UOttawaOrtho



DIVISION OF ORTHOPEDIC SURGERY

UNIVERSITY OF OTTAWA

H. K. UHTHOFF ANNUAL RESEARCH DAY

THURSDAY, APRIL 26, 2012

THE OTTAWA HOSPITAL – GENERAL CAMPUS

MAIN AUDITORIUM

VISITING PROFESSOR

Dr. Yoga Raja Rampersaud, MD FRCSC

Associate Professor, Department of Surgery, University of Toronto

Divisions of Orthopedic Surgery and Neurosurgery,

University Health Network

Medical Director, Back and Neck Specialty Program, Altum Health

Immediate Past President Canadian Spine Society

We are pleased to welcome Yoga Raja Rampersaud, MD, FRCSC,

as the 2012 H. K. Uhthoff Visiting Professor

South America-born Dr. Rampersaud graduated in 1992 with his honours Medical Degree from the University of Western Ontario (UWO) in London, Ontario and completed Orthopedic specialty training at UWO in 1997. Two fellowships followed – in Orthopedic Spine Surgery at UWO in 1997 and in Neurosurgical Spine Surgery in 1998 at University of Tennessee, Memphis.

Currently an Associate Professor in Surgery at University of Toronto, Dr. Rampersaud joined University Health Network’s Division of Orthopedic Surgery and Neurosurgery as a consultant in 1999. Dr. Rampersaud is the immediate past president of the Canadian Spine Society. His academic interests are in minimally invasive spine surgery, surgical safety and outcomes from a health services perspective.

RESIDENT RESEARCH REQUIREMENTS

THE DIVISION OF ORTHOPEDIC SURGERY

UNIVERSITY OF OTTAWA

1. All residents must participate in a minimum of two research projects during their residency.

2. Research plan and protocol is presented to the Research Visiting Professor in November.

3. Preliminary results are presented to the Division of Orthopedic Surgery Research Committee in early April.

4. The final paper is presented at the H.K. Uhthoff Research Day in April.

5. Papers are chosen for submission to Collins Day in May.

6. Two completed manuscripts must be written in style of the Journal of Bone and Joint Surgery and submitted to the Chairman of the Resident Research Committee, one by the end of the PGY-3 year and one by the end of the PGY-4 year.

RESIDENTS/FELLOWS

DIVISION OF ORTHOPEDIC SURGERY

2011 - 2012

PGY-5 PGY-2

Dr. Parham Daneshvar Dr. Gillian Bayley

Dr. Luke Gauthier Dr. Kelly Hynes

Dr. Krista Goulding Dr. Matthew MacEwan

Dr. Gregory Hansen Dr. Ian MacNiven

Dr. Maher Khan Dr. Travis Marion

Dr. William Weiss Dr. Scott McGuffin

PGY-4 PGY-1

Dr. Derek Butterwick Dr. Christopher Dowding

Dr. Sasha Carsen Dr. Heathcliff D’Sa

Dr. Michael Creech Dr. Adrian Huang

Dr. William Desloges Dr. Brian Le

Dr. Markian Pahuta Dr. Andrew Tice

Dr. Marc Prud’homme-Foster Dr. Kristi Wood

Dr. Nathan Sacevich

PGY-3 FELLOWS

Dr. Natasha Holder Dr. Francesco Blumetti

Dr. Bradley Meulenkamp Dr. Vikram Chatrath

Dr. Marie-France Rancourt Dr. Emmanuel Illical

Dr. Cai Wadden Dr. Milton Parai

Dr. Geoffrey Wilkin Dr. Hani Zamil

DIVISION OF ORTHOPEDIC SURGERY

RESIDENCY TRAINING COMMITTEE

2011 – 2012

CHAIRMAN

Dr. Joel Werier

MEMBERS

Dr. Ben Bessette

Dr. Wade Gofton

Dr. James Jarvis

Dr. Ken Kontio

Dr. Karl-André Lalonde

Dr. Louis Lawton

Dr. Allan Liew

Dr. Peter Thurston

RESIDENT REPRESENTATIVES

Dr. Parham Daneshvar

Dr. Geoffrey Wilkin

DIRECTOR OF RESEARCH

Dr. Peter Lapner

ACKNOWLEDGEMENTS

The Division of Orthopedic Surgery greatly acknowledges the support of the

H. K. Uhthoff Research Day by the following companies:

Baxter Corporation

Bayer Inc.

Biomet Canada

Bristol-Myers Squibb Canada

ConMed Linvatec

Convatec

KCI Medical Canada Inc.

Kinemedics

Medtronic of Canada Ltd.

Stryker Canada

Synthes Canada

Tribe Medical Group

Wright Medical (Mr. Trevor Fisher)

PROGRAM

0800 Opening Remarks

Dr. Joel Werier, Director of the Orthopedic Surgery Residency Training Program, University of Ottawa

0805 Welcome/Introduction of Dr. Rampersaud

Dr. Eugene K. Wai, Department of Orthopedic Surgery, University of Ottawa

0810 Comparative Effectiveness of the Surgical Management of Focal Spinal Stenosis Compared to Hip and Knee Osteoarthritis

Dr. Yoga Raja Rampersaud, Visiting Professor

0830 Discussion

SESSION I

MODERATOR: Dr. Wade Gofton

0840 1. Quantitative CT and MRI Changes in Arthritic and Prearthritic Hips

Andrew Speirs, Graduate Student, University of Ottawa

0848 Discussion

0852 2. Can the Alpha Angle Assessment of Cam Impingement Predict Acetabular Cartilage

Delamination?

Dr. Kelly Hynes, PGY-2

0900 Discussion

0904 3. A Randomized Controlled Trial of a Cemented vs. Cementless Femoral Component for

Metal-on-Metal Hip Resurfacing: A Bone Mineral Density Study

Dr. Andrew Tice, PGY-1

0912 Discussion

0916 4. Stress Distributions in the Hip Before and After Corrective FAI Surgery

K.C. Geoffrey Ng, Graduate Student, Department of Mechanical Engineering, University

of Ottawa

0924 Discussion

0928 5. Open Reduction and Internal Fixation of Pilon Fractures: Violating the 7 cm Skin Bridge

Rule

Dr. Geoffrey Wilkin, PGY-3

0936 Discussion

0940 6. Vacuum Assisted Closure (V.A.C.TM) Effects on Skeletal Muscle After Compartment

Syndrome in an Animal Model

Dr. Geoffrey Wilkin, PGY-3

0948 Discussion

Refreshment Break and Exhibits, Royal Room

SESSION II

MODERATOR: Dr. Karl-André Lalonde

1041 7. Arthroscopic Acetabular Labral Debridement in Patients Aged >45 Years has Minimal

Clinical Benefit

Dr. Geoffrey Wilkin, PGY-3

1049 Discussion

1053 8. The Ottawa Experience Using a Modular Neck System for Primary Total Hip

Arthroplasty

Dr. Emmanuel Illical, Clinical Fellow

1061 Discussion

1105 9. Radiographic Outcomes of Closed Diaphyseal Femur Fractures Treated with the SIGN

Nail

Dr. Sasha Carsen, PGY-4

1113 Discussion

1117 10. Outcome Comparison of Revised Hip Resurfacing with Primary and Revised Total Hip

Arthroplasties

Dr. William Desloges, PGY-4

1125 Discussion

1129 11. Ulnar Placement of the Distal Biceps Tendon During Repair Improves Supination

Strength: A Biomechanical Analysis

Dr. Marc Prud’homme-Foster, PGY-4

1137 Discussion

1141 12. Comparing the Extensor Digitorum Communis Splitting Approach to the Posterolateral

Kocher Approach: A Novel Method of Measuring Articular Surface Area

Dr. William Desloges, PGY-4

1149 Discussion

1153 13. Lesser Tuberosity Osteotomy versus Subscapularis Tendon Peel: Differences in Healing

Rates and Fatty Infiltration.

Dr. Milton Parai, Clinical Fellow

1201 Discussion

Lunch and Exhibits, Royal Room

SESSION III

MODERATOR: Dr. J Pollock

1315 In Experimental Surgery Is The Use of the Contralateral Limb for Comparison

Acceptable?

Dr. Hans K. Uhthoff

1323 Discussion

1327 Systematic approach to Orthopedic Surgical Adverse Events (OrthoSAVES): A

Health Services Perspective

Dr. Yoga Raja Rampersaud, Visiting Professor

1347 Discussion

1357 14. Early High Failure Rate of Large Head Metal-on-Metal Total Hip Replacement

  Dr. Vikram Chatrath, Clinical Fellow

1405 Discussion

1409 15. Percutaneously Assisted Total Hip (PATH) Arthroplasty: Learning Curve and Early

Results in a Canadian Centre

Dr. Cai Wadden, PGY-3

1417 Discussion

1421 16. Does Weight-bearing Status Following Surgery for Hip Fracture Affect Outcomes?

Dr. Cai Wadden, PGY-3

1429 Discussion

1433 17. Effects of Autogenous Hamstring Tendon Harvesting for Anterior Cruciate Ligament

Reconstruction on Hamstring Strength at Deeper Knee Flexion Angles. Does Single

Versus Double Tendon Sacrifice Affect Hamstring Strength?

Dr. Parham Daneshvar, PGY-4

1441 Discussion

Refreshment Break, Royal Room

SESSION IV

MODERATOR: Dr. Stephen Kingwell

1500 18. Quantifying Acetabular Overcoverage

Dr. Nathan Sacevich, PGY-4

1508 Discussion

1512 19. Tibial Nail Distal Positioning: A Radiographic Study

Dr. Travis Marion, PGY-2

1520 Discussion

1524 20. Normal Anatomy of the Distal Radio-Ulnar Joint Anatomy - A Bayesian Analysis of

1,000 Wrists

Dr. Markian Pahuta, PGY-4

1532 Discussion

1536 21. Patella Tendon Insertion Failure: Evaluation of a Reconstructive Technique

Dr. Hani Zamil, Clinical Fellow

1544 Discussion

1548 22. Stimulation of Macrophages by Chromium (III) Ions Induces an Increase of TRAP

Expression In Vitro

Stephen Baskey, M.A.Sc. Student, Department of Mechanical Engineering, University of

Ottawa

1556 Discussion

1600 23. Level and Upslope Walking After TKA: Biomechanical Implications for the Non-

Operated Knee

Sarah Reynolds, Graduate Student, University of Ottawa

1608 Discussion

1612 Closing Remarks

Dr. Peter Lapner, Director of Research, Division of Orthopedic Surgery, University of

Ottawa

ABSTRACTS

1. QUANTITATIVE CT AND MRI CHANGES IN ARTHRITIC AND PREARTHRITIC

HIPS

Andrew Speirs MASc, Arturo Cardenas-Blanco PhD, Kawan Rakhra MD, Mark Schweitzer MD,

Paul Beaulé MD, Hanspeter Frei PhD

Background

Arthritic degeneration of articular joints involves complex biochemical changes in the cartilage tissue and frequently also involves changes in subchondral bone density, evident as subchondral sclerosis. Femoroacetabular impingement (FAI) results from a morphological deformity of the hip and has been associated with osteoarthritis.

Purpose

To examine differences in subchondral bone and cartilage in FAI and control subjects using quantitative CT and T1ρ magnetic resonance imaging.

Materials and Methods

Prior to surgery, patients undergoing surgical correction of a cam-type FAI deformity as well as asymptomatic subjects underwent quantitative CT scans including a calibration phantom. Asymptomatic subjects were classified as normal controls or asymptomatic with deformity based on the alpha angle. Subjects also underwent T1ρ MRI to determine proteoglycan content. The contralateral hip of surgical patients was also analysed. Bone mineral density was measured in four equal wedges of the superior acetabulum to a depth of 10 mm from the bone surface. The density was normalized by bone density in lumbar vertebra L5 to account for general bone density variation between subjects. T1ρ values were calculated for analogous regions on oblique sagittal MRI slices. Differences between groups were tested using ANOVA and CT and MRI compared using linear regression.

Results

Bone density was significantly higher in all groups compared to controls (p45 YEARS HAS MINIMAL CLINICAL BENEFIT

Geoffrey Wilkin1, Gerard March, Paul E. Beaulé1

1Division of Orthopedic Surgery, University of Ottawa

Purpose

The practice of hip arthroscopy is increasing and labral tears are a common indication. Previous reports have suggested advanced age may be associated with poor outcomes after arthroscopic debridement. Our purpose was to quantify the post-operative functional outcomes in older patients (age >45y). We hypothesized that this group would derive minimal clinical benefit and would have a higher re-operation rate than younger patients.

Methods

Forty (40) patients age >45 years who had arthroscopic labral debridement were included. Prospectively collected pre- and post-operative WOMAC, SF-12, and Harris Hip Scores (HHS) were retrospectively analyzed. Post-hoc univariate logistic regression analysis was performed to identify factors associated with a positive clinical response.

Results

Re-operation rate was 18.4%. WOMAC and HHS scores were significantly improved post-operatively. The overall magnitude of response was small and was less than the minimal clinically important difference for the WOMAC score. Only 6 patients (15%) had a good/excellent outcome based on HHS. There was a bimodal distribution in the magnitude of clinical response. Age was positively associated with improvements in WOMAC Stiffness score, and pre-operative HHS was negatively associated with improvement in post-operative HHS.

Conclusions

Arthroscopic labral debridement in patients aged >45 years is associated with a high re-operation rate and minimal overall functional improvement. However, some patients do derive benefit. The factors associated with positive clinical response are unclear. Arthroscopic debridement of labral tears in this patient population must be approached with caution as the clinical benefit is unpredictable.

8. THE OTTAWA EXPERIENCE USING A MODULAR NECK SYSTEM FOR

PRIMARY TOTAL HIP ARTHROPLASTY

Illical E, Beaulé P, Feibel R, Thurston P, Kim P, Gofton W

Introduction

Modular neck systems for total hip arthoplasty offer the ability to alter femoral version, offset, and leg length independently from the femoral stem that has been inserted. However, concerns have been raised about neck fracture as well as corrosion at the modular head-neck interface. The purpose of this study was to describe the experience of using a modular neck system at our institution and to report any potential complications.

Methods

Between January 2006 and June 2011, 580 primary total hip arthroplasties were performed at our center using either a flat tapered wedge geometry femoral stem or rectangular tapered stem with a titanium modular neck option (Profemur TL and Z) by five different surgeons with 3 surgical approaches: posterior, anterior, or lateral. Implant details were recorded in a database at the time of surgery and the patients are being prospectively followed for any complications associated with the modular femoral neck.

Results

The patient demographics were as follows: mean age 61.5 +/- 12 years; mean height 168 +/- 12 cm; mean weight 81 +/- 19 kg; 318 females (55%) and 262 males (45%). Distribution of the modular femoral necks used are shown in Figure 1.

[pic]

A neutral neck was used in only 18.6% of cases (106/580). The most common neck used was the varus/valgus accounting for 56.9% of cases (330/580). The anteverted/retroverted options accounted for 12.9% of cases (77/580). The anteverted/retroverted and varus/valgus option accounting for 11.2% of cases (65/580). Ninety two percent (533/580) of necks implanted were short with 57% (302/533) being female. Only 8% (47/580) of necks were long with 66% (31/47) being males. There were no complications associated with the modular femoral neck at the latest follow up for all patients.

Conclusion

A significant number of patients benefitted from the modular necks in optimizing their biomechanical reconstruction. Unlike previous reports, at mid-term follow-up there were no complications associated with the modular femoral neck in our series with only 8% of patients requiring the long neck options. Further long term follow-up is required to determine if other failure modes will occur.

9. RADIOGRAPHIC OUTCOMES OF CLOSED DIAPHYSEAL FEMUR FRACTURES

TREATED WITH THE SIGN NAIL

Carsen S; Park S; Simon D; Feibel RJ

Purpose

The burden of orthopedic trauma in the developing world is very significant in both health and economic terms. The Surgical Implant Generation Network (SIGN) provides universal femoral/tibial intramedullary nails and instruments on a donated basis to surgeons in resource-limited settings. Replacement nails are provided once pre-operative and post-operative radiographs are uploaded to the SIGN database for critique by SIGN surgeon-educators. Despite the clinical success of the SIGN Nail, with more than 50,000 surgeries performed, there has been very little research examining outcomes. The primary purpose of this study was to examine the post-operative radiographs of closed diaphyseal femur fractures treated with the SIGN Nail to assess for alignment as a measure of quality. The secondary goal was to assess the functionality and robustness of data in the SIGN database.

Methods

A retrospective review was undertaken of patients treated with the standard SIGN Nail, which at the time of the study totaled 32,362 patients. Further inclusion criteria included the treatment of a diaphyseal femur fracture. Exclusion criteria included open fractures and those cases without post-operative radiographs. A random number generator was used to select 500 cases for analysis. Location of the fracture within the diaphysis; fracture classification (AO/OTA classification); degree of fragmentation (Winquist classification); and patient demographics were recorded. Measurements of alignment were made based on the Antero-Posterior and Lateral radiographs, with mal-alignment defined conservatively as deformity in either the sagittal or coronal plane greater than 5 degrees. Measurements were made manually using on-screen protractor software (Screen Protractor, by Iconico, Inc.), and intra- and inter-observer reliability assessed. The quality of radiographs for each surgical case was graded based on adequacy for visualization of the fracture and the femur, and the ability to measure alignment in orthogonal planes.

Results

The incidence of malalignment on post-operative radiographs was found to be 10.0%, with malalignment defined as deformity in either the sagittal or coronal plane of greater than 5 degrees or 1.6% for a deformity of greater than 10 degrees. Ninety-two percent of reviewed radiographs were of acceptable or good quality. The degree of fragmentation was found to be an independent predictor of angulation and malalignment.

Conclusion

The incidence of malalignment in femoral fractures treated with the SIGN intramedullary nail closely approximated the incidence previously reported in the literature for a Level 1 North American trauma centre. This is an encouraging finding and provides support for the continued and expanded use of SIGN implants throughout the developing world. In addition, the SIGN database was found to be a satisfactory resource for the purpose of retrospective research.

10. OUTCOME COMPARISON OF REVISED HIP RESURFACING WITH PRIMARY

AND REVISED TOTAL HIP ARTHROPLASTIES

William Desloges MD, Isabelle Catelas PhD, Toru Nishiwaki MD, Kyle A. Kemp MSc,

Paul R. Kim MD, FRCSC, Paul E. Beaulé MD, FRCSC

Background

A clinical advantage of hip resurfacing (HR) is the preservation of femoral bone,

facilitating revision surgery when indicated.

Questions/Purposes

To determine if patients: 1) undergoing HR revision have comparable

outcomes to patients undergoing primary THA or revision of primary THA; 2) undergoing

revision of both the femoral and acetabular HR components have different outcomes than those

undergoing isolated femoral component revision.

Patients and Methods

Twenty-two HR patients who underwent HR revision to a THA were

retrospectively reviewed and compared to 23 matched (age, gender, BMI) patients undergoing

primary THA and 12 patients undergoing revision of primary THA. Patients completed the

WOMAC and SF-12 questionnaires prior to surgery and at latest follow-up. Blood loss, days in

hospital, complications, and outcome scores were compared between groups.

Results

The HR revision group had greater intraoperative blood loss compared to the primary

THA group (p= 0.002), but not the THA revision group. At follow-up, no differences in SF-12

scores were present, but higher WOMAC stiffness (p=0.014), function (p=0.016) and total

(p=0.033) scores were observed in the HR revision group, compared to primary THA. HR

patients undergoing revision of both components compared to femoral side only had comparable

SF-12, WOMAC stiffness, function, and total scores but overall higher WOMAC pain scores

(p=0.050).

Conclusion

Our results indicate the outcomes of HR revision are comparable to THA revision,

but not primary THA. Longer follow-up is required to determine if these differences persist.

Finally, HR patients undergoing revision of one or both components can expect similar

outcomes.

11. ULNAR PLACEMENT OF THE DISTAL BICEPS TENDON DURING REPAIR

IMPROVES SUPINATION STRENGTH – A BIOMECHANICAL ANALYSIS

M Prud’homme-Foster, J Pollock, H Louati, S Papp

Department of Orthopedics, University of Ottawa

Purpose

Repair of distal biceps tendon rupture requires re-establishing its insertion site on the radial tuberosity. Based on anatomical studies it has been suggested that the heads should be inserted on the ulnar aspect of the footprint. This study examines the effect of the repair site on forearm supination strength, and provides biomechanical evidence for ideal insertion placement, which has not previously been studied.

Method

Twelve fresh-frozen cadaveric arms were secured using an in vitro elbow simulator and a two- head repair was performed in ulnar and radial locations on the radial tuberosity. Isometric supination torque and elbow flexion force were recorded with the forearm in 45 degrees supination, neutral rotation and 45 degrees pronation.

Results

In all specimens elbow flexion strength was not affected by - biceps repair in the ulnar or radial configuration on the tuberosity. Forearm supination was significantly stronger with a more ulnar insertion placement on the tuberosity. While the difference in was less pronounced in pronation, radial placement resulted in a mean drop of 78% (p ................
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