Brochure - Division of Orthopaedic Surgery

Inaugural Division of
Orthopaedic Surgery
City-Wide University of Toronto
Fellowship Day
Sidney Smith Hall 100 St. George Street
June 11th, 2010
Inaugural Division of Orthopaedic Surgery
City-Wide University of Toronto Fellowship Day
Sidney Smith Hall, 100 St. George Street - June 11th, 2010
700
Welcome - Coffee, Tea, and Snacks
730
Sign In
745
Welcome & Introductory Comments
Albert Yee & Ben Alman
800
Dr. Markku Nousiainen
Surgical Fellowship Training in Canada:
Where Are We At And Is Improvement Required?
820
Session I: Fellow Presentations
Dr. Raz
Mean 20 years follow up for distal femur
fresh osteochondral allografted patients –
prospective study
Dr. Markku Nousiainen (Moderator)
825
Dr. Bhumbra
Outcomes After Revision for Mechanical
Failure of The Kotz Modular Femoral Tibial
Replacement (KMFTR) Prosthesis
830
Dr. Peleg
Patient specific quantitative analysis of fracture
fixation in the proximal femur implementing
principal strain ratios. Method and
experimental validation.
835
Dr. Lubovsky
Prognosticating Acetabular Fractures Using CT
Analysis
840
Dr. Butt
Stemmed versus non-stemmed femoral
components in total knee arthroplasty using
any constraint
845
DISCUSSION
910
BREAK
925
Dr. W. Kraemer & Dr. P. Ferguson
Competency-based curriculum in orthopaedic surgery:
development, implementation and initial results
945
Session II: Fellow Presentations
Dr. Weiss
Fixation Of Pathologic Humerus Fractures With
The Cemented Plate Technique
Dr. Jeremy Hall (Moderator)
950
Dr. Petrera
A Meta-Analysis of Open Versus Arthroscopic
Bankart Repair Using Suture Anchors
1000
Dr. Ristevski
The radiographic quantification of scapular
winging following malunion of displaced
clavicular shaft fractures
1005
Dr. Filomeno
An In Vivo Assessment of the Effects of
Bone Marrow Stromal Cell Injection on Local
Recurence of Soft Tissue Sarcoma
1010
1030
DISCUSSION
Dr. David Latter
Interim Chair, Department of Surgery, University of Toronto Remarks from the Fellowship Committee
1050
Introduction of Annual Professorship Lecture (Dr. Marvin Tile, Order of Canada)
1100
Dr. Marvin Tile
1200
Establishing Deep Fellowship Training Roots:
What path less travelled will they lead you to follow?
LUNCH
Session III: Fellow Presentations
1245
Dr. Pally
Communication and the Intra-operative
Direction of C-arm Fluoroscopy
Dr. Khaled Syed (Moderator)
1250
Dr. Nauth
Endothelial Progenitor Cells for Healing and
Angiogenesis in a Segmental Bone Defect
Model: A Comparison with Mesenchymal Stem
Cells
1255
Dr. Geddes
A Long-Term Clinical Outcome and 3-Tesla
Magnetic Resonance Imaging (3T-MRI) Study
of The Hip Following Slipped Capital Femoral
Epiphysis (SCFE) Treated with In-Situ Pinning
1300
Dr. Alves
Surgical management of habitual dislocation of
the hip in children with Down Syndrome
1305
DISCUSSION
1325
BREAK
1340
Dr. Jeremy Hall
Preparing for Clinical Practice
1400
Session IV: Fellow Presentations
Dr. Saidi
Long Term Survival of Large Segment
Intercalary Allograft Reinforced With
Intramedullary Cement.
Dr. Frank Mastrogiacomo (Moderator)
1405
Dr. Poutawera
Cemented short tibial stems in revision knee
arthroplasty: Cohort report of 77 patients
1410
Dr. Hurson
Oblique tibial osteotomy and TKA in patients
with extra articular tibial deformity
1415
Dr. Biau
Monitoring surgical performance. An
application to open biopies and resection of
bone and soft tissue sarcoma.
1420
Dr. Allison
Comparison of 2.7 mm cortical screw fixation
versus 4.0 cancellous screw fixation of medial
malleolar fractures in a cadaveric model.
1425
DISCUSSION
1445
1500
Awards and Closing Remarks
Best Clinical Paper at Fellowship Day
Best Pre-Clinical Paper at Fellowship Day
Outstanding Orthopaedic Fellow Award End of Day
Colleagues
I
t is with pleasure that we welcome you to
our Inaugural University of Toronto Division of
Orthopaedics City-Wide Fellowship Day. The
2009-10 academic year has marked an important
time of program strengthening with focus and
ongoing interest in fellowship training, education,
and research. These efforts are reflected by an
enhanced academic calendar of events for orthopaedic
fellow trainees. Building upon existing venues in the
Department of Surgery, we have established a Divisional
Orthopaedic Fellowship Committee with broad faculty,
fellow and resident trainee representation from across
Toronto Academic Health Science Network (TAHSN)
hospitals. As a University Division, we are appreciative
of the committees’ ongoing effort, time, and genuine
interest, without which the fruition of this day would
not be possible. Apart from fellow trainee presentations
highlighting their activities of the past academic year,
we look forward to faculty presentations focusing
on fellowship activities. Dr. Markku Nousiainen will
provide a perspective on the current status of Canadian
Fellowship Educational Research and opportunities for
the future. Drs. William Kraemer and Peter Ferguson
will provide first hand knowledge of their experience
with novel models of surgical training through their
CBC program initiative. Dr. Jeremy Hall will provide a
perspective as a junior faculty in establishing a clinical
and academic orthopaedic practice. Dr. Latter, as
interim Chairman of the Department of Surgery and
Chair of the Departmental Fellowship Committee, will
provide a university perspective on current fellowship
training and future opportunities in the integration of
local and national efforts. Sincere thanks also to Drs.
Mastrogiacomo, Syed, Nousiainen, and Murnaghan
for their ongoing contributions as well as contributing
towards moderating today’s scientific specialty sessions.
We are also distinctly privileged to honour Dr. Marvin
Tile, recent recipient of the Order of Canada, recognizing his valued contributions to the university orthopaedic mandate. We look forward to his keynote lecture on establishing strong roots in fellowship training
-- we anticipate his talk, as many of you may know
him, to be not only informative but also provocative in
6
academic thought. Most importantly, we are here today
to celebrate clinical and fundamental research activities
of our post-graduate fellows and to hear about their
experiences of orthopaedic academia in Toronto. We
respect the varied medical backgrounds internationally,
which is reflective of Toronto as a recognized multi-cultural metropolis and look forward to working with them
as respected colleagues in the future. The spectrum
of academia and productivity presented by our fellow
trainees today reflects our diverse areas of interest
within orthopaedic subspecialties that also recognizes
an approach that transcends fundamental bench top
research through clinical translation.
At this time earmarking the end of the current academic
year, we also recognize the recent passing of pillar orthopaedic academics of the University – Dr. Robert Salter for
his contributions to academia and for challenging conventional wisdom of the time by advancing continuous
motion strategies. We also remember Dr. David Hastings
for his leadership and motivational abilities as well as his
contributions in advancement of total joint arthroplasty
during a dynamic time of this field’s emerging history.
Both will be tremendously missed and are mentors of
many of the university division’s faculty.
Finally, we would like to especially thank Dan Stojimirovic
and Sarah Davies for their invaluable contributions to the
expert coordination, communications, and promotion of
this important Divisional inaugural event.
Respectfully submitted,
Albert Yee
Fellowship Director, Orthopaedics
University of Toronto
Ben Alman
Chairman, Division of Orthopaedics,
University of Toronto
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
Inaugural Annual
Professorship Lecturer
Marvin Tile
Born in Toronto to immigrant parents, Dr.
Tile attended Harbord
Collegiate and the University of Toronto Medical School, graduating
with B.Sc. (Medicine)
and M.D.(5T7) degrees. As a student at
the University of Toronto, he was very athletic
and played for three
years on the senior basketball team. The connection
of sports and trauma, as well as “the ability to do good
and see your results almost immediately,” drew him to
orthopaedic surgery. He became a Fellow of the Royal
College of Physicians & Surgeons of Canada in 1963,
and spent 18 months working with his Mentor, George
Pennal, as a research and clinical Fellow. Subsequently
as a Detweiler Traveling Fellow of the Royal College of
Physicians and Surgeons of Canada, he visited the major orthopaedic centres in England and Europe, meeting Sir John Charnley, who pioneered total hip replacement, and Dr. Maurice Muller, who spearheaded new
work in fracture care.
He has lectured around the world at universities, colleges and conferences. His fellows are now Heads of
Orthopaedic Trauma Departments all over the world,
including, among others, Oxford, Cambridge, London,
Harvard, and Hong Kong.
Appointed to Sunnybrook’s surgical staff in 1966, Dr. Tile
became Chief of the Division of Orthopaedic Surgery in
1971. He was instrumental in the development of the internationally renowned Sunnybrook Trauma Unit, the first
and still largest in Canada, which opened in 1976. From
1985 to 1996 he was Surgeon-in-Chief. He chaired the
Sunnybrook Foundation from 1996-2002.
He has been very active in Philanthropy, having
chaired the Sunnybrook Foundation and its governing Council. He has also chaired the Holy Blossom
Temple Foundation.
A world authority on the treatment of pelvic and acetabular trauma, Dr. Tile has published widely, including
two standard Fracture texts, Fractures of the Pelvis and
Acetabulum and with Dr. Joseph Schatzker, The Rationale of Operative Fracture Care, widely translated into
many languages. Both texts are in third editions.
• Inaugural Rose Award for volunteerism at
Sunnybrook HSC
He has been Chair of the Examining Board in Orthopaedic Surgery for the Royal College of Surgeons of
Canada, was the Founding President of the Ontario
Orthopaedic Association, President of the Canadian
Orthopaedic Association, President of the International
Society for Surgery of the Lumbar Spine and President
of the AO/ASIF Foundation, dedicated to research and
education in trauma and fractures, headquartered in
Switzerland.
He is a member of the hip society, and has performed
more than 4000 hip surgeries (mostly Total Hip Arthroplasty) in his career.
Dr. Marvin Tile is currently Professor (Emeritus) of Surgery at the University of Toronto, Consultant Orthopaedic Surgeon at Sunnybrook Health Sciences Centre,
and the orthopaedic consultant to the WSIAT (Worker’s
Tribunal, Ontario).
He has received many Honours, including:
• The Marvin Tile Chair in Orthopaedic Surgery,
Sunnybrook HSC and the University of Toronto
• Member of the Order of Canada (July 2, 2009)
But he is most proud of his 55 year marriage to Esther,
and his immediate family now numbering seventeen.
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
7
FELLOW PRESENTERS
GUY RAZ
REJ BHUMBRA
Born in Israel 1971
Medical School: Szeged
University 1996-2002
Guy started his residency
at Kaplan Medical Center,
Rehovot, Israel - affiliated
to the Hebrew University
in Jerusalem. He is currently spending a year
of research fellowship in
adult lower limb reconstruction at Mount Sinai Hospital, which will be followed by a final year of residency
in Israel.
Dr. Bhumbra graduated
in Medicine from Imperial
College, London. He was
awarded a First Class with
Honours Bachelor degree in
Orthopaedic Sciences and
a PhD in Orthopaedic Surgery at the Institute of Orthopaedics, Royal National
Orthopaedic Hospital, University College London. Following Basic Surgical Training in East London and Higher Surgical Training on the
North West London rotation he is about to complete
the Orthopaedic Oncology Fellowship at Mount Sinai
Hospital. Next year he will start a second tumour and
joint reconstruction fellowship at the Royal Orthopaedic
Hospital in Birmingham, after which he has to stop procrastinating and find a proper job. His wife is currently
also working at Mount Sinai hospital as a radiology fellow and his 6 year old daughter and 4 year old son
have adopted both Canada and Canadian accents!
Mean 20 years follow up for distal femur fresh
osteochondral allografted patients – prospective
study
Purpose: To study the long term result of fresh osteochondral allografts.
Method: We enrolled 72 patients in prospective non-randomized study. Inclusion criteria: patients younger than 60
years of age, large unipolar defects. Follow up was focusing
on clinical, radiological and survival of the implanted knees.
Results: 62 patients were followed for 15-31 years, 20
grafts failed, 5 having graft removal and 15 converted to
arthroplasty. Survivorship analysis showed: 92%, 56%, and
49% graft survival at 10, 20, and 25 years, respectively.
Conclusion: We confirmed the value of fresh osteochondral allograft for treating large articular defect in the young
patient’s knees.
Outcomes after revision for mechanical failure
of the Kotz Modular Femoral Tibal Replacement
(KMFTR) prosthesis
Purpose: We present our experience with revision of broken Kotz prosthesis, highlighting the surgical techniques and
functional outcomes.
Methods: We reviewed patients who developed massive
mechanical failure of a metallic part of their Kotz prosthesis.
Results: Out of 180 currently living patients, there were
26 implant fractures in 22 patients (12.2%). Average followup post-revision was 42.2 months. The overall post-revision
complication rate was 42% with the average MSTS score at
74 and TESS 81.
Conclusions: By appreciating the modalities in which
these failures can occur and being aware of the peri-operative issues patients can return to the pre-fracture status.
Authors: Rej Bhumbra. Anthony Griffin. Kurt Weiss. Soha
Riad. David Biau. Ben Deheshi. Robert Bell. Jay Wunder. Peter Ferguson. All at Mount Sinai Hospital
8
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
ERAN PELEG
OMRI LUBOVSKY
Dr Eran Peleg, PhD is the head
of the department of biomedical engineering at Hadassah
University Medical Centre in
Jerusalem Israel. He recently graduated with a PhD in
Medical Sciences (2010) from
Hebrew University and is currently completing a one year
Postdoctoral Fellowship in the Orthopedic Biomechanics
Laboratory at Sunnybrook Health Sciences Centre under
the supervision of Dr Cari Whyne, supported by the Osteosynthesis and Trauma Care Foundation. His research
is focused in the areas of computer assisted surgical
technologies research and implementation and patient
specific quantitative analysis in Orthopaedic Surgery.
Dr Omri Lubovsky attended
medical school and completed his residency in orthopedic
surgery at Hadassah University Hospital and School of
Medicine in Jerusalem Israel.
He is currently a clinical fellow in trauma and joint arthroplasty at Sunnybrook Health
Sciences Centre and the Holland Centre doing image
analysis research in the orthopedic bio mechanic lab.
Patient specific quantitative analysis of fracture fixation in the proximal femur implementing principal
strain ratios: Method and experimental validation
Prognosticating Acetabular Fractures Using CT
Analysis
Purpose: To prognosticate acetabular fracture outcome
from analysis of post traumatic CT scan subchondral bone
density changes.
Methods: bone density maps created from CT scans of 25
uni lateral acetabular fracture were analyzed and correlated to
Purpose: To evaluate the performance of a load indepen-
functional outcome
dent principal strain fixation ratio measure (SR) for computa-
Results: A multiple regression analysis of average fracture
tional based analysis of femoral fracture fixation.
line length and the difference in density distribution for re-
Methods: Specimen specific finite element analysis and
gions representing the dome and posterior wall yielded the
experimental strain gauge measurement of 6 cadaveric fem-
strongest correlation with functional outcome (Adjusted R2 =
ora, intact and following proximal hip fracture fixation.
0.519, p<0.0005)
Results: SR was found to be insensitive to uncertainties
Conclusion: This work adds a new tool for prognosticat-
in density-based elasticity relationships and load amplitude.
ing acetabular fracture outcome by analysis of the preopera-
Average errors of SR (computational vs. experimental) were
tive CT scan.
reduced by 44% as compared to strain values alone.
Authors: Omri Lubovsky, MD; Michael Kreder; David
Conclusions: Direct clinical interpretation of SR (SR<1,
Wright, BSc; Alex Kiss, PHD; Hans J Kreder, MD, MPH, FRCS;
stress shielding; SR>1, overstressed) may ultimately provide
an appropriate and easily understood comparative measure
Cari M Whyne, PHD Sunnybrook Health Sciences Center, Ontario, Canada Senior Author: [email protected]
to choose between fixation alternatives.
Authors: Eran Peleg, Maarten Beek, Leo Joskowicz, Meir
Liebergall, Rami Mosheiff, Cari Whyne
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
9
AHSAN BUTT
KURT WEISS
Ahsan Butt is a fellow of the
Royal College of Surgeons
UK/ Ireland. He is currently
doing an Arthroplasty fellowship at the Holland Orthopaedic and Arthritic Centre,
Sunnybrook Health Sciences
Centre, University of Toronto.
Stemmed versus non-stemmed femoral components in total knee arthroplasty using any constraint
Background: Use of constrained knee prosthesis is on
the rise due to increased awareness of its indications. However there is no published data comparing use of stemmed
and non-stemmed femoral components in constrained TKA.
The purpose of this study is to evaluate the long term results
of constrained cam and post type knee replacements using
stemmed or non-stemmed femoral components.
Method: This is a retrospective review of prospectively
collected data on constrained TKAs performed by a single
surgeon. The medical records of these patients were used to
collect information. Knees were graded as excellent, good,
fair and poor depending on pain scores and range of motion
measurements. X-rays were evaluated for signs of loosening or mechanical failure. Complications and revisions for any
reason were recorded.
Results: A total of 240 constrained TKAs were performed
between 1988 and 2007. 48 knees were excluded from the
study. Mean age of the patients was 67 years. Follow up
range was 2 to 20 years. 115 (59.8%) surgeries were revision
TKAs. 77 (40.1%) were primary TKAs for a variety of diagnoses. Stemmed femoral components were used in 98 patients
(51%) and no stem in 94 (49%). Knees were graded according to pain and ROM as excellent in 44 (23%) patients, good
in 73 (38%), fair in 44 (23%) and poor in 31 (16%). Radiological findings were not found to be consistent with clinical
symptoms. Six of 94 (6.3%) knees with standard femoral implant required revision for loosening at an average of 7 years
post surgery. One of 98 (1.02%) knees with stemmed femoral
implants required revision at three years for a broken stem.
Conclusion: Our data showed that standard un-stemmed
femoral components have a higher incidence of loosening requiring revision, compared to stemmed femoral implants when
using a high cam and post constraint. We advocate and continue to use stemmed femoral implants when constraint is indicated.
Authors: Dr. Ahsan J Butt MBBS FRCS Tr. &Ortho; Dr.
Vaughan R. Poutawera MBChB, FRCAS; Dr. Hugh U. Cameron MD, FRCSC: Holland Orthopaedic & Arthritic Centre,
Kurt Weiss was born and
raised in Pittsburgh. Kurt attended Jefferson Medical
College in Philadelphia. He
participated in the Howard
Hughes Medical Institute/National Institutes of Health Research Scholars Program in
Washington, DC. Kurt then completed his orthopaedic
surgery residency at the University of Pittsburgh. Kurt is
completing his fellowship in musculoskeletal oncology
at Mount Sinai Hospital with Doctors Wunder, Ferguson, Deheshi, and Bell. Although Kurt, his wife Laura,
and their children Connor and Anna are sad to leave Toronto, they are looking forward to going home to Pittsburgh where Kurt will join the faculty at the University of
Pittsburgh Department of Orthopaedic Surgery. He will
work with many physicians and nurses who took care
of him during his battle with bone cancer.
Fixation of Pathologic Humerus Fractures With
the Cemented Plate Technique
Purpose: Pathologic humerus fractures cause significant
pain and disability.
Methods: Patients received the following treatment: Gross
tumor was curetted. Bone cement was placed into the humeral canal and bone defect. The humerus was stabilized
with plates and screws through the bone/cement composite.
Results: 63 patients were studied. 76% presented with
fracture, while in 24% it was impending. The commonest
histology was myeloma (22%), followed by renal and lung
adenocarcinoma (21%). Complications occurred in 14 (22%)
patients, and 7 (11%) required reoperation.
Conclusions: This technique provides immediate rigidity and return of function. It provides a durable solution for
pathologic humerus fractures.
Authors: Kurt R. Weiss MD, Rej Bhumbra MD, Wazzan
Al-Juhani MD, David Biau MD, Anthony Griffin MS, Jay Wunder MD, Peter Ferguson MD, Benjamin Deheshi MD, Robert
Bell MD: University Musculoskeletal Oncology Unit, University
of Toronto.
Sunnybrook Health Sciences Centre.
10
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
MASSIMO PETRERA
BILL RISTEVSKI
Dr. Massimo Petrera is an orthopaedic surgeon. He completed his education in Italy at
the University of Bari, where he
received the degree of Medical Doctor in July 2004 and
the specialty degree of Orthopaedic Surgery and Trauma
in October 2009. His primary area of interest is Sports
Medicine/Arthroscopy. During his residency, he focused
his practice and research on foot and ankle surgery, osteoporosis and joint replacement, publishing articles and
cooperating in the elaboration of book chapters. Since
February 2010, he has been involved in clinical and basic science research focused on cartilage repair and
sports injuries. For two months, he visited the Cartilage
Restoration Center at Rush University Medical Center,
Chicago, cooperating in the elaboration of a book chapter on cartilage injuries. Dr. Petrera is member of the Italian Society of Orthopaedic Surgery, the Italian Society of
Arthroscopy, and the Italian Foot and Ankle Society.
Bill was born on July 16th,
1975. He grew up in Toronto
where he completed all of his
educational training including
his MSc, MD and Orthopaedic surgical training. During his
senior year he served as Chief
Resident for the division of Orthopaedics. His fellowship training at St. Michaels under the supervision of Dr. Michael McKee has focused
on upper extremity and trauma.
The radiographic quantification of scapular winging following malunion of displaced clavicular
shaft fractures.
Purpose: To investigate and quantify the scapular winging
we have observed in patients with clavicle malunions.
Methods: Eighteen patients underwent standardized CT
scans in the prone position with arms pressed against the
gantry to determine the relative malpositioning of the affected
A Meta-Analysis Of Open Versus Arthroscopic
Bankart Repair Using Suture Anchors
Purpose: To conduct a meta-analysis comparing the results of open and arthroscopic Bankart repair using suture
anchors in recurrent traumatic anterior shoulder instability.
Methods: A search of all published articles was performed,
only studies that compared open and arthroscopic repair using suture anchors were included. Chi-square test was used
for the statistical analysis.
Results: Six studies met the inclusion criteria. Total number of patients was 501, 234 performed arthroscopically and
267 open. Recurrence rate in the arthroscopic group was
6% vs. 6.7% in the open group; reoperation rate was 4.7%
in the arthroscopic group vs. 6.6% in open (not significant).
The recurrence rate was significantly (P < 0.05) lower in the
arthroscopic group in studies performed after 2002 (2.9% of
recurrence in the arthroscopic group vs. 9.2% in open; 2.2%
of reoperation in the arthroscopic group vs. 9.2% in open).
scapula.
Results: The mean shortening of the clavicle was 14.4mm
(P>0.001). The differences in relative elevation, protraction
and anterior rotation of the affected scapulae were quantified
using linear and 3D measurements.
Conclusion: Patients with symptomatic clavicle malunions often experience a characteristic scapular winging.
Ours is the first study to quantify scapular malalignment in
this clinical setting.
Authors: Bill Ristevski, MD FRCS(C), Jeremy A. Hall, MD
FRCS(C), Dawn Pearce, MD FR, Jeff Potter BSc, Michael Faruggia BSc,Michael D. McKee, MD FRCS(C)
Conclusion: Arthroscopic repair using suture anchors results in similar redislocation and reoperation rate compared to
open Bankart repair. Recent studies (post 2002) revealed lower
redislocation and reoperation rates in arthroscopic Bankart repair using suture anchors.
Authors: Petrera M, Theodoropoulos J
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
11
PAOLA FILOMENO
ELLIOTT PALLY
Paola Filomeno is an MD,
graduated from the University
of the Republic of Uruguay
(UdelR), 2006. She is a resident of Orthopedic Surgery at
the National Institute of Trauma and Orthopedic Surgery in
Uruguay, and she is currently
doing a Post Doc Research Fellow supervised by Dr
Ferguson as my PI.
Elliott Pally grew up and received his medical training
in Saskatchewan and is uncomfortable writing his own
bio. Despite being a boat
mechanic before switching
to orthopedics his research
interests are typically not mechanical. He will be returning to Saskatoon to practice
primarily orthopedic trauma
after an unforgettable year at Sunnybrook
An In Vivo Assessment of the Effect of human
Bone Marrow Stromal Cell (hBM-MSC) Injection
on Local Recurrence of Human Soft Tissue Sarcoma (STS)
Communication and the Intra-operative Direction
of C-arm Fluoroscopy
Purpose: This study was designed to investigate the cur-
Purpose: Evaluate the effect of hBM-MSC on the growth
rent language used to direct the use of the c-arm fluoroscope
of STS.
during orthopaedic surgery and using this information pro-
Methods: Two STS xenograft (mice) tumor models were
pose a standardized set of terms.
used: 1- fresh tumor tissue (myxofibrosarcoma) and 2-
Methods: On online survey was distributed to the mem-
HT1080 (fibrosarcoma) cell line transduced with an eGFP/luc
bers of the Canadian Orthopaedic Association Canadian As-
lentiviral construct. Animals underwent localized radiotherapy
sociation and the Canadian Association of Medical Radiation
and surgery with injection of hBM-MSC or medium. Histologi-
Technologists.
cal and in vivo Bioluminescence analyses were performed.
Results: The responses illustrated a large number of po-
Results: There was no recurrence of myxofibrosarcoma
tential verbal instructions for any single motion of the fluoro-
in the treated or medium control group. Fibrosarcoma recur-
scope.
rence (histologically and by bioluminescence) was similar be-
Conclusions: The lack of a common language between
tween medium control and hBM-MSC groups.
surgeon and technologist regarding the fluoroscope results in
Conclusions: Our preliminary results show that human
frustration and inefficiency. A standard set of terms based on
BM-MSCs do not increase the risk of local tumor recurrence.
the results of surveys of the COA and CAMRT is proposed to
Authors: Filomeno, Paola A., Kandel, Rita A., Dayan,
improve communication.
Victor, Wang, XIng-Hua, Felizardo, Tania C., Jelveh, Salomeh,
Authors: Elliott Pally MD BSc FRCSC, Hans Kreder MD
Kosaka, Yoko, Medin, Jeffrey, Armand, Keating, Ferguson,
MPH FRCSC University of Toronto, Sunnybrook Health Sci-
Peter C.
ences Centre.
12
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
AARON NAUTH
Chris Geddes
Aaron Nauth completed medical school at Queen’s University and subsequently came
to Toronto for Orthopaedic
Residency. During his residency he joined the Surgeon
Scientist Program at the University of Toronto and is presently completing his masters. He is currently a Trauma
and Research Fellow at St. Michael’s Hospital.
A Long-Term Clinical Outcome And 3-Tesla Magnetic Resonance Imaging (3T-Mri) Study Of The
Hip Following Slipped Capital Femoral Epiphysis
(Scfe) Treated With In-Situ Pinning
Purpose: Studies report good long-term clinical outcomes
in SCFE patients treated with in situ pinning, but even mild
SCFEs may cause femoroacetabular impingement and early
degenerative hip joint disease. We hypothesized that patients
with previous SCFE would have hallmark radiographic findings of early OA with associated physical exam findings.
Methods: 10 hips, 6 patients, treated for stable SCFEs
Endothelial Progenitor Cells for Healing and Angiogenesis in a Segmental Bone Defect Model: A
Comparison with Mesenchymal Stem Cells
completed outcome questionnaires, underwent physical examination and a 3-Tesla MRI scan. Two fellowship trained
musculoskeletal radiologists assessed each hip independently. The scoring system was developed specifically for
Purpose: The purpose of this study was to compare the
femoroacetabular impingement to examine the morphology
effects of two types of stem/progenitor cells [endothelial pro-
and extent of degenerative changes to the acetabulum, fe-
genitor cells (EPCs) and mesenchymal stem cells (MSCs)] on
mur, labrum and articular cartilage. The physical examina-
the healing of critical sized bone defects in a rat model.
tions and clinical outcome scores were correlated to the MRI
Methods: EPCs and MSCs were isolated from the bone
scores.
marrow of syngeneic rats by differential culture and implanted
Results: Mean follow-up was 22 years (18, 27), mean
into a 5mm segmental defect in a rat femur.
clinical measurements included Harris hip score 97, Oxford
Results: All specimens in the EPC group were radiograph-
hip score 13, UCLA 9, WOMAC 98. 3T MRIs demonstrated
ically healed at 6 weeks. Both the control group and the MSC
100% femoral neck retroversion, 86% an osseous bump,
group showed no radiographic evidence of healing at 10
86% labral tears and 100% abnormal articular cartilage.
weeks. Laser Doppler assessment showed significantly more
Conclusion: All patients showed evidence of degenera-
soft tissue and bone blood flow at 2 and 3 weeks in the EPC
tive hip joint disease including labral tears, cartilage damage
group versus the control group (p=0.021).
(fraying and/or delamination) and bone changes seen with
Conclusions: These results strongly suggest that EPCs
cam-type impingement. However these findings did not cor-
are effective for therapeutic angiogenesis and osteogenesis
relate to the physical examination and/or limitations in their
in fracture healing.
function as determined by the outcome scores. Our results
Authors: Aaron Nauth MD, Ru Li MD PhD, Emil
suggest that despite early degenerative changes in patients
Schemitsch MD: Muskuloskeletal Research Laboratory, St.
treated for SCFE with in-situ pinning, there appears to be an
Michael’s Hospital, University of Toronto.
excellent long-term clinical outcome with most patients experiencing few if any limitations.
Authors: C Geddes, D Knight, E Lobo, K Logan, C
Mamisch, L White, J Wedge, J Wright
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
13
DOMINIQUE KNIGHT
KEVAN SAIDI
Dominique Knight is a senior registrar in orthopaedic and trauma
surgery at the Royal Infirmary of
Edinburgh. She graduated from
the Royal Free Hospital Medical
School and undertook junior surgical training at the Hammersmith
Hospital and the Royal National
Orthopaedic Hospital, Stanmore. Her registrar training
took place in London and Edinburgh. In 2009-2010
she was a clinical fellow in paediatric orthopaedic surgery at the Hospital for Sick Children, Toronto.
After completing a Master of Science at the University of Western
Ontario in 2000 with Dr. Kirkley,
he attended McMaster University
Medical School. Saidi was then
fortunate enough to gain acceptance to the University of Western
Ontario, where he completed his
residency in 2008. During his time at McMaster and
Western he organized several electives at Mount Sinai with Drs. Bell, White, Wunder and Ferguson. Their
enthusiasm and dedication inspired him to complete a
fellowship with them from 2008 to 2009. He enjoyed
Mount Sinai so much that he was able to convince Drs.
Gross, Backstein, and Safir to let him stay for another
year to learn Adult Reconstruction. He then organized
a three month travelling fellowship to Hong Kong, Bologna, Italy and New York. His time at Mount Sinai and the
University of Toronto has been truly memorable from a
personal and educational perspective. He hopes that in
the future he will be able to repay such an immense gift.
Presented by Cristina Alves for Dominique Knight
Surgical Management of Habitual Dislocation of
the Hip in Children with Down Syndrome
Purpose: Hip subluxation/dislocation is a potentially disabling feature of Trisomy 21. We describe long-term outcomes following precise use of femoral varus derotation osteotomy.
Methods: 16 consecutive hips, 9 children, with Trisomy 21
aged ≤10 years, were treated.
Results: Mean follow-up was 5.9 years (+/-2.9). Mean
Long Term Survival of Large Segment Intercallary
Allograft Reinforced with Intramedullary Cement
femoral neck shaft angle (NSA) fell from 166.7° (+/-6.9°) to
Purpose: To determine the long-term survival of intercalary
106.0 (+/-5.4 ). 1 hip (6.2%) developed painful arthritis. 14
allografts reinforced with pressurized intramedullary cement.
hips developed peri-trochanteric varus deformity, 2 (12.5%)
Method: Prospectively collected records of 36 were re-
developed periprosthetic fractures 4 and 8 years post-op-
viewed between 1989 and 2006.
eratively.
Results: 8 humeral, 14 femoral and 14 tibial reconstruc-
°
°
Conclusions: NSA of approximately 106 stabilized all
tions. The average age was 32 years old (14 – 77 range). 26
hips preventing recurrent dislocation/subluxation. Patients
of 36 patients were alive at a mean follow-up of 70 months
aged ≤9, postoperative pain/disability were minimal with
(50.6 month SD; 5 to 207 month range) with 22 allografts in
good outcome.
situ. Average time to union was 8 months. The estimated 10-
Authors: Knight DMA, Alves C, Wedge JH: The Hospital
year allograft survival rate was 86.2%.
for Sick Children, Toronto.
Conclusion: Very good long-term survival in large segment
°
intercalary allografts reinforced with intramedullary cement.
Authors: Kevan Saidi MD MSc FRCSC, Anthony Griffin MSc, Mike Biddulph MD FRCSC, Benjamin Deheshi MD
FRCSC, Robert Bell MD MSc FRCSC, Jay Wunder MD MSc
FRCSC, Peter Ferguson MD MSc FRCSC: University Musculoskeletal Oncology Unit, Division of Orthopaedic Surgery,
Mount Sinai Hospital, Department of Surgery, University of
Toronto, Toronto, Canada
14
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
VAUGHAN POUTAWERA
Vaughan is currently an Arthroplasty Fellow at the Holland Centre,
Sunnybrook Health Sciences Centre. He is a New Zealander who
graduated from Otago Medical
school, in Dunedin, New Zealand
in 1999. He did his orthopaedic
training in New Zealand, completing his Royal Australasian Fellowship in 2008. He will
be returning to practice in New Zealand in 2011.
Cemented short tibial stems in revision knee arthroplasty: cohort report of 77 patients
CONOR HURSON
College: University College Dublin
National Orthopaedic Training
Scheme, Ireland Current Fellowship: Arthroplasty fellowship: Dr. Murnaghan and Dr.
Gollish, Holland Centre, Sunnybrook Health Science Centre.
Oblique tibial osteotomy and TKA in patients
with extra articular tibial deformity
Authors: Conor Hurson, Jeffery Gollish, John Murnaghan:
The Holland Orthopaedic and Arthritis Centre, Sunnybrook
Health Science Centre
Purpose: To evaluate the clinical outcomes of using short
Purpose: We describe an oblique tibial osteotomy with a
cemented stubby tibial stems in revision TKA.
long stemmed TKA to treat patients with extra-articular tibial
Methods: Retrospective analysis of patients who had re-
deformities and knee arthritis.
vision knee arthroplasty using short cemented tibial stems.
Methods: Case series of 3 patients with severe valgus
Clinical and radiological data were evaluated to determine
tibial deformities. Ave age 66yrs, ave f/u 26mths.
patient outcomes and identify failures.
Results: Patient demographics, operative, in-hospital and
Results: No patients have undergone further surgery and
outpatient data was collected. Pain, ROM, satisfaction and
none have further surgery planned for mechanical failure or
complications were recorded in clinic. All patients had satis-
malalignment of the tibial prosthesis. No failure or early me-
factory ROM and none developed non-union.
chanical complication of using a short cemented tibial stem
Conclusions: This method allows correction of the tibial
was identified.
mechanical axis by an oblique osteotomy, which is stabilised
Conclusions: The use of short cemented tibial stems
by the long tibial stem of a relatively standard TKA. This al-
in revision knee arthroplasty surgery is a safe and effective
lows immediate weight bearing, early rehabilitation and mini-
technique.
mises patient morbidity.
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
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DAVID BIAU
Patrick Allison
Dr Biau graduated in Montpellier in 2000. During medical
school he became interested
in biostatistics and obtained
a Master I in biostatistics. He
then went to Paris for his residency training in orthopaedic
surgery. During his residency
he obtained a Master II in biostatistics and clinical epidemiology and started working
on his PhD. He finished his residency training in 2007
and did 2 years of post-residency where he developed
a specific interest in musculoskeletal oncology. However, due to an expected shortage of units of blood available in France he decided to go Mount Sinai to learn
how to operate on tumors in a proper fashion. He obtained his PhD in biostatistics and clinical epidemiology
in March of this year and next year he will start another
fellowship in joint replacement in Vancouver. His wife is
currently probably somewhere but he has statistically
very little chance of finding her!
Patrick attended Queen’s University, the University of Ottawa
and McGill University for his undergraduate, medical and post
graduate medical training before finally arriving at the University of Toronto for a fellowship
in orthopedic trauma and lower
extremity reconstruction at the
Sunnybrook campus. He is originally from Thunder Bay
and will be returning to Northern Ontario after accepting a position in Sudbury in affiliation with the Northern
Ontario School of Medicine. At that time, he plans to
do research on the finer points of the mullet and how it
correlates to the size of 4x4 truck tires.
Comparison of 2.7 mm cortical screw fixation
versus 4.0 cancellous screw fixation of medial
malleolar fractures in a cadaveric model.
The classic fixation of medial malleolar ankle fractures is
performed with two 4.0 mm by 40 mm cancellous, partially
Monitoring surgical performance: an application
to open biopsies for bone and soft tissue lesions
threaded, small fragment screws inserted from distal to proximal through the distal portion of the medial malleolus into the
cancellous bone of the tibial plafond. The advent of smaller
Purpose: To monitor the quality of open biopsies for bone
diameter screws for fracture fixation allows the treating sur-
and soft tissue lesions.
geon to select these implants when deemed necessary in
Methods: Biopsies are considered as failure if another bi-
patient care. This study proposes to test the biomechanical
opsy is necessary or if inadequate treatment is given based
strength using donated anonymous cadaveric tissue in axial
on the results of the biopsy. A CUSUM test is used to monitor
compression to failure of these two fixation constructs in a
surgical performance.
classic medial malleolar fracture model.
Results: To date, 12 biopsies have been monitored (70
expected by June) and one is a failure. The CUSUM test has
not emitted an alarm and performance is considered as adequate.
Conclusion: Monitoring surgical performance is useful in
ensuring that adequate care is provided to patients and is
applicable to open biopsies.
Authors: David J Biau, Rej Bhumbra, Kurt Weiss, Benjamin Deheshi, Peter Ferguson, Jay Wunder: Musculoskeletal
oncology – Mount Sinai Hospital
16
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
FACULTY SPEAKERS
Markku Nousiainen
Dr. Markku Nousiainen is an Assistant Professor in the
Department of Surgery at the University of Toronto. He
completed his residency training in orthopaedic surgery
at the University of Toronto, graduating in 2005. He
completed a Master of Education degree at the Ontario
Institute of Studies in Education, University of Toronto,
specializing in Health Professions Education in 2008.
Dr. Nousiainen’s clinical interests lie in adult trauma
(pelvic, acetabular, periarticular fractures) and reconstruction (primary and revision total hip and knee arthroplasty). His research interests involve training policy
in fellowship-level education and in surgical skills education (particularly involving computer navigation) at the
novice and expert levels.
Following his Orthopaedic training, Dr. Ferguson completed fellowships in Orthopaedic Oncology at Mount
Sinai Hospital in Toronto and the Royal Orthopaedic
Hospital in Birmingham, England. He was then appointed to active staff at Mount Sinai Hospital and Princess Margaret Hospital. He is currently an Assistant
Professor in the Department of Surgery at the University of Toronto and Adjunct Professor at the University of
Western Ontario. His other appointments include Associate Program Director of the Orthopaedic Surgery
training program at the University of Toronto, Director
of the Competency Based Curriculum stream in Orthopaedic Surgery, member of the Sarcoma Executive
Committee of the National Cancer Institute of Canada,
Sarcoma Site Group Leader at Princess Margaret Hospital and President of the Canadian Orthopaedic Oncology Society.
William Kraemer
Dr. William Kraemer is an Assistant Professor in the
Department of Surgery. He graduated from the University of Toronto Orthopaedic Training Program in 1995.
Following a general orthopaedics fellowship at Toronto
East General Hospital and spine fellowship at Sunnybrook Hospital, he joined the Orthopaedic division at
Toronto East General in 1996. He has been involved
in resident education since then, and became the site
supervisor for resident education in 2001.
David Latter
Specialty
Adult Cardiac Surgery with a special interest in mitral
valve surgery
Background
• Queen’s University (B.A. 1978)
• McGill University (M.D., C.M. 1982)
In 2006 Dr. Kraemer became the Program Director for the
orthopaedic residency program. In 2008 he was promoted to Assistant Professor in the Department of Surgery.
• McGill University Cardiovascular and Thoracic
Surgery Residency (1987-1989)
Peter Ferguson
• Royal Victoria Hospital Attending Cardiac Surgeon
(1991-1996)
Dr. Peter Ferguson received a Bachelor of Science
degree from the University of Western Ontario before
attending medical school at the University of Toronto.
After receiving his Doctor of Medicine (9T4) degree, he
entered the Orthopaedic Surgery residency program
at the University of Toronto. During this training, he received a concurrent Master of Science degree from the
Institute of Medical Science.
• Stanford University Transplant Fellowship (19891990)
• McGill University Assistant Professor (1991-1995)
• McGill University Associate Professor (1995-1996)
• St. Michael’s Hospital Attending Cardiac Surgeon
(1996-present)
• University of Toronto Associate Professor
(1996-present)
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
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• Chairman, Cardiac Surgery Examination Board,
Royal College of Physicians and Surgeons of
Canada (2001-2004)
• Program Director, Cardiac Surgery Residency
Program, University of Toronto (2003-2009)
• Director Clinical Fellowship, Dept of Surgery,
University of Toronto, 2006-present
• Vice-Chief of Surgery, St. Michael’s Hospital,
2007-present
• Vice Chair of Education, Dept of Surgery,
University of Toronto, 2008- present
• Acting/Interim Chair, Dept of Surgery, University of
Toronto, May 2010- present
Jeremy Hall
Dr. Jeremy Hall joined the Division of Orthopaedics
at St. Michael’s Hospital as an Associate SurgeonInvestigator in July 2005 and subsequently, as an
Assistant Professor in Orthopaedic Surgery in 2008.
Dr. Hall completed his medical school and residency
training in Orthopaedic Surgery at the University of
Toronto. This was followed by a Fellowship in Upper Extremity Reconstruction, Trauma and Ilizarov
Reconstruction at St. Michael’s Hospital, under Dr.
Michael McKee. During his years as an associate, he
completed his Masters in Education at the Ontario Institute for Studies in Education/University of Toronto.
Dr. Hall is a trauma team leader at St. Michael’s Hospital. Dr. Hall has clinical interests in upper extremity
reconstruction, complex fracture care and post-traumatic fracture reconstruction. His research interests
include fracture care, inter-professional education
and collaboration and medical education policy. Dr.
Hall has been involved in the development of the first
year of the University of Toronto Orthopaedic Residency Competency Based Curriculum.
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Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
Inaugural Division of Orthopaedic Surgery City-Wide University of Toronto Fellowship Day
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