware and outweigh the risks. Despite the
small number of patients and short duration of follow up
(average 1.25 years) we believe are results are promising
particularly when these challenging conditions are
considered. The patients in our series had a success
rate of 91.7 percent in eradication of the infection and
no fractures or dislocations. Based on these results we
believe that this very select subset of patients can benefit
from the use of our modified technique.
Figure 1
Figure 1a
Pre operation radiograph infected
THA with Pelvic discontinuity
53
Figure 1b
Post first stage radiograph. Osteotomy
protected with a plate and the discontinuity
is protected with an iliuischial cage
Figure 1c
Post operative radiograph after second
stage
Cup cage reconstruction of the
acetabulum. Femur reconstructed with
ZMR.
Figure 2 – The surgical procedure
Figure Legends
A: removal of the previous infected femoral stem through an ETO
B: Assembly of the antibiotic impregnated cement spacer and the nail
C: Covering the plate with antibiotic impregnated cement
D: The articulating spacer and plate covered with cement prior to implantation
E:The articulating spacer in the femur. Note the antibiotic impregnated cement
Covering the acetabular cage
F: The plate secured to the femur with cerclage wires.
a
b
c
c
d
e
54
Figure 3
Figure 3a
Figure 3c
Post operative radiograph
following second stage Roof ring
reconstruction of the acetabulum.
Femur reconstructed with ZMR.
Pre-operation radiograph, Infected
THA with dislocated cement spacer.
Figure 4
Figure 4a
Figure 3b
Pre operative radiograph infected cemented THA
Post first stage radiograph. We
used a Roof ring to obtain the
needed stability; the osteotomy was
protected with a plate.
55
Figure 4b
Post first stage radiograph
- cement spacer, assembled
and pres-fit into a pre-cut
reamed intramedullary nail. The
osteotomy was protected with
a plate.
Table 1
2 St Stage
Final Components
1
IMN, plate, ZCA Cage, 1 SAS.
ZMR Stem, cup cage short
flange, TMC 66
2
CRC stem, plate, Cemented
liner.
PFA, CRC stem, TMRS column
augment, TMC 64
3
IMN, plate, Roof Ring , 3
SAS, cement roof held with 2
screws
ZMR stem, Roof ring, TMC 56,
Constrained liner
4
IMN, plate
ZMR Stem, TMC 64
5
IMN, plate
ZMR stem, TMC 66
6
IMN, plate
ZMR stem, TMC 70
7
IMN, plate
ZMR stem, TMC 64
8
IMN, ZCA Cage, 4 SAS
ZMR stem, cup cage, TMC 66
9
IMN
ZMR stem, TMC 62
IMN, plate
ZMR stem, TMC 68
IMN, plate, Roof Ring 54, SAS
ZMR stem, TMC 62
Primary
10
Revision
Figure 4c
Post operative radiograph
following second stage,
trabecular metal cup. Femur
reconstructed with ZMR.
1 ST Stage
Components In addition
to the cement spacer
Gross Bone Loss Classifications
11
Acetabular Bone loss
• Type I: No notable loss of bone stock
• Type II: Contained loss of bone stock
• Type III: Uncontained (segmental) loss of bone stock involving < 50 percent of the
acetabulum.
• Type IV: Uncontained (segmental) loss of bone stock involving > 50 percent of the
acetabulum
IMN – Intra medullar Nail, ZCA, SAS - Supra Acetabular Screw.
ZMR, TMC - Trabecular Metal Cup, PFA – proximal femoral Allograft,
TMRS, CRC,
Femoral Bone Loss
• Type I: No notable loss of bone stock
• Type II: Contained loss of bone stock with cortical thinning
• Type III: Uncontained loss of bone stock involving the calcar and the lesser
trochanter
• Type IV: Uncontained circumferential loss of bone stock > 5 centimeter in length
extends into the diaphysis
• Type V: Periprosthetic fracture with circumferential loss of bone stock proximal to
the fracture
56
Table 2
Bone Loss
Acetabulum
Years between
former THA
and the 1st
stage revision
HHS Pre-Op
HHS Post-Op
Patient
Age
Sex
Culture
Bone Loss
Femur
1
79
F
Entercoccus
Faecium
IV
V
7
36
70
2
72
M
No growth
IV
III
14
37
66
3
77
F
Coag-neg
Staph
IV
III
6
56
72
4
82
F
Entercoccus,
Coagluase-neg
Staph
III
II
3
51
73
5
79
M
Escherichia
coli
III
II
13
38
76
6
75
M
Staphylococcus
V
III
5
33
71
7
65
M
Coag-neg
Staph
IV
II
4
48
66
8
68
F
Staphylococcus
II
V
3
28
73
9
69
M
Streptococcus
viridans, mitis
II
II
15
80
86
10
81
M
No growth
II
III
10
52
79
11
66
M
Coag-neg
Staph
II
III
0.5
48
57
References
15. Younger A, Duncan C, Masri B.Treatment of infection associated
with segmental bone loss in the proximal part of the femur in
two stages with Use of an antibiotic-loaded interval prosthesis. J
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1. Mahomed NN. Rates and outcomes of primary and revision
total hip replacement in the United States Medicare population.
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2. Phillips CB. Incidence rates of dislocation, pulmonary embolism,
and deep infection during the first six months after elective total
hip replacement. J Bone Joint Surg Am. 2003; 85:20-6.
16. Cabrita HB, Croci AT, Camargo OP, et al. Prospective study of
the treatment of infected hip arthroplasties with or without the
use of an antibiotic-loaded cement spacer. Clinics (Sao Paulo)
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3. Zhan C. Incidence and short-term outcomes of primary and
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17. Leunig M, Chosa E, Speck M, et al. A cement spacer for twostage revision of infected implants of the hip joint. Int. Ortho.
1998; 22: 209-14.
4. Garvin KL. Infection after total hip arthroplasty. Past, present,
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5. Blom AW. Infection after total hip arthroplasty. The Avon
experience. J Bone Joint Surg Br. 2003; 85:956-9.
18. Magnan B, Regis D, Biscaglia R, Bartolozzi P. Preformed acrylic
bone cement spacer loaded with antibiotics. Use of two-stage
procedure in 10 patients because of infected hips after total
replacement. Acta Orthop Scand 2001; 72: 591-4.
6. Anagnostakos K, Furst O, Kelm J. Antibiotic-impregnated
PMMA hip spacers: current status. Acta Orthop 2006; 77: 62837.
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replacement system for management of complex infections
involving the hip. Orthop Clin North Am 1993; 24:751-9.
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Anagnostakos K, Jung J, Schmid NV, et al. Mechanical
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The long modified extended sliding trochanteric osteotomy. Int
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21. Masri BA, Duncan CP, Beauchamp CP. Long-term elution
of antibiotics from bone-cement: an in vivo study using the
prosthesis of antibiotic-loaded acrylic cement (PROSTALAC)
system. J Arthroplasty. 1998;13:331-8.
9. DeLee JG, Charnley J.Radiological demarcation of cemented
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Joint Surg Am. 1969 Jun;51(4):737-55.
11. Lakstein D, Backstein DJ, Safir O, Kosashvili Y, Gross AE.
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Apr;25(3):363-8.
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13. Lai KA, Shen WJ,Yang CY, Lin RM, Lin CJ, Jou IM. Two-stage
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58
Om Prakash Sharma
Address for correspondence:
Dr. Stephen J Lewis, MD, MSc, FRCS(C)
Associate Professor,
Division of Orthopedics,
Toronto Western Hospital,
East wing,1-E442,
399, Bathrust Street,
Toronto, Ontario
M5T2S8, Canada
Tel. (416) 603-5851
Fax (416) 603-3437
E-mail: Stephen.lewis@uhn.on.ca
Did residency in Orthopedic
surgery in India and worked
as staff. Moved to Saudi Arabia
and worked for Oil Company
hospital for few years. Joined
Pediatric orthopedic fellowship
at Sick Kids in Jan 2007. Started
Orthopaedic residency at UFT
in 2008. Om is proud father
of two daughters. He will be doing 6 months of lower
limb reconstruction fellowship at Mount Sinai Hospital
followed by Paediatric orthopedic. Om would like to
thank all the faculty and his family for their support over
last few years
Introduction
The treatment of Adolescent Idiopathic Scoliosis (AIS)
has undergone a significant evolution in the past several
years. Previously, large magnitude curves have been treated
with combined anterior releases and posterior fusion.
Anterior releases in large curves are beneficial in terms
of releasing the spine to allow for more correction and
to provide a greater surface area for fusion.1-3 However,
despite these advantages, anterior releases are associated
with increased morbidity due to chest wall violation,
which negatively impacts pulmonary function.4-6 In
addition, treating scoliosis with a combined anterior
release and posterior fusion requires two procedures,
which has been noted to include increases in operative
time and blood loss.1,6-8
With the advent of pedicle screws, similar corrections
can be achieved through a single posterior approach
without the need for an anterior release. This option still
enables good correction without the associated anterior
morbidity. Pedicle screws have been found to be safe
and effective in the treatment of AIS, with improved
correction power compared to hooks.1,9-15 Several
authors have confirmed the benefits of pedicle screws
compared with hook and hybrid constructs. Pedicle
screws provide three-column fixation of the vertebral
body allowing for improved correction over hooks.1,10,14
Additional advantages of pedicle screw constructs over
hooks include less risk of dislodgement or migration,
Combined Anterior/
Posterior Spinal Fusion
Compared to Posterior
Fusion with the Use of
Skull-Skeletal Traction
in the Correction of
Adolescent Idiopathic
Scoliosis Curves
Greater than 75
Degrees
Authors:
Om Prakash Sharma, MD
Sarah A. Bacon, BSc
Subir Jhaveri, MD
Elise M. Halpern, Bsc
Douglas Hedded, MD
Andrew Howard, MD
Stephen J Lewis, MD, MSc, FRCS(C)
59
ability to derotate the spine, allow for fusion of fewer
motion segments of the spine, and avoid the need to
enter the canal.1,10,11,16,17 A study by Kim et al14 found
pedicle screw constructs to provide significantly better
major curve correction than hybrid constructs with
an average correction of 70% in the pedicle screw
group and 56% in the hybrid group, with improved
postoperative pulmonary function. Similarly, Dobbs et
al18 showed selective thoracic fusion of AIS curves with
pedicle screws allowed for better thoracic correction
than seen with hooks as well as less postoperative coronal
decompensation. In addition to thoracic correction,
pedicle screw instrumentation in lumbar curves has
been shown in several studies to allow improved curve
correction compared to hook constructs.9,13
While the use of traction is not a new concept, the
technique of intra-operative skeletal traction is has not
yet been studied extensively. Preoperative traction has
been popular in the past, especially in patients with
severe and rigid curves; however, its use has decreased
with the introduction of modern posterior segmental
instrumentation systems.19 Advocates of intra-operative
traction argue that it increases pre-instrumentation curve
correction, as well as facilitates correction.19 A previous
study analyzing the use of intra-operative halo-femoral
traction with non-ambulatory neuromuscular scoliosis
found traction to be a useful technique providing
significantly improved lumbar curve and pelvic obliquity
correction.20 In addition, Hamzaoglu et al21 demonstrated
the surgical correction achieved by intraoperative halofemoral traction with posterior only pedicle screw
instrumentation for curves over 100° and found an
average improvement of 51% in the major thoracic curve.
They concluded that traction was beneficial in not only
elongating the spinal column but also the thoracic cavity,
which in turn improves pulmonary function.
The purpose of this study is to compare combined
anterior/posterior spinal fusion (APSF) corrections for
AIS curves ≥ 75° with similar curves undergoing posterior
spinal fusion with intra-operative traction (PSF+T) and
pedicle screw constructs. It was hypothesized that PSF+T
would provide at least the same or better correction as
APSF with less associated peri-operative morbidity.
A retrospective radiographic and chart review was
conducted on a total of 40 patients with AIS. All
demographic, radiographic, and clinical data collection
and analysis were performed by individuals not
involved directly in the patients’ surgery or care. There
were 20 consecutive cases treated with combined
anterior releases followed by posterior corrections
with hook or hybrid constructs between 2002 and
2005. The remaining 20 consecutive cases underwent
intra-operative skull-skeletal traction and posterioronly spinal fusion with pedicle screw constructs by
a different physician between 2005 and 2007. The
inclusion criteria for both groups were pediatric cases
diagnosed with AIS having a major Cobb angle of 75°
or greater on the standing films.
Subjects were analyzed by age and weight at the
date of surgery, gender, number of surgeries and total
operative time, intensive care unit and in-hospital stay,
and major and minor curve corrections. The quantity of
blood transfusions was examined, including autologous
transfusions, cell saver, allogenic directed and nondirected blood transfusions, and the use of albumin and
fresh frozen plasma (FFP). Complications were noted in
each case.
For the APSF group, patients underwent either same
day or staged anterior release and fusion through a
thoracotomy, followed by posterior instrumentation and
fusion through a hook or hybrid construct.For the traction
group, following induction of general anesthesia in the
operating room, Gardiner-Wells tongs were applied to the
skull, and smooth 4 mm distal femoral traction pins were
placed just proximal to the superior pole of the patella.
Following this preparation, approximately 50% of body
weight was applied symmetrically through the femurs,
and approximately 20% of body weight was applied in
counter-traction through the head. Sommatosensory
and transcranial motor evoked potential monitoring
were used and adjustments in weight were made based
on monitoring changes.
60
Results
anterior-posterior group was more than 2.5 times longer
(15.4 vs. 6.0 hours). The mean time between anterior
and posterior procedures in the APSF group was 13.6
days (range 0-21). The in-hospital stay was significantly
longer in the APSF group (35.3 vs. 6.4 days).
In terms of blood transfusions, significantly more
(P<0.05) APSF patients received allogenic nondirected blood products (P=0.000), albumin (P=0.003),
autologous blood transfusion (P=0.01) and cell saver
transfusion (P=0.000). Although patients undergoing
APSF received more allogenic directed blood and FFP
compared to the PSF+T group, it was not a significant
amount (P=0.63, P=0.11).
All 20 patients undergoing APSF received at least one
type of blood transfusion intra-operatively, whereas only
8 patients undergoing PSF+T surgery received blood
products. Non-autologous transfusions were received by
17 patients of the APSF group versus only 4 patients
in the traction group. More specifically, allogenic nondirected blood was required by 15 patients undergoing
APSF surgery with a mean of 876.3 mL (range 90-2675
mL) transfused, while only 1 PSF+T patient received
330 mL. Furthermore, 13 ASPF patients received
albumin with a mean of 750 mL (range 250-1500 mL),
and only 3 PSF+T patients received this blood product,
each receiving 250 mL. While no patients undergoing
PSF+T received FFP, 4 APSF patients received this blood
product averaging 457.5 mL (range 345-555 mL).
Allogenic directed blood transfusions were received
by 3 APSF patients and 2 PSF+T patients (417.8 vs.
602.5 mL). Of the traction patients, a total of 4 parents
chose to donate blood, however the donation was only
transfused in 2 patients.
With respect to autologous blood donation, 13 APSF
patients received a mean of 807.7 mL (range 420-1380
mL), and only 4 PSF+T patients required a mean 480 mL
(range 380-670 mL) of this blood transfusion. Finally, cell
saver blood was transfused in all 20 APSF patients with
a mean of 233.6 mL (range 75-630 mL), while only 4
PSF+T receieved a mean 150 mL (range 90-300 mL) of
cell saver blood. Estimated blood losses were not accurately
recorded and therefore these figures are not available.
The mean age at the time of surgery of the PSF+T
patients was 13.8 years (range 11-17) and 14.3 years
(range 11-18) for the APSF surgery patients. There were
5 males and 15 females in the traction group, and 7
males and 13 females in the latter group. Subjects were
comparable in age (P=0.384) and weight (P=0.439).
Mean pre-operative major curve Cobb angle was
85.6˚ (range 77˚-103˚) for the PSF+T group and 86.2˚
(range 75˚-108˚) for the APSF group (P=0.82). The
curves were less flexible in the PSF+T group with a mean
bending angle of 70.9° (range 35°-93°) compared to the
APSF group with a bending angle of 63.2° (range 40°92°), although not significant (P=0.11). The flexibility
index for the PSF+T group was 17.3% compared to a
flexibility index of 26.8% in the APSF group. In terms of
pre-operative thoracic kyphosis, the PSF+T group had a
mean angle of 41.6° (range 8°-72°), whereas the APSF
group had a mean angle of 33° (range 5°-68°). Following
surgery, the mean major Cobb angle in the traction group
decreased to 32.2˚ (range 11˚-58˚) as compared to 28.1˚
(range 10˚-51˚) in the anterior-posterior group (P=0.30).
Mean percent correction of the major curve was 62.4%
for the PSF+T group, and 67.4% for the APSF group.
The levels fused were greater in the APSF group (12.6 vs.
11.5, P=0.03), which is consistent with hook or hybrid
constructs when compared to pedicle screw constructs.
In terms of the minor curve, the pre-operative Cobb
angle was significantly larger in the PSF+T group
compared to the APSF group, with angles 57.3˚ and
45.2˚, respectively (P=0.005). Minor curves were also
significantly stiffer in the PSF+T group with a bending
angle of 39.3˚ compared to 28.4˚ in the APSF group
(P=0.02). The minor curve flexibility index for the
PSF+T group was 34.1% and 35.9% for the APSF group.
Final Cobb angles for the minor curve averaged 25.3˚ for
the PSF+T and 15.7˚ for APSF (P=0.02). Mean percent
correction of the minor curve was 55.8% for the PSF+T
group, and 65.3 % for the APSF group.
The APSF group required a mean 2.6 (range 2-7)
procedures compared to the mean of 1.1 (range 1-3) in
the PSF+T group. As a result, total operative time in the
61
In addition to blood transfusions, fewer major
complications were noted in the PSF+T group. Of the
20 patients undergoing PSF+T surgery, complications
included one patient with an incomplete brown-sequard
cord injury from medial placement of the pedicle probe
at the apical vertebra on the concavity. The patient had
transient left leg weakness that quickly recovered over the
ensuing days, however, has some residual spinothalamic
tract dysfunction on the contralateral leg. In addition, one
patient lost her MEP monitoring during traction and
rod placement. After multiple attempts at rod placement,
each associated with loss of MEP, it was decided to leave
the rod out. The patient returned to the operating room
the next week, at which time the rod was successfully
Table 1. Demographic, operative and radiographic data.
Traction
(n=20)
Anterior/ Posterior (n=20)
Significance
Age (years)
13.8 (11-17)
14.3 (11-18)
NS (P=0.38)
Weight (kg)
47.6 (31-66)
51.2 (31-120)
NS (P=0.44)
Hospital Stay (days)
6.4 (5-13)
35.3 (7-101)
P=0.000
ICU Stay
0.3 (0-1)
1.6 (0-4)
P=0.000
Duration of Surgery (hours) *
6.0 (4.1-9.7)
15.4 (7.4-23.4)
P=0.000
# Levels Fused
11.5 (7-14)
12.6 (8-15)
P=0.03
Total Number of Procedures
1.1 (1-3)
2.6 (2-7)
P=0.000
n
4
13
P=0.01
mL
480 (380-670)
807.7 (420-1380)
n
4
20
mL
150 (90-300)
233.6 (75-630)
n
2
3
mL
602.5 (250-955)
417.8 (200-1225)
Allogenic Non-Directed
Blood
n
1
15
mL
330
876.3 (90-2675)
Albumin
n
3
13
mL
250
750 (250-1500)
n
0
4
mL
0
457.5 (345-555)
Pre-op Cobb
85.6 (77-103°)
86.2 (75-108°)
NS (P=0.82)
Thoracic Kyphosis
41.6 (8-72°)
33 (5-68°)
NS (P=0.16)
Bending
70.9 (35-93°)
63.2 (40-92°)
NS (P=0.11)
Final Cobb
32.2 (11-58°)
28.1 (10-51°)
NS (P=0.30)
Pre-op Cobb
57.3 (33-84°)
45.2 (25-71°)
P=0.005
Bending
39.3 (6-65°)
28.4 (12-46°)
P=0.02
Final Cobb
25.3 (3-58°)
15.7 (0-38°)
P=0.02
Autologous Blood
Cell Saver
Allogenic Directed Blood
Minor Curve
Major Curve
FFP
P=0.000
NS (P=0.63)
P=0.000
P=0.003
NS (P=0.11)
* Duration of surgery = total operative time of all procedures patient underwent
62
inserted without neurological issues. Unfortunately her
sub-muscular drain was sewn in and a third surgery was
required to remove it. There were no post-operative
wound infections.
The following complications were noted in the APSF
group: 3 cases of SMA syndrome, one of which also had
Candida sepsis and another with tachycardiac episodes, 1
patient with excessive bleeding after the anterior surgery
which required returning to the operating room, 1
postoperative deep spinal wound infection and one patient
with infected spinal instrumentation which required several
additional surgeries. In addition, there were 3 cases with
monitoring difficulties, which were all abandoned and
completed at a later date. Of these 3 patients, one developed
a skin wound, and another developed chylothorax.
This emphasizes the benefit of intra-operative traction in
facilitating correction in posterior-only surgeries.
Another study by Dobbs et al7 analyzing APSF versus
PSF in the treatment of AIS curves over 90° found the
immediate postoperative major curve correction averaged
44% in both groups. While the major curves in the
patients of our study ranged from 75-108°, by analyzing
only the patients with a major curve of at least 90°, which
included 6 APSF patients with a mean major curve of
98.3° and 6 PSF+T patients with a mean major curve of
93.2°, percent correction averaged 71% in both the APSF
and PSF+T groups. Curve flexibility was similar in both
the study by Dobbs et al7 and ours, with a preoperative
bending angle mean of 75° and 76° in their study for
APSF and PSF, respectively, and 73° and 74° in our APSF
and PSF+T groups that had curves greater than 90°.
A limitation of this study was that a different physician
performed the anterior/posterior surgical corrections
compared to the traction group, and the surgeries were
in slightly different time periods with the anterior/
posterior surgery dates ranging from 2002-2005 and the
traction surgeries from 2005-2007. Transfusion triggers
and instrumentation available may have differed. In
addition, the anterior/posterior group used hooks and
hybrid constructs, whereas the posterior with traction
group used pedicle screw constructs. Despite these
differences, the groups themselves were very similar and
therefore we feel the observed differences were real.
In terms of future directions, a comparison between
posterior fusions with pedicle screw constructs with and
without intra-operative skeletal traction or with and
without minimally invasive anterior releases would be
interesting to isolate the effects of traction alone.
Discussion
Posterior scoliosis correction with pedicle screw
constructs and intra-operative skull-femoral traction
provided equivalent correction with less associated
morbidity and blood products than similar cases of AIS
treated with combined anterior release and posterior
spinal fusion with hooks or hybrid constructs. With
the two subject groups comparable in age, weight, and
gender, no significant difference was found in the preoperative (86.2 vs. 85.6°) or post-operative (28.1 vs.
32.2°) major Cobb angle. Despite less flexible curves in
the PSF+T group compared to the APSF group, for both
the major curve bending (70.9° vs. 63.2°, respectively)
and the minor curve bending (39.3° vs. 28.4°), and
greater thoracic kyphosis in the PSF+T group, similar
major curve correction was achieved. Mean percent
correction of the major curve was 62.4% for PSF+T,
and 67.4% for APSF. The anterior/posterior group had
significantly more levels fused and number of surgeries;
longer hospital stay and duration of surgery; and required
more blood products compared to the traction group.
With the use of intra-operative skeletal traction, similar
correction between APSF and PSF+T was achieved. By
comparing these two groupings in a study without the
use of traction, Luhmann et al22 found significantly better
correction in the APSF group versus PSF (P=0.0008).
Conclusion
Posterior fusion alone with intra-operative traction
achieved comparable surgical correction and significantly
less morbidity and need for transfusions than anteriorposterior correction for large magnitude AIS curves.
Intra-operative skull-skeletal traction facilitated curve
correction obviating the need for anterior release in
pediatric AIS cases greater than 75°.
63
References
1.
16. Polly DW Jr, Potter BK, Kuklo T, et al. Volumetric spinal canal
intrusion: a comparison between thoracic pedicle screws and
thoracic hooks. Spine 2003;29:63-9.
Lehman RA, Lenke LG, Keeler KA, et al. Operative treatment of
adolescent idiopathic scoliosis with posterior pedicle screw-only
constructs. Spine 2008;33:1598-604.
17. Lenke LG, Kuklo TR, Ondra S, et al. Rationale behind the
current state-of-the-art treatment of scoliosis (in the pedicle
screw era). Spine 2008;33:1051-4.
2. Waisman M, Saute M. Thoracoscopic spine release before
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3. Sucato DJ. Thoracoscopic anterior instrumentation and fusion
for idiopathic scoliosis. J Am Acad Orthop Surg 2003;11:221-7.
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Kim YJ, Lenke LG, Bridwell KH, et al. Pulmonary function in
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J Bone Joint Surg Am 2005;87:1534-41.
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Kim YJ, Lenke LG, Bridwell KH, et al. Prospective pulmonary
function comparison of anterior spinal fusion in adolescent
idiopathic scoliosis: Thoracotomy versus thoracoabdominal
approach. Spine 2008;33:1055-60.
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McDonnell MF, Glassman SD, Dimar JR II, et al. Perioperative
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Surg Am 1996;78:839-47.
7.
Dobbs MB, Lenke LG, Kim YJ, et al. Anterior/posterior spinal
instrumentation versus posterior instrumentation alone for the
treatment of adolescent idiopathic scoliotic curves more than
90°. Spine 2006;31:2386-91.
8.
19. Mac-Thiong JM, Labelle H, Poitras B, et al. The effect of
intraoperative traction during posterior spinal instrumentation
and fusion for adolescent idiopathic scoliosis. Spine
2004;29:1549-54.
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with nonambulatory neuromuscular scoliosis surgically treated
to the pelvis with intraoperative halo-femoral traction. Spine
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screw instrumentation with intraoperative halo-femoral traction
in the surgical treatment of severe scoliosis (>70 degrees). Spine
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22. Luhmann SJ, Lenke LG, Kim YJ, et al. Thoracic adolescent
idiopathic scoliosis curves between 70° and 100°: is anterior
release necessary? Spine 2005;30:2061-7.
Burton DC, Sama AA, Asher MA, et al. The treatment of large
(>70 degrees) thoracic idiopathic scoliosis curves with posterior
instrumentation and arthrodesis: when is anterior release
indicated? Spine 2005;30:1979-84.
9. Hamill CL, Lenke LG, Bridwell KH, et al. The use of pedicle
screw fixation to improve correction in the lumbar spine
of patients with idiopathic scoliosis: is it warranted? Spine
1996;21:1241-9.
10. Suk S, Kim WJ, Lee SM, et al.Thoracic pedicle screw fixation in
spinal deformities: are they really safe? Spine 2001;26:2049-57.
11. Suk S, Lee SM, Chung ER, et al. Selective thoracic fusion with
segmental pedicle screw fixation in the treatment of thoracic
idiopathic scoliosis. Spine 2005;30:1602-9.
12. Bess RS, Lenke LG, Bridwell KH, et al. Comparison of thoracic
pedicle screw to hook instrumentation for the treatment of
adult spinal deformity. Spine 2007;32:555-61.
13. Gaines RW. The use of pedicle-screw internal fixation for the
operative treatment of spinal disorders. J Bone Joint Surg Am
2000;82:1458.
14. Kim YJ, Lenke LG, Kim J, et al. Comparative analysis of pedicle
screws versus hybrid instrumentation in posterior spinal fusion
of adolescent idiopathic scoliosis. Spine 2006;31:291-8.
15. Kim YJ, Lenke LG, Bridwell KH, et al. Free hand pedicle screw
placement in the thoracic spine: Is it safe? Spine 2004;29:33342.
64
Figure 1
90º
90º
59º
41º
a
b
65º
47º
27º
19º
15º
c
d
e
f
Figure 2
103º
62º
30º
71º
a
21º
25º
b
c
65
d
What Do Patients Want
to Know? Determining
the Information
Needs of Patients
Undergoing Lumbar
Microdiscectomy
Ali Zahrai
Ali Zahrai grew up in
Toronto and completed his
undergraduate degree at the
University of Toronto. While
his pre-medical days revolved
around riding motorcycles and
playing hockey, he discovered
his passion for medicine and
moved to Winnipeg in 2001 to attend medical school
at the University of Manitoba. During his time in
Winnipeg he also met his wife, Lucy and made several
life-long friendships. Ali returned back home to Toronto
in 2005 where he began his residency in Orthopaedic
surgery. He was admitted to the Surgeon Scientist
Program in 2008 obtaining a Master of Science degree
from the Department of Health Policy, Management
and Evaluation (HPME). His academic accomplishments
include the Robin Sullivan Award and the JA Nutter
Award for best paper at the 2010 Canadian Orthopaedic
Residents Association meeting. Ali will be commencing
a spine surgery fellowship at Emory University in
Atlanta this summer and would like to pursue a career
in academic spine surgery. Ali would like to thank all the
faculty, his wife Lucy and his parents for all their support
over the last several years. Ali is most looking forward to
becoming a father this upcoming September.
Ali Zahrai, MD, MSc
Valerie Palda MD, MSc; Aileen Davis, PhD; and
Albert Yee, MD, MSc
Abstract
Background: Patients desire information about their
health. Patient educational tools can reinforce the
information covered during a consultation, and cover
material not covered or asked about. Spine-specific
educational tools are not routinely used in practice.
Traditional educational tools available to preoperative
patients are usually derived by physicians or other
allied health care professionals. Surgeons often assume
what patients want, and/or should know about their
surgery. To the best of our knowledge, no spine-specific
educational tool has been developed using input from all
relevant stakeholders, including patients.
Purpose: The objective of this study was to determine
the information needs of microdiscectomy patients.
Our findings will then generate the main components
to a preliminary education resource for spine patients
undergoing microdiscectomy. Methods: Qualitative methods with thematic analysis
was used in this study. The following cohorts underwent
focus interviews: 1) preoperative microdiscectomy
patients; 2) postoperative microdiscectomy patients;
3) spine surgeons; 4) spine fellows; 5) orthopaedic
surgery residents; 6) anesthesiologists; 7) surgeons’
administrative assistants; and 8) preoperative assessment
team. Interviews were conducted by a moderator, and
66
non-verbal responses were recorded by a note-taker.
Focus groups were audio taped and transcribed for
verbatim analysis using a descriptive qualitative approach
– thematic analysis.Two analysts independently reviewed
each transcription to ensure consistency and transparency.
Each analyst developed a list of themes (i.e. information
need) and through comparison established consensus
on a final list of themes and subthemes. Focus groups
were conducted until no new or relevant data emerged
on a theme. The appropriateness of our derived themes
were secondarily confirmed by surgeons, and pre- and
postoperative patients.
By identifying the information needs of these patients,
our study has generated the main components to a
preliminary education tool for spine patients undergoing
microdiscectomy. Future research will test the reliability
and validity of our novel tool and investigate its
effectiveness to improve functional outcomes, reduce
anxiety, and enhance patient satisfaction.
Introduction:
Lumbar disc herniation is a prevalent condition and
symptomatic patients present a significant socioeconomic
and health burden (Katz, 2006). Spinal surgery in
carefully selected patients who have failed conservative
treatments can significantly improve quality of life (Katz,
2006; Weinstein et al., 2008). While the main indication
for microdiscectomy is relief of leg pain, many patients
also have concomitant back pain that can be severe
(Hoffman et al., 1993). Unfortunately, while patients are
relieved of their leg pain post-surgery, back pain usually
does not improve (Hoffman et al., 1993). The false
expectation that back pain will improve may result in
patients perceiving a poor outcome in their level of pain
related function after surgery.
Patients forget or misunderstand much of the
information that is shared with them in a consultation
with a physician (Kenny et al., 1998). One study showed
that patients forget more than 50 percent of what they
were told within five minutes of leaving the consultation
(Kitching, 1990).Another study determined that generally
people remember only 20 percent of what they hear and
this may increase to 50 percent if additional written or
visual information is added (Gauld, 1981). In particular,
retention of information about postoperative recovery
time frames and possible operative complications is poor
(Turner and Williams, 2002).
Information tools can reinforce the material covered
by the surgeon during the consultation and include
material not discussed or asked about. It is important
to determine if an information resource would better
align perceived and realistic expectations. Providing an
education resource to patients pre-surgery may result
in better self-rated functional outcomes post-surgery, as
Results: Themes emerging from the data were organized
according to: 1) content areas of information needs,
and 2) factors influencing the delivered information.
Major information needs were on anesthesia, procedure
details and postoperative course. Patients desired more
information on the postoperative course, whereas
surgeons perceived their patients desired more
information on the procedure. Desired attributes of
information tools included: definition of terminology,
visual aids, a time-specific outline of contents (i.e.
two, six, twelve weeks postoperative) and multi-format
delivery. Patient factors such as age, comprehension, and
presence of family members all influence the extent of
information shared by surgeons. Communication helps
establish patient trust and improve satisfaction; however,
it must be consistent at every point of care. Stakeholder
consensus was that information packages should be
given to patients as soon as they are deemed surgical
candidates. The final derived themes were shared with
surgeons, and pre- and postoperative patients, and were
deemed to be appropriate and inclusive.
Conclusion: A gap in information provision that
informs education needs, particularly related to the
postoperative period of the continuum of care, was
identified for people undergoing microdiscectomy.
Utilization of all relevant stakeholders, especially the
end users, in deriving the patient information needs,
ensured that it met the stakeholder needs and values.
67
there is a better alignment of patient’s expectations with
realistic anticipated outcomes. Such a resource would
provide patients all the relevant information relating to
the procedure and aftercare.
The quality of the existing educational tools are
difficult to assess due to: 1) lack of adequate reporting
of the methods used in their development; and, 2) lack
of comprehensive stakeholder engagement in their
development, particularly of the end users – surgeons and
patients. Given these development limitations to existing
information tools, the first step in the development of
an education resource for microdiscectomy patients
requires a needs assessment. The objective of this study
was therefore to: 1) determine the information needs
of microdiscectomy patients; and, 2) generate the main
components to a preliminary education resource for
spine patients undergoing microdiscectomy. allowed the recording of non-verbal responses such as
facial expressions and body postures that may assist in
understanding on how participants feel about particular
issues (Liamputtong and Ezzy, 2001).
Semi-structured interview guide
A semi-structured interview guide was developed
for each focus group. The moderator and the primary
investigator designed each question in an open-ended
format. For each open-ended question, a series of prompts
were designed to elicit the desired answers if participants
were off topic. The interview guide questions were then
reviewed by two qualitative researchers for content and
language and further modified. As the focus groups went
on, the questions changed over time to reflect the data
of previous focus groups and thus became more refined.
Sampling
One or two focus groups were planned with each of
the stakeholder groups (Table 1). The final number
of each stakeholder group was determined when
saturation was reached, specifically when no new or
relevant data seemed to emerge regarding a theme (i.e.
category), the theme was well developed in terms of its
properties and dimensions demonstrating variation, and
the relationships among themes were well-established
(Strauss and Corbin, 1998).
In this study, data source triangulation was used as
relevant stakeholders (i.e. surgeons, anesthesiologists,
and patients) represented multiple information sources.
Researcher triangulation was also utilized in this study
by combining the perspectives of qualitative researchers
and clinicians.
Methods:
Study design
This research utilized a qualitative design using focus
groups. Such a design uses an inductive approach to make
sense of complex processes and generates information
in areas where the existing knowledge base may be
inadequate. It maximizes the integrity of participant
responses by drawing on issues important to individuals
in their own words (Krippendorff, 2004).
Focus groups
Focus group interviews were chosen as a qualitative
method with the primary aim of describing and
understanding beliefs, perceptions, and interpretations of
a select population to gain understanding of a particular
issue from the perspective of the group’s participants
(Khan and Manderson, 1992). In this study, focus groups
were used as a “self-contained method” serving as the
main primary means of data collection.
Participants
Important stakeholders in the care of microdiscectomy
patients were identified and approached to participate
in the study. The two main stakeholders invested in the
spine surgical decision-making process are surgeons and
patients. Participants were chosen according to: 1) their
perceived contact with the patient (residents, fellows,
surgeons,administrative assistants);and,2) their knowledge
The Moderator
An experienced moderator was used to ensure effective
elicitation of data. The primary investigator served
as the note-taker in the focus group interview. This
68
of the surgical process (surgeons, anesthesiologists)
and their experience in the surgical consultation and
procedure (preoperative and postoperative patients).
of spine training;
6)Anesthesiologists;
7) Surgeons’ administrative assistants; and,
8) Preadmission team personnel (i.e., nurses, educators,
managers).
Inclusion criteria for patients were:
1. Age 18 or older, and,
2. Eligible for,and having consented to,microdiscectomy
(preoperative patients):
a. Patients seen by a spine surgeon with clinical
examination and history confirming back and
neurologic leg symptoms relating to disk herniation for at least 12 weeks that have failed nonsurgical therapies;
b. Confirmatory cross-sectional imaging demonstrating neurologic compression consistent with
clinical presentation;
c. Signed informed consent, and on a waiting list
for surgery.
Procedures
Approval from the Research Ethics Board of Sunnybrook
Health Sciences Centre, as well as the University of
Toronto, was obtained. A written consent form was
completed by patients and all other participants.
Data Collection
or,
Demographic information including age, gender, highest
level of education obtained, employment status, worker’s
compensations (WSIB), and duration of symptoms were
collected via a written questionnaire. A Visual Analogue
(VAS) pain score was completed by patients individually
rating their back and leg pain. The preferred format of
an education tool was specifically posed to patients as a
question.
1. Postoperative from a microdiscectomy.
Data Analysis
The duration of the focus groups conducted were
within one to one and one-half hours. The interviews
were audio taped and transcribed verbatim, with the
exception of identifying information, which was
deleted. All transcripts were typed into a Microsoft
Word document. The moderator and two analysts (AZ,
VP, CB), all with experience with qualitative research,
independently reviewed the first transcript. A line-byline analysis method was used, and transcripts were
analyzed. Transcripts were analyzed using content
analysis, a method for systematically making inferences
from text (Krippendorff, 2004). Content analysis
involves a process of coding text into themes.Themes are
categories that are inductively identified from the data.
Subthemes or subcategories are related to the theme
or category, and aim to describe the properties of the
theme thus forming more concrete explanations about
the concept the theme represents (Strauss and Corbin,
1998). Each analyst independently developed a list of
Exclusion criteria for patients were:
1. Emergency spinal conditions (i.e. cauda equina
syndrome with acute bowel/bladder dysfunction);
2. Language or cognitive impairments that would
prevent participation in interviews conducted in the
English language.
The eligible stakeholders who consented to the study
were interviewed in a focus group format (as described)
by a moderator and the primary investigator. The
following cohorts were interviewed (Table 1):
1)
2)
3)
4)
5)
Preoperative patients meeting inclusion criteria;
Postoperative microdiscectomy patients;
Fellowship trained spine surgeons;
Spine fellows;
Orthopaedic surgery residents with at least 2 months
69
identified themes and through comparison the analysts
established consensus on a list of themes and subthemes.
Each theme was developed and refined based on analysis
of each focus group transcript in a continuous back
and forth process. Focus groups were conducted until
saturation was reached.
respectively. Mean postoperative patient VAS score for
leg pain and back pain were 4.3 and 3.4, respectively.
Employment status as depicted in Figure 1 illustrates
the percentages of patients employed versus patients on
lost time injury claim with the Workplace Safety and
Insurance Board (WSIB) of Ontario.
Member Checking
Themes from the data
Member checks were carried out to increase the
credibility of the study findings. This was accomplished
by sharing the findings of the study with the participants
involved. This allowed participants to critically analyze
the findings and comment on them. The synthesized
themes and subthemes derived from all focus groups
were shared with the following groups:
When the data were specifically analyzed for responses
unique to gender, education, Visual Analogue Scale
(VAS) pain scores, and age, no dissents of opinion or new
themes were found.
The following analysis aims to describe the themes that
emerged from the data.The central theme was identified
as: desired components to an education resource.Themes
and subthemes derived from the latter were organized
according to: 1) content areas of patient information
needs; and, 2) desired attributes and format of an
education resource for patients. Causal conditions with
direct impact on the transfer of information to patients
were identified. The identified causal conditions were:
1) patient factors influencing the extent of delivered
information; and, 2) communication of information
with patients.
1. Spine surgeons;
2. The preoperative focus group used in our initial
analysis who had subsequently undergone the
surgical procedure; and,
3. One-on-one interview with two preoperative spine
patients.
Results:
1) Reported content areas of patient information needs
(Themes):
Participants
Focus groups were conducted with the following health
care providers: 1) fellowship trained spine surgeons
(n=6, all males); 2) spine fellows (n=3, all males); 3)
orthopaedic surgery residents (n=5, four male, one
female); 4) anesthesiologists (n=4, one male, three
female); 5) surgeons’ administrative assistants (n=2,
all female); and, 6) the preoperative team (n=6, one
male, five female) (Table 1). The patient focus group
demographics are presented in Table 2. A total of ten
patients were interviewed (six male and four female).
The mean patient age was 42.6 years (range 20-67).
Preoperative and postoperative patient leg and back pain
as recorded by the Visual Analogue Scale (VAS, out of
ten) is represented in Table 2. Mean preoperative patient
VAS score for leg pain and back pain were 6.2 and 5.5,
A) Anesthesia information
One of the themes relating to content area of information
need by participants was identified as anesthesia
information (Figure 2). Subthemes of anesthesia-related
information were anesthetic risks and postoperative pain
management. Anesthesiologists were the predominant
stakeholder in their contribution to this theme and its
subthemes. Of all types of information relating to spine
surgery, patients had the least desire for information
related to anesthesia.
i. Anesthesia risk
One subtheme related to anesthesia was the risk
associated with anesthetic. When anaesthesiologists were
70
iii. Overview of procedure
asked about patient’s desired information on anaesthesia,
they felt patients often say, “I don’t know what to ask.”
Anaesthesiologists communicate to patients “what they
think they should know” about the aesthetic.
The overview of the procedure was a subtheme identified
by all stakeholders. The use of patient imaging or a spine
model were examples of effective visual aids used to
describe the procedure to patients by the surgical team.
The spine models are used “to show them [patients] what
exactly you’re doing, in a very simple way” expressed a
spine fellow. Surgeons used a patient’s diagnostic images
to illustrate their condition. Surgeons felt that patients
“connect with you when they see their own image.”
ii. Postoperative pain management
Postoperative pain management was another subtheme
related to anaesthesia. Both patients and anaesthesiologists
viewed this as an important content area of preoperative
information. This was especially vital to patients with
chronic pain or patients who had been on a high dose
of pain medication prior to surgery. The challenge of
postoperative pain control was summarized by one
anaesthesiologist as: “I don’t think they [patients] realize
that it’s going to be a big problem to have their pain
under control post-op. I don’t think they have any idea.”
iv. Surgical goals and outcomes
With regard to the goal of surgery, surgeons emphasized
the importance of managing patient expectations. The
surgeons wanted to ensure that patient’s expectations
regarding the surgical goal were consistent with their
own view of the goals of surgery. One surgeon echoed
the consensus among surgeons that “what to expect with
the surgery, what’s the objective, what are the typical
outcomes” are important for patients to understand
prior to considering surgery.
B) Procedure-related content (Figure 3)
i. Definition of terminology
Both preoperative and postoperative patients were
unfamiliar with the terminology that was used by
surgeons to describe their condition and/or procedure.
“I didn’t even know the term ‘microdiscectomy’ until
after I’d left the building”, admitted one postoperative
patient. It was apparent that many patients were confused
about the procedure they had given consent for due to
their inability to understand the terms used to describe
it. For example, one postoperative patient confessed “I’m
not really sure what I’m agreeing to”, while another
patient stated “even the word microdiscectomy I’d never
heard before! I had no clue what that was.”
v. Surgical complications
Surgical risks and complications are often discussed
during the initial consultation since it is considered
to be an intricate component to obtaining informed
consent. Surgeons, fellows and residents all indicated
the importance of discussing surgical risks with patients.
Surgeons “spend a great deal of time looking at risk and
possible complications, making it very clear to them
[patients].” Information needs on surgical risks were
identified by patients but far less often in comparison
to the surgeons, fellows and residents. A postoperative
patient conveyed this notion saying, “I wasn’t interested
in the technicalities…I didn’t care.”
ii. Diagnosis and treatment options
Surgeons convey to patients their diagnosis during
the initial consultation based on the history, physical
examination and imaging results. The diagnosis serves
as the basis for the recommended treatments. Surgeons
believe that, for the surgical candidates, “the main things
are that they understand the diagnosis, they understand
what the surgery is going to treat, what it’s likely not
going to treat.”
vi. Length of Hospitalization
Although the majority of microdiscectomy procedures
are performed as outpatient surgery, questions relating to
the length of hospital stay were repeatedly brought up by
patients and all other stakeholder groups.
71
C. Postoperative care
and limitations postoperatively. Patients were frequently
unsure and confused about what they were and were not
able to do safely postoperatively. One patient stated: “I
was in a lot of pain so I couldn’t remember what anyone
was saying to me… So when I came out of surgery I had
no idea what I was supposed to do.”
Postoperative-related content was identified as a main
theme from the analysis of the transcripts from all
stakeholder interviews. The patients contributed the
most to data that derived the subthemes in postoperativerelated care. Utilizing qualitative methodology a gap in
the continuum of care for microdiscectomy patients
was identified. Analysis of the data from the preand postoperative patients, administrative assistants
and the preadmission team focus groups identified
postoperative-related content as the most deficient
in terms of information available to patients prior to
surgery. Figure 4 illustrates how this study finding is
placed into a framework representing the continuum
of care. The subthemes identified under postoperative
care were: recovery time, expected symptoms including
postoperative pain management, restrictions and
limitations, wound care, need for a caregiver, and
physiotherapy (Figure 5).
iv. Wound care
The patients interviewed desired information on
wound care. Patients seemed better informed, however,
on managing their wound in comparison to other
subthemes in postoperative care.
v. Need for a caregiver
Given most microdiscectomy patients are discharged
the same day as their surgery, the topic of arranging for
a caregiver was strongly emphasized by postoperative
patients as their hindsight advice for future patients.
“I wish they had told me that for the next four days I
needed somebody there” stated one patient, and another
patient advised future patients of the need for a caregiver
after surgery saying, “if they have a partner, spouse,…
somebody who’s going to help them.”
i. Recovery time
Of the postoperative care subthemes, recovery was the
most desired content area. Postoperative patients felt that
they were greatly unprepared for their postoperative care
as they were told little to no information relating to it.
“For me what was going to be most important – was
recovery” and “I wish I knew how long the recovery
was really going to be”, stated one postoperative
patient, expressing a preponderant view. One surgeon’s
administrative assistant also observed that, “it’s more
recovery [types of questions]” when asked about the
most common types of patient inquires encountered.
vi. Physiotherapy
Residents were often asked by patients preoperatively
and on follow-up about the need for and the role
of physiotherapy in their rehabilitation. The role of
physiotherapy and its appropriateness was information
that patients stated they desired preoperatively.
2) Desired format and attributes of a patient education
resource (Figure 6):
ii. Expected symptoms
Patients often stated that they were unsure of what
to expect after surgery in terms of pain. Patients felt
unprepared and wished they had “understood the extent
of the pain [after surgery]” they may experience.
A. Patient preferred format of an educational resource
All patients were asked about their preferred format
of an educational resource once available for patients
preoperatively. The majority of patients preferred a
written pamphlet (Figure 7). Other formats, including
Internet, CD-ROM, DVD, and face-to-face education,
were less desired as an adjunct to the consultation with
the surgeon.
iii. Restrictions and limitations
Interviews with the postoperative patients emphasized
the need for more information on patients’ restrictions
72
All stakeholders wanted a Frequently Asked Questions
(FAQs) component to the education resource that would
be specific to the microdiscectomy patient population.
This would ensure patients get “a personalized answer to
questions” said one manager in the preoperative team. In
addition, the ability for patients to have a visual diagram
of the procedure and/or anatomy in the pamphlet and
website would help patients better understand their
disease process especially given the complex nature of
spinal anatomy. Finally, a patient suggested the addition
of an electronic message board or e-mail massage where
patients can post their specific questions that were not
answered by the pamphlet or FAQs. The response to the
postings would, according to patients, come from any
member of the surgical or spine care team.
information is at the initial consultation once a patient is
determined to be a surgical candidate. This would allow
the patient who consented to the surgery to reinforce the
information at home, and for those who are undecided,
to review the material and return for a second visit once
a decision is made to proceed with surgery.
B. Desired attributes of the educational resource
A. Age
The most important attribute required for the
postoperative care component of an educational resource
is a time-specific or temporal outline according to the
patients. Patients realized that their activities, restrictions
and limitations would vary from the immediate
postoperative to weeks or months after surgery.The need
for postoperative information in a time-specific format
was noted by one patient as “what can I expect [in my
recovery] sort of a month, two months, three months
out?”
Patient age was a variable that influenced the extent of
information that was delivered to patients. This was due
to the perceived notion that ‘younger’ patients are more
inquisitive about their health status.
3) Causal condition: Patient factors influencing the extent of delivered information:
Data from the participating health care providers showed
that factors that influence the extent of the information
provided to patients relating to the surgery are: patient’s
age, language, education/socioeconomic status, patient
comprehension and presence of family members during
consultation (Figure 8).
B. Language
The focus groups identified perceived fluency of the
English language as a barrier to delivery of information
to patients.
C. Patient education/socioeconomic status and patient
comprehension/self-education
C. Optimal time for patients to receive preoperative
information
There were differing views on the impact that a
patient’s education or socioeconomic status had on
the extent of information delivered by health care
providers. With further probing, it became apparent
that patient ‘education’ was interpreted as the patient’s
understanding of their condition rather than the highest
level of education obtained by a patient. As the subtheme
of patient education was further explored with spine
surgeons, it was apparent that for them a patient’s
comprehension during the consultation and insight into
their condition influenced the extent of information
they provided. One surgeon explained that “there is
difference with regards to the level of questioning
When is the best time to hand out an educational
resource to patients who have been deemed surgical
candidates? According to pre- and postoperative patients,
the consensus was “the earlier the better”. One patient
described the consultation experience with the surgeon
as “they bombard you with a lot of information all at
once, and the questions don’t come until after [leaving
the consultation].” Another patient admitted that, “I
didn’t ask any questions because I was so nervous, and
I didn’t even remember what he was saying to me.” It
was apparent based on the data from all stakeholders
that the most appropriate and desired timing for such
73
[by patients] and... the depth of information that gets
transferred in someone, say, who’s done a lot of research
about it… sort of read around the topic.”
believe this [derived themes and subthemes] tool would
be useful to patients” while some admitted that they
had not thought of some of the derived content areas
previously.
One-on-one interviews with preoperative patients
confirmed the utility of such a resource by comments
such as “it would have been great to have this [derived
themes and subthemes]” and “this saves resources by me
not going to see my doctor to ask about it.” The derived
themes of this educational resource were shared with
postoperative patients that were initially interviewed
prior to their surgery. As with other groups, the themes
were inclusive for their needs and highly valuable. When
asked about what instructions were given to patients after
surgery, the responses by patients included: “we were
sent home with one page, and the top portion was how
to care for your wound, and the second one was basically
take your medication” and, “I went home blind.” These
findings validate the importance of providing patients
with information relating to their entire spectrum of
care with emphasis on the postoperative course.
D. Presence of family members
Patients who had a spouse or a family member present
during the consultation may receive more information
from their provider by virtue of the fact that family
members often asked surgeons questions related to the
surgical procedure or process.
E. Previous surgical experience
Patients with previous experience with surgery and more
specifically a negative experience or a complication,
asked more questions relating to the surgery.
4) Causal condition: Communication of information with
patients
The importance of the use of simple and easy to
understand language as well as defining the common
medical terminologies used was highlighted above. The
communication of information to patients prior to surgery
is a causal condition that influences the described themes
and subthemes. Important subcategories identified by all
stakeholders under communication where identified as:
reinforcement of information, time constraints, faceto-face communication, consistency of the provided
information, need for a liaison between surgeons and
patients, and role of the primary care physician in the
continuity of patient care (Figure 9).
Discussion:
The objective of this study was to determine
the information needs of patients undergoing
microdiscectomy. Using qualitative methodology a
gap in information provision that informs education
needs, particularly related to the postoperative period
of the continuum of care, was identified for people
undergoing microdiscectomy. This information gap
was developed inductively from the data. Figure 4
contextualizes the finding within the continuum of care
for microdiscectomy patients. The context within which
the themes are embedded requires knowledge of the
patient care pathway (i.e. environment), understanding
the participant’s point of view and the interaction
between the individuals within the care pathway
(Benzies and Allen, 2001; Jeon, 2004). It was therefore
important for the observer of the interviews to capture
what information patients knew, what they deemed
important to know, and the context of this information
need within the care pathway.
Member-checking of the study findings:
A written format of the derived themes and subthemes
(Figure 10) were shared with three stakeholders: 1) spine
surgeons; 2) preoperative microdiscectomy patients;
and, 3) postoperative microdiscectomy patients. The
stakeholders were specifically asked to comment on: a)
the usefulness of such information; b) the appropriateness
of the themes and subthemes; and, c) if they would
use such a resource. Spine surgeons agreed with the
appropriateness and inclusiveness of the derived themes
and subthemes stating that it “covers all areas” and “I
74
It would seem logical that a common understanding of
the terminology and spinal anatomy by patients would be
necessary in order for them to participate in a meaningful
discussion about their diagnosis and proposed treatment
options. Nevertheless, despite the surgeon’s best efforts
to speak using non-medical terms, patients often left the
consultation confused and unsure of what they were told
and what they had consented to. This potentially leads
to a barrier to patient participation in their treatment.
Patient participation was further hindered by patient
pain and nervousness during their consultation with the
surgeon. One preoperative patient conveyed this as: “I
was so nervous that I didn’t remember what he [spine
surgeon] was telling me about surgery… I was really
in pain.” Given that under the best of circumstances
patients retain only a fraction of the information during
a consultation (Gauld, 1981; Kitching, 1990; Turner and
Williams, 2002), one ponders on how much is retained
by patients in excruciating pain due to sciatica. An
education resource that provides common definitions of
spinal anatomy and procedure terminology administered
to patients could improve their understanding and
encourage participation in their care.
Given the risks at stake in spine surgery, ensuring
patient expectations are realistic and obtainable are
essential. Yet given the limited face-to-face time
surgeons have with their patients and the numerous
health care providers that a typical patient interacts
with, it is not surprising that the goals of surgery can be
misinterpreted. Providing the goals of surgery, outcomes,
risks and other procedure-related details in a resource to
surgical patients at the time of the initial consult would
allow patients to study and reinforce this information. If
nothing more, it at least highlights the discussion points
during the consultation in the event of disagreements
with regards to surgical goals and risks postoperatively
between patients and surgeons.
Currently, surgeons, fellows and residents spend
the majority of their time-limited discussion with
patients on information related to the procedure
and its associated risks and benefits, and not on the
postoperative course. This is understandable given the
medico-legal implications of not covering risks and
benefits with patients in the informed consent process.
With limited time available to surgeons during a
consultation with patients, perhaps it seems unnecessary
for them to be discussing postoperative care details such
as need for caregiver so far in advance. However, with
patients’ interest hinged on postoperative information,
the current content areas covered during consultations
leave their needs unmet. Patients interviewed wanted to
get on with their lives and once relieved of their pain,
wanted to do everything possible to get back to ‘normal’.
Unfortunately, as it stands, patients are ill prepared for
many aspects related to their postoperative care, and
identify lack of information as a barrier to recovery.
Given that most patients undergoing microdiscectomy
are discharged the same day as their surgery, there is no
opportunity for a health care provider to discuss their
recovery course with them prior to discharge.A discussion
by surgeons with patients post-anesthesia in the recovery
room is not optimal as conveyed by patients who had
little recollection of such conversations. The interview
with the preoperative team revealed patients receive a
generic booklet prior to discharge outlining wound
care with no specific details on recovery, ambulation and
limitations. Patients corroborated this and, as a result, left
the hospital “blind” and unsure of what activities they
were allowed and what limitations they had. This leaves
patients in a state of uncertainty until their follow-up,
which can be as long as six weeks after surgery. Lack
of advice, or inconsistent and contradictory advice,
creates uncertainty for patients as to what they should
or should not do postoperatively. This uncertainty may
result in fear by patients to mobilize after surgery, which
can create anxiety, inhibit rehabilitation and potentially
compromise a desired outcome (McGregor et al., 2007).
Given that the rate of recovery from lumbar discectomy is
greatest within the first three months of surgery, patients
may benefit from an education resource that provides
the content of such information in a time-specific or
temporal format. This is especially true of postoperative
subthemes such as recovery and limitations. Patients
realized that what they can or cannot do at week one
75
after surgery is different than at week four. Patients did
not see their surgeon until six weeks after surgery, yet
no time-specific information was given to them prior
to leaving the hospital on their recovery, restrictions
and limitations. As a result, patients are often afraid to
partake in any activity for fear of damaging their spine.
Providing time-specific recovery-related information in
an education resource to patients would provide them
with guidance and likely decrease their fears and anxiety
around ambulation and activity postoperatively which
may lead to improved outcomes.
The typical spine patient will interact with many health
care providers during their circle of care and, as a result,
the information given to them may vary in consistency.
This inconsistency in the provided information causes
patient confusion and can potentially affect their ability
to trust the information they received from their surgeon.
Surgeons unanimously agreed that such inconsistency
is problematic for patients. The challenge is hinged
on the variability that exists in the surgeon’s practices
both within and between institutions. Therefore, it
would be difficult to provide identical information to
patients undergoing discectomy in a large academic
centre with several spine surgeons.To overcome this, any
communication tool using the identified themes from
this study would need to have its contents populated
by individual surgeons. This would ensure consistency
for all patients in the surgeon’s practice. In addition, a
hand-written component in the pamphlet for proposed
return to work date and other patient-specific details
could be formatted, allowing the information resource
to be customizable to patients. Research has shown such
tailored information is associated with patient benefits
(Damian and Tattersall, 1991; Hogbin et al., 1992;
O’Connor et al., 1999).The information resource would
then be shared with other health care providers within
the patient’s circle of care, and in turn, serve to educate
them on the surgeon’s practice, further reinforcing
consistency.
Patients’ response to the optimal time of providing
surgical information was unanimously “the earlier the
better”. Having the primary care physician provide such
information prior to the consult with the spine surgeon
– the earliest time frame – would create unnecessary
anxiety or give false expectations to nonoperative patients.
Providing such information during the preoperative visit is
also suboptimal given its close timing to the actual surgery
(e.g. usually a week before surgery). This would not allow
patients enough time for preparation. Furthermore, patients
expressed that shortly prior to surgery they felt too anxious
to comprehend such a volume of information. This was
conveyed by one patient as:“your brain is already saturated
with so much, and plus you worry about the surgery.” It
was apparent from the interviews with patients that the
majority of their questions were generated after leaving
the consultation. This was attributed to their nervousness,
lack of understanding of the proposed procedure (i.e. the
terminology used), and the pain they experienced during
the consult.This study strongly suggested that the optimal
time for providing an information resource to surgical
patients was at the initial consultation, as soon as they are
deemed a surgical candidate. This would optimize the
patient’s knowledge of the surgical process and allow for
them to formulate questions based on their reading of
the material provided. It would also allow them to discuss
the surgery and review the provided resource with family
members. A Frequently Asked Questions (FAQs) section
to the booklet or website would allow patients to not
only get answers to common questions they may have
but also to read answers to questions they did no think
of. Where patients have more specific or unanswered
questions an email or electronic message forum can be
created and monitored by a health care provider if the
spine practice or institution deems feasible.Those patients
whose information needs are still unmet can be brought
back for another visit with the surgeon to discuss their
questions and concerns.
Future Direction
In order to address the existing gap on the need for
postoperative-related information by microdiscectomy
patients a better understanding of the meaning of
recovery in this patient population is required. Beaton
and colleagues conducted a qualitative study on the
76
Strengths
meaning of recovery among people with musculoskeletal
disorders of the upper limb (Beaton et al., 2001). The
study found that the perception of “being better”
is highly contextualized in the experience of the
individual. In order words, having recovered or “being
better” does not necessarily mean that the disease state
has resolved. Spine surgeons need to understand the full
impact of disc herniation on a patient’s life in order to
completely understand what recovery means. A study
into the meaning of recovery for patients with lumbar
disc herniation should thus be conducted.
Currently, there is a lack of consensus among surgeons
in respect of the need for, and the nature and timing of
postoperative restrictions. Despite the strong evidence
that most postoperative restrictions are not necessary and
delay recovery and return to work, imposition of such
restrictions seems to relate to clinician/patient anxiety and
uncertainty (McGregor et al., 2007). A formal systematic
review on the best evidence for postoperative-related
themes such as restrictions, limitations, physiotherapy
and expected symptoms should to be undertaken. Gaps
in the literature should be identified and investigated
with subsequent research studies.
The content under each derived theme and subtheme
from this study can be populated using the best available
evidence. For content that is missing in the literature,
expert opinion can be utilized.Therefore, the immediate
next steps to this research are: 1) populating the defined
themes and subthemes based on the best available
evidence; 2) ensuring the provided information is specific
to each institution and/or practice where necessary; and,
3) refining the final resource through feedback from its
end users - patients. In the near future, the impact of
using such an informational resource should be assessed
on outcomes such as patient satisfaction and anxiety level.
Future research should also investigate the impact of
using this information resource on patient’s general and
spine-specific outcomes. Utilizing an education resource
to reinforce realistic expectations around surgery and
providing an outline of the postoperative course to
patients, may translate into better-perceived outcomes
by patients as reported by outcome questionnaires.
Rigour was met for this study by ensuring the availability
of an audit trail, field notes and memos that would allow
for subsequent reviews by other researchers.Triangulation
in this study involved the use of multiple stakeholders as
the data source as well as the use of multiple researchers
(i.e. clinicians and qualitative researchers) possessing
unique skills and perspectives. Member checks with
patients and surgeons allowed feedback and provided
credibility regarding the accuracy of established themes
and subthemes. The use of at least two researchers
in independently coding each transcript and sharing
the study findings with stakeholders for appraisal also
afforded the study rigor.
Finally, the use of focus groups as the primary
methods of data collections had several advantages.
Focus groups allowed for an in-depth exploration of
participants’ knowledge. The range of the focus groups
was reflected in their ability to reveal unexpected issues
while exploring as much information specific to the
participants’ experiences and perspectives as possible.
Another successful feature unique to focus groups was
their ability to produce information by promoting
interaction.
Limitations
There are several limitations to this study. Information
gathered from focus groups represents only the
perspective of the participants.The gathered information
thus represents the range of views amongst stakeholders
and not their prevalence. The assumption of using the
focus groups as a representative sample of the population
maybe problematic. The study findings may not be
generalizable to other surgical procedures and institutions,
especially where the time frames between consultation
and surgery differ form those in our institution. Another
potential weakness is the external validity of focus group
results. Focus group data are contextualized within a
specific social situation (Sim, 1998). In other words, it
cannot be assumed that what a person says in a focus
group is a predictor of what he or she will say in another
social situation.
77
Conclusion:
Table 1: Stakeholder Focus Groups
The quality of existing educational materials is difficult
to assess without adequate reporting of the methods used
to develop them. Few of the studies reviewed disclosed
how the content of the information resources were
developed. The key weakness common to all existing
education resources is the lack of involvement of all
relevant stakeholders in their conception in particular,
the intended end user – patients. To the best of my
knowledge, this is the first study that has utilized all
relevant stakeholders in deriving the information needs
of microdiscectomy patients. Involvement of stakeholders
in devising an education resource is important in its
acceptance by the end users and its success in translation
to clinical practice. Involving patients in my study
provided data that no other stakeholder possessed as
concurred by one patient, “there’s knowledge that the
patients have that only the patients have.” I derived the
essential framework of an educational resource utilizing
all relevant stakeholders for its conception.
Patients need mechanisms to obtain information.
Currently, the existing mechanisms to provide patients
with information at our institution are limited to
surgeons and other health care providers, administrative
assistants and the Internet. This study has demonstrated
that these mechanisms were not sufficient for the patients
interviewed in this study setting particularly in providing
postoperative-related information.
Table 2: Focus Group Patient Demographics
Preoperative Patients
Age (mean)
Gender
Pain duration (range)
VAS back
(mean)
VAS leg
(mean)
43.7
(20-67)
1 Male
2 Female
6 weeks-30
yrs
5.5
(1-8.5)
6.2
(3-8.5)
Postoperative Patients
Age
(mean)
Gender
Pain
duration
(range)
VAS back
(mean)
VAS leg
(mean)
Weeks
postop
(mean)
42.1
(29-58)
5 Male
2 Female
7 months
4 years
3.4
(0-8)
4.3
(0-8)
5
(2-12)
Figure 1: Postoperative Patient Focus Group Employment Status
78
Figure 2: Anesthesia Information Content Area Subthemes and
Descriptors
Figure 4: Placing the Findings into a Framework
Figure 3: Procedure-related Subthemes and Descriptors
Figure 5: Postoperative-related Subthemes and Descriptors
79
Figure 6:
Figure 9: Causal Condition: Communication of Information with
Patients
Figure 10: Derived Content Areas or “Themes” (in shaded blue
boxes), and Subthemes (in clear boxes) of Patient Information Needs
According to Stakeholders
Figure 7: Patients’ Preferred Format for an Information Resource
Figure 8: Causal Condition: Patient Factors Influencing the Extent of
Information Delivered by Surgical Team
80
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81
Olanrewaju Okusanya
Methods: Prospective cohort study: A consecutive sample
of children with severe non-ambulant CP (GMFCS
level IV and V) with radiographically documented hip
instability (grade two to five) were administered the
CPCHILD questionnaire at baseline and at three, six,
and twelve months follow-up. Those that underwent
hip reconstructive and salvage surgery were compared
with those that did not (control group). The difference
in CPCHILD scores from baseline were compared
between both groups using ANOVA with multivariate
analysis to control for differences in baseline prognostic
characteristics between each group.We hypothesized that
there would be a significant improvement in CPCHILD
scores in symptomatic children who underwent surgical
reconstruction and that children in the control group
would have a significant decline in their CPCHILD
scores over the study period.
Lanre was born in Lagos and
did Medical school in Ibadan.
He worked in The Republic
of Ireland, in Orthopedics
and migrated to Canada
to further his Orthopedic
ambition. He has three girls
and one boy.
Measuring the Benefit
of Hip Surgery in NonAmbulant Children with
Severe Cerebral Palsy:
A Prospective Cohort
Study
Results: Data for forty three patients who had surgery
and 22 matched controls were analysed. At baseline
there was a significant inverse correlation between the
severity of hip pathology and the CPCHILD scores for
all children in this cohort. This correlation remained
significant even after adjusting for other co-morbid
conditions. Reconstruction and salvage procedure causes
increase in the CPCHILD scores with P Value of 0.030.
There was deterioration in the Health related Quality of
life notice in the control group over the study period,
but this is not statistically significant.
Olanrewaju O. Okusanya MBBS FRCSI(Dublin), Unni
G. Narayanan MBBS FRCSC, Shannon Weir BSc, MSc
The Hospital for Sick Children ,Toronto, Ontario
Bloorview Macmillan Children’s Centre,Toronto, Ontario.
Abstract
Background: Children with severe non-ambulatory
cerebral palsy (GMFCS level IV & V) are at high risk
for developing progressive hip instability that affects their
overall quality of life. [1,2,3] The is no concession about
the benefits of reconstructive or salvage hip surgery on
the quality of life in this population as the effectiveness
of these interventions have not been evaluated using
outcomes that are meaningful to these patients or their
parents/caregivers. The aim of this study was to measure
the benefit after hip surgery in children with severe
non-ambulant cerebral palsy using the CPCHILD
questionnaire.
Conclusion: For children with symptomatic hip instability,
hip reconstructive surgery provides significant benefit
as measured by the CPCHILD questionnaire, while
untreated children deteriorate in the face of natural history
.Reconstructive hip surgery to relieve symptoms (reactive
surgery) substantially improves the health related quality
of life of children with symptomatic hip instability 12
months after the reconstruction. Clinical trials are needed
to compare whether a reactive approach is superior to a
prophylactic approach.
82
Level of Evidence: Therapeutic level 2, Prospective
HIP Instability
comparative study.
Disease of the hip in CP children can be characterized
by four stages of progression:
1. Hip at risk, when abduction is less than 45 degrees with
partial un-coverage of femoral head on radiograph;
2. Hip subluxation, when the hip migration percentage
is equal or more than 30 percent but less that 100
percent;
3.Hip spastic dislocation, when the hip migration is
more than 99 percent and the severe form;
4.Windswept hips.
Key Words: Cerebral Palsy, Outcomes, CPCHILD, Hip
surgery
Introduction
Cerebral palsy is a common non-progressive neurologic
disorder in children, characterized by physical impairment
that impedes child’s function and health. Its clinical
manifestation varies with the severity of the impairment
and several classification systems are available to assist in
the management of the children with CP. Gross motor
function classification system (GMFCS)7(Fig. 1) is
widely used for assessing children with CP and it groups
children into five levels. Level V are non ambulatory
and level IV has the ability to stand for transfer but rely
on wheeled mobility for any distance. These two levels
reflects the severe form of clinical presentation in CP
and the children with severe motor involvement are at
higher risk (70-90 percent)
Patients presented to us late, at stage two to four, because
quite often they remain asymptomatic with subluxed hip
and a close watch on the hips has been advocated especially
at the seven year old age mark and at the 12 to 14 year
age mark which will correspond to growth spurts in this
population.12 Depending on the level at presentation,
the definitive surgical intervention ranges from adductor
tenotomy, gracilles release, and psoas lengthening to
more extensive procedure such as proximal femur varus,
and derotatory osteotomy.We excluded patients that had
soft tissue release and no osteotomy from the analysis.
In some cases, salvage procedure, femoral head excision
and valgus osteotomy was offered to relieve patient’s
symptoms or prevent progression.
Hip pain is still one of the main complaints of young
adults with cerebral palsy. Sixty percent of dependent
sitters have hip subluxation and dislocation. Though
Pritchett and O’Brien in their study found out that
pain is not a major problem, if dislocated hip remained
unreduced, pain prevalence in children with severe
cerebral palsy is not insignificant. Hip dislocation has
a tremendous impact on the life of these children as it
leads to contracture and interferes with perineal hygiene,
upright positioning, mobility and overall quality of life.
Bony deformities in cerebral palsy are developmental
and they include acetabular dysplasia, excessive femoral
anteversion and increased neck-shaft angle. Studies have
showed the benefit of soft tissue procedure in preventing
or delaying progression to hip dislocation (5) but not
many prospective studies have looked into patient
Figure 1 - The Gross Motor Function Classification System (GMFCS):
83
outcomes following hip reconstruction or salvage
surgery, and the evidence is neither for nor against hip
surgery 6,8,11.
It is easy to reason that reconstructive or salvage
procedure will benefit a child with severe symptomatic
stages two to four of hip pathology albeit, this was not
the findings in children with myelomeningocele that
had relocation hip reconstruction. Our hypothesis is that
there will be a benefit following hip surgery in children
with severe symptomatic hip pathology and we test this
hypothesis by measuring the outcome of surgery using
CPCHILD questionnaire
Caregiver Priorities and Child Health Index of Life
Disabilities (CPCHILD) is a measuring tool that has been
validated for use to assess the health related quality of life
in patient with severe CP. In this study, the questionnaire
was used to scientifically quantify the benefit of surgery
in patient with hip instability.
CPCHILD Questionnaire has items spanning six
domains and are rated on an ordinal scale. It takes on
the average 20 minutes to complete. The six domains
are 1. Personal care (eight items); 2. Positioning, Transfer,
and Mobility (eight items); 3. Communication and
Social interaction (seven items); 4. Comfort, Emotions
and Behavior (nine items); 5. Health (three items); and 6.
Overall Quality of life (one item).
pathology as diagnosed clinically and radiologically
graded as being 2-6. We adopted modified version of
Classification system for hip disease in cerebral palsy as
developed by Jonathan Robin, H Kerr Graham et al. (9)
For ease of analysis we used alphanumeric numbers for
the grading.
Grade 1: Normal hip
Grade 2: Near normal hip with 10-15 percent migration
percentage of Reimers (MPOR)
Grade 3: Dysplastic hip with 16-30 MPOR
Grade 4: Subluxed hip with 31-99 MPOR.
Grade 5: Dislocated hip with >100 MPOR and Grade 6
is loss of hip joint from salvage surgery
Grade 6: Loss of hip joint with previous hip salvage
procedure
METHOD
Prospective cohort study
At the start of the study in 2004, most children with
cerebral palsy that had been referred to the senior author
(UN), at Bloorview Macmillan Children’s centre, and
The Hospital for Sick Children, Toronto, were enrolled
in the study, and was asked to fill the CPCHILD
questionnaire.
This study was approved by the Research and ethics
board and written consent obtained from parent/
caregiver of the CP children. The sample of children in
this study were non-verbal due to the severity of the
neurologic involvement and are non-ambulatory. The
sample was stratified by the GMFCS classification.
Inclusion criteria were GMFCS IV and V with hip
Non cerebral palsy patient with hip pathology were
excluded and ambulating CP child with hip pathology
were also excluded from the study. Co-morbidities,
previous hip surgery , presence or absence of pelvic tilt
were not used as excluding criteria for the study.
Consecutive children with severe CP with clinically and
84
radiologically documented hip instability (grade 2-4) seen
at our institution, Bloorview MacMillan Children’s centre
and The Hospital for Sick Children,Toronto, over a five year
period were the population of the study. One arm of the
cohort had surgery and their outcome were compared with
a control group waiting to have or had declined surgery.
and the data quantified. We tested our hypothesis that
reconstruction or salvage surgery improves the child’s
quality of life using ANOVA(analysis of variance).
The Hip classification was done by the PGY 5
orthopedic resident member of the team who classified
the electronic radiographs of the cases and the control to
reduce inter-observer error.
Surgery
Patients had Proximal Femoral Derotatory Osteotomy
in most cases and DEGA peri-acetabular osteotomy if
there was acetabular dysplasia.
Surgery was done with the child supine and the operated
side slightly propped up. Initial soft tissue release and hip
relocation was performed , followed by proximal femoral
osteotomy (a closing wedge from the medial cortex) to dial
in the varus and at the same time derotate the fumur. The
correction was fixed with a fixed blade plate that is usually
permanent. The DEGA osteotomy was performed if the
femur head was not adequately covered.
Wedge orthosis was used to abduct the legs post op
and child was nursed supine and allowed two hours
of prone positioning. Analgesia administration was by
epidural infusion during the first few days, to be followed
by oral and parenteral. Physiotherapy was started day
after surgery while the epidural was still in place, and this
regimen was well tolerated.
Statistical method
We compared the baseline characteristics of the controls
and the cases using Analysis of variance, and at 12 month
we compared the different in scores at each domain of
CHCHILD Questionnaire and the overall score and
analyze the difference. We were able to compare the scores
at six months to show the trend in the gain in scores and the
difference was compared with those of the control.
Results
Forty three patients, twenty three boys and twenty two
girls met the criteria and about half (eleven boys and
eleven girls) were the matched control. There was great
similarities between the cases and the control in regard
to age, sex and GMFCS level and the p-values were not
significant for the differences as shown in tables 1-4.The
caregivers were mainly women, 89 percent for cases and
82 percent for control.
Table 1. Demographic characteristics of cases and controls
Data collection
CPCHILD questionnaire was administered at baseline
and at three months, six months, and 12 months followup. Baseline data was collected after obtaining consent
at the pre-op visit clinic. Caregivers were giving
the questionnaire and they were giving the option
of returning the completed forms at the next visit. A
help line was available to help with completing the
questionnaire.
Caregivers for forty three patients had completed the
questionnaire before and after hip reconstruction or
salvage procedure. The CPCHILD scores, demographs,
GMFCS score, hip classifications, presence or absence
of scoliosis and few significant co-morbidities that
affect quality of life were entered on the spread sheet
Cases
(n=43)
Controls
(n=22)
P Value
Child Age
M: 10.4
SD: 4.0
M: 11.2
SD: 3.7
0.453
Child Sex
22 boys (51%)
21 girls (49%)
11 boys (51%)
11 girls (49%)
0.929
Caregiver Age
M: 42.8
SD: 8.4
M: 44.2
SD: 8.0
0.525
Caregiver Sex
5 men (12%)
38 women
(88%)
4 men (18%)
18 women
(82%)
0.469
85
Table 2. Clinical status of cases and controls (Baseline)
Group
GMFCS
Hip Pathology (Y/N)
No hip pathology
Adduction contractures
Controls
(n=22)
P
Value
28 level V (65%)
17 level V (77%)
0.315
43 (100%)
22 (100%)
Undefined
0 (0%)
0 (0%)
4 (9%)
3 (13%)
Painless Subluxated / Dislocated
20 (47%)
14 (64%)
Painful Subluxated / Dislocated
19 (44%)
5 (23%)
21 (49%)
14 (64%)
Scoliosis (Y/N)
0.257
No curve
22 (51%)
8 (36%)
Curve ≤ 30
14 (33%)
4 (18%)
Curve 31-60
3 (6%)
4 (18%)
Curve 61-90
2 (5%)
2 (9%)
Curve ≥ 91
2 (5%)
4 (18%)
41 (30.1)
72 (33.2)
1 (2%)
2 (9%)
0.219
16 (37%)
12 (55%)
0.182
27 (63%)
10 (45%)
Degrees (M, SD)
ITB (Y/N)
Feeding Tube (Y/N)
Oral Only
Oral & Tube
5 (12%)
1 (5%)
G-Tube Only
10 (23%)
10 (45%)
G-J Tube Only
1 (2%)
1 (5%)
26 (60%)
15 (68%)
Contractures Any (Y/N)
Flexion contractures (Y/N)
10 (23%)
5 (23%)
Hip adduction contractures (Y/N)
19 (44%)
8 (36%)
Windswept hips (Y/N)
6 (14%)
4 (18%)
Knee flexion contractures (Y/N)
7 (16%)
6 (27%)
Foot contractures (Y/N)
1 (2%)
2 (9%)
Seizures (Y/N)
Previous Surgery (Y/N)
Cases
(n=43)
25 (58%)
12 (55%)
No seizures
18 (42%)
10 (45%)
Yes seizures (controlled)
18 (42%)
11 (50%)
Yes seizures (not controlled)
7 (16%)
1 (5%)
12 (28%)
3 (14%)
86
0.542
0.782
0.196
Table 3. Hip classification status of cases and controls (Baseline)
Group
Cases
(n=43)
Controls
(n=22)
1
6 (14%)
6 (27%)
2
1 (2%)
1 (5%)
3
15 (35%)
5 (23%)
4
16 (37%)
6 (27%)
5
5 (12%)
4 (18%)
6
0 (0%)
0 (0%)
0
10 (23%)
7 (32%)
1
20 (47%)
8 (36%)
2
9 (21%)
6 (27%)
3
4 (9%)
1 (5%)
0
6 (14%)
5 (23%)
1
13 (30%)
6 (27%)
2
17 (40%)
8 (36%)
3
7 (16%)
3 (14%)
7 (16%)
8 (36%)
2
3 (7%)
4 (18%)
3
11 (25%)
2 (9%)
4
17 (40%)
5 (23%)
5
5 (12%)
3 (14%)
6
0 (0%)
0 (0%)
0
15 (35%)
13 (59%)
1
15 (35%)
6 (27%)
2
11 (25%)
2 (9%)
3
2 (5%)
1 (5%)
0
6 (14%)
8 (36%)
1
15 (35%)
7 (32%)
2
14 (32%)
5 (23%)
3
8 (19%)
2 (9%)
0
24 (56%)
14 (64%)
1
15 (35%)
4 (18%)
2
3 (7%)
4 (18%)
3
1 (2%)
0 (0%)
Right CPHC
Right FHD
Right AD
Left CPHC
1
Left FHD
Left AD
Pelvic Obliq
87
Table 4. Comparison of mean standardized scores between cases and
controls (Baseline)
(Two sample unpaired t-test)
CPCHILD
Total Score
Cases
(n=43)
Controls
(n=22)
P Value
Mean: 47.1
Median: 48.1
SD: 14.6
Range: 19.1 –
70.7
Mean: 47.6
Median: 45.8
SD: 12.8
Range: 22.6 –
73.4
0.883
PCA
Baseline
Mean
Median
SD
Min
Max
3-month
Mean
Median
SD
Min
Max
6-month
Mean
Median
SD
Min
Max
12-month
Mean
Median
SD
Min
Max
*SRM
Baseline to 3 month:
PTM
Table 5. Summary of domain & total scores over time (cases)
*Standardized Response Mean (SRM): is one of several effect size indices used
to gauge the responsiveness of scales to clinical change. The SRM is computed by
dividing the mean score change (i.e., follow-up minus baseline) by the standard
deviation of the change score (difference scores calculated elsewhere). An SRM >0.8
is considered large.
Eg. Total CPCHILD Score
Baseline to 3 month: 4.07 / 12.3 = 0.33
*Effect Size (ES): is defined as mean score change divided by the standard deviation
of the pre-operative score. Effect sizes >0.8 are considered large.
Eg. Total CPCHILD Score
Baseline to 3 month: 51.4 – 47.1 / 14.6 = 0.29
CE
CSI
H
OQL
Total
32.53
34.72
14.65
0
59.26
30.56
30.56
14.27
0
62.5
64.50
65.08
27.85
1.59
100
52.42
50
18.18
16.67
95.24
66.20
66.67
23.97
20
100
55.24
60
24.12
0
100
47.09
48.12
14.64
19.12
70.72
41.68
43.83
12.91
7.41
62.96
35.58
36.81
12.52
3.17
56.94
65.28
58.73
20.54
30.36
98.41
57.25
61.11
20.72
19.05
85.71
60.44
60
16.80
26.67
86.67
57.33
60
21.20
0
80
51.41
54.26
11.44
26.50
65.65
45.01
40.74
8.59
31.94
58.02
39
38.89
12.42
15.56
59.72
75.07
74.60
21.14
28.57
95.24
57.14
61.11
22.40
16.67
85.71
72.44
66.67
19.00
46.67
100
61.33
60
19.22
20
80
56.16
56.33
11.11
30.65
73.81
49.18
51.23
9.28
33.33
59.26
40.55
43.06
14.33
18.06
59.72
81.57
88.19
16.52
53.97
100
61.48
65.48
21.93
19.05
92.86
72.86
70
21.48
40
100
70
80
20.38
40
100
60.06
64.86
12.43
40.57
72.80
0.86
0.49
1.11
0.22
0.31
0.63
0.06
0.33
0.59
0.28
0.19
0.49
-0.50
0.21
0.64
0.06
0.05
0.63
0.33
0.41
0.82
0.62
0.85
1.14
0.35
0.59
0.70
0.03
0.38
0.61
0.27
0.26
0.50
-0.24
0.26
0.28
0.09
0.25
0.61
0.29
0.62
0.89
*ES
88
Table 6. Summary of domain & total scores over time (controls
PCA
Baseline
Mean
Median
SD
Min
Max
12-month
Mean
Median
SD
Min
Max
24-month
Mean
Median
SD
Min
Max
PTM
CE
CSI
H
OQL
Total
30.82
31.48
13.66
0
55.56
30.04
29.17
15.88
0
62.5
73.33
77.78
19.22
23.81
98.41
50.05
47.82
27.64
0
95.24
64.85
66.67
22.93
26.67
100
63.81
60
24.99
20
100
47.61
45.80
12.82
22.64
73.43
34.41
34.57
16.46
0
61.73
31.13
30.56
17.20
5.56
69.44
73.43
71.43
11.34
58.73
93.65
46.39
42.86
28.20
0
90.48
69.17
66.67
17.19
46.67
100
61.25
60
22.47
20
100
49.43
47.59
12.32
29.20
71.73
39.20
37.65
14.70
16.05
66.67
31.82
30.56
15.03
11.11
62.5
84.26
87.30
10.41
65.08
100
40.60
32.14
25.71
0
92.86
65.83
63.33
19.08
30
93.33
58.33
60
23.29
20
80
52.06
55.22
12.51
29.94
70.84
0.18
0.49
0.15
0.10
0.07
0.38
-0.22
-0.22
0.00
0.58
-0.20
0.08
0.17
0.52
0.26
0.61
0.07
0.11
0.01
0.57
-0.13
-0.34
0.19
0.04
-0.10
-0.22
0.14
0.35
SRM
ES
Table 7. Comparison of mean standardized scores between cases and
controls (12 months)
(Two sample unpaired t-test)
CPCHILD
Total Score
Cases
(n=14)
Controls
(n=16)
P Value
Mean: 60.1
Median: 64.9
SD: 12.4
Range: 40.6 72.8
Mean: 49.4
Median: 47.6
SD: 12.3
Range: 29.2 71.7
0.027
89
Table 8. Comparison of differences in scores between Baseline and
12months for cases and controls (difference of differences) (Paired
T-test because dependent repeated measures)
Cases
(n=14)
Controls
(n=16)
P Value
CPCHILD
Total Score
Mean difference: Mean difference: 0.020
1.24
12.9
SD: 7.21
SD: 15.6
CPCHILD
PCA Score
2.7
14.6
SD: 14.7
SD: 13.2
CPCHILD
PTM Score
1.24
9.8
SD: 8.29
SD: 15.6
CPCHILD
CE Score
1.4
17.5
SD: 19.0
SD: 29.7
CPCHILD
CSI Score
-3.7
9.6
SD: 16.5
SD: 19.6
CPCHILD
H Score
0.0
8.6
SD: 13.1
SD: 13.4
CPCHILD
OQL Score
-5.0
20.0
SD: 24.8
SD: 31.6
90
Outcome scores at baseline and at 12 months follow
up for the cases and the control are shown in tables 5 to
8. The CPCHILD score ranged from 19.1 to 70.7 with
mean value of 47.5 amongst the cases that were operated
on. The range improved with least score of 40.6 at 12
months follow up from 19.1 prior to surgery and the
mean score improved from 47.5 to 59.5 The bar diagram
(Figure 3) showed this difference placed side by side and
the p- value was 0.030.
The mean CPCHILD score for the controls was 47.6
at baseline and 49.4 at 12 months showing no significant
difference (Tables 4 to 8)
The graphs showed the trend in the scores in the
individual domain of the CHCILD questionnaire. Most
scores improved with time except for Health related (H)
which initially decreased before a steady increase after
three months. This is because the scores included time
spent in hospital in recent time and this will affect the
score. All the scores improved over the period of study
and the difference was statistically significant.
Figure 3
91
Discussion
REFERENCES
The mean CPCHILD scores of cases and controls at
baseline and at 12 months were calculated in this study,
while there is no change in the control group the mean
score improved by 25.3% in those that had surgery and
also the highest score attained by the control group
decreased from 73.4 to 71.7 show a deterioration though
not of a significant proportion.
Ethical approval will be a challenge to do clinical trial
on to treat or not to treat a severely affected cerebral palsy
child with symptomatic hip instability .This prospective
cohort study was able to show that patient with severe
CP with symptomatic hip subluxation or dislocation
do benefit from hip reconstruction and hip salvage
procedure. Major gains are in the perineal hygiene and
toileting and relieve of pain area of the scores. Social
communication and positioning and comfort also show
satisfactory improvement. Also caregivers were more able
to take care of the child and this is line with previous
finding by other investigators Webb et al 13 and Krebs
et al 14.
The study is weak in that it has a short follow up
and it is not possible to predict the future from the
findings. Also the total number of cases that met the
inclusion criteria reduced the power of the study and
the study was done in pediatric hospital so it may not be
a reflection of quality of life in adult with cerebral palsy.
Retrospective studies of adults with severe cerebral palsy
showed that restricted hip abduction interferes with
perineal care and also associated with hip pain. (Noonan
et al)(Cooperman et al). Our study however showed that
the Health related quality of life can be improved by
surgery and we recommend surgical intervention in a
non-verbal non-ambulatory cerebral palsy child with
symptomatic dislocated or subluxed hip.
1. Hip dislocation in severe cerebral palsy
2. Archives of Disease in Childhood 2007 February; 92(2) 141
3. Long term follow up of hip subluxation in CP patients
4. Bagg MR, Faber J, Miller F, J pediatric Orthop 1993;13:32
5. Setting for children with cerebral palsy
6. Rang M, Douglas G, Bennet GC et al J Pediatr Orthop
1981;1:279
7. Hip Displacement in Cerebral Palsy
8. Soo B, Howard JJ, Boyd RN et al JBJS Am 2006; 88:126
9. Cerebral Palsy – Hip Subluxation- Soft tissue release
10. Sherif NG et al Ann Royal Coll Surg England 2008 ; 90:127132
11. Neurogenic Hip Dislocation in CP: Quality of life and results
after hip reconstrucition
12. J Child Orthop (2008) 2: 125-131
13. Classifying Cerebral Palsy
14. Graham HK J Pediatr Orthop 2005; 25:128
15. Hip Dislocation in Spastic Cerebral palsy; Long term
consequences
16. Cooperman D et al. J Pediatric Orthop 1987 7: 268-276
17. A Classification System for Hip Disease in Cerebral palsy
18. Robin J, Graham H Kerr, Baker R Developmental Medicine
& Child Neurology
19. Treated and Untreated Unstable hips in severe Cerebral Palsy
20. Pritchett JW Dev Med Child Neurol 1990 32:3
21. Hips Dysplasia in bilateral cerebral palsy: Incidence and Natural
History in Children 18 months and 5 years. Serutton D,, Baird
G
22.
Dislocation and Subluxation of the hip in Cerebral Palsy,
pathogenesis, natural history and management
23. Samilson RL, Tsou P et al JBJS Am 1972; 54:863
24. Proximal Femoral Osteotomy in Children using the Richards
Hip Screw; Technique outcome and subsequent removal.
25. Webb J et al J Child Orthop 2008 ; 2: 417-423
92
Shayne Keetbaas
peroneal nerve frequently suffers irreversible damage
requiring adjunctive treatment. The nature of the injury
typically involves traction or contusion of the nerve over
a broad zone of injury making repair or reconstruction
challenging.3,4,5
Although nerve repair and nerve grafting have been
described in the treatment of peroneal nerve palsy, the
functional results are inconsistent. Provided that the
affected foot and ankle remain supple with a functional
passive range of motion, posterior tibial tendon transfer
(PTTT) can be performed in an attempt to restore active
dorsiflexion.6,7,8,9 This may in turn allow for functional
orthoses to be discontinued, potentially restoring an
overall more normal gait.
Good functional outcome following treatment for
peroneal nerve palsy implies the ability to dorsiflex the
foot during the swing phase of gait.9 PTT transfer ideally
allows active ankle dorsiflexion, however the transfer
often functions as a tenodesis, thus maintaining the foot
in a neutral position. Although the patient may not have
active functioning of the transferred musculo-tendinous
unit, the tenodesis effect allows for improved foot and
ankle function.10,11,12
The purpose of this manuscript is to present a novel
technique for fixation of the transferred posterior tibial
tendon utilizing a metallic button. In addition, we describe
some of the modifications during its development that
may improve success in the short term.
Shayne was born and raised
in Calgary. After playing and
focusing on hockey until the age
of 18, he turned his attention
to traveling and completing an
undergraduate degree in biology.
He stayed in Calgary for medical
school and moved to Toronto for
his orthopaedic residency. He is
now happily living with his girlfriend Scarlet, who hails
from Brandon, Manitoba. Shayne is looking forward
to starting his sports fellowship this summer here in
Toronto. He would like to thank his loving family for all
the support over the years, as well as a very supportive
Orthopaedic Division throughout his residency.
Posterior Tibial
Tendon Transfer For
Treatment Of Peroneal
Nerve Palsy: A Novel
Technique With Use Of
A Metallic Button
Keetbaas S., Peskun C., Whelan D. St. Michael’s
Hospital, Toronto, Canada.
All patients treated with PTTT utilizing a metallic button
were identified via a chart review. Data with respect to
ankle range of motion, surgical date, injury classification,
and details about the respective nerve injuries, were
recorded utilizing a data abstraction form. Patients were
evaluated at regular intervals postoperatively with clinical
examination and radiographs. At their six-month follow
up visit, patients were asked if they were satisfied with
the overall outcome of the procedure.
Introduction
Knee dislocation is an uncommon orthopaedic injury
with a high rate of limb-threatening complications.
Peroneal nerve palsy in the setting of knee dislocation,
occurs with a frequency of approximately 30%, and
can be a functionally disabling problem.1,2 Neuropathic
pain and difficulty with ambulation can complicate the
management of knee dislocation with peroneal nerve
palsy and may ultimately compromise outcome. Despite
a spontaneous recovery rate of approximately 40%, the
93
Surgical Technique
then tensioned ensuring adequate excursion to allow for
passage and ‘flipping’ of the button to the dorsum of the
foot. Neuromuscular paralytic agents were administered
by the anaesthetist to assist in improving excursion of the
musculotendinous unit.
A fourth and final incision, 4-5 cm in length, was
made over the dorsum of the midfoot, slightly lateral to
the tibialis anterior tendon and directly over the middle
cuneiform. Superficial tendons were retracted and
image intensification used to confirm identification
of the middle cuneiform. A guidewire with an eyelet
was drilled in the center of the middle cuneiform. A
4.5mm cannulated drill bit was then used to create a
pilot hole through the middle cuneiform from superior
to inferior. With the guidewire still in place, a 7mm
cannulated drill bit was then used to create a 7mm
socket on the dorsum of the middle cuneiform taking
care not to violate the inferior cortex. The guidewire
was kept in place.
An extended length Kelly forceps was used to pass
the button-tendon construct from the third to fourth
incisions. Care was taken to pass the construct deep to the
extensor retinaculum to avoid subsequent ‘bowstringing’.
The endobutton/extendobutton construct was then
passed through the socket and pilot channel in the
middle cuneiform. With the foot maximally dorsiflexed
and the knee flexed (and with adequate neuromuscular
relaxation), the button was then flipped on the plantar
surface of the cuneiform, thereby securing the transferred
tendon. Image intensification was used to confirm
appropriate deployment of the button.
A single surgeon performed all procedures (DBW). A
tourniquet was used in all cases. The procedure utilized
four incisions to remove, transfer and fixate the tendon.
The first incision was made along the inferomedial arch
of the foot at the level of the distal insertion (navicular
tuberosity/base of second metatarsal). Sharp dissection
was performed down to level of the tendon sheath which
was incised inline with the skin incision to expose the
tendon. The main insertion at the navicular tuberosity
was then released as were any secondary insertion slips
projecting medially to the second, third, and occasionally
fourth metatarsals. A stay suture was then placed in the
released tendon end.
A second (2-3cm) incision was made 5 cm proximal
to the medial malleolus and along the posteromedial
border of the tibia. The posterior fascia was incised
in line with this incision and the musculotendinous
complex of the posterior tibialis was identified. The
released tendon end was brought out through this
proximal medial wound via traction on the identified
musculotendinous junction.
A third 2-3cm incision was then made over the
anterolateral aspect of the lower leg at the same level
as the previous posteromedial incision. Following a
fascial incision the tibialis anterior muscle was retracted
laterally to expose the anterolateral surface of the
tibia. Blunt dissection was then performed along the
periosteum to the interosseous membrane. A window in
the interosseous membrane was made and a curved Kelly
forceps was passed from posterolateral to anteromedial
through the membrane to allow for passage of the tendon.
At this point the endobutton/extendobutton (Smith
& Nephew inc) construct was secured to the free end
of the tendon using a high tensile, nonabsorbable suture.
The sutures were ‘whip stitched’ through the tendon
from a point approximately three centimeters proximal
to the free end of the tendon.The suture was run distally
and passed through the two middle holes of the button
then run back from the distal end to the proximal start
point. Care was taken to tension the stitch as it was
passed. The entire button-tendon-muscle construct is
Post operative rehabilitation
Patients were immediately immobilized in an aircast
boot which was left on for a total of six weeks. A lift
was placed under the forefoot to position the foot in
slight dorsiflexion. Touch weight bearing was allowed
immediately with transition to weight bearing at six
week. Passive and active assisted motion was allowed at
eight weeks. Strengthening (against gravity) was initiated
at twelve weeks. Resisted dorsiflexion was restricted
until four months post operative.
94
Results
both of which were unsuccessful. All 6 patients required
the use of an ankle-foot orthosis (AFO) for foot-drop. All
6 patients were able to achieve a functional passive range
of motion of the foot/ankle with the aid of aggressive
physiotherapy, keeping the foot/ankle supple prior to
surgery.
The average time from knee dislocation to PTT
transfer was 21.8 months (range 11-42 months). Four
patients had no intra-operative complications; G. K. (case
1) had his PTTT placed in the navicular as opposed
to the intermediate cuneiform, and R. B. (case 4) had
an intra-operative loss of fixation of the EndoButton
which was corrected by cutting it free from the tendon
The described procedure was performed on a total of
six patients, who suffered traumatic knee dislocations,
between 2006 and 2008. All six patients were male
with a mean age of 34.3 years (range 17-48 years). G.
K. (case 1) was hit by a tree branch being dragged by a
tractor. G. P. (case 2) fell awkwardly while playing street
hockey. C. J. (case 3) had his injury approximately 3
years prior to being seen in our clinic, the mechanism
of which is unknown. R. B. (case 4) fell awkwardly
while playing soccer. I. G. (case 5) tripped and fell while
Table 1.
Patient Baseline Demographics Prior to PTTT
G. K.
(case 1)
G. P.
(case 2)
C. J.
(case 3)
R. B.
(case 4)
I. G.
(case 5)
J. K.
(case 6)
M
M
M
M
M
M
Age at time of injury 46
(years)
17
46
48
18
31
Time from injury to
surgery (months)
17
16
42
21
24
11
Schenck knee
dislocation (KD)
classification
KDIIIL
KDIIIL
KDII
KDIIIL
KDIIIL
KDIIIL
Nerve Grafting
procedure?
No
No
Yes (12 months
postinjury)
No
Yes (4 months postinjury)
No
Method by which
Intra-op and clininerve was evaluated cally
Intra-op, clinically,
and EMG
Clinically
and EMG
and EMG
and EMG
EMG findings
n/a
No peroneal nerve
function
n/a
No peroneal nerve
function
No peroneal nerve
function
No peroneal nerve
function
Requirement for
AFO?
Yes
Yes
Yes
Yes
Yes
Yes
Sex
running in his gym-class auditorium. J. K. (case 6) was
involved in a motorcycle accident. All 6 patients had
their peroneal nerves evaluated clinically, and all except
C. J. (case 3) had their peroneal nerves neurolysed and
decompressed intraoperatively during multi-ligament
knee reconstruction. C.J. did not undergo ligamentous
reconstruction. Four patients had at least one EMG
evaluation of peroneal nerve function. Two patients
underwent nerve-grafting procedures. C. J. (case 3) and I.
G. (case 5) had sural nerve grafts performed approximately
1 year, and 3.5 months after their injuries, respectively,
and re-suturing a second EndoButton to the tendon.
Postoperatively, 5 of 6 patients had no complications. G.
P.’s (case 2) PTTT fixation failed while attempting to
actively dorsiflex upon removal of his circumferential
cast at the 2-week post-op visit, which retrospectively,
may have been too early for postoperative cast removal.
Upon his revision surgery one month later, in addition
to the PTT being reinforced with another FiberWire
suture, an ExtendoButton was placed over top of the
pre-existing EndoButton for further reinforcement.
ExtendoButtons were also used in the two most recent
95
G. K.
(case 1)
G. P.
(case 2)
C. J.
(case 3)
R. B.
(case 4)
I. G.
(case 5)
J. K.
(case 6)
Duration of
follow-up (months)
24
13
7
7
6
6
Intra-op
complications?
PTTT placed in
navicular
No
No
Loss of Endo-Button No
fixation
No
Post-op
complications?
No
Failure of PTTT
fixation
No
No
No
No
Need for revision
surgery
No
Yes
No
No
No
No
PROM ankle
dorsiflexion
30°
20°
20°
20°
Planti-grade
20°
AROM ankle
dorsiflexion
30°
5°
20°
Planti-grade
Planti-grade
20°
Need for AFO
post-op?
No
No
No
No
No
No
treated by a single surgeon at a level-one trauma centre
over a course of 50 months, the incidence of peroneal
nerve injury was 14.3% (6/42), a value considerably lower
than that in the literature. This may be accounted for by
the fact that the majority of knee dislocations treated
at our centre are referred from outside institutions, thus
our cohort is not completely representative of the true
incidence of peroneal injury.
Limited success with repair of the peroneal nerve
has forced surgeons to consider non-anatomic
reconstructions.The EndoButton technique can be used
effectively to secure the transferred posterior tibial tendon
in patients with peroneal nerve dysfunction following
multi-ligament knee injury. The goal of this transfer is to
improve foot and ankle function in an attempt to restore
a more normal gait that does not require the use of an
orthotic.
The described technique required two modifications
over the course of the six cases. First, we created a larger
tunnel in the intermediate cuneiform (7mm vs. 4.5mm)
to allow for easier tendon passage. Second, we used the
ExtendoButton as opposed to the EndoButton in order
to promote more stable fixation.
Table 2.
Patient Outcomes Following PTTT
cases given the relative success with the inherent
increased reinforcement of fixation.
Five of six patients regained partial active dorsiflexion
of the foot, to neutral or greater. None of the patients
required an AFO to aid in ambulation postoperatively. A
steppage gait was common postoperatively although there
appeared to be some ongoing long-term normalization
of gait. Five of six patients subjectively accounted a very
high level of overall satisfaction with their postoperative
functioning. All regained the ability to ambulate without
aids, as well as a return to normal activities of daily living.
Some have even been able to return to participation in
sport at their pre-injury level.
Discussion/Conclusions
Traumatic knee dislocation can undoubtedly have
devastating consequences. Peroneal nerve palsy in the
setting of knee dislocation can present problems that are
difficult to treat and often leave those who suffer the
injury with permanent disability.
In a consecutive series of multi-ligament knee injuries
96
References
This study has several strengths. The six patients were
a very heterogeneous group with a wide range of ages
(17-48 years) and varied body habitus’.They all had very
different mechanisms of injury and different times from
injury to PTT transfer (11 to 42 months). We feel that
this allows a certain degree of generalizability of our
results and may allow widespread use of the technique
regardless of specific patient or injury characteristics.
In addition, the technique utilizes a device and general
principles familiar to most orthopaedic surgeons, thus
facilitating the learning process.
This study also has several limitations. The study
design is that of a retrospective case series with no cohort
for comparison. The relatively short duration of followup does not allow us to evaluate long-term outcome
and complications.The potential exists for the buttons to
be bothersome on the sole of the foot with ambulation,
although none of our patients complained of this
problem.There also remains the potential for the transfer
to stretch out over time and become dysfunctional.
In summary, this study describes acceptable functional
results for treatment of peroneal nerve palsy in the
setting of traumatic knee dislocation. We feel this is a
good option to help improve outcomes in these difficult
to treat patients.
1.
Goitz RJ,Tomaino MM: Management of peroneal nerve injuries
associated with knee dislocations, Am J Orthop 32(1):14-6, 2003.
2. Tomaino M, Day C, Papageorgiou C, Harner C, Fu FHP:
Peroneal nerve palsy following knee dislocation: pathoanatomy
and implications for treatment, Knee Surg Sports Traumatol
Arthrosc 8(3):163-5, 2000.
3. Garozzo D, Ferraresi S, Buffatti P: Surgical treatment of common
peroneal nerve injuries: indications and results. A series of 62
cases, J Neurosurg Sci 48(3):105-12; discussion 112, 2004 Sep.
4. Ferraresi S, Garozzo D, Buffatti P: Common peroneal nerve
injuries: results with one-stage nerve repair and tendon transfer,
Neurosurg Rev 26(3):175-9, 2003 Jul.
5. Demuynck M, Zuker RM: The peroneal nerve: is repair
worthwhile?, J Reconstr Microsurg 3(3):193-7, 199, 1987 Apr.
6. Rodriguez RP: The Bridle procedure in the treatment of
paralysis of the foot, Foot Ankle 13(2):63-9, 1992 Feb.
7.
Hsu JD, Huffer MM: Posterior tibial transfer anteriorly through
the interossius membrane, Clin Orthop 131:202, 1978.
8.
Vigasio A, Marcoccio I, Patelli A, Mattiuzzo V, Prestini G: New
tendon transfer for correction of drop-foot in common peroneal
nerve palsy, Clin Orthop Relat Res 466(6):1454-66, 2008 Jun.
9.
Coughlin MJ, Mann RA: Surgery of the Foot and Ankle. Mosby,
Inc., St. Louis, MO: 7(1) pp552-3.
10. Richard BM: Interosseous transfer of tibialis posterior for
common peroneal nerve palsy, J Bone Joint Surg Br 71(5):834-7,
1989 Nov.
11. De Marchi F, Malerba F, Montrasio Alfieri U, Ferrarin M,
Rabufetti M: Tibialis posterior tendon transfer through the
interosseal membrane in paralysis of the common peroneal
nerve, Foot Ankle Surg 6(1):19-25, 2000.
12. Hove LM, Nilsen PT: Posterior tibial tendon transfer for drop
foot, Acta Orthop Scand 69(6):608-10, 1998.
97
Balancing surgical
inequities around the
globe: The role of
academic partnerships
Michael Blankstein
Michael was born in Switzerland,
raised in Israel and moved to
Toronto as a teenager. Having
fallen in love with the city, he
decided to call it his home.
He proceeded to complete his
undergraduate, graduate, and
medical school degrees all at
the University of Toronto. His
Masters degree investigated the
pathophysiologic effects of fat
embolism in a polytrauma setting, under the supervision
of Dr. Emil Schemitsch and Dr. Robin Richards.
Michael is a committed scuba diver, an avid
photographer, and a member of a small local scotch club.
His true passion, however, is world travel. Throughout
his journeys he realized his fascination with various
cultures and developed a desire to reach the world’s
most remote destinations. Motivated by the inequalities
he was exposed to, Michael decided to devote time to
global health. During his residency, under the guidance
of Dr. Andrew Howard, he spent three months in Addis
Ababa, Ethiopia working at the Black Lion Hospital. In
addition, he is currently completing a Global Health
Certificate Program with the Global Health Education
Institute (Dalla Lana School of Public Health). He aspires
to contribute to the improvement of Orthopaedic care
in developing countries around the world.
Next year he will return to St. Michael’s Hospital to
complete a fellowship in arthroplasty and trauma under
the supervision of Dr. Emil Schemitsch and Dr. James
Waddell.
Most importantly, this June, Michael is getting married
in Israel to the love of his life.
Michael Blankstein1, David W. Cadotte2, Abebe Bekele4,
Selamu Dessalegn5 ,Clare Pain3, Milliard Derbew4, Mark
Bernstein2, Andrew Howard1
Author Affiliations:
University of Toronto, Department of Surgery,
Division of Orthopedic Surgery
2
Division of Neurosurgery
3
University of Toronto, Department of Psychiatry
4
Addis Ababa University, Department of Surgery,
Division of General Surgery
5
Addis Ababa University, Department of Orthopedic
Surgery
6
Division of General Surgery
1
Abstract
Background
The Toronto Addis Ababa academic collaboration was
established in 2008 in order to assist in the underserviced
population of Ethiopia. With a population nearing 80
million, cared for by less than 200 surgeons, a significant
shortage of surgical care exists. Our goal was to identify
the needs of the surgical community, both staff and
residents, at Addis Ababa University (AAU) and propose
specific ways in which the University of Toronto
department of surgery may offer assistance through a
surgical teaching partnership.
Methods
We used a mixed methods design whereby surgical
disease data in Addis Ababa, Ethiopia was collected by
retrospective review of operative logs. Needs assessment
surveys were developed in order to collect educational and
98
work-environment data from both faculty and residents.
The staff members were individually interviewed. The
residents were interviewed in small groups. Finally,
validation strategies were employed.
treatment of burns covering less than 30 percent of the
body, come at an average cost of between seven to 215
United States dollars (USD) per disability adjusted life
year (DALY) averted, and have been labeled as neglected
low cost opportunities (3). For comparison, HIV / AIDS
prevention and treatment programs come at an average
cost of between six to 377 USD per DALY averted
in similar sub-Saharan African countries (3). These
important research projects have brought the treatment
of surgical conditions out of the shadow of infectious
disease whereby the international community can
recognize the potential benefit of establishing equitable
partnerships to address the disparity.
Post-graduate surgical education within low and
middle-income countries is the cornerstone to develop
an able-bodied workforce to address these disparities.
While surgical missions and visiting groups who bring
supplies are certainly of value, their contribution is often
not quantifiable and not sustainable. Other organizations,
government-based or otherwise, that contribute surgical
equipment, supplies or financing, are certainly of value, but
do not address the concern for surgical decision making
and talent in the operating room. Academic partnerships,
on the other hand, are in a unique position to aid in the
development of surgical residency programs. In turn, local
resident training offers a sustainable resource to meet local
population needs. Partnerships between universities in the
developed world and those in low and middle-income
countries have potential to foster equitable relationships
where each member stands to gain. Universities within
developed countries have declared their interest and social
responsibility to aid low and middle income countries.
Improved clinical acumen in the absence of advanced
diagnostic testing and exposure to a variety of disease that
is often not present in developed countries are the two
most quoted advantages to studying medicine in low and
middle-income countries (4). An increased exposure to
culturally sensitive situations is another (5). Universities
from low and middle-income countries have also expressed
an interest in such partnerships in order to optimize the
delivery of health care services given significant resource
limitations.
Results
Eighty-six percent of surgical faculty participated in
the study, identifying the management of trauma and
emergency related surgical care as a priority. Specifically, the
faculty desired supervision in the operating room, topicspecific lectures and supervising resident assessments in the
clinic. Residents were in agreement with faculty. Eighty
percent of all surgical residents participated in the study
highlighting a desire for supervision in the operating room
and topic specific lectures.When questioned about specific
knowledge gaps, each of general surgery, neurosurgery and
orthopedic surgery provided specific areas.
Conclusion
This study demonstrates that by interviewing both
surgical staff and residents, at a large academic training
program in the developing world, specific goals can be
outlined to create a partnership in surgical education.
Subsequent to the establishment of specific AAU
perceived needs, the partner Universities can go on to
outline explicit goals and objectives that directly meet
the requirements of both staff and residents caring for an
underserviced population.
Introduction
Ethiopia, like many low and middle-income countries,
faces an enormous shortage of surgical talent to meet the
needs of its population. The World Health Organization
has set a minimum density of 2.28 health care workers
per 1000 population in order to achieve desired levels of
important health interventions (1). Currently, Ethiopia
has 0.03 physicians and 0.21 nurses and midwives per
1000 population for a combined total of 0.24 health
care workers – well short of the desired level(2). Parallel
streams of research have established that many surgical
interventions, including but not limited to chest tube
placement, trachesostomy, management of fractures and
99
In this study, we outline a method by which an
equitable partnership between two universities can be
formed. This model has the potential to change the way
by which international surgeons and physicians approach
universities in low and middle-income countries. The
essence of this model rests in understanding each other’s
needs and limitations. Specifically, we aim to:
Anbessa Hospital). Needs assessment surveys were used
to collect educational and work-environment data from
both faculty and residents. Finally, validation strategies
were employed.
Survey development, testing, restructuring, administration and validation
1. Outline the burden of surgical disease in Ethiopia’s
largest public hospital where the majority of surgical
residents complete their education. Specifically we
will outline the number and type of surgical cases
that were conducted within a given period of time;
2. Outline the perceived needs of surgical residents
and faculty that are preventing them from providing
optimal care to their patients; and,
3. To distinguish between perceived needs that can
be addressed through a university partnership and
those that must be advocated for by other means (i.e.
advocating for biomedical engineering departments
to get involved in aiding or management, storage of
surgical supplies, etc.).
Methods
The work presented here represents the efforts of the
Departments of Surgery at Addis Ababa University
(AAU) and the University of Toronto (UT) within the
context of a broader partnership termed the Toronto
Addis Ababa Academic Collaboration (TAAAC). This
relationship was initially formed to aid in the development
of a psychiatry residency program in Ethiopia. Since its
inception in 2008, the program has expanded to involve
collaborations in several departments within the faculty of
medicine including nursing, library services, biomedical
engineering, rehabilitation sciences, and others.
We used a mixed methods design whereby surgical
disease data in Addis Ababa, Ethiopia was collected by
retrospective review of operative logs and emergency
consultation logs at the primary academic teaching
centre, Black Lion Hospital (also known as Tikur
Two comprehensive questionnaires were developed
based on previously published studies (6) and current
curriculum at both institutions. One questionnaire was
aimed at the AAU surgical faculty and the other at surgical
residents. Drafts underwent several revisions based on
input from both partners. Two UT surgical residents
worked alongside their Ethiopian counterparts in Addis
Ababa for six weeks before making the final revisions
to the questionnaires for local clinical sensibility and
terminology. The final surveys were then reviewed with
Ethiopian project supervisors (AB and MD). The survey
was submitted for Ethics approval at both institutions.
Each of the ethics review boards granted approval prior
to administration of the survey.
Assessing the surgical burden of disease by retrospective review of operative logs and emergency consultation logs at Black Lion Hospital
Information regarding the surgical burden of disease in
Ethiopia was collected by retrospective review of operative
case logs for each of general surgery, neurosurgery and
orthopedic surgery. General surgery data were collected
based on three months spanning November 2008
through January 2009. Neurosurgery data was collected
based on six months spanning from January through
June 2007. Orthopedic data was collected based on three
months spanning from November 2008 through January
2009.
Perceived needs survey: administration and validation
We conducted personal interviews with the faculty
surgeons and administered the resident surveys in small
groups regarding working environment and surgical
training. Faculty surgeons were asked their opinion
with regard to resident education and surgical care in
100
Ethiopia; they were not limited in the number of answers.
Residents were polled with regard to their educational
activities in four domains: clinic responsibilities, oncall duties, operating room experience and overall
educational experiences (including educational resources
and specialty specific knowledge base). Following
completion of the survey administration, we analyzed
the results and presented the information to ensure it
was an accurate reflection of the training environment.
We identified three surgical training programs at
Black Lion Hospital: general surgery (20 faculty and
31 residents), neurosurgery (three faculty and seven
residents) and orthopedic surgery (six faculty and eight
residents).
in resident education made up 26 percent of the total
responses whereby faculty cited a lack of knowledge to
manage emergency surgical conditions, sub-specialized
surgical services and a lack of disease specific knowledge.
The remainder of the answers fell outside the scope
of what an academic partnership may be able to assist
with. These responses included notions such as trained
surgeons tend to work in private practice or emigrate
to neighboring countries where pay is higher. Within
Ethiopia, surgical centers cluster in urban environments
resulting in too few centers across the county and delayed
care due to patient transport over long distances and
poor roads. Only 16 percent of responses were related
to infrastructure whereby limited equipment, lack of
anesthesia, nursing support and surgical beds were cited.
When asked how the UT surgeons could help train
residents, AAU faculty suggested efforts would be best
spent by offering supervision in the operating room,
providing topic-specific lectures and supervising resident
assessments in the clinic.
Surgical caseload at the University Hospital in Ethiopia
Specific educational activities of Residents
A total of 466 general surgery, 96 neurosurgery and 134
orthopedic surgery cases presented to Black Lion hospital
during the analysis period. A clear trend emerges whereby 38
percent of general surgery, 47 percent of neurosurgery, and 62
percent of orthopedic surgery cases are trauma related. Table 1
summarizes the surgical case type and their frequency
within each respective field.
Outpatient clinics are held at least once weekly at Black
Lion Hospital. As a part of their educational experience,
residents attend clinics along with staff spending an
average of 10.6 hours (range 5-30) per week and
reviewing an average of 26 patients (range 8-30) during
that time.
All surgical residents take call shifts, a mean of 9.2 per
month (range 8-16). In addition to call responsibility
for residency training, many surgical residents also take
call for private general practice to supplement income, a
mean of 3.4 times per month (range 0-12).
Training in the operating room occurs at least twice
weekly for all surgical residents. Senior and junior
surgical residents reported on their role in the operating
room (primary surgeon, first assistant or second assistant)
and their opinion regarding the presence of a faculty
member (ranging from very little to optimal). Residents
in all programs demonstrated an increased level of
responsibility in the operating room as they progress
from junior to senior residency. Junior residents spend
Data analysis
Microsoft Excel was used to tabulate results and prepare
descriptive figures and charts.
Results
Faculty and Resident Survey: Response Rate and Validation
We had an overall response rate of 86 percent of the
surgical faculty and 80 percent of the surgical residents.
Ninety-five percent of residents who completed the
original survey also completed the validation survey.
Residents unanimously agreed that their experiences
were accurately reflected by the surveys.
Faculty survey
Forty-three answers were offered that highlighted
reasons for a lack of surgical care across Ethiopia. Deficits
101
an average of 17.9 percent (range 0-80 percent) of their
time operating as the primary surgeon whereas senior
residents spend an average of 44.3 percent (range 10-80
percent) of their time as primary surgeon. All surgical
residents felt that staff supervision in the operating room
was less than optimal and provided a ranking of 2.8
(+/- 1.04, Std. dev.) on a scale of one to five, where five
represents optimal staff supervision.
Self directed learning is a major component of any
residency training. Residents were polled as to how long
they spend each week on self-directed or small group
learning: general surgery residents spend an average of
10.6 hours per week, neurosurgery residents spend an
average of 12.1 hours per week and orthopedic surgery
residents spend an average of 14.6 hours per week.
Residents report inadequate access to the Internet,
journals and books.
Residents were asked to review a specialty specific list
of topics and rank the various topics using a five-point
scale. The results are presented in Figures 1 (general
surgery), 2 (neurosurgery) and 3 (orthopedic surgery).
Several specialty specific deficits in training were
highlighted: general surgery: vascular, cardiothoracic
and oncology surgery; neurosurgery: peripheral nerve,
neuropathology and vascular neurosurgery; orthopedic
surgery: degenerative spine, arthroscopy and spinal
trauma. Not all specialty specific deficits can be related
to surgical training in Ethiopia, as some sub-specialties
are not performed in Ethiopia.
Surgical residents were questioned as to how best
the Toronto faculty can help them train to be better
surgeons. A clear trend emerged whereby residents
desired supervision in the operating room and topical
lectures.
Identified barriers to optimal surgical residency in
Ethiopia
AAU surgical faculty was polled with regard to specific
barriers preventing them from providing optimal
education to residents. Using a five-point scale, where
one represents least hindering and five represents most
hindering, a clear trend emerged whereby educational
resources and surgical equipment were the top two
barriers.
Using the same scale, surgical residents were also asked
to outline barriers that affect their quality of education.
A lack of educational resources, formal evaluations,
operative supervision and an organized curriculum
emerged as top items.
Discussion
In this study, we used a mixed methods design to
determine the perceived needs of both faculty and
residents engaged in an academic surgical training
program in a resource-limited setting. Our aim was
to develop an understanding of how an academic
partnership may be able to improve the current state of
surgical training. Eighty-six percent of surgical faculty
participated in the study, identifying the management
of trauma and emergency related surgical care as a
priority. Specifically, the faculty desired supervision
in the operating room, topic-specific lectures and
supervising resident assessments in the clinic. Residents
were in agreement with faculty. Eighty percent of all
surgical residents participated in the study highlighting
a desire for supervision in the operating room and
topic specific lectures. When questioned about specific
knowledge gaps, each of general surgery, neurosurgery
and orthopedic surgery provided specific areas of study
(figures 1 to 3) and also highlighted a lack of educational
resources including books, journals, formal evaluations
and an organized curriculum. The results of this study
have allowed us to compile a specific set of objectives
that aim to improve surgical training in Ethiopia.
The concept of an academic partnership must be
rooted in an equitable exchange.The treatment of surgical
disease is logistically demanding and we find it necessary
to separate areas where an academic partnership will
flourish and those that are out of reach.
For example, when we polled the faculty with regard
to reasons for a lack of surgical care across Ethiopia,
26 percent of the responses were related to surgical
education, and 74 percent were related to concerns such as
physician emigration, practice patterns or infrastructure.
102
When reviewing the results with the Ethiopia faculty,
we highlighted that the University of Toronto is not able
to make a large financial commitment to address these
concerns. The second aspect of an equitable partnership
comes in the form of what UT will gain.
The strengths of this research are in the effort to form
a meaningful relationship between two academic centers.
Involving both faculty and residents in the design and
implementation of the needs assessment helped to build
the foundation for collaboration. In addition, setting
boundaries on what needs the academic partnership
can address is important. Severe resource limitations at
Black Lion hospital make operative care challenging.
Unfortunately, universities, whether from developed
countries or low-income countries are usually not in a
position to donate large sums of money or equipment.
By establishing this boundary upfront, both partners
are in a position to focus their efforts on collaborative
projects that address the needs of each other. The main
weakness of this work is that it represents a snapshot in
a complicated and changing system. It will be important
to continue to reassess the needs of both surgical faculty
and residents in Ethiopia as the partnership grows
Our effort represents a unique contribution in
a number of investigations that attempt to outline
strategies for improved health delivery to low and
middle-income countries. Drain’s research group point
out the increasing mobility of the world’s population,
and the need to understand disease at an international
level, though clinical rotations during residency training
(4, 7). Bernstein has also commented on the ethical
dilemmas encountered in the international setting (8).
The results of our study encompass the surgical burden
of a disease in a specific training center along with both
faculty and resident perceived needs. By involving both
partners in the design and collection of this information,
we have demonstrated a means of fostering an equitable
partnership that can grow on a strong foundation.
As with any budding partnership, the need for follow
up and continued assessment is important. In addition,
it will be important to study and evaluate the perceived
needs and impressions of UT faculty and residents as
they engage in the educational partnership. By working
together, students and educators from both the developed,
and developing world, have a lot to gain.
References
1. The world health report 2006: working together for health.
Geneva: World Health Organization; 2006.
2.
Kinfu Y, Dal Poz MR, Mercer H, Evans DB. The health worker
shortage in Africa: are enough physicians and nurses being
trained? Bull World Health Organ. 2009 Mar;87(3):225-30.
3.
Laxminarayan R, Mills AJ, Breman JG, Measham AR, Alleyne G,
Claeson M, et al. Advancement of global health: key messages
from the Disease Control Priorities Project. Lancet. 2006 Apr
8;367(9517):1193-208.
4. Drain PK, Primack A, Hunt DD, Fawzi WW, Holmes KK,
Gardner P. Global health in medical education: a call for more
training and opportunities. Acad Med. 2007 Mar;82(3):226-30.
5. Grudzen CR, Legome E. Loss of international medical
experiences: knowledge, attitudes and skills at risk. BMC Med
Educ. 2007;7:47.
6. Bernstein M, Hamstra SJ, Woodrow S, Goldsman S, Reznick
RK, Fairholm D. Needs assessment of neurosurgery trainees: a
survey study of two large training programs in the developing
and developed worlds. Surg Neurol. 2006 Aug;66(2):117-24;
discussion 24-6.
7. Drain PK, Holmes KK, Skeff KM, Hall TL, Gardner P. Global
health training and international clinical rotations during
residency: current status, needs, and opportunities. Acad Med.
2009 Mar;84(3):320-5.
8. Bernstein M. Ethical dilemmas encountered while operating
and teaching in a developing country. Can J Surg. 2004
Jun;47(3):170-2.
103
Table 1. Surgical diseases treated at Black Lion Hospital
Relative percent (%)
General Surgery
Organic disease
Acute appendicitis
17
total cases = 466
(46%)
Small / Large bowel obstruction
17
Complications from previous surgery: re-do laparotomy and wound dehiscence
5
Perforated PUD
3
Upper airway obstruction requiring tracheostomy
2
Other including: colostomy complications, diverticulitis, upper GI bleeding and testicular
torsion
2
Oncology
Lung cancer and Esophageal ca.
<1
Infectious
Pyothorax
6
(8%)
Ileal perforation suspicious for Thyphoid
1
Wound infections
1
Perianal abscess
<1
Trauma / accidental injury
Head / Spinal cord injury
(38%)
Penetrating Thoraco-abdominal injury
11
Blunt Thoraco-abdominal injury
12
Foreign body swallow / aspiration
3
12
Other general surgery cases – not classified
9
Neurosurgery
Intracranial disease
Oncology
20
Total cases = 96
(39%)
Hydrocephalus, shunt complications
14
Pediatric – neural tube defects, craniosynostosis
5
Spinal disease
Degenerative
5
(9%)
Oncology
4
Trauma
Skull fracture
22
(47%)
Acute and chronic subdural and epidural hematoma
19
Spine trauma
6
Other (5%)
5
Orthopedic surgery
Oncology
Bone/soft tissue biopsy
17
Total cases = 134
(24%)
Amputations/disarticulations
7
Trauma
Irrigations and debridements
18
(62%)
Amputations/disarticulations
10
Upper extremity open reduction internal fixation (ORIF)
9
Upper extremity external –fixation
2
Femoral neck fractures ORIF / hemiarthroplasty
3
Lower extremity ORIF
16
Lower extremity external -fixation
4
Reconstruction
Other (soft tissue releases, osteotomies,fusions)
6
(14%)
Skin grafting
8
Table 1. Surgical cases and their frequency within each respective field. General surgery and Orthopaedic surgery data were collected based on three months spanning November
2008 through January 2009. Neurosurgery data was collected based on six months spanning January through June 2007.
104
Figure 1. General surgery residents were asked to rate the amount of training in
subspecialty areas using a 5 point Likert scale where 1 represents very little and 5
represents optimal. The responses were charted in order of most deficient areas of
training to optimal areas of training.
Figure 3. Orthopedic surgery residents were asked to rate the amount of training
in subspecialty areas using a 5 point Likert scale where 1 represents very little and
5 represents optimal. The responses were charted in order of most deficient areas of
Figure 2. Neurosurgery residents were asked to rate the amount of training in
subspecialty areas using a 5 point Likert scale where 1 represents very little and 5
represents optimal. The responses were charted in order of most deficient areas of
105
Nicholas Yardley
Nick grew up in the Region of
Niagara where he first fostered
a love for athletics and applied
science. While competing for
the McMaster University varsity
cross country and track team
and qualifying for the national
junior duathlon team, Nick
earned a honours degree in Arts
and Science at McMaster. He
subsequently went on to complete his undergraduate
medical training in London, Ontario.
His nomadic nature brought him to the University of
Toronto in 2006 for his Orthopaedic Surgery training.
He is grateful to all of those who have embraced him
during his 5yr journey while studying here. Recently
married to Kathy, Nick is excited to pursue the next step
with her. Next year he will be completing a fellowship
in orthopaedic sports medicine Dr. Whelan and Dr.
Theodoropulos.
Patellar Tendon and
Hamstring Tendon
Autografts in ACL
Reconstruction:
An Assessment of
the Methodological
Quality of Published
Randomized Control
Trials
Yardley NJ, Dainty KN, Chahal J, Peskun C, Whelan DB
Abstract
Background
The purpose of this study was: (1) to evaluate the
methodological quality of the randomized control trials
(RCTs) comparing bone-patellar-tendon bone (BPTB)
to hamstring allograft (ST/G) for anterior cruciate
ligament (ACK) reconstruction using the Detsky Quality
Index, Revised CONSORT Checklist, and Delphi
List rating systems; (2) to compare the inter-observer
reliability of each rating system, and, (3) to determine if
any predictors of overall study quality existed.
Methods
By combination of reviewing previously performed
meta-analyses and performing a PubMed search, 27
RCTs comparing single bundle BPTB vs ST/G were
identified. Fourteen of these met all the eligibility
criteria for this investigation. These were subsequently
reviewed by four independent assessors using each of the
three rating systems.
Results
The mean Delphi score for the 14 trials was 3.64/9
(range 0.75-5.75), CONSORT score 12/22 (range
5.75-15.25), Detsky score for positive trials 13.4/20
106
(range 9.75-16) and for negative trails 13.1/21 (range
6.75-18.75).The intraclass correlation coefficient for the
Delphi, CONSORT and Detsky Scales were 0.68, 0.67,
and 075, respectively. The impact factor (as reported in
2010) of the journal in which the study was published
was the sole variable which correlated with quality (p =
0.032, R2 0.28 – 0.44).
Conclusions
The overall methodological quality of the RCTs
investigating single bundle BPTB and ST/G autograft
for ACL reconstruction compare similarly to other areas
of orthopaedic research. However, the methodologic
quality in the orthopaedic literature overall remains
fairly low despite increasing information and reports
on the importance of methodological rigor. There is
little use for further similar investigations unless they are
adequately powered, included significant methodological
rigor, and include validated, clinically relevant, primary
outcomes. Until then, the dilemma of graft choice will
remain unresolved.
Introduction
Anterior cruciate ligament (ACL) reconstruction is
a common and increasingly performed1 orthopaedic
procedure, with recent estimates reporting an annual
incidence of >30/100 0002. The most common
autogenous graft choices for reconstruction are central
third bone patellar tendon bone (BPTB) and quadrupled
semitendinosus/gracilis
(ST/G). Despite
many
comparison trials, including over 30 randomized control
trials and four meta-analyses, there is significant ongoing
controversy over their clinical differences, and ultimately,
which graft is the optimal choice.
Concurrent to these investigations, there has
been considerable interest in the evaluation of the
methodological quality of randomized trials. Although
significant agreement exists that randomized control
trials are often the most accurate method of evaluating the
clinical differences between two surgical interventions,
there is significant evidence their quality varies greatly3.
This, in combination with relative study heterogeneity,
creates a significant dilemma when trying to generate
clinically relevant inferences based on their conclusions.
This becomes particularly relevant when trying to
perform meta-analyses.
The primary objective of this study was to evaluate
the quality of the randomized control trials comparing
BPTB to ST/G using the Detsky Quality Index4,
Revised CONSORT Checklist5,6, and Delphi List7
rating systems. Secondary objectives were to compare
the inter-observer reliability of each of these rating
systems and to attempt to identify predictors of overall
study quality (i.e., impact factor, number of total patients,
average duration of follow-up, year of publication,
weather a primary outcome measure was either stated or
implied, weather a difference in primary outcome was
found, and whether a difference in laxity measurement
was found).
Methods
Eligibility Criteria
A study was considered for inclusion if: (1) it was
described as randomized, (2) had only two treatment
arms comparing single bundle autogenous BPTB and
autogenous ST/G for ACL reconstruction, (3) it was
published between 1995-2009, and (4) the full text
article was available in the English language (including
translations). A study was excluded if: (1) it was a substudy of a larger trial, (2) investigated the same patient
population at a different time point, (3) had less than two
year outcome data, or (4) it was, upon examination, not
randomized.
Study Identification and Selection of Reviewers
Recent review articles and meta-analysis comparing
BPTB and ST/G were used to identify the potential
RCT papers for this investigation. An additional
PubMed database search was performed using the key
words “anterior cruciate ligament” and limited to only
RCTs from January 1995 and January 2009. These
lists were then cross-referenced to ensure all potential
studies were considered for analysis. Four individuals,
107
three with graduate training in clinical epidemiology,
were selected to independently review each article. One
staff orthopaedic surgeon (DW), one senior orthopaedic
researcher (KD), one orthopaedic sports medicine fellow
(JC), and one senior orthopaedic surgery resident (NY)
were chosen to assess the articles.
Assessment of Methodological Quality
The eligible studies were independently reviewed
by each of the four raters, using three quality scales.
Although many quality scales exist8, scales that had
been used in previous orthopaedic investigations on
methodological quality were chosen for this investigation.
The three quality scales chosen were the Detsky Quality
Scale, Delphi List, Revised CONSORT Checklist. A
standardized collection form was used by each of the
four assessors.
The Detsky Quality Scale contains 14 items in the
categories of: (1) randomization, (2) outcome measures,
(3) eligibility criteria and reasons for exclusion, (4)
interventions, and (5) statistical issues. Each category
is given equal weight (four points). The final section
includes an additional question of whether confidence
intervals or post hoc power calculation were performed
or not. The total possible scores for positive and negative
trails were 21 and 20 respectively.
The Delphi List includes nine items including
randomization, similarity at base line, eligibility criteria,
allocation concealment, blinding of outcome assessor,
patient and care provider, inclusion of intention to treat,
and report of point estimates and variability. Each item
is assigned one point for a possible total of nine points.
The Revised CONSORT Checklist is a series of
22 questions which were designed as guidelines for
improving the quality of the reporting of randomized
controlled trials. Each question was given a single point
creating a total possible score out of 22. The raters did
not receive standardized training for use of any of the
scales prior to the study, but did review the guidelines
for each.
Data Extraction
To facilitate the identification of predictors of study
quality, pertinent data was extracted from each eligible
study by one investigator (NY). The variables of interest
included: number of total patients, average duration
of follow-up, year of publication, weather a primary
outcome measure was either stated or implied, weather
a difference in primary outcome was found, and
whether a difference in laxity measurement was found.
Additionally, the impact factor in 2010 for each journal
that the studies were published was determined by using
Google search engine.
Data/Statistical Analysis
All statistical analyses were performed by an independent
statistician (CP) using Minitab 15 Software (State College,
Pennsylvania). To assess the agreement among the
observers for each of the quality measures, an intraclass
correlation co-efficient, with 95 percent confidence
intervals was calculated. We chose an a priori criterion
of “substantial agreement” for ICCs > 0.65 as defined
by Landis and Koch9. To identify predictors of study
quality, several statistical techniques were employed.
Specifically, univariate regression analysis was used for
impact factor, number of patients, and average length of
follow up; Rank correlation was used to evaluate year of
publication; An independent sample student T-test was
used to evaluate for primary outcome stated, difference
in outcome, and difference in laxity. For all analysis, a p
value of <0.05 was considered significant.
Results
Study Identification
The search for RCTs comparing single bundle BPTB
and ST/G, revealed 27 trials. A total of 13 of these were
excluded because they had one or a combination of:
more than two treatment arms (5), less than two year
follow up (3), or used the same study participants as a
previously published study with different outcomes
(7). The remaining 14 RCTs were included for
analysis10,11,12,13,14,15,16,17,18,19,20,21,22,23.
108
Study Characteristics
Discussion
The 14 RCTS included in the trial were published
from 2001-2007 (median 2003), in six different journals,
which had an average impact factor rating of 3.098 (range
0.59-3.605). The average number of participants in each
study was 81.85 (range 40-164). The average length of
follow-up was 36.5 months (range 24-81). A primary
outcome was stated, or implied by a power calculation
or an a priori hypothesis, in seven of the 14 studies.
Four of these seven, showed a statistical difference with
regards to their primary outcome. A statistical difference
in anteroposterior laxity was reported in four of the 14
studies.
With an ever increasing emphasis being placed on
evidence based practice, today’s clinicians often turn
to peer reviewed journal articles for guidance in their
clinical practice. Randomized control trials have
long been considered the gold standard. It is natural,
therefore, to accept the conclusions of RCTs, or their
subsequent meta analyses, as often being the best possible
guidance for clinical practice. However, merely having a
randomized prospective trial alone does not guarantee
high quality. In fact, there is good evidence that the
overall methodological quality in surgical research is
quite poor24,25,26,27,28,29 - the orthopaedic literature is
certainly no exception to this30,31,32,33,34,35,36. Ultimately,
with increased methodological quality orthopaedic
physicians can make more confident and informed
clinical decisions.
In 2002, Bhandari et al30 made the first objective
and relatively comprehensive attempt to evaluate
methodological quality in the orthopaedic literature.
They evaluated the quality of studies published in the
Journal of Bone and Joint Surgery (JBJS) from 1998-2000
using the Detsky Quality Index. The methodological
quality of the RCTs reviewed in the current study paper
was comparable to the studies reviewed by Bhandari
et al. They transformed their Detsky scores to be out
of one hundred to allow comparison between positive
trials (out of 20) and negative trials (out of 21). Their
average Destky score for orthopaedic surgical RCTs was
63.9±2.5/100, which compared closely to our average
converted score of 63.6±14.7/100. Similarly, in 2009,
Arneja et al34, performed a systematic review of the effect
of graft tension on ACL reconstruction and included a
Detsky score to evaluate overall quality. They reviewed
studies from 1998-2007. The average Detsky score in
their study was 61.3 ± 15.2/100.
Dulai et al31, used the Detsky score to evaluate the
orthopaedic literature specifically to randomized control
trials in pediatric orthopaedics from 1995-2005. Their
average Detsky score was 53±7/100 – considerably
lower than that found by Bhandari et al and the current
study.
Scientific Quality
The mean Delphi score for the 14 trials was 3.64/9
(range 0.75-5.75). For the Consort, the average score
was 12/22 (range 5.75-15.25). Finally, the mean Detsky
score for positive trials was 13.4/20 (range 9.75-16)
while for negative trails the mean score was 13.1/21
(range 6.75-18.75).
Correlates of Quality
An analysis was performed to determine the association
between potential prognostic variables and each of the
average quality scores (table 1). The impact factor (as
reported in 2010) of the journal in which the study was
published was the sole variable which correlated with
quality (p = 0.032, R2 0.28 – 0.44). The others: number
of total patients, average duration of follow-up, year of
publication, weather a primary outcome measure was
either stated or implied, weather a difference in primary
outcome was found, and whether a difference in laxity
measurement was found showed no association.
Inter-Rater Reliability of Quality Scales
The ICC for the Delphi, CONSORT and Detsky Scales
were 0.68, 0.67, and 075, respectively.The average overall
agreement on quality (single intra class correlations) for
the three scales was 0.7015. All three of the reported
scales had ‘substantial agreement’ among raters according
to the a priori criteria.
109
It has been proposed by Bhandari et al.30 that a Detsky
score of >75/100 would correspond to high quality.
Only one of fourteen papers (7 percent)in our study met
this criteria, although three were >0.7. This is relatively
low compared to other trials which ranged from 1940 percent30,31,34. One caveat to using a threshold to
determine if a study is ‘high quality’ is that the raw scores
may mask pertinent details which can contradict such
a black and white classification. For example, if a study
scores 19/20, yet it is clear from the paper that there was
no allocation concealment during the randomization
process, then it can never be truly understood whether
the findings are free of bias and whether the results are
accurate.
In a recent review of methodological quality in hip
and knee arthroplasty papers from 1997-200636, the
average Delphi list score was 5.33 ± 1.6 /9. This was
markedly higher in comparison to our average of 3.64
± 1.4/9. This difference may be explained by the fact
that 34 percent of the studies they investigated were for
pharmacologic interventions. Pharmacologic studies
have been frequently shown to have higher methodologic
quality37,38, potentially biasing their overall score higher.
In 2002, Bhandari et al32, evaluated RCTs in the
fracture literature from 1969-1999 using the CONSORT
checklist. They found the average study adhered to 32 ±
29 percent of the CONSORT items. This compares to
54.5 ± 14.7 percent found in our study. The difference
in these is potentially explained by the inclusion of
papers prior to 1990, when less stringent guidelines on
methodological quality existed.
We looked at impact factor correlated with overall
methodological quality. Singh et al36, similarly, found
a correlation between impact factor and overall
methodologic quality in univariate, but not multivariable
analysis. This suggests the possibility, that high impact
factor journals may be a better source for high
methodologic quality than their counterparts. However,
we caution extrapolating this finding outside of ACL
reconstruction research, or into potential future research
and blindly accepting the conclusion of RCTs in high
impact journals. Instead, we suggest studies, regardless of
the journal that they are published in, be scrutinized for
methodologic rigor.
Lastly, ‘substantial agreement’ among the three rating
scales was demonstrated (average ICC 0.70).This suggests
each of the scales can be used fairly reliably amongst a
broad spectrum of evaluators. When using these quality
scales, we recommend the use of more than one evaluator
to ensure an accurate evaluation is performed, however,
four is likely not necessary.
We were unable to show an association between quality
and other factors such as the number of total patients,
average duration of follow-up, year of publication,
whether a primary outcome measure was either stated or
implied, whether a difference in primary outcome was
found, and whether a difference in laxity measurement
was found. Our analysis was limited by the fact that there
are a relatively small number of randomized control
trials comparing single bundle ACL reconstruction. As a
result, finding correlations to quality is quite statistically
difficult and risks Type 2 error.
The strengths of this study are that this is a complete
summary of the currently available evidence of the
reporting of trials comparing single bundle hamstrings
and bone patellar tendon autograft in ACL reconstruction.
Further, three different rating scales were used to analyze
quality and to the best of our knowledge this is the first
study to compare the inter-rater reliability of each of
these indices simultaneously in the orthopaedic literature.
This study does however have some limitations. Firstly,
individuals who reviewed the randomized trials in this
study were not blinded to the authors, journal name,
geographic location or hospital affiliation. Second, an
attempt to evaluate trial quality cannot truly evaluate
the trial itself, but rather the way in which the trial is
reported. Lastly, the nature of quality scales is that they
attribute equal weight to their individual components,
when each component may in fact have a different
impact on overall methodological quality. For example, a
study performed with perfect rigor, but not randomized,
could receive a high score yet be still subject to significant
bias and subsequent error. Issues with the scoring of
trial methodological quality, particularly for purpose of
110
meta-analysis, such as this have been described in detail
previously39,40. Nevertheless, the information provided by
the conducted review certainly does indicate that there
needs to be more uniform reporting of randomized trials.
Conclusion
The overall methodological quality of the RCTs
investigating single bundle BPTB and ST/G autograft
compare similarly to other areas of orthopaedic
research. However, the methodologic quality in the
orthopaedic literature overall remains fairly low despite
increasing information and reports on the importance
of methodological rigor. As we increasing rely on
investigational research for guidance in our clinical
practice, the importance of methodological rigor will
become increasingly more paramount.
Although there are now many trials that have
attempted to delineate the differences between graft
choices for ACL reconstruction, ultimately, little clarity
on choice exists. We believe there is little use for further
investigation unless studies are adequately powered,
included significant methodological rigor, and include
validated, clinically relevant, primary outcomes. Until
then, the dilemma of graft choice will remain unresolved.
Appendix
Table 1:
Univariate Regression Analysis
Consort
Delphi
Detsky
p value
r2
p value
r2
p value
r2
Impact Factor
0.01
0.437
0.037
0.3142
0.051
0.282
Number of Patients
0.539
0.03
0.776
0.007
0.694
0.013
Average F/U
0.357
0.071
0.387
0.063
0.141
0.171
Year of Publication
0.892
0.956
0.676
Outcome Stated
0.34
0.498
0.14
Laxity
0.825
0.715
0.543
Outcome Difference
0.876
0.948
0.76
* Univariate Regression used for Impact Factor, Number of Patients, and Average F/U
** Rank Correlation used for Year of Publication
*** T-test used for Outcome Stated, Laxity, and Outcome Difference
Table 2:
Intraclass Correlation Coefficient
r
95 percent CI
Consort
single
0.6705
[0.4325,0.8594]
Delphi
single
0.6812
[0.4467,0.8648]
Detsky
single
0.7528
[0.5474,0.8992]
Avg
0.7015
111
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113
Dawi .H.M. Amariyen
due to the quality of their bone and the actual cost of
the implants. Most published data on cementless THA in
the elderly focuses on cost-effectiveness and economic
consequences. Our aim was to assess the clinical and
radiographic results of cementless THA in patients who
were 75 years of age and older at the time of their surgery.
Dawi was born in Tripoli, Libya
and he completed his medical
school over there.
His family lives in Tripoli. He
has five brothers and one sister and
they are with his mother .
Dawi is married and has two
kids. Son Mohab is three years old
and daughter Tawab is four months old. His wife is a
physician too.
Cementless Total Hip
Arthroplasty in Patients
75 Years of Age and
Older:
A Clinical and Radiographic
Analysis
Dawi Amariyen M.D. , and J. Rod Davey, M.D., FRCS(C)
Abstract: A retrospective review of patients who were
75 years of age or older at the time of cementless total
hip arthroplasty (THA) was conducted. A cementless,
titanium plasma sprayed stem, was used in all patients.
Two designs of cementless, acetabular components were
used. Sixty-two patients were available for a clinical
and radiographic analysis at a minimum of 36 months
following surgery. No patient reported pain sufficient to
interfere with activities of daily living. There were no
peri-prosthetic fractures, no dislocations and no revisions
of the components. The study suggests that cementless
THA in the elderly is a reliable form of treatment for
advanced degenerative disease of the hip.There have been
many studies on cementless total hip arthroplasty (THA)
in young patients. Not as much is known, however, about
cementless THA in older people. Many authors have
recommended cemented THA in these older patients
Seventy consecutive uncemented, primary THA’s in
seventy patients were performed between January
1, 2003 and December 31, 2005. All patients were 75
years of age or older at the time of their surgery. The
femoral component used in all patients was the MalloryHead porous stem (Biomet, Warsaw, Indiana). This is a
dual tapered titanium stem with circumferential plasma
sprayed onto the proximal one third, a textured middle
third, and a smooth distal third. Cobalt-chrome femoral
heads were used. The uncemented cups were of two
designs: a Ring-Loc (Biomet), and a Refelection (Smith
and Nephew, Memphis, Tennessee).
The surgery was performed by the senior surgeon
or by a fellow or resident with direct supervision. A
Harding approach was used for all hips and forty-eight
hours of prophylactic antibiotics were given in all cases.
Anticoagulation with low molecular weight heparin was
used for ten days following surgery. Immediate weight
bearing as tolerated was prescribed along with abductor
muscle strengthening exercises and gait training.
Follow-up involved clinical examination and standard
anteroposterior pelvis and lateral hip x-rays.
Femoral component loosening was defined as a
migration or breakage of the femoral component. The
proximal femoral morphology was classified according
the Dorr classification. The x-rays were also assessed for
radiolucent lines in all Gruen zones. The occurrence of
cortical hypertrophy and endosteal osteolysis was also noted.
The acetabulum was assessed with standard x-rays.
Loosening was defined as migration of two millimetres
or more, change in component inclination, or the
presence of a complete radiolucency at the boneprosthesis interface. The acetabulum was further assessed
by recording the presence of radiolucent lines in
114
Charnley-DeLee zones one to three, and any evidence
of polyethylene wear.
Results
Three patients (three hips) had died, and five patients
(five hips) were unavailable for follow-up due to medical
reasons. The remaining sixty-two patients (62 hips) were
available for final follow-up at a minimum of 36 months
following surgery.
There were no revisions of the femoral or acetabular
components for aseptic loosening or for any other
reason. Survivorship analysis of both the femoral and
acetabular components revealed the rate of survival of
the components at a minimum of 36 months was 100
percent with aseptic loosening considered the end point
for failure.
There were no peri-prosthetic fractures, no postoperative infections and no dislocations. No patient
reported pain sufficient to interfere with activities of daily
living. Thigh pain was uncommon but two patients did
complain of posterior thigh pain which was attributed to
degenerative disc disease and spinal stenosis.
Radiographic follow-up was available for all sixtytwo patients. Six femurs were classified as Type B, and
56 femurs as Type C according to the Dorr classification.
All femoral components appeared to be well fixed
with no subsidence and no worrisome radiolucencies
(Figure 1). Cortical hypertrophy was seen in six hips.
Proximal femoral bone loss was not seen in any patient.
All acetabular components looked to be well fixed with
no circumferential radiolucencies, no osteolysis and no
evidence of polyethylene wear (Figure 1).
Discussion
This retrospective review showed that patients 75 years of
age or older at the time of cementless THA have reliable
clinical and radiographic results at a minimum of 36
months following surgery. Since elderly patients will have
a reduced life expectancy most publications reporting on
THA in this age group will have a short follow-up and a
large number of patients lost to follow-up.
Due to the morphology of the proximal femur in elderly
patients a cemented femoral stem has been recommended
by many authors. It is believed that a cementless stem
may subside or a fracture of the femur may occur in the
peri-operative period if cement is not used for fixation.
Fifty-six of the sixty-two femurs were classified as Type C
using the Dorr classification yet there were no fractures
and no subsidence even with early full weight bearing in
this elderly population. At the same time, some studies
showed that proximal coated hydroxyapatite with distal
grit –blasted stem have less subsidence or migration (37).
A cost analysis was performed comparing a hybrid
THA (cemented stem and cementless acetabulum) and
a cementless THA. The procedure is lengthened by
approximately 20 minutes when cement is used on the
femoral side. Taking into account the cost of O.R. time,
the cost of the stem as well as the cost of the PMMA and
the cement mixer, there is no difference in cost between
the two procedures (Figure 2).
In conclusion, cementless THA in the elderly is a
reliable form of treatment for degenerative joint disease.
It produces reliable clinical and radiographic results at
follow-up.
References
1. Cementless total hip arthroplasty in patients older than 80 years
of age H. Pieringer, G. Labek, V. Auersperg, N. Böhler From the
Allgemeines Krankenhaus, Linz, Austria
2.Radiological Demarcation of Cemented Sockets in Total Hip
Replacement JESSE G. DELEE AND JOHN CHARNLE
1976;121:20
3. A Radiographic Analysis of Loosening THOMAAS . GRUEN,M
.S.,* GREGORYM . MCNEICEP, H.D.** AND HARLANc .
AMSTUTZM, .D.1-1979;141:17
4. bilateral Total hip arthroplasty comparing hydroxyapatite coating
To porous-coated fixation Lawrence D.Dorr,MD,Zhinain Wan,
MD ,Michael Song BA ,and Anil Ranawat, BS 1998;13:729
5.Hydroxyapatite Coated Femoral Stems in Primary Total Hip
Arthroplasty A Meta-Analysis Rajiv Gandhi, MD, J. Roderick
Davey, MD, and Nizar N. Mahomed, MD
115
Figure 1
No osteolysis and radiolucent lines seen according to the Gruen zones
O.R. time 60 min. = $500
stem
Bag of cement
Cement vacuum mixer
cemented
Average 90 min. = $750
$700
$133 x 2
$ 58
cementless
Average 70 min. = $584
$1150
Figure 2
116
Simon Kelley
Richard Jenkinson
Dr
Kelley
received
his
undergraduate medical degree from
the University of Birmingham,UK
in 1997. He undertook his basic
surgical training in Leeds, UK
then moved to Bristol in South
West, UK to join the higher
surgical residency training scheme
in trauma and orthopaedics. It
was there that he developed a passion for children’s
orthopaedics, and in particular limb lengthening,
deformity correction and hip surgery. Dr Kelley pursued
these areas of clinical interest in a series of fellowships.
He undertook the limb reconstruction fellowship at the
Royal Children’s Hospital in Melbourne, Australia in
2008 followed by being awarded the first Trans-Canada
paediatric orthopaedic fellowship in 2008-2009 at the
Hospital for Sick Children, Toronto; Shriner’s Hospital
for Children, Montreal and BC Children’s Hospital,
Vancouver.
Throughout his training Dr Kelley has won awards
for clinical excellence, teaching and research. He won
the Sir Walter Mercer Medal in Orthopaedic and
Trauma Surgery for the most outstanding performance
in the FRCS (Tr and Orth) in 2007. He has presented
his research at national and international meetings in
North America, Europe and Asia. Furthermore he has
published research papers on awide range of topics and
has written 7 book chapters. Simon also pioneered 2
large educational website projects, developing a unique
core regional educational website for orthopaedic
trainees in Bristol, UK and a large national educational
website project named ArgO for orthopaedic trainees
across the UK. Simon was selected as the British
Orthopaedic Association Young Ambassador in 2008. He
is delighted to join the Hospital for Sick Children to
develop a limb reconstruction and hip surgery practice
with a research focus on stem cell technologies and how
they may be used to enhance limb regeneration.
Richard was raised in Calgary,
Alberta and completed his
honours undergraduate biology
degree at the University of Calgary.
After this, he was transplanted to
Ontario where he completed his
medical degree with distinction
in London at the University of
Western Ontario. Developing
during these years was a passion for orthopaedic surgery.
Richard undertook his orthopaedic residency training at the
University of Western Ontario in London.After these 5 years
he came to Toronto, to pursue fellowship training in trauma
and adult reconstruction at Sunnybrook hospital.This period
at Sunnybrook, introduced Richard to a world of challenging
trauma which ignited a desire to pursue a career attempting
to reconstruct severe injuries and degenerative joint disease.
After fellowship, Richard joined the Sunnybrook and
Holland Center team as a clinical associate for 2 years.
During this time, he developed a knack for attracting
difficult referrals usually involving destroyed joints,
infections or both. While working in Toronto, he found
teaching of residents and fellows to be a particular talent
and Richard looks forward to taking an active teaching
role at Sunnybrook and the University of Toronto
division of Orthopaedic Surgery.
When spare time presents itself, Richard spends time
with his wife and young family and also enjoys travelling,
golfing and photography. Despite rational misgivings, he
still can’t help but cheer for the Calgary Flames. The
sports teams in Toronto have yet to capture his heart.
Richard’s clinical practise will be based at Sunnybrook
Hospital focusing on lower extremity trauma and at the
Holland Orthopaedic and Arthritic Center performing
hip and knee arthroplasty. Richard is currently pursuing a
master’s degree in Clinical Epidemiology at the University
of Toronto investigating modifiable factors that may reduce
deep infection rates in open fracture patients. His future
research program will explore his interests in clinical
improvement in trauma and arthritis care and translation of
scientific knowledge into widespread clinical practise.
117
Borna Meisami-Fard
Award
T
he world lost a fine human being when Borna
Meisami-Fard suddenly passed away on July 1,
2007 shortly after his 40th birthday.
Borna was polite, professional
and respectful at all times and,
irrespective of the situation,
always rose above negativity.
He was personable and
driven, and could make things
happen. Borna was a cheerful
person with an excellent sense
of humor who was kind and
thoughtful throughout a long
illness in my family.
Dr. Meisami-Fard brought people together and as an
example, there has not been a more eclectic and beautiful
event at Hart House than the reception following
Borna’s wedding to Marjan. Borna was a proud father
and became a fine teacher. It is unfortunate that Ava
was robbed of her father at such a young age and
Borna’s close-knit family including his parents, Marjan
and sister Tina no longer have his companionship and
energetic enthusiasm. No one was more passionate and
compassionate in his personal and professional life than
Borna Meisami-Fard. Borna lived life to the fullest,
bringing together many people from around the world
and making the world a better place.
Dr. Meisami-Fard’s memory will live on by the Division
of Orthopaedic Surgery’s endowed award in his memory
recognizing his compassion. Each and every one who
met Dr. Borna Meisami-Fard was a better person for
having known him and in the end are fortunate to have
made his acquaintance. Even though Borna has passed
on he leaves a rich legacy and gave many of us an abiding
perspective on how to live life.
118
Anne Lawson Award
Years of painful arthritis led Anne to many consultations
with orthopaedic surgeons. It appeared that it was too late
in life for surgery to help Anne but her frustration was
tempered when she realized there was an opportunity to
fight back.
M
s. Anne Lawson made a generous charitable
bequest of $1.1 million to the Division
of Orthopaedic Surgery to establish two
endowments: (1) the Lawson Family Post-Graduate
and Graduate Fellowships, and (2) the Lawson Family
Post-Graduate Fellowships. World traveller, teacher, and
historian, Anne decided to build this legacy of excellence
based on a lifetime of intellectual curiosity and a thirst
for knowledge.
Anne grew up in an era when young women often had
limited education. Her father, William, was adamant that
his daughters obtain higher education. With his support,
they all graduated with honours from the University of
Toronto. Anne later completed her Master of Science
degree at Iowa State College after teaching secondary
school in Fort Frances and serving as a section officer
and chief dietician in the Second World War. But Anne
stayed close to UofT and became a welcome regular at
the University Women’s Club.
Anne and her friends explored the world, travelling to
Japan, Norway, Paris, and Prague. It helped satisfy her
intellectual appetite and seemingly endless curiosity.
From those travels she wove fantastic stories to share over
the years. A voracious reader of history and art, Anne’s
family remembers her for having a passion for excellence
in herself and those about her.
Confident her family was well looked after, Anne looked
to Uof T as a means for her estate to assist with the training
of top orthopaedic surgeons thereby helping countless
patients that would turn to them in need of care.
With a $1.1 million gift from her estate, Anne was able
to establish two endowed family fellowships in loving
memory of her parents and sisters, and honouring the
educational legacy of her father. The fellowships will
assist post-graduate and graduate fellows who have
specialized or plan to specialize in orthopaedic surgery.
We are tremendously grateful to Anne and her family
for this legacy of excellence. Anne’s leadership in
recognizing and supporting the world class work of
this Division enhances our critical role in advancing
patient care.
119
Division of Orthopaedics – April 14, 2010

Brochure - Division of Orthopaedic Surgery

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