Total Hip Replacement: Relieving Pain and Restoring Function Bradley Ashman, MD, David Cruikshank, MD, Michael Moran, FRCSC

Home , Paul Dooley

Is lesion location random, November 2016; 58: 9 and does it matter? Pages 489–540 The scoop on supplements for disease prevention BC doctors reduce unnecessary antibiotic use Achilles tendon ruptures Billing tips: Telephone fees Division-created patient resources Fake joints, Proust: Dr Vishal Varshney real results Part 1: Hip and knee replacement

bcmj.org

November 2016 Volume 58 • Number 9 Pages 489–540 contents

A R T I C L E S

THEME ISSUE: FAKE JOINTS, REAL RESULTS, PART 1

504 Guest editorial: Hip and knee replacement Established 1959 Bas Masri, MD

505 Total hip replacement: Relieving pain and restoring function Bradley Ashman, MD, David Cruikshank, MD, Michael Moran, FRCSC

514 Total knee replacement: Understanding patient-related factors Paul Dooley, MD, Charles Secretan, MD

O P I N I O N S On the cover: In this first of a two-part theme issue Editorials on joint replacement, we 494 consider the most common Apply healing paint daily, David R. Richardson, MD (494) joint replacement surger- Quest for Superdoc, Jeevyn K. Chahal, MD (495) ies: hip and knee replacement. Dr Masri’s guest editorial begins these articles President’s Comment on page 504. 497 The value of social media to you and the profession Alan Ruddiman, MBBCh, Dip PEMP, FRRMS

498 Personal View Expectation of fairness, Michael A. Ross, FRCSC Pharmacy prescribing and renewal system, Jack Boxer, MD 538 Back Page Proust Questionnaire: Vishal Varshney, MD

ECO-AUDIT: D E P A R T M E N T S Environmental benefits of using recycled paper Using recycled paper made with post- consumer waste and bleached without the use Premise of chlorine or chlorine compounds results in 499 measurable environmental benefits. We are Is lesion location random, and does it really matter? pleased to report the following savings. • 1399 pounds of post-consumer waste used Margo S. Clarke, MD instead of virgin fibre saves: • 8 trees • 760 pounds of solid waste BC Centre for Disease Control • 837 gallons of water 501 • 1091 kilowatt hours of electricity (equivalent: BC physicians reduce unnecessary antibiotic use—and costs 1.4 months of electric power required by the average home) David M. Patrick, MD, Laura Dale, Mark McCabe, MPH, Bin Zhao, MSc, • 1382 pounds of greenhouse gases (equivalent: Mei Chong, MSc, Edith Blondel-Hill, MD, Fawziah Marra, PharmD 1119 miles traveled in the average car) • 6 pounds of HAPs, VOCs, and AOX combined • 2 cubic yards of landfill space Environmental impact estimates were made Council on Health Promotion using the Environmental Paper Network Paper 502 Calculator Version 3.2. For more information visit The scoop on supplements for disease prevention www.papercalculator.org. Ilona Hale, MD, Kathleen Cadenhead, MD, Mary Hinchliffe, MD

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 491 #115–1665 West Broadway, Vancouver, BC, Canada V6J 5A4 Tel: 604 638-2815 or 604 638-2858 Fax: 604 638-2917 contents E-mail: [email protected] Web: www.bcmj.org

D E P A R T M E N T S ( Continued) 520 WorkSafeBC Achilles tendon ruptures—a review for primary care Derek Smith, MD

editor 522 Pulsimeter David R. Richardson, MD New procedures for CL19 medical reports (522); Congratulations editorial board from the BCMJ (522); Planning your family: The insurance Jeevyn Chahal, MD Ada Lo (522); (523); David B. Chapman, MBChB essentials, Practice support: 1300 docs Anne I. Clarke, MD Physicians honored with Above & Beyond Awards (523); Resource Brian Day, MB for treating obese or overweight child patients (523); Study: COPD Timothy C. Rowe, MB (523); Cynthia Verchere, MD epidemic looms New weapon for hard-to-treat bacterial Willem R. Vroom, MD infections (524); Uncovering cancer’s invisibility cloak (524) managing editor Jay Draper 525 Billing Tips senior editorial and Telephone fees: SSC fee items 10001, 10002, 10003, and 10004 production coordinator Kashmira Suraliwalla Keith J. White, MD

associate editor Joanne Jablkowski 526 In Memoriam copy editor Dr Eugene Giuseppe Caira, Nadia Caira (526) Barbara Tomlin Dr Sheldon C. (Shelly) Naiman, Gershon Growe, MD, The Naiman proofreader family (526) Ruth Wilson Dr Charles Edward (Ted) Reeve, Charles Reeve, Jr., PhD (527) design and production Scout Creative General Practice Services Committee COVER CONCEPT 528 & ART DIRECTION Division-created patient resources: Empowering patients to make Jerry Wong Peaceful Warrior Arts healthy choices Afsaneh Moradi printing Mitchell Press advertising 530 Calendar Kashmira Suraliwalla 604 638-2815 [email protected] 533 Classifieds

ISSN: 0007-0556 536 Advertiser Index 539 Club MD

Advertisements and enclosures carry no endorsement of Doctors of BC or BCMJ. © British Columbia Medical Journal, 2016. All rights reserved. No part of this journal may be re- Subscriptions produced, stored in a retrieval system, or transmitted in any form or by any other means—electronic, Single issue...... $8.00 mechanical, photocopying, recording, or otherwise—without prior permission in writing from the Canada per year...... $60.00 British Columbia Medical Journal. To seek permission to use BCMJ material in any form for any Foreign (surface mail)...... $75.00 purpose, send an e-mail to [email protected] or call 604 638-2815. The BCMJ is published 10 times per year by Doctors of BC as a vehicle for continuing medical Postage paid at Vancouver, BC. Canadian Publications Mail, Product Sales Agreement #40841036. education and a forum for association news and members’ opinions. The BCMJ is distributed by Return undeliverable copies to BC Medical Journal, 115-1665 West Broadway, Vancouver, BC V6J second-class mail in the second week of each month except January and August. 5A4; tel: 604 638-2815; e-mail: [email protected] Prospective authors should consult the “Guidelines for Authors,” which appears regularly in the Journal, is available at our website at www.bcmj.org, or can be obtained from the BCMJ office. Statements and opinions expressed in the BCMJ reflect the opinions of the authors and not necessarily those of Doctors of BC or the institutions they may be assoicated with. Doctors of BC does not assume responsibility or liability for damages arising from errors or omissions, or from the use of information or advice contained in the BCMJ. The BCMJ reserves the right to refuse advertising.

492 bc medical journal vol. 58 no. 9, november 2016 bcmj.org bc medical journal vol. 58 no. 9, november 2016 bcmj.org 493 editorials

Apply healing paint daily “ ake the coast road. It’s in way ing as it passed each vehicle in a long my bicycle. I remember one patient better condition and much nic- line behind some poor scared tourist stating the obvious: “Dr Richardson, Ter to drive.” a few cars ahead. There was even a have you ever considered that maybe This was the e-mail advice I re- grandma in the passenger seat gestur- you aren’t very good at this bike rid- ceived from the nice woman at the ing as only an Italian can. I’m pretty ing thing?” This is probably why I’ve hotel in Amalfi, Italy, in response to sure she wasn’t mouthing “Welcome never had the urge to get a tattoo— my query as to the best method of ar- to the coast.” I’ve been doing a pretty good job of rival by car. After spending a week that on my own. And physical scars in Tuscany and then another 10 days are one thing, but emotional scars on a bike tour across Italy, the Amalfi Like the Amalfi car, run deeper. As physicians, we often coast seemed like a perfect ending to I now have numerous deal with our patients’ mental dents. a fairytale trip. So on a beautiful Mon- scars. A privilege of general practice is that day morning we headed out on our as the physician-patient relation- 5-hour drive from southern Tuscany. ship grows through the years patients Apart from the numerous tolls and As you can deduce from the fact let down their guard and share their high-performance vehicles traveling that I penned this editorial after my stories. We are trusted with tales of around 200 km/hr on the autostrade, encounters, Grandma didn’t cause my childhood trauma, relationship fail- the trip was uneventful until I piloted death, and I sincerely hope her heaven- ure, addiction, loss, and more. It is in my little Fiat 500 onto road SS163. ly bubble wasn’t burst by a large, cor- these moments that heartfelt words of Two Fiat 500s might be able to pass nering, two-wheeling tour bus (prior support can mean so much to those one another on this ever-twisting, to my trip I wasn’t aware such a thing we care for. Therefore, I have made a walled avenue of death but not the was even possible). I did notice that commitment to acknowledge at least collection of buses, trucks, vans, peo- the walls that lined “S-cared S-… less one patient’s emotional dent each day ple, and bikes we encountered. How- 163” have numerous gouges. I also and, if possible, to apply a little heal- ever, none of the local drivers seemed noticed that the typical Amalfi vehicle ing paint. to be aware of the physical principles has dents on all four sides. I wonder how much Limoncello of space and time, and drove as if God This got me thinking about how and gelato I would have had to con- himself had blessed them with a pro- we all develop scratches along the sume to calm my nerves had I driven tective bubble. The icing on the cake way. In my 50s I have to admit that, the much more dangerous mountain was when I looked to my left to see an like the Amalfi car, I now have numer- road. even smaller Fiat honking and weav- ous scars, most of them from crashing —DRR

494 bc medical journal vol. 58 no. 9, november 2016 bcmj.org editorials

Quest for Superdoc

ock-a-doodle-doo! Sun rays So could it get any better? Could I you’re in the hospital. hit the room. Max the cat is be doing more as a family doc? Have So I am going to start visiting my Cin my face whining to be let I failed because I’m not a full-service inpatients once a week. I hope to pro- out. Baby’s foot is in my ear. Hubby is GP? I don’t do obstetrics and I have vide some emotional support to my snoring. It’s 5:30 a.m. Good morning! only associate privileges at the hospi- patients and any additional informa- Here I go—hit the bamboo floors tal. My dreams of being Superdoc … tion I can to the doc looking after running. First sip of tea does it. Ahhh! gone? them. Good morning world! Back in the day docs did 24-hour But should I feel guilty? I’ve only I owe, I owe, it’s off to work I go. call and in some places they still do. taken 2 weeks off this year. I have a Love going to work. Love my as- Times have changed. Expectations to solo family practice with no locums sistant, Connie, who seems to know have a fulfilling family life have tak- available. I drag around my faithful what I’m thinking at all times and is en precedence. But there are docs out computer, with my EMR, everywhere always one step ahead of me. Love there who still do it all. And kudos to I go, tasking every free moment I get. the patients who ask how my day is them. I do my own call and have my cell- going and how my daughter is do- I had to come to terms with the phone on me 24/7. I visit patients in ing (every one of them asks) and who fact that I can’t do it all. I’d love to, their own homes. I’ve adopted the share special tidbits of their lives. but there are not enough hours in open-access model for patient care at Love going to my family home the day to be Superdoc, Superwife, my clinic. with my husband and my daughter Supermom, Supersis, Superauntie, One day, when my daughter is in after work a few days each week to and Superfriend. school, I may return to hospital work. enjoy the most amazing Indian food There is a fleeting moment of I aspire to one day joining Doctors ever made. And to enjoy seeing the guilt when I discover that one of my Without Borders. whole family, but especially the two patients has been admitted to the hos- I’ve spent my whole life trying to people who got me to this point in life pital—the burden on the ER and on be Super Jeeves. But now I realize my and who continue to be my heroes— the hospitalists, my patient seeing happiness and self-contentment trans- my parents. different docs during their hospital lates into healthy relationships with Then I get to go home and spend stay when it’s already so stressful for my family, friends, and patients. Life time with my beautiful fur babies and them. I rationalize by thinking how is like riding a bicycle. You can coast, play in my garden and run around on great our hospitalists are and how brake, or go full speed ahead. But you the farm after the chickens. Occasion- my patient is receiving the best care. always need balance. ally I get to go for a 10 km run and But in my heart I know there is noth- —JKC throw around some weights. Hercules! ing like seeing your family doc while

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bc medical journal vol. 58 no. 9, november 2016 bcmj.org 495 BC MEDICAL JOURNAL CRUISE CONFERENCE

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CONFERENCE HIGHLIGHTS Clarke: Ofﬁ ce emergencies: What to do before ambulance arrives; That pill did what? Adverse drug reactions that wind up in ER Giles: Practical approach to the neurological history; Practical approach to the neurological exam; Multiple sclerosis: What’s new since medical school? Practical approach to the diagnosis & management of headache; Diagnosis and management of concussion; Cancer and the nervous system; Video session cases in neurology Hutchison: Permanent clinical impairment: How it works and the family physician role; Injured workers: Early return back to work Johnston: Nurse practitioners on the ICU: The role for physician extenders; Physical & psychological consequences of admission to the ICU Pavri: An approach to developmental delay; Skin rashes and spots; Dysmorphism; Behaviour problems with comorbid conditions Raffard: PCOS: The polycystic ovarian sisterhood, The egg and I: Advances in treatment for infertility; Sneeze before you squeeze: Management of female urinary incontinence; Why don’t I want to have sex: Female libido; From precocious puberty to premature ovarian failure; Care of the transgendered patient Richardson: Humour and compassion in medicine

FACULTY Drs Anne Clarke (emergency medicine), Kathryn Giles (neurology), Susan Hutchison (family medicine), Colin Johnston (family medicine), Daisy Pavri (perdiatrics), Skye Raffard (obstetrics and gynaecology), David Richardson (family medicine).

Book now for best stateroom selection and pricing [email protected] • 604 684 7327 496 bc medical journal vol. 58 no. 9, november 2016 bcmj.org 1 888 647 7327 • seacourses.com president’s comment

The value of social media to you and the profession

ow up to speed are you ers because, I imagine, they believe care system. It allows us to expand on Twitter, Facebook, Ins- the information I push out—brewing our breadth of connectivity, engage- H tagram, LinkedIn, or Snap- health system issues, good news or ment, and knowledge beyond the bor- chat? Would you know how to reach provocative media stories, or just ders of our offices, our specialties, @doctorsofbc or @awruddiman, or about anything else that relates to my our hospitals, even our communities. what to do with #ilovesocialmedia or role as Doctors of BC president, my And, in so doing, it enables doctors #physicianleadership? If you’re like rural professional life, or my life as a to position ourselves as a trusted and many people and professionals, these member of a vibrant rural BC commu- knowledgeable source, to fill in gaps social media terms may be familiar nity—is of value or interest to them. in information, to change how the yet applying them can be a little mind Increasingly more members of public and stakeholders view certain boggling. We’ve all heard the term the medical profession are embrac- issues, and to strengthen our profes- social media and generally speaking ing social media as a way to connect, sional voice. we know what it is, yet understanding engage, and influence. Whether it’s I recognize the hesitation some how to embrace and use it may be a to share helpful medical information, may have about being proactive on little daunting for some. I am active stay connected on a collegial level social media. Concerns over privacy on Twitter, but only picked it up as with family and friends, or network and confidentiality, or inadvertently a communication and information with colleagues and peers, it helps saying something that is incorrect or forum 2 years ago. build and foster two-way relation- offensive, are important consider- Research shows that more and ships. ations. However, there is no risk to more people, including professionals, And it’s not just individuals who simply following someone on social are relying on social media as their use social media. As an organization, media. In fact, there’s a great deal of primary source of communication Doctors of BC is very active on social value in seeing what’s being said by because it’s instant and in real time. media platforms such as Twitter and, those you admire or respect. And as You can reach a broad audience in one more recently, Facebook, often using long as you’re circumspect about the click, and you can just as efficiently them to communicate key positions content of what you post and you stick receive comprehensive responses on on important issues to the public, to the general rule of thinking twice a host of topics. stakeholders, media, and our mem- before you post, you will be fine. But what does social media have bers quickly, early, and often. Social media broadly reaches and to do with health care? Today, pro- At this year’s CMA General connects not only the profession, but fessional influence is increasingly Council Meeting, the hashtag #cmagc key partners and stakeholders, those derived through social media, pro- was tweeted on average 106 times per interested in our activities, and the viding a huge opportunity for physi- hour, and received over 68 million public. As physicians we have the cians and health care organizations impressions—or, in simpler terms, it opportunity to harness this tool and to use this communication channel to was seen and viewed over 68 million the online world to inform, to con- inform, to connect, and to influence. times. This allowed members who nect, and to influence. So have some My current social media tool of couldn’t attend, key stakeholders, fun and join the world of social me- choice is Twitter. I see it as an in- the public, and the media—everyone dia! And when you do, don’t forget to creasingly effective way to express who followed that hashtag—to stay “like” Doctors of BC’s new Facebook my thoughts, ideas, and opinions on connected and to keep abreast of each page, and I would appreciate the fol- what is occurring locally and globally turn of events at the CMA GC in real low on Twitter at @awruddiman. I’d and on what those interested in my time. be delighted to follow you back and thoughts (referred to as my follow- One of the greatest opportunities together we can broaden our profes- ers) might be interested in knowing. social media provides physicians is sional networks and reach. For instance, on Twitter I have 1774 the ability to leverage information— —Alan Ruddiman, MBBCh, Dip followers who range from physicians, to highlight individual professional PEMP, FRRMS stakeholders, government, media, activities and interests, to advocate Doctors of BC President friends, family, and, more broadly, for the profession, or to influence the public. I have acquired follow- behavior to the benefit of the health

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 497 personal view

Letters of less than 300 words are welcomed provided they do not contain material that has been submitted or published elsewhere; they may be edited for clarity and length. Letters may be e-mailed to [email protected], submitted online at bcmj.org/content/ contribute, or sent through the post and must include your mailing address, telephone number, and e-mail address.

Expectation of fairness that are now available) that come to for an Rx, when there might be sev- For most families in BC the dinner us in all shapes and sizes. I wonder eral versions of a given drug. hour of 6 p.m. and onward is a time how much pharmacies are billing us There would be no or many fewer for coming together to eat and enjoy to inundate us with a continuous bar- errors fulfilling scripts, especially for some relaxation after the work of the rage of faxes relating to our prescrib- patients discharged from hospitals. I day. For a family or individual to be ing practices. have often found discrepancies in the deprived of this expectation requires medications prescribed to a patient on some compensation. MSP is morally discharge by both hospitalist and spe- wrong in not compensating surgeons There would be cialist. I’ve had the same medication and their assistants for the loss of given but with different doses pre- no or many fewer errors this sweet time, disruption of meals, scribed by each doctor. A recent rul- and reduced family togetherness if fulfilling scripts, especially ing by the College of Pharmacists of an operation starts before 6 p.m. and for patients discharged BC requires that every patient’s meds continues to 11 p.m. Cynically, MSP from hospitals. be cancelled upon discharge and must pays at night rates for the few proce- be represcribed. Thus, to keep one’s dures that start before 8 a.m. and con- EMR happy, this might require many tinue into business hours. Such extra How much negotiating has Doc- scripts, especially for elderly patients payment is not indicated and makes tors of BC done on our behalf, push- with polypharmacy issues, to be further mockery of what is then incor- ing to establish Real Time Online manually represcribed and re-entered rectly called out-of-office hours pre- Prescription Fulfillment (RTOPF) each time they visit the hospital. This miums. from doctors anywhere—at special- is clerical work, not medicine, and a —Michael A. Ross, FRCSC ists’ offices, walk-in clinics, ERs, and very large time waster. Victoria regular offices? There would also be many few- Ideally in the RTOPF scenario, er interruptions to our day by phar- Pharmacy prescribing at the time of completion of the pre- macies’ faxes querying details of a and renewal system scription order, the dose, quantity, prescription being renewed by the It’s been 19 years since I last wrote a prescriber’s name and contact inpatient’s regular doctor with adjust- letter to the BCMJ, at which time I put formation, and location filled are all ments made outside the office other forth the Peter Finch quote from the transmitted to the EMR of the doc- than by the renewing doctor. And of movie Network, “I’m mad as hell and tors who need to know—mainly the course we must not forget the numer- I’m not going to take it anymore!” patient’s regular physician but also ous times that a specialist changes Recently I got to thinking about anyone who has an active EMR with meds, and we might be remiss and how the current pharmacy prescrib- the patient’s records. I liken it to with- forget to enter this manually into our ing and renewal system is antiquated, drawing funds with one’s debit card. EMR. fraught with errors, and a huge time Even if one were in Timbuktu, all who Remedies as described above for waster for all involved. I got to think- need to know would have the trans- this pharmacy issue would save us ing once again about the frustrations action details of how much one with- docs much time and the system mil- of dealing with trashed-out looking drew and what the balance was. This lions of dollars! faxes (really a dinosaur of technolo- would mean no time wasted on faxes —Jack Boxer, MD gy compared to the electronic portals for explanations of what was meant Vancouver

498 bc medical journal vol. 58 no. 9, november 2016 bcmj.org premise

Is lesion location random, and does it really matter?

We physicians are so busy labeling and treating that we don’t have the time to question why lesions occur where they do.

Margo S. Clarke, MD

very peculiar feature of What I have described for iritis is our understanding of disease mecha- HLA-B27 uveitis is the ten- not unique. Many inflammatory con- nism, which could lead to more spe- A dency for one eye to become ditions occur asymmetrically and at cific therapy. involved during an attack. This can very select locations. These specific Amazing developmental biology be so profound that that cells precipi- features of preferred sites of pathol- has made great strides in determin- tate in the anterior chamber forming a ogy are used in determining a dif- ing the molecular organization that snowbank appearance. Curiously the ferential diagnosis. Why each dis- guides assembly of all body sites, and other eye is completely unaffected, ease has susceptible anatomic sites significant portions of this molecular with not a single visible cell floating is often unknown. Although rheuma- map persist in adult tissue. Remark- in the anterior chamber. Clearly the toid arthritis involves the metacar- ably, the blueprint for the body as a immune system has the ability to dis- pophalangeal joint and not the distal whole and for each organ follows a criminate between the two eyes, yet interphalangeal joint, and this pat- repetitive plan drawn on coordinates why this occurs is a complete mys- tern of involvement assists diagnosti- (head-tail, back-front, and left-right). tery. What is fascinating is that some cally, we don’t question why the dis- Hence each position in the body has individuals will repeatedly have an tal interphalangeal joint is spared in molecular coordinates where tissue attack in one eye while others will rheumatoid arthritis yet involved with varies along these axes and the vari- flip-flop between eyes in a seeming psoriatic arthritis. Similarly psoriasis ances can create differential resis- ly unpredictable fashion. These odd tends to involve extensor skin surfac- tance or susceptibility to disease and ities happen consistently, but in a es and each dermatological condition may explain why all tissue does not busy practice these observations sim- has specified regions of involvement, succumb simultaneously. ply help to confirm the diagnosis of but there is currently very little data to Another fascinating finding in HLA-B27 iritis. We think it is strange explain these patterns. developmental biology is that the that iritis occurs this way but perhaps Degenerative diseases also occur mesoderm (fibroblasts and their close these oddities are clues to finding the in specified sites, and as imaging tech- relatives in other tissue) carries most cause of immune misdirection. More nology advances it has been noted that of the position code. This was illus- importantly, finding answers may there is often directional evolution. trated in chicks that had epithelium lead to truly definitive treatment rath- Asymmetrical presentation occurs from the wing switched to the loca- er than symptom control. frequently, Parkinson disease being tion where a leg was to develop: a classic example of unilateral onset. scales appeared instead of feathers, If we perceive asymmetry and lesion hence determining that the mesoderm Dr Clarke is a clinical assistant professor site to be random, then we limit the directed the options inherent in the in the Department of Ophthalmology and observations that will be made. If we epithelium. Of relevance to the role Visual Sciences at the University of British are willing to imagine that tissue that of mesoderm in human adult tissue, Columbia. She is now retired. Dr Clarke’s appears to be the same microscopical- fibroblasts were cultured from 43 additional areas of special interest include ly is in fact molecularly different and body sites and a position code, analo- immunology, developmental biology, and that these variances may determine gous to a postal code, was identified genetics. why lesions occur where they do, then unique to each body site, yet follow- asymmetry and directional evolution ing developmental coordinates. Since This article has been peer reviewed. become powerful clues that can assist Continued on page 500

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 499 premise

Continued from page 499 eling disease mechanism. To ignore This article is written with hope then fibroblasts from many organs the cause of asymmetry in HLA-B27 that physicians in clinical practice— have been examined with similar iritis, and not determine the cause for especially those new to practice— findings. The concept advanced is distal interphalangeal involvement will become curious, if they are not that positional variances present in in psoriatic arthritis or the reason for already, and that through their patient fibroblasts then direct changes in skin distal to proximal spread in derma- encounters they will continue to and hair, explaining the different pat- tomyositis, may mean that valuable question current concepts and form terns present over the surface of the clues are being missed. Mechanisms alliances with researchers to pursue body. Understanding the combinato- to use these clues include compara- questions that address basic concepts. rial regulatory modules that define tive omics by site and phenotyping Lesion location is not random. It dermatological patterns remains one in genome-wide association studies is generated by a combination of phe- of the goals of future research. Per- according to lesion site and direction- notype variances superimposed on a haps one day the molecular mean- al evolution. In select diseases these core developmental map altered by ing of the lupus butterfly rash will be approaches are being pursued in part. circumstances such as aging, infec- known. Unfortunately as clinicians we are tion, and trauma, and further modified Spectacular progress has occurred so busy diagnosing and treating dis- by the visiting immune system that in the field of genetics in the last few eases that getting the job done and can react appropriately, overreact, or decades and it is clear that the further staying on top of recent advances con- underreact according to clues from one goes into genetic analysis the sumes our time and energy. We have the tissue or its innate predecessors. more complex it becomes. Each dis- been saturated with data to memo- It is all logical but it depends on com- ease is recognized to exhibit hetero- rize, and asking why has often been plex overlapping databases that are geneity. With each person averaging shelved. Recently it has been reported inherently faulty if the developmental a base-pair substitution every 2000 that the top-earning treatments for the map is absent. The constant features base pairs, the implication is that with pharmacological industry are bio- of location, direction, and asymmetry 3 billion base pairs in our genome we logicals. And the focus of research are potent allies in the quest to ulti- each harbor over a million base-pair is increasingly directed at new bio- mately find new specific, definitive variances. Although the vast majority logicals rather than traditional small- treatments. of these changes have little impact on molecule drugs. The expense of this the quality or quantity of the proteins approach is concerning. Clearly one Competing interests we produce, it is easy to understand can understand that financial incen- None declared. why there is inter-individual varia- tives direct pharmaceutical research, tion in all diseases. Hence any feature but as patient advocates we need to of a disease where there is a constant foster alternative treatment direc- provides an important clue to unrav- tions.

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500 bc medical journal vol. 58 no. 9, november 2016 bcmj.org bc centre for disease control

BC physicians reduce unnecessary antibiotic use—and costs

t is rare to find a health intervention that both improves a standard I of practice and reduces costs, but Total Cost Pharmacare Cost Prescription Rate this seems to be the case for the Do Bugs Need Drugs? program in BC. $400 2 The World Health Organization $350 and the Public Health Agency of Can- $300 1.5 ada recognize the rapid emergence of antibiotic-resistant organisms as $250 being among the most significant $200 1 threats to health and health care– $150

system sustainability. Wise use and Cost (millions) stewardship of antibiotics are essen- $100 0.5 tial in mitigating the threat by reduc- $50 ing the pressure for natural selection $0 0 Prescriptions per 1000 person days of resistant organisms and preserving 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 the value of antibiotics for future generations. Between 80% and 90% of antibi- Figure. Prescription rate, total cost, and cost to BC Pharmacare for antibiotics, 2005–2014. otics used in human populations are Source: BC Ministry of Health. PharmaNet. Victoria, BC, 2013. prescribed in the community. In 2005 the BC Ministry of Health funded Do emergence of more resistant strains. effort into educating health care pro- Bugs Need Drugs?, a program of pro- Reduced prescribing is associated fessionals on appropriate antibiotic fessional and public education aimed with a reduction in costs for BC. Over use, and other educational programs at reducing the risk of antibiotic the first 10 years of the program, the have been at play. resistance and improving prescribing annual cost of community antibiotic But cost reductions are only inci- practices at the population level. The prescribing fell by 15.5%, from $342 dental. The goal of stewardship is to BCCDC routinely assesses changes million to $289 million, a difference avoid unnecessary antibiotic use in in patterns of antibiotic prescribing of $53 million in 2014 alone. As well, order to slow emergence of resistance in the community by analyzing non over the same time period, there has and to reduce complications from identifying data made available for been a 31% decrease in annual costs to unnecessary treatments. The country this purpose from PharmaNet. Pharmacare for antibiotic claims, sav- furthest along on this continuum is Between 2005 and 2014 the rate ing the Ministry of Health $25 million the Netherlands, which experiences of antibiotic prescribing fell 15% in 2014 compared with 2005. Other lower rates of antibiotic use with no from 1.79 to 1.53 antibiotic pre- changes have played into costs over evident increase in complications scriptions per thousand person days time; however, declines in the aver- from bacterial infections. BC would ( Figure ). This drop can be explained age cost of a prescription (–10.4%) approach the same success if there by steep declines in prescribing for were of the same order of magnitude were a further 20% to 25% reduction children and for respiratory infec- as increases in population (+10.4%) in prescribing. tions, which were the original targets over the decade, so these effects tend Can we get there safely? The an of the program. The declines have to cancel each other out. (The cost swer is, almost certainly, yes. We are occurred over a period where many of a prescription has decreased due beginning to see reductions in pre- trends in resistance stabilized, though to lower costs for generic antibiot- scribing for residents of long-term we remain under constant threat of ic drugs and because of some drug- care facilities, where a tendency to switching by BC physicians back to overtreat asymptomatic bacteriuria This article is the opinion of the BC Centre first-line, narrower-spectrum agents.) is being slowly reversed. We are for Disease Control and has not been peer The BC Ministry of Health’s aca- also collaborating with our dental reviewed by the BCMJ Editorial Board. demic detailing program has also put Continued on page 503

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 501 council on health promotion

The scoop on supplements for disease prevention

pproximately 40% of Canad vitamin C, omega-3s, co-enzyme rolithiasis from zinc, vitamin C, and ians regularly consume vita Q10, and zinc, there is no evidence of calcium.1 A min and mineral supplements, benefit for disease prevention2-6 and Minerals like calcium or iron can hoping to prevent disease, promote no indication for routine screening impair absorption of levothyroxine, longevity, or compensate for the infor deficiencies. bisphosphonates, and fluoroquino- adequacies of the typical Canadian lones, and vitamin B6 reduces absorp- diet. Epidemiologic studies suggest tion of medications like levodopa and that diets high in nutrient-rich foods antiepileptics. Vitamin A and beta- like fruits, vegetables, and fish are carotene can increase hepatotoxicity effective in preventing disease.1 The of medications including acetamino- Unfortunately, although traditional assumption is that simply phen, carbamazepine, methotrexate, replacing these nutrients with supple- supplementation may warfarin, and retinoids. Vitamin E can ments will provide the same benefit. change serum levels, total potentiate the bleeding risk of warfa- Unfortunately, although supplemen- intake, or other surrogate rin, ASA, and NSAIDs.1 The cost of tation may change serum levels, total markers, well-designed supplements can be significant. intake, or other surrogate markers, controlled studies on Studies have repeatedly found well-designed controlled studies on examples of supplements containing artificial supplementation artificial supplementation have failed contaminants, dangerous additives, to show consistent reduction in frac- have failed to show and misleading or inaccurate label- tures, heart disease, cancer, or demen- consistent reduction in ing or dosage information.8 Unfortu- tia.2-6 The synergy of nutrients and fractures, heart disease, nately, the supplement industry has related substances (e.g., phytochemi- cancer, or dementia. resisted stricter regulation to ensure cals, antioxidants, fibre) available in consumer safety.8 foods has yet to be replicated by a pill. Despite the consistent lack of evi- There are certain situations where dence of benefit, many patients con- supplementation should be consid- tinue to take supplements. The fol- ered: lowing recommendations can help • Folic acid to prevent congenital neu- Although taking a daily multivi- patients minimize potential harms: ral tube defects (strong evidence).1 tamin is considered safe, it is unnec- • Do not exceed recommended doses. • Vitamin D in breastfed infants essary for most Canadians. Some • Discuss supplements with health (strong evidence), frail elderly wom- experts suggest that food-insecure care providers. en (moderate evidence), and dark- Canadians or those with a very poor • Purchase well-known brands labeled skinned or homebound patients (low diet may benefit; however, this has with Health Canada natural product evidence).7 not been proven. Many foods in Can- numbers. • Iron for those with low intake (veg- ada are already enriched to prevent As trusted sources of up-to-date, etarians), regular blood loss (e.g., widespread deficiencies.2,3 evidence-based information, physi- menorrhagia), or at risk for poor Contrary to the widely held belief cians need to help patients interpret absorption (elderly on medications that vitamins and minerals are natural the overwhelming volume of often such as metformin, proton pump in- and therefore safe, supplements can poor quality information available by hibitors).1 be harmful, particularly if exceed- providing clear guidance. Required • Vitamin B12 for vegans and those ing tolerable upper levels, but also in nutrients are best obtained through a at risk for poor absorption.1 recommended doses. Recent studies healthy diet rich in whole foods. We For other supplements, including have shown increased risk of myo- can’t replace a poor diet with a pill. calcium, antioxidants, B vitamins, cardial infarction with beta-carotene, “Let food be your medicine, and med- calcium, and vitamin E; increased icine be your food.” —Hippocrates This article is the opinion of the Council on all-cause mortality from vitamin E —Ilona Hale, MD Health Promotion and has not been peer and beta-carotene; teratogenesis from —Kathleen Cadenhead, MD reviewed by the BCMJ Editorial Board. vitamin A at high doses; and neph- —Mary Hinchliffe, MD

502 bc medical journal vol. 58 no. 9, november 2016 bcmj.org cohp bccdc

Continued from page 501 References atic review and network meta-analysis of colleagues, who now account for over 1. McCord P, Opsteen J. Vitamin and min- primary prevention trials. Syst Rev 11% of prescriptions in BC. Den- eral supplementation: Primary disease 2015;4:34. tal practitioners are identifying the prevention. Foundation for Medical Prac- 6. Theodoratou E, Tzoulaki I, Zgaga L, Ioan- opportunity to reduce unnecessary tice Education 2016;24(6). nidis JP. Vitamin D and multiple health perioperative prophylaxis as well as 2. Singal M, Banh HL, Allan GM. Daily multi- outcomes: Umbrella review of systematic prescribing for periapical abscess and vitamins to reduce mortality, cardiovascu- reviews and meta-analyses of observa- other indications. We also laud work lar disease, and cancer. Can Fam Physi- tional studies and randomised trials. BMJ being done at the BC Divisions of cian 2013;59:847. 2014;348:g2035. Family Practice to pilot personalized 3. Macpherson H, Pipingas A, Pase MP. Mul- 7. Bjelakovic G, Gluud LL, Nikolova D, et al. feedback on antibiotic prescribing for tivitamin-multimineral supplementation Vitamin D supplementation for prevention family physicians through an elec- and mortality: A meta-analysis of random- of mortality in adults. Cochrane Database tronic health record platform. ized controlled trials. Am J Clin Nutr Syst Rev 2014;(1):CD007470. Thanks to many BC practitioners, 2013;97:437-444. 8. Newmaster SG, Grguric M, Shanmu- our province is now moving in the 4. Fortmann SP, Burda BU, Senger CA, et al. ghanandhan D, et al. DNA barcoding de- right direction with community anti- Vitamin and mineral supplements in the tects contamination and substitution in biotic use. primary prevention of cardiovascular dis- North American herbal products. BMC —David M. Patrick, MD, ease and cancer: An updated systematic Med 2013;11:222. FRCPC, MHSc evidence review for the US Preventive —Laura Dale Services Task Force. Ann Intern Med —Mark McCabe, MPH 2013;159:824-834. —Bin Zhao, MSc 5. Schwingshackl L, Hoffmann G, Buijsse B, —Mei Chong, MSc et al. Dietary supplements and risk of —Edith Blondel-Hill, MD, FRCPC cause-specific death, cardiovascular dis- —Fawziah Marra, PharmD ease, and cancer: A protocol for a system-

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bc medical journal vol. 58 no. 9, november 2016 bcmj.org 503 Guest editorial

Fake joints, real results, Part 1: Hip and knee replacement

rthritic conditions have and materials used for components plagued humanity since the in 2016, while Drs Paul Dooley and A beginning of time. It was Charles Secretan examine the indi- not long ago that becoming unable cations for and expectations of knee to walk or needing to rely on walk- replacement. In the second part of ing aids was considered a normal part the theme issue to be published next of aging. Efforts to replace arthritic month, we will consider joint replace- joints began in 1890, when Profes- ments that are becoming increasingly sor Gluck tried to replace an arthritic common. Dr Kelly Apostle will dis- femoral head with an ivory one. After cuss advances in ankle replacement, this unsuccessful first effort at hip re- while Dr Derek Plausinis will review placement, numerous attempts were current options for shoulder replace- Dr Bas Masri made with variable and generally ment. poor or unpredictable results. In the What is most remarkable about early 1960s, Sir John Charnley de- this group of authors is that so many veloped low-friction arthroplasty of of them are faculty members in the the hip, which is basically the mod- Department of Orthopaedics at the ern hip replacement. Without a doubt, University of British Columbia, and this was one of the most significant most of them practise outside Van- advances in orthopaedics in particu- couver. This is very different from the lar and medicine in general. Further situation in the department, the uni- advances have since led to a rapid versity, and the province when I first expansion in the application of hip re- enrolled at UBC in 1981, and reflects placement beyond arthritic conditions the benefits that have come from to traumatic and neoplastic affliction. expanding the Faculty of Medicine Over the years, joint replacement across BC. technology has also moved beyond I am very grateful for the con- hips. In fact, knee replacements have tributions made by the theme issue surpassed hip replacement in terms authors and hope that you will enjoy of numbers done in British Colum- these articles and find them of use in bia. Other joints are now successfully your practice. treated with arthroplasty as well, in- —Bas Masri, MD, FRCSC cluding shoulders, elbows, wrists, Professor and Head of knuckles, and ankles. Orthopaedics, University of British In this first of a two-part theme Columbia and Vancouver Acute issue, we consider the most common (VGH and UBCH) joint replacement surgeries. Drs Brad- Surgeon-in-Chief, ley Ashman, David Cruikshank, and Vancouver Acute Michael Moran outline the history of (VGH and UBCH) This article has been peer reviewed. hip replacement and the many designs

504 bc medical journal vol. 58 no. 9, november 2016 bcmj.org Bradley Ashman, MD, David Cruikshank, MD, Michael Moran, MBBCh, FRCSC

Total hip replacement: Relieving pain and restoring function

Since the first successful modern hip arthroplasty was performed by Sir John Charnley in the 1960s, procedures and components have evolved and made joint replacement available to patients younger than 65.

ABSTRACT: Total hip replacement metal or ceramic femoral heads; and otal hip replacement is a re- is one of the most common ortho- polyethylene or ceramic acetabular markable procedure that can paedic reconstructive procedures liners. In British Columbia, the stan- Trelieve pain and restore func- performed today, with more than dard of care is a metal acetabular tion. According to the Canadian Insti- 40 000 replacements completed an- shell with a polyethylene liner and tute for Health Information, more than nually in Canada. New surgical tech- a cemented or uncemented femoral 40 000 hip replacements are complet- niques and materials have led to stem with a metal femoral head. Hip ed annually in Canada (https://secure procedures that produce profound resurfacing is an option for young .cihi.ca/estore/productFamily.htm? changes in the lives of patients and active patients, although its use locale=en&pf=PFC2945&lang=en). allow them to resume virtually all of worldwide has declined dramatical- For most patients with a destructive their previous activities. Sir John ly. Early mobilization after total hip process occurring in the hip joint, to- Charnley developed low-friction ar- replacement is recommended. While tal hip arthroplasty (THA) is a viable throplasty in the 1960s. Since then, complication rates are low, possible option. Since the first successful THA procedures have evolved to address postoperative problems include ve- was performed in the 1960s, proce- the issues of wear and bone loss and nous thromboembolism and nerve dures and the components used have permit joint replacement in patients injury in the short-term, and peri- evolved and we now have a better un- younger than 65. Pain is the prima- prosthetic fracture and osteolysis in derstanding of post-op considerations ry indication for a hip replacement, the long-term. If there is a failure of and possible complications. with osteoarthritis being the most the hip replacement for some rea- common cause. State-of-the-art im- son, the likelihood of a revision pro- History plants in 2016 include cemented, cedure succeeding is good. Beginning in the 1800s, a number of uncemented, or hybrid components; attempts were made at hip replacement for infection and fracture using implants of ivory, glass, ceramic, and metal. These trials continued through to the 1960s, when Sir John Charnley

Drs Ashman and Cruikshank are residents in the Department of Orthopaedics at the University of British Columbia. Dr Moran is an orthopaedic surgeon at the University Hospital of Northern BC and a clinical professor in the Department of Orthopaedics This article has been peer reviewed. at the University of British Columbia.

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developed the modern total hip often. These include metal-on-metal been resolved. Patients unable to per- replacement, which he called low- and ceramic-on-ceramic bearing sur- form activities of daily living or with friction arthroplasty.1 Charnley’s faces. While the risk of wear is mini- deformities such as a leg-length dis- procedure used a single-component mal with these articulations, metal- crepancy or flexion deformity are (monoblock) metal femoral stem and on-metal total hip arthroplasty has prime candidates for this operation. head combined with a cemented poly- been abandoned because of the many Such patients tend to have significant ethylene acetabular shell. The arthro- failures related to adverse local tissue pain. With the improving outcomes plasty of Charnley’s era survived for reactions to metal debris and the for- of hip replacement it is no longer many years but had problems. The mation of pseudotumors. Currently, necessary to wait until patients are 22.25-mm femoral head was prone the only hard-on-hard bearing surface completely disabled before considering surgery. Earlier intervention yields better outcomes provided that nonoperative treatments are no longer effective and the patient has pain that is related to the hip joint and not referred from the lumbar spine or With the improving outcomes related to extra-articular structures. of hip replacement it is no Pain from the hip joint is typically located in the groin or buttock, longer necessary to wait until with referral to the thigh and often patients are completely disabled to the knee. Hip arthritis can present solely with knee pain, a finding espe- before considering surgery. cially common in elderly patients. All patients presenting with knee pain should undergo a physical examination of the hip and appropriate radiographs should be obtained if abnormalities are found during the hip to dislocation and the polyethylene available for a total hip arthroplasty examination. shell to eccentric wear. Larger femo- is ceramic-on-ceramic, and accord- ral heads were developed that reduced ing to joint registry data there is no Diagnoses the rate of dislocation, but at the cost evidence of superiority when ceramic Obviously, patients being considered of increased wear. Whatever the size and highly crosslinked polyethylene for THA need to have an underlying of the head, the cement mantle tended are compared at 10 years follow-up. condition that can be addressed using to loosen and then fail. The problem Today’s state-of-the art implants joint replacement. In broad terms, any of loosening was essentially solved include: patient with a pathology that leads to with the introduction of uncemented • Femoral heads of metal or ceramic. degeneration of the articular carti- components. However, failures con- • Acetabular liners of polyethylene or lage of the joint might benefit from tinued to occur with the breakdown ceramic. replacement of that joint. Osteoar- of the polyethylene and subsequent • Components that are cemented, un- thritis, whether idiopathic, develop- bone loss. cemented, or hybrid (uncemented mental, or posttraumatic, is by far Since the late 1990s, highly cross- acetabulum and cemented femur). the most common diagnosis lead- linked polyethylene with much im- ing to hip replacement surgery. This proved wear characteristics has been Indications includes osteoarthritis in the medial used with excellent results. Today The primary indication for total hip wall of the acetabulum, which is often wear and bone loss as a result of hip replacement is pain. Patients who are missed because the radiological find- replacement are exceedingly rare, unable to sleep because of pain will ings can be subtle and the presenting regardless of patient age or activity generally have a remarkable outcome symptoms can be somewhat unusu- level. In addition, so-called hard-on- from THA and will likely awake from al. For example, a patient may have hard articulations are being used more surgery to realize that their pain has pain at night and with certain activi-

506 bc medical journal vol. 58 no. 9, november 2016 bcmj.org Total hip replacement: Relieving pain and restoring function

A B

Figure 1. Anteroposterior view of left hip (A) shows minor changes at the dome of the acetabulum and difficult-to-assess osteoarthritis (solid arrow) in the acetabular medial wall. Lateral view of the left hip (B) reveals osteoarthritis (dashed arrow) in the acetabular medial wall. ties because the medial wall of the hip will rarely change the manage- collapse and cause degeneration of the acetabulum is affected, but can still ment and should not be ordered if hip joint. However, the radiological have good walking tolerance because there is any evidence of degenera- findings are often not as pronounced the dome of the acetabulum (the tive arthritis. Hip-preserving surgery as the patient symptoms. MRI will weight-bearing surface) is relatively (hip arthroscopy or open dislocation reveal the extent of the disease but is unaffected. In these cases, the lateral and debridement) in the presence of not usually a necessary investigation radiograph can be helpful in assessing degeneration will not lead to a good unless the plain X-ray images do not medial wall osteoarthritis ( Figure 1 ). outcome and may lead to more rapid reveal any abnormalities early in the Over the past decade femoroac- progression of the arthritis and an ear- course of the disease. etabular impingement (FAI) has been lier need for a hip replacement. Inflammatory arthropathies such recognized as a precursor of and pos- Acetabular dysplasia involves a as rheumatoid arthritis, ankylosing sibly one of the ultimate causes of shallow or underdeveloped acetabu- spondylitis, and psoriatic arthritis all idiopathic osteoarthritis of the hip. lum that leads to early hip osteoar- present with degenerative changes The condition commonly occurs as thritis. As in cases of femoroacetabu- similar to those seen in osteoarthri- either cam FAI (deformity of the fem- lar impingement, patients older than tis and should be treated in the same oral neck) or pincer FAI (deformity 40 with acetabular dysplasia will not manner. of the acetabulum). The impingement benefit from osteotomies and labral caused by deformed hip bones even- repairs. The only effective surgi- Age tually leads to acetabular labral tears cal option is a total hip replacement. In the past, being younger than 65 and concomitant articular cartilage As such, there is no role for MRI in was considered a barrier to joint degeneration. Because the labral tears diagnosing acetabular dysplasia and replacement. This is no longer the are part of the degenerative process, degenerative change. case. Although patients with hip- the repair of these in patients older Avascular necrosis occurs when related pain should be counseled to than 40 without a bona fide injury the blood supply to the femoral head persist with nonoperative treatment and FAI is almost never indicated. is disrupted. In such cases the avas- until such time as their symptoms are An MRI or MRI/arthrogram of the cular portion of the femoral head can severe enough to warrant THA, it is

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important to recognize that patients contact during the joint articulation The main difference between mod- age 40 to 50 may be better served by consists of the femoral head and the ern implants and the original 1960s replacement than by hip arthroscopy acetabular liner. The search for the implants is the move away from the or further waiting. These patients are best materials to use in this bearing monoblock head-and-stem construct. not too young for hip replacement, surface have led to industry innova- The implant used by Charnley was a and the thinking that only patients tion and much debate. femoral stem and head that had been older than 65 should be offered THA Options today include a femoral machined as a single unit, whereas is no longer correct. head made of metal (cobalt and chro- current implants consist of a femo- As the bearing surfaces used for mium) or ceramic and an acetabular ral stem with a trunnion that permits hip replacement have improved, the liner made of metal, ceramic, or poly- attachment of a head and thus allows lifespan of implants has increased, ethylene. In British Columbia, the for more sizing options. In recent years, however, trunnion corrosion has led to pseudotumor formation similar to that experienced by patients with metal-on-metal total hip replacement.2 Although rare, these inflamma- Implants are now good enough to tory masses have been reported with metal-on-polyethylene hip replace- outlast the patient in most cases. ments and are thought to be related to metallic corrosion where the head of cobalt and chromium joins with the femoral stem, which in most cases is made of titanium. In North America currently, the and the age of the patient is not as Medical Services Plan covers the cost metal-on-polyethylene bearing sur- critical a consideration as it once of a cemented or uncemented femoral face is used most commonly.3 It has was. Implants are now good enough stem with a metal femoral head and a good wear characteristics, a high sur- to outlast the patient in most cases. metal acetabular shell with a polyeth- vivorship, and remains the workhorse Therefore, the status of the joint and ylene liner (either ultra high molecular of arthroplasty surgeons now that the symptoms of the patient, not the weight or highly crosslinked polyeth- the early problem of liner wear has age of the patient, should determine ylene). If a patient asks for a differ- been addressed. Originally, the pres- whether a THA is appropriate. ent component because of a perceived sure of the metal femoral head on the benefit, there is an additional charge softer polyethylene liner produced an Implants since no benefit has been found with eccentric wear pattern that eventu- Many implant designs have been other articulating surfaces. ally led to joint failure and the need used during the development of total for revision.4 Over the last 15 years or hip arthroplasty. Research into vari- Metal-on-polyethylene bearing so the use of crosslinked polyethylene ous implant materials and different surface has significantly reduced the rate of shapes and sizes of both the femoral In the 1960s, Charnley pioneered the wear, and revisions for polyethylene and acetabular components has made use of a metal femoral head and an wear are now uncommon. this field a diverse and exciting one. acetabular component of ultra high During a total hip arthroplasty molecular weight polyethylene. This Ceramic-on-ceramic and procedure, the degenerated femoral metal-on-polyethylene bearing sur- ceramic-on-polyethylene head and acetabulum are replaced face was adapted from the impact bearing surface with a metal femoral stem and head bearings used for looms in the textile An alternative to metal-on- (cemented or uncemented), a metal industry.1 polyethylene is a bearing surface of acetabular shell (cemented or unce- Since Charnley’s time, only a few medical grade ceramic. The ceramic- mented), and an acetabular liner that improvements have been made, and on-ceramic bearing surface is more locks into the acetabular shell. The the metal-on-polyethylene bearing expensive but has better wear char- bearing surface that takes the force of now has an excellent track record. acteristics, reduced particulate debris

508 bc medical journal vol. 58 no. 9, november 2016 bcmj.org Total hip replacement: Relieving pain and restoring function

generation, and greater biocompat- in total hip arthroplasty. The advan- ibility.5 tages included low volumetric wear, The use of ceramic bearings is high resistance to implant fracture, increasing in North America and and lower rates of dislocation with is used in the majority of cases in the increased femoral head sizes per- Europe. Earlier generations of ceram- mitted by large-head metal-on-metal ic were relatively brittle, which lead to THA.8 a high risk of component fracturing.6 This enthusiasm was short lived, Improvements in ceramic technology however. It has now been well docu- and manufacturing techniques have mented that patients with a metal-on- dramatically reduced the incidence of metal THA have elevated serum lev- implant fracturing5 along with the risk els of cobalt and chromium, of which of squeaking from the hip with walk- the clinical effects are unknown. Fur- ing and bending motions.7 Despite ther, it has been discovered that in the potential advantages of a ceramic- some patients the metallic ion wear on-ceramic bearing surface, the rate debris leads to formation of benign of revision at 10 years is identical to solid or cystic masses. Investiga- that of metal-on-polyethylene and the tions have found that the prevalence cost is greater. While the ceramic-on- of these pseudotumors in asymp- ceramic bearing surface is considered tomatic patients with metal-on-metal an option for young, active patients implants is unacceptably high.9 Given who require a total hip arthroplasty,7 the complications and the high revi- the routine use of ceramic-on-ceramic sion rates for large-head metal-on- instead of metal-on-polyethylene is metal implants, this bearing surface Figure 2. Total hip replacement with cemented components. not considered cost-effective. is no longer an option for total hip An alternative to the standard arthroplasty. ceramic-on-ceramic bearing is a ceramic femoral head with a poly- Cemented versus uncemented ethylene liner. This ceramic-on- implants polyethylene bearing surface does not A major consideration in THA is pose a squeaking risk and is cheaper whether to use a cemented or an unce- than a ceramic-on-ceramic bearing. mented implant. Early procedures While the wear rates of ceramic-on- relied on polymethylmethacrylate polyethylene and metal-on-poly cement from the dental industry,10 a ethylene are not appreciably different, bonding agent that failed to adequate- the risk of pseudotumor formation ly secure arthroplasty implants to from metallic debris is eliminated with bone. Charnley recognized that rather the use of ceramic-on-polyethylene. than using the cement for bonding, he Despite this advantage, the routine should use it as a grout to create an use of ceramic-on-polyethylene is interface between the porous meta not considered to be cost-effective physeal and cortical bone and the because of the rarity of pseudotumors metal implant in order to greatly in the large number of hip replace- increase the surface contact area and ments done annually and the higher achieve long-term stability. While cost of ceramic implants. cemented implants ( Figure 2 ) are still favored in some parts of the world, Metal-on-metal bearing surface including Sweden and Norway,10 From the late 1990s to the early 2000s the most common type of prosthesis there was a resurgence in the use of in North America is an uncemented Figure 3. Total hip replacement with a metal-on-metal bearing surface implant ( Figure 3 ). uncemented components.

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In uncemented techniques, both The use of hip resurfacing has have not resulted in higher dislocation the femoral and acetabular com- declined dramatically worldwide over rates when patients undergo an ante- ponents are coated with a porous the past few years, but remains a via- rior or anterolateral approach THA. material that encourages the bone to ble option for young, active patients Similarly, there is no strong evidence grow into the surface of the implant. with disabling osteoarthritis. While for higher dislocation rates with Initial stability depends on having the hip resurfacing must be used with precaution-free post-op protocols implant firmly pressed into the bone, caution, it can lead to good and long- when patients undergo a posteri- and long-term stability is gained by lasting outcomes when performed by or approach replacement.13 While the bone bonding to the implant. In an experienced surgeon and in a well- patients are encouraged to observe some cases, such as when the femo- selected patient. Currently the proce- hip precautions, a commonsense ral bone is of poor quality and can- dure is not recommended for women, approach should be followed and not support a firmly press-fit femoral men of small stature, or patients older patients should not be too worried component, cement can be used. This than 65. about dislocation, which remains a is known as a hybrid THA, in which relatively rare complication provided the acetabular component is unce- Post-op considerations the implants are positioned correctly. mented, but the femoral component After patients have undergone total is cemented. There is no substan- hip arthroplasty, they should be en- Venous thromboembolism tial difference in outcome between couraged to mobilize early and to ob- Venous thromboembolism is a well- uncemented and hybrid fixation tech- serve hip precautions. Patients should documented complication of total niques, and the choice of fixation also be monitored for possible com- hip arthroplasty. THA patients are at depends on surgeon experience and plications. Complications that may particular risk because of both intrao- patient characteristics. occur in the short-term are: perative endothelial trauma and ven- • Venous thromboembolism (VTE) ous stasis from relative immobiliza- Hip resurfacing • Prosthetic joint infection tion in the perioperative period. A Hip resurfacing is an alternative to • Nerve injury recent systematic review found ap- the traditional total hip arthroplasty, • Vascular injury proximately 1 in 200 patients (0.53%) which requires the removal of the • Bleeding developed symptomatic VTE prior to femoral head and neck. In a resurfac- • Leg-length discrepancy hospital discharge following hip arth- ing procedure, the femoral head is • Dislocation/instability roplasty despite receiving VTE pro- machined to accept a metal cap and • Fracture phylaxis.14 This same study found the acetabulum is replaced in a man- Complications that may occur in rates of symptomatic VTE events oc- ner similar to that used for THA. In the long-term are: curred in approximately 2% to 5% this way the large-diameter head and • Prosthetic joint infection of hip arthroplasty patients within 3 acetabular component make a metal- • Periprosthetic fracture months of surgery.14 The rate of clin- on-metal bearing surface. • Dislocation/instability ically asymptomatic VTE events is The advantages of a hip resurfac- • Polyethylene wear higher still but clinical relevance of ing procedure include the maintenance • Osteolysis asymptomatic VTE is not known.14 of bone stock, which can eventually The American Academy of Or- be converted to a THA should the re- Mobilization and hip precautions thopaedic Surgeons (AAOS) and the surfaced joint wear out or fail. The Postoperative patient mobilization American College of Chest Physi- disadvantages include a risk of femo- should begin within 24 hours of hip cians (ACCP) have published guide- ral neck fracture and the risks that go replacement surgery.12 Benefits of lines regarding VTE prophylaxis in along with a metal-on-metal bearing early mobilization include decreased joint arthroplasty patients.15,16 The surface, such as elevated serum levels risk of venous thromboembolism, AAOS guidelines state that moderate of metal ions and adverse tissue reac- shorter inpatient stay, and lower total evidence supports the use of pharma- tions. However, it has been shown that cost of care.12 cological and/or mechanical VTE pro- the serum metal ion concentrations Hip precautions following THA phylaxis for routine hip replacement, generated by hip resurfacing are much have become routine in postopera- but do not recommend one particular less than those generated by a large- tive care. Recent research suggests prophylactic regimen over another head metal-on-metal THA.11 precaution-free post-op protocols because of inconclusive evidence.16

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The ACCP guidelines state that grade monary embolism and require antico- (with or without erythrocyte sedi- 1B evidence supports the use of ei- agulation. Because DVT/PE after hip mentation rate), and obtaining sterile ther low molecular weight heparin, replacement is a provoked event, anti- joint aspirate for culturing and sensi- fondaparinux, apixaban, dabigatran, coagulation is not required long-term tivity testing and cell count with dif- rivaroxaban, low-dose unfractionated and may be stopped after 3 months ferential. Obtaining aspirate prior to heparin, warfarin, or aspirin for VTE unless the condition is a recurrent initiating systemic antibiotic therapy prophylaxis in THA patients. Fur- one, in which case the patient should prevents compromising the diagnos- thermore, the ACCP cites grade 1C be referred to a thrombosis clinic or tic value of the aspiration and allows evidence for intermittent pneumatic to a hematologist to see if long-term selection of an appropriate antibi- compression devices as mechanical anticoagulation is indicated. otic. A prospective multicentre study VTE prophylaxis.15 Following surgery, patients who develop VTE can remain asymptomatic, experience leg swelling suggestive of deep vein thrombosis (DVT), or exhibit one or more of the following A methodical approach to symptoms suggestive of pulmonary the evaluation and management embolism (PE): tachycardia, short- ness of breath, chest pain, hemopty- of surgical wounds following 17 sis, hypotension, anxiety. Knowing THA is critical. the likelihood of VTE developing and promptly recognizing the signs and symptoms can permit early workup and treatment to limit morbidity, reduce cost of care, and prevent mortality. It should be emphasized that a Prosthetic joint infection of arthroplasty patients compared D-dimer assay has no role in the post- Prosthetic joint infection is a serious results from superficial cultures of op workup given the expected eleva- complication that occurs in 1% to 2% wound exudate with deep cultures of tion of D-dimer levels due to recent of patients and has negative effects on intra-articular tissue or aspirate and surgery.18 Duplex Doppler ultrasound patient morbidity and satisfaction and found poor concordance, with many can help in the diagnosis of DVT, on the overall cost of care. A method- superficial cultures yielding bacterial but should not be used to scan the ical approach to the evaluation and growth while deep cultures and fur- calf because a diagnosis of calf DVT management of surgical wounds fol- ther workup suggested the absence based on duplex Doppler ultrasound lowing THA is critical. Postopera- of infection. Based on these findings, is unreliable and the risk of embolism tive wound infection can result from the authors of the study recommend from calf DVT is very low in the post- surgical contamination, contiguous against the use of superficial cultures operative setting and does not warrant spread, or hematogenous spread.18 to prevent misdiagnosis and medical the risk of anticoagulation. CT pul- Acute THA wound infections mani- or surgical mismanagement.19 Ide- monary angiography (or ventilation- fest within days or weeks of surgery ally, when patients present with con- perfusion scan in patients unable to and present with localized hip pain, cerning surgical wounds, workup for undergo CT angiography) is the test swelling, erythema, and warmth. infection and prompt follow-up with of choice to assess for pulmonary Wound drainage or a draining sinus their surgeon or an on-call orthopae- embolism.18 When the radiologist tract may be evident and the presen- dic surgeon should occur before anti- reports a filling defect on a CT pulmo- tation can include fever, malaise, and biotics are initiated. nary angiogram, it needs to be noted frank sepsis.18 Chronic wound infec- Until recently, patients with ortho whether this is a segmental or subseg- tions present more subtly but are com- paedic implants, including hip re- mental filling defect. Subsegmental monly associated with pain. Standard placements, were routinely given an- filling defects do not require antico- workup for wound infection includes tibiotic prophylaxis when undergoing agulation. Segmental filling defects obtaining blood for culturing and low- or high-risk dental procedures are consistent with a diagnosis of pul- WBC and C-reactive protein testing to prevent prosthetic joint infections.

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Clinical practice guidelines released lous. Preoperative cessation of anti- solves within 3 months and does not in 2012 by the AAOS in conjunction coagulants should be undertaken, and require any specific treatment. Intra- with the American Dental Associa- the use of tranexamic acid for bleed- operative fracture can happen on the tion now recommend against antibi- ing prophylaxis should be consid- acetabular or, more commonly, the otic prophylaxis for dental procedures ered.18 Patients should also be coun- femoral side during bony preparation because of a lack of evidence that seled preoperatively regarding the or implant insertion. If identified in- dental-procedure-induced bacteremia possible need for perioperative blood traoperatively, additional fixation is leads to prosthetic joint infections. transfusion, although this is becom- often necessary to ensure prosthesis The grade of recommendation for this ing rare in patients with a preopera- stability. Postoperative recognition of is designated as Limited.20,21 tive hemoglobin level over 125 g/dL. fracture, especially involving the acetabulum, could alter clinical course and may require revision surgery to ensure implant stability.18 Hip instability or dislocation occurs in approximately 1% to 3% of THA patients and is the second most common indication for revision sur- The incidence of nerve injury gery after infection. Dislocation most commonly happens within 1 month following THA is approximately of surgery.17 Numerous factors can 1 to 2 cases per thousand. lead to instability, including infection, trauma, patient noncompliance, implant wear or loosening, pseudotumor formation, and component mal- position. Treatment of a dislocated prosthesis is closed reduction under procedural sedation with orthopaedic referral.18 Recurrent dislocations gen- Other complications Leg-length discrepancy may oc- erally require revision surgery. The incidence of nerve injury fol- cur following THA. Patients tend to Periprosthetic fractures secondary lowing THA is approximately 1 to tolerate up to 2 cm of LLD without to trauma can occur at any point post- 2 cases per thousand, with the pero- need for treatment, but a greater dis- operatively. Immediate orthopaedic neal branch of the sciatic nerve and crepancy can become clinically im- referral is required to determine the the femoral nerve most commonly portant, potentially manifesting as need for operative fixation or revision affected.17 Multiple causes must be knee, hip, or lumbar pain or as gait arthroplasty. considered, including traction injury, disturbance.18 Most symptomatic Components wear over time with compression, and direct trauma, al- LLD can be treated with a shoe lift. repetitive loading and friction within though in many cases the cause will In patients requiring bilateral THA, the artificial joint; this natural wear remain unknown. Prognosis tends to subsequent arthroplasty on the con- process can be exacerbated by com- be favorable for partial, if not full, tralateral hip may actually balance ponent malpositioning.18 Research return of function, but depends on out the inequality. It is not unusual for into implant biomechanics is con- the cause of the injury. Support- patients with no measurable LLD to tinuing in an attempt to maximize ive treatment, including a foot drop complain that the surgical limb seems component lifespan by minimizing orthosis for sciatic nerve palsies, is longer. This is known as a functional wear. Wear debris, particularly from recommended.17,18 leg-length discrepancy and is related the breakdown of polyethylene, trig- While vascular injury is exceed- to mobilization of a previously stiff gers an immune response and can ingly rare during THA surgery,18 hip in which the hip is held in an ab- lead to prosthesis instability and oste- bleeding in the perioperative period ducted position to avoid dislocation olysis. This bone resorption, in turn, remains a well-established risk even and also due to weak hip abductor can cause component loosening and when surgical technique is meticu- muscles. In most patients, this re- pain.18 Osteolysis is a complication

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of older implants from the 1990s al. Adverse local tissue reactions on metal- 13. Husted H, Gromov K, Malchau H, et al. and earlier, and is seen rarely now. on-polyethylene total hip arthroplasty due Traditions and myths in hip and knee arth- Implant loosening can still be seen, to trunnion corrosion. Bone Joint J roplasty. Acta Orthop 2014;85:548-555. however, and is related to either the 2015;97B:1024-1030. 14. Januel JM, Chen G, Ruffieux C, et al. failure of the cement or the failure of 3. Lehil MS, Bozic KJ. Trends in total hip Symptomatic in-hospital deep vein throm- bone ingrowth in uncemented com- arthroplasty implant utilization in the Unit- bosis and pulmonary embolism following ponents. Patients with persistent hip ed States. J Arthroplasty 2014;29:1915- hip and knee arthroplasty among patients pain following THA, especially of 1918. receiving recommended prophylaxis: A new onset, should be re-referred to 4. Abu-Amer Y, Darwech I, Clohisy JC. Asep- systematic review. JAMA 2012;307:294- their orthopaedic surgeon for workup. tic loosening of total joint replacements: 303. If there is a failure of a hip re- Mechanisms underlying osteolysis and 15. Falck-Ytter Y, Francis CW, Johanson NA, placement due to infection, osteoly- potential therapies. Arthritis Res Ther et al. Prevention of VTE in orthopedic sur- sis, periprosthetic fracture, or some 2007;9(suppl 1):S6. gery patients: Antithrombotic therapy and other cause, the likelihood of a revi- 5. Masson B. Emergence of the alumina ma- prevention of thrombosis, 9th ed: Amer- sion procedure succeeding is good. trix composite in total hip arthroplasty. Int ican College of Chest Physicians evi- Revision THA produces results that Orthop 2009;33:359-363. dence-based clinical practice guidelines. approach those of the initial surgery. 6. Boutin P. Total hip arthroplasty using a ce- Chest 2012;141(suppl 2):e278S-e325S. ramic prosthesis. Pierre Boutin (1924- 16. Jacobs JJ, Mont MA, Bozic KJ, et al. Summary 1989). Clin Orthop Relat Res 2000;(379):3- American Academy of Orthopaedic Sur- Total hip arthroplasty can relieve 11. geons Clinical Practice Guideline on: Pre- pain, restore function, allow patients 7. Aoude AA, Antoniou J, Epure LM, et al. venting venous thromboembolic disease to return to normal activities, and is Midterm outcomes of the recently FDA in patients undergoing elective hip and a viable option for most patients with approved ceramic on ceramic bearing in knee arthroplasty. J Bone Joint Surg Am a degenerative process occurring in total hip arthroplasty patients under 65 2012;94:746-747. their hip joint. In BC the standard of years of age. J Arthroplasty 2015;30: 17. Lieberman JR (ed). AAOS comprehen- care for hip implants is a metal ace- 1388-1392. sive orthopaedic review. Rosemont, IL: tabular shell with a polyethylene liner 8. Jacobs JJ, Urban RM, Hallab NJ, et al. American Academy of Orthopaedic Sur- and a cemented or uncemented femo- Metal-on-metal bearing surfaces. J Am geons; 2009. ral stem with a metal femoral head. Acad Orthop Surg 2009;17:69-76. 18. Nutt JL, Papanikolaou K, Kellett CF. Com- Early mobilization after total hip 9. Williams DH, Greidanus NV, Masri BA, et plications of total hip arthroplasty. Orthop replacement is recommended. While al. Prevalence of pseudotumor in asymp- Trauma 2013;27:272-276. complication rates are low, possible tomatic patients after metal-on-metal hip 19. Tetreault MW, Wetters NG, Aggarwal VK, postoperative problems can include arthroplasty. J Bone Joint Surg Am 2011; et al. Should draining wounds and sinuses venous thromboembolism, prosthet- 93:2164-2171. associated with hip and knee arthroplas- ic joint infection, and periprosthetic 10. Troelsen A, Malchau E, Sillesen N, Mal- ties be cultured? J Arthroplasty 2013; fracture. When a hip replacement fails chau H. A review of current fixation use 28:133-136. for some reason, there is a good like- and registry outcomes in total hip arthro- 20. Watters W, Rethman MP, Hanson NB, et lihood that a revision procedure will plasty: The uncemented paradox. Clin Or- al. Prevention of orthopaedic implant in- succeed. thop Relat Res 2013;471:2052-2059. fection in patients undergoing dental pro- 11. Garbuz DS, Tanzer M, Greidanus NV, et al. cedures. J Am Acad Orthop Surg 2013; Competing interests The John Charnley Award: Metal-on-met- 21:180-189. None declared. al hip resurfacing versus large-diameter 21. Jevsevar DS, Abt E. The new AAOS-ADA head metal-on-metal total hip arthroplas- clinical practice guideline on prevention of References ty: A randomized clinical trial. Clin Orthop orthopaedic implant infection in patients 1. Gomez PF, Morcuende JA. A historical Relat Res 2010;468:318-325. undergoing dental procedures. J Am Acad and economic perspective on Sir John 12. Stowers MD, Lemanu DP, Coleman B, et Orthop Surg 2013;21:195-197. Charnley, Chas F. Thackray Limited, and al. Review article: Perioperative care in the early arthroplasty industry. Iowa Or- enhanced recovery for total hip and knee thop J 2005;25:30-37. arthroplasty. J Orthop Surg (Hong Kong) 2. Whitehouse MR, Endo M, Zachara S, et 2014;22:383-392.

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 513 Paul Dooley, MD, MSc, FRCSC, Charles Secretan, MD, PhD, FRCSC

Total knee replacement: Understanding patient-related factors

Obesity, comorbidities, and unrealistic expectations can all contribute to poor outcome after knee arthroplasty and should be discussed by surgeons and patients during the preoperative informed consent process.

ABSTRACT: Total arthroplasty of ties, and unrealistic expectations otal arthroplasty of the knee the knee to address symptomatic for total pain relief and joint func- continues to be among the osteoarthritis has become increas- tion. Absolute contraindications to Tmost common and successful ingly common as the population knee arthroplasty include active major elective surgical procedures. ages. Many nonoperative treatment knee sepsis and severe untreated or The aging of the population has re- approaches exist and should be at- untreatable peripheral arterial dis- sulted in a significant increase in the tempted before surgical intervention ease. Total knee replacement may demand for this procedure. This is is considered. Surgical alternatives be considered for patients of any due, in part, to an increase in patient to total knee arthroplasty also ex- age once a diagnosis of osteoarthri- expectation for high functional capac- ist and may be appropriate. These tis is confirmed clinically and radio- ity into the later decades of life despite include osteotomy, unicompartmen- graphically, the patient continues the presence of a painful degenerative tal arthroplasty, and patellofemoral to experience moderate to severe joint condition. Additionally, the suc- joint arthroplasty. Though suitable pain and poor quality of life despite cess of knee arthroplasty in alleviat- for some patients, these less inva- an extended course of nonoperative ing arthritis-related joint pain in most sive procedures have reduced sur- treatment, and no contraindications patients, both young and old, has in- vivorship at 10 years when com- exist. Referral before the patient’s creased patient demand. pared with total knee arthroplasty. disease reaches an extremely ad- The primary indication for knee re- vanced stage leads to better out- History placement is pain that significantly comes. While usually beneficial, Knee replacement has evolved con- reduces walking tolerance, impairs knee arthroplasty is a major surgi- siderably over the past 100 years. In ability to perform activities of dai- cal procedure with possible compli- ly living, and interferes with sleep. cations and risk of failure to provide Dr Dooley is an orthopaedic surgeon at Ver- Patient-related factors that can af- the desired result. An understanding non Jubilee Hospital and a clinical instruc- fect the success of knee replace- of the many patient-related factors tor at the University of British Columbia. Dr ment include obesity, comorbidi- that can greatly affect outcome and Secretan is an orthopaedic surgeon at Ver- patient satisfaction is essential. non Jubilee Hospital and a clinical instructor This article has been peer reviewed. at the University of British Columbia.

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its earliest form, interposition arthro- tous instability, and lack inflammato- can be isolated to the patellofem- plasty was attempted to manage the ry condition of the joint. The success oral articulation. When nonoperative most severe pathology of the knee of the procedure is highly dependent treatments fail to control symptoms using materials such as bursa, fascia on accurate correction of alignment related to degeneration, isolated arth- lata, skin, and pig bladder, usually and requires adherence to postopera- roplasty of the patellofemoral articu- with very poor results. Until the 20th tive protocols, which may involve lation may be considered. This pro- century, arthrodesis remained the restricted weight bearing for up to cedure involves resurfacing of the treatment of choice for severe degen- 12 weeks. Osteotomy may be con- patella as well as the femoral trochlea erative knee conditions. sidered in the individual who meets while leaving the tibiofemoral com- Metallic interposition arthroplas- the above criteria and wants to con- partments alone. ty of the tibiofemoral joint has been tinue engaging in high-impact activ- Though less invasive than total evolving since the 1930s with the use ity or be able to kneel on the affected knee arthroplasty, patellofemoral joint of many different designs and mate- knee—an action poorly tolerated by arthroplasty clearly demonstrates re- rials. Modern total knee arthroplasty many total knee arthroplasty designs. duced survivorship at 10 years, with (TKA) was born when the importance It is generally accepted that pain relief a cumulative revision rate of 27.0% of the patellofemoral articulation was after osteotomy is not as predictable compared with 5.5% for TKA. recognized and the patellar compo- as after knee arthroplasty. Persistence nent was introduced in the 1970s. or development of degenerative pain Indications after osteotomy may require further The primary indication for total knee Surgical alternatives to surgical intervention in the form of replacement has been and continues total knee replacement arthroplasty. While arthroplasty fol- to be arthritis-related pain that sig- Concurrent with the evolution of the lowing osteotomy is certainly possi- nificantly reduces walking tolerance, modern TKA, other surgical options ble, the procedure can be more com- impairs ability to perform activities for management of knee arthritis were plicated and it is unclear at this time of daily living, and interferes with developing. These options are still whether outcomes following this pro- sleep. Furthermore, such symptoms viable today in appropriate patients cedure are equivalent to primary knee must be resistant to readily available, and include osteotomy, unicompart- arthroplasty.1-3 less invasive, and more cost-effective mental arthroplasty, and patellofemo- management approaches. Once it has ral joint arthroplasty. Unicompartmental arthroplasty been determined that surgical inter- Unicompartmental arthroplasty may vention is warranted, consideration Osteotomy be an option for individuals with must be given to options other than Osteotomy refers to cutting of bone symptoms of isolated compartment total knee arthroplasty, including for the purpose of altering alignment. arthrosis. For isolated medial or lat- osteotomy and isolated compartment In the management of knee arthrosis, eral compartment arthrosis, the surgi- replacement, where appropriate. this most often involves osteotomy of cal indications and contraindications It is critical that both surgeons the proximal tibia in a varus knee with are similar to those for osteotomy. and patients understand that knee medial compartment arthritis. Proxi- Recovery is typically quicker after arthroplasty is not without risk and mal tibia osteotomy has several other unicompartmental arthroplasty than are fully in agreement regarding rea- indications that are beyond the scope after osteotomy, but at this time it is sonable expectations following knee of this article. unclear which of the two is better in arthroplasty. To this end, patient ex- Osteotomy may be considered as terms of function and survivorship.4 It pectations need to be discussed and an alternative to total knee arthroplas- is well understood, however, that total tempered by reality prior to embark- ty, but an understanding of the indi- knee arthroplasty provides superior ing on a knee replacement. Surgeons cations, contraindications, and limita- survivorship when compared with must explain that patient-related fac- tions is essential. Typically, patients both osteotomy and unicompartmen- tors such as obesity and comorbid- are younger than 65, have good range tal arthroplasty. ity can significantly affect outcome of motion (more than 120 degrees and following this increasingly common less than 5 degrees flexion contrac- Patellofemoral joint arthroplasty procedure. ture), have arthrosis isolated to one Although not a common occurrence, compartment only, have no ligamen- symptomatic degenerative change

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Patient-related factors affect the success of the procedure,8-12 of stay and hospital cost, as well as affecting outcome and can also contribute to increased poorer patient-reported outcome.15 After undergoing knee arthroplasty, length of stay and direct medical costs Other studies have found a similar the majority of patients demonstrate following knee arthroplasty.11,13 This relationship between comorbidity significant improvement over their is an area of increasing interest and and decreased patient satisfaction fol- preoperative state. An appreciable study in our current environment of lowing knee arthroplasty.16,17 While minority of patients (10% to 20%) fiscal restraint in health care. good outcomes have been reported demonstrate some degree of func- Despite concerns about the impact in octogenarians and nonagenarians, tional impairment or dissatisfaction of obesity on knee arthroplasty, most postoperative delirium is a major risk despite an absence of identifiable obese patients will benefit from the in this age group. Interviewing fam- technical deficiency or complication.5 procedure. In some patients with mor- ily members to make sure that early A number of patient-related fac- bid obesity, however, knee replace- cognitive impairment is not present tors have been found to contribute to ment should probably not be offered. can lessen the chance of postoperative poor outcome following knee arthro- While each surgeon’s practice varies, delirium occurring. Patients need to plasty. These include, but are not lim- and understanding that body mass be counseled about this real risk prior ited to, obesity, comorbidities, unre- index (BMI) is not necessarily a per- to agreeing to joint replacement sur- alistic expectations, and tolerance to fect measure of obesity, many surgery. Similarly, mental health issues narcotics. It is important that clini- geons would agree that a BMI of 45 to such as anxiety, depression, and pain cians identify patients at risk of poor 50 or greater should be considered a catastrophizing must be considered in outcome in order to counsel them contraindication to joint replacement, the preoperative consultation process, appropriately during the process of and patients should be counseled as these factors have been shown to deciding whether TKA is appropriate. about the importance of weight loss contribute to dissatisfaction and poor as treatment of their life-threatening outcome following arthroplasty.16,18 Obesity condition. Increasingly, bariatric The Canadian Institute for Health surgery is being used to assist in the Expectations Information estimates that 1 in 4 management of morbid obesity and Patient satisfaction is becoming an Canadians are obese and that the rates its long-term health consequences. increasingly important metric in are continuing to increase. Along A recent systematic review indicates health care delivery, particularly in with contributing to the development that bariatric surgery in the setting of publicly funded and third-party pay- of comorbidities such as diabetes, prearthritic knee pain resulted in sig- er systems. Patient expectations can hypertension, and coronary artery nificantly decreased knee pain and contribute significantly to satisfac- disease, obesity can contribute to the stiffness as well as improved function following knee arthroplasty, and development and severity of symp- tion.14 It has not yet been determined should be addressed as part of the tomatic knee arthritis.6 how this approach to weight reduc- informed consent process. It is now Conflicting evidence exists re- tion might affect outcome following well established that unrealistic or garding the impact of obesity on out- knee arthroplasty in previously mor- unmet expectations can lead to patient comes following arthroplasty of the bidly obese patients. dissatisfaction independent of objec- knee and those studies that exist tend tive measures of knee function.19,20 To to be low-level case series. A recent Comorbidities ensure patient expectations are real- systematic review identified 41 stud- As the population ages, the num- istic, the limitations of knee replace- ies looking at this issue and found that ber of elderly patients proceeding to ment surgery must be discussed. the majority, including three system- knee arthroplasty is growing. With Patients who expect to be 100% pain- atic reviews, concluded that obesity increasing age comes increasing free after surgery, to return to a high adversely affected outcome, rate of comorbidity. It is well established level of athletic performance, or to be complications, implant survival, and that such comorbidity can negative- able to squat and kneel unimpeded cost of TKA.7 ly affect outcome following knee will inevitably be disappointed with Obesity can increase the risk of arthroplasty. In a prospective study, the outcome of the operation. superficial and deep infection of sur- Wasielewski and colleagues deter- gical wounds, one of the most signifi- mined that increased comorbidity Tolerance to narcotics cant complications that can arise and was associated with increased length The increasing use of narcotic medi-

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cations in the medical management of When to refer anesthetic is essential and referral for arthritis means that patients may be Referral for total knee arthroplasty is image-guided injection can be uti- on high-dose narcotics prior to sur- appropriate when pain arising from lized. Once the diagnosis is confirmed gery. This can put them at substantial joint failure due to osteoarthritis, on radiographs, there is no need for risk of a poor outcome because their osteonecrosis, rheumatoid arthritis, magnetic resonance imaging. MRI tolerance to narcotics makes safely and other inflammatory arthropathies scans yield no useful information and achieving adequate pain control after is refractory to nonoperative manage- should not be ordered. The first-line surgery almost impossible.21 Escalat- ment. The first step in determining investigation in the assessment of ing doses of narcotics can be needed the need for knee replacement is to knee pain in any patient older than 40 postoperatively, and pain can worsen confirm the diagnosis that surgery is should be standing radiographs and as narcotics are withdrawn. To end the expected to address. Causes of knee not an MRI scan. vicious circle of escalating and reduc- pain other than arthritis must be ruled Once the patient’s symptoms, ing doses, narcotics need to be without, including pain referred from the signs, and radiographic features are drawn gradually or reduced to below hip and lumbar radicular pain. Appro- clinically clear, nonoperative man- 100 mg of morphine equivalent per priate weight-bearing radiographs of agement should be initiated. First-line day prior to joint replacement sur- the knee ( Figure ) and skyline views treatments include activity modifica- gery. Long-acting narcotics need to of the patella must be obtained. If tion, weight loss, and the use of walk- be replaced with immediate-release there is a question regarding the true ing aids such as a cane. Although narcotics and the doses tapered off source of the pain, diagnostic injec- patients may resist such options, a prior to surgery. tions with anesthetic agents can be treatment plan should be discussed helpful. Appropriate placement of the and agreed upon. Acetaminophen and

A B

Figure. Two anteroposterior radiographs of the same knee. The non-weight-bearing radiograph (A) shows minimal medial joint space loss, while the weight-bearing radiograph (B) reveals significant loss.

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 517 Total knee replacement: Understanding patient-related factors

NSAIDs may be added to the treat- gical intervention can be considered ner, orthopaedic surgeon, and internal ment plan if appropriate, although for any patient with ongoing moder- medicine specialist/rheumatologist. long-term NSAID use should be ate to severe pain that is significantly Malnutrition is also a common occur- avoided. If NSAIDs are used, patients affecting quality of life. It is impor- rence in the aging population and can must be monitored for renal and car- tant to refer the patient early once it adversely affect surgical outcomes. diac toxicity. Narcotics should nev- is clear that nonoperative treatment is Appropriate screening tools should be er be used for the treatment of pain failing because surgical outcomes are used and referral made to a dietitian related to osteoarthritis. Patients better when patients are operated on or nutrition support team when prob- should be referred for surgical con- before the disease is at an extremely lems are identified.28 sideration well before narcotics are advanced stage. Although there is interest in even considered as dependence on developing a clinical tool that can be opioids can lead to complications How to optimize outcomes applied preoperatively to predict the and delays in recovery during the When TKA has been deemed appro- likelihood of positive or negative out- postoperative period.21 Other treat- priate and the patient is awaiting come, 29 no such tool is readily avail- ment options, including viscosupple- surgery, any modifiable risk factors able yet. Certainly an outcome predic- mentation, prolotherapy, and injec- should be addressed. Medical treat- tion tool of some kind could improve tions of steroids, platelet rich plasma ment of diabetes and cardiopulmo- the informed consent process as well stem cells, or glucose, lack definitive nary illness should be optimized. as the delivery of health care services, clinical evidence.22-24 Physiotherapy, While there is no evidence that tight including knee arthroplasty. chiropractic treatment, and acupunc- glycemic control prevents complica- ture also lack evidence of significant tions after knee replacement, better Summary benefit.25,26 Joint mobility and patient glycemic control is good for patients Total arthroplasty of the knee con- activity should be encouraged with an in general, and patients contemplat- tinues to be one of the most common emphasis on those activities that limit ing referral for knee replacement surgical procedures as the popula- joint load and focus on cardiovascular surgery should have an HbA1c of tion ages and patients with painful health. 7% or less. Smoking cessation proto- degenerative joint conditions seek Absolute contraindications to cols should be initiated if necessary. high functional capacity in their later knee arthroplasty include active knee Although complete cessation can be decades. Overall, the majority of pa- sepsis, previously untreated or chron- an unrealistic goal for some smok- tients who undergo knee arthroplasty ic osteomyelitis, ongoing remote ers, patients should be informed that have a significant reduction in pain source of infection, absent extensor even a reduction in smoking can lead and improvement in function. How- mechanism, and severe untreated or to a lower risk of perioperative com- ever, outcomes following knee arth- untreatable peripheral arterial dis- plication. Patients who are immuno- roplasty vary and clearly involve a ease. Relative contraindications in- compromised because of medication complex interplay of technical and clude surgical site skin conditions load or illness should be assessed and patient-related factors. Until we have such as psoriasis and excessive scar- appropriate treatment changes should a tool that can reliably predict patient ring, physical and mental conditions be initiated. Immunocompromise is a outcome based on these factors, we that prohibit appropriate rehabilita- common concern for those suffering must focus on appropriate diagnosis tion, morbid obesity, and a neuropath- from rheumatoid arthritis. Many of and patient selection, establish appro- ic joint. Age is not a contraindication the disease-modifying antirheumatic priate expectations, optimize patient to surgery. There is no age cut-off for drugs (DMARDs) such as methotrex- health, and avoid preventable compli- surgery, and patients of all ages may ate and gold can be continued through cations. In this way we will be able be suitable candidates for a knee re- the perioperative period; however, to improve outcomes and maximize placement. the biologic agents associated with patient satisfaction. Once a diagnosis of osteoarthritis the treatment of rheumatoid arthritis has been confirmed clinically and ra- may need to be stopped temporar- Competing interests diographically, nonoperative manage- ily.27 Steroid use should be reduced None declared. ment has been optimized and used for or stopped where possible. Decisions an extended period, and any contra- regarding DMARDs should be made References indications have been ruled out, sur- with input from the family practitio- 1. Amendola A, Bonasia DE. Results of high

518 bc medical journal vol. 58 no. 9, november 2016 bcmj.org Total knee replacement: Understanding patient-related factors

tibial osteotomy: Review of the literature. The influence of obesity on the complica- 23. Rutjes AW, Juni P, da Costa BR, et al. Vis- Int Orthop 2010;34:155-160. tion rate and outcome of total knee arthro- cosupplementation for osteoarthritis of 2. van Raaij TM, Reijman M, Verhaar JA. To- plasty: A meta-analysis and systematic the knee: A systematic review and meta- tal knee arthroplasty after high tibial oste- literature review. J Bone Joint Surg Am analysis. Ann Intern Med 2012;157:180- otomy: A systematic review. BMC Mus- 2012;94:1839-1844. 191. culoskelet Disord 2009;10:88. 13. Kremers HM, Visscher SL, Kremers WK, 24. Rabago D, Best TM, Beamsley M, Patter- 3. Erak S, Naudie D, MacDonald SJ, et al. et al. The effect of obesity on direct med- son J. A systematic review of prolothera- Total knee arthroplasty following medial ical costs in total knee arthroplasty. J Bone py for chronic musculoskeletal pain. Clin J opening wedge tibial osteotomy: Techni- Joint Surg Am 2014;96:718-724. Sport Med 2005;15:376-380. cal issues early clinical radiological results. 14. Groen VA, van de Graaf VA, Scholtes VA, 25. French HP, Brennan A, White B, Cusack Knee 2011;18:499-504. et al. Effects of bariatric surgery for knee T. Manual therapy for osteoarthritis of the 4. Dettoni F, Bonasia DE, Castoli F, et al. High complaints in (morbidly) obese adult pa- hip and knee—A systematic review. Man tibial osteotomy versus unicompartmen- tients: A systematic review. Obes Rev Ther 2011;2:109-117. tal knee arthroplasty for medial compart- 2015;16:161-170. 26. Quilty B, Tucker M, Campbell R, Dieppe P. ment arthrosis of the knee: A review of 15. Wasielewski RC, Weed H, Prezioso C, et Physiotherapy, including quadriceps exer- the literature. Iowa Orthop J 2010;30:131- al. Patient comorbidity: Relationship to cises and patellar taping, for knee osteo- 140. outcomes of total knee arthroplasty. Clin arthritis with predominant patello-femoral 5. Robertsson O, Dunbar M, Pehrsson T, et Orthop Relat Res 1998;356:85-92. joint involvement: Randomized controlled al. Patient satisfaction after knee arthro- 16. Clement ND. Patient factors that influ- trial. J Rheumatol 2003;30:1311-1317. plasty: A report on 27 372 knees operated ence the outcome of total knee replace- 27. Howe CR, Gardner GC, Kadel NJ. Periop- on between 1981 and 1995 in Sweden. ment: A critical review of the literature. OA erative medication management for the Acta Orthop Scand 2000;71-3:262-267. Orthopaedics 2013;1:11. patient with rheumatoid arthritis. J Am 6. Blagojevic M, Jinks C, Jeffery A, Jordan 17. Scott CE, Bugler KE, Clement ND, et al. Acad Orthop Surg 2006;14:544-551. KP. Risk factors for onset of osteoarthritis Patient expectations of arthroplasty of the 28. Gherini S, Vaughn BK, Lombardi AV, Mal- of the knee in older adults: A systematic hip and knee. J Bone Joint Surg Br 2012; lory TH. Delayed wound healing and nutri- review and meta-analysis. Osteoarthritis 94:974-981. tional deficiencies after total hip arthro- Cartilage 2010;18:24-33. 18. Scott CE, Howie CR, MacDonald D, Biant plasty. Clin Orthop Relat Res 1993;293: 7. Rodriguez-Merchan EC. Review article: LC. Predicting dissatisfaction following 188-195. Outcome of total knee arthroplasty in total knee replacement: A prospective 29. Barlow T, Dunbar M, Sprowson A, et al. obese patients. J Orthop Surg (Hong study of 1217 patients. J Bone Joint Surg Development of an outcome prediction Kong) 2015;23:107-110. Br 2010;92:1253-1258. tool for patients considering a total knee 8. Namba RS, Paxton L, Fithian DC, Stone 19. Noble PC, Conditt MA, Cook KF, Mathis replacement—The knee outcome predic- ML. Obesity and perioperative morbidity KB. Patient expectations affect satisfaction study (KOPS). BMC Musculoskelet in total hip and total knee arthroplasty pa- tion with total knee arthroplasty. Clin Or- Disord 2014;15:451. tients. J Arthroplasty 2005;20(7suppl thop Relat Res 2006;452:35-43. 3):46-50. 20. Dunbar MJ, Richardson G, Robertsson O. 9. Dowsey MM, Choong PF. Obese diabetic I can’t get no satisfaction after my total patients are at substantial risk for deep knee replacement: Rhymes and reasons. infection after TKA. Clin Orthop Relat Res Bone Joint J 2013;95-B(11suppl A): 2009;467:1577-1581. 148-152. 10. Samson AJ, Mercer GE, Campbell DG. 21. Zywiel MG, Stroh DA, Lee SY, et al. Chron- Total knee replacement in the morbidly ic opioid use prior to total knee arthro obese: A literature review. ANZ J Surg plasty. J Bone Joint Surg Am 2011;93: 2010;80:595-599. 1988-1993. 11. D’Apuzzo MR, Novicoff WM, Browne JA. 22. Filardo G, Kon E, Di Martino A, et al. Plate- Morbid obesity independently impacts let-rich plasma vs hyaluronic acid to treat complications, mortality, and resource knee degenerative pathology: Study de- use after TKA. Clin Orthop Relat Res sign and preliminary results of a random- 2015;473:57-63. ized controlled trial. BMC Musculoskelet 12. Kerkhoffs GM, Servien E, Dunn W, et al. Disord 2012;13:22.

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Achilles tendon ruptures—a review for primary care

he Achilles tendon is the most Treatment for patients in whom treatment is commonly ruptured tendon Treatment of Achilles tendon rup- begun more than 14 days after injury. and the incidence is increas- tures is currently undergoing transi- Acute Achilles ruptures are most T1-3 ing. Unfortunately, 20% to 25% tion. Traditional treatment involves common in male weekend warriors. of acute Achilles tendon ruptures are 12 weeks of immobilization. If treat- Diagnosis is made with history and misdiagnosed initially.1,4 Diagnosis is ed surgically, the tendon is repaired physical examination. Treatment based on history and physical exami- and the foot immobilized in equinus. can be conservative or surgical, with nation. Use of MRI or ultrasound is Immobilization could be splinting accelerated function rehabilitation not indicated unless there are equivo- followed by casting at 2 weeks, or, offering conservative management cal physical exam findings. more recently, a cast boot with heel the advantages of surgery without the Common mechanisms include wedges. If treated conservatively, the risks. The conservative approach can pushing off with the weight-bearing foot is immobilized in equinus. Both be used only if treatment is initiated foot while extending the knee; a sud- approaches are non-weight-bearing within 14 days of injury. A patient den, unexpected dorsiflexion of the and the foot is incrementally brought diagnosed with acute Achilles rup- ankle; or violent ankle dorsiflexion of up to a neutral position over approxi- ture should be immediately made a plantar flexed foot.1 Patients often mately 6 weeks by recasting or remov- non-weight-bearing, immobilized describe feeling as if they were kicked ing the heel. The second 6 weeks have in equinus, and referred to the local in the back of the ankle. Some will the foot immobilized at 90 degrees. orthopaedic surgeon on call. This have minimal discomfort and may be Some surgeons may opt to allow pro- will allow all treatment options to be weight-bearing. They may describe tected weight-bearing at this point. If available to the patient and treating a “pop” at the time of injury. Fluoro- the injury is identified and treatment surgeon. quinolone or steroid use, diabetes, or started within 14 days, the primary —Derek Smith, MD, FRCSC chronic renal failure can increase the difference between the options is WorkSafeBC Orthopaedic risk of rupture but make small contri- higher re-rupture rates with conser- Specialist Advisor butions to overall incidence.5,6 vative management (meta-analyses The Thompson test is considered found this to be approximately 3% References to be the most accurate—it is positive vs 13%)10,11 vs the risks of surgery. 1. Uquillas CA, Guss MS, Ryan DJ, et al. Ev- in 96% to 100% of acute ruptures.7-9 Some surgeons believe surgical repair erything Achilles: Knowledge update and Other physical findings include a pal- has better functional outcomes, but current concepts in management. J Bone pable tendon gap, tenderness, and this has not been conclusively dem- Joint Surg Am 2015;97:1187-1195. possibly swelling/bruising depending onstrated. 2. Guss D, Smith JT, Chiodo CP. Acute Achil- on injury acuity. In the prone position A multicentre study in 2010 using les tendon rupture: A critical analysis re- with the patient’s feet off the examin- an accelerated functional rehabilita- view. JBJS Rev 2015;3:e2. ing table, the injured foot will hang tion protocol changed the landscape.3 3. Willits K, Amendola A, Bryant D, et al. Op- in more dorsiflexion than the contra- It found no clinically significant dif- erative versus nonoperative treatment of lateral foot. The patient may be able ferences in outcome or re-rupture acute Achilles tendon ruptures: A multi- to plantarflex and the Thompson test rates. This protocol involved limited center randomized trial using accelerated may result in some movement, but immobilization with early motion. functional rehabilitation. J Bone Joint Surg in both cases the injured side will be The original protocol (see Table ) 3 Am 2010;92:2767-2775. weaker and decreased compared with has since been slightly modified by 4. Cooper MT. Acute Achilles tendon rup- the uninjured side. This is due to other various surgeons. This approach is tures: Does surgery offer superior results musculotendinous structures that pass currently used by a significant number (and other confusing issues)? Clin Sports the ankle posteriorly. of orthopaedic surgeons in BC. Other Med 2015;34:595-606. studies have validated the results of 5. Raikin SM, Garras DN, Krapchev PV. Achil- this approach.12-15 There may be an les tendon injuries in a United States pop- This article is the opinion of WorkSafeBC advantage of earlier return to work ulation. Foot Ankle Int 2013;34:475-480. and has not been peer reviewed by the with surgical intervention.12 Surgical 6. Sode J, Obel N, Hallas J, Lassen A. Use BCMJ Editorial Board. treatment remains the primary option of fluroquinolone and risk of Achilles ten-

520 bc medical journal vol. 58 no. 9, november 2016 bcmj.org worksafebc

don rupture: A population-based cohort tures: A systematic overview and meta- a recent Cochrane review. J Bone Joint study. Eur J Clin Pharmacol 2007;63: analysis. Clin Orthop Relat Res 2002; Surg Am 2012;94:e88. 499-503. (400):190-200. 14. Olsson N, Silbernagel KG, Eriksson BI, et 7. Thompson TC, Doherty JH. Spontaneous 11. Khan RJ, Fick D, Keogh A, et al. Treatment al. Stable surgical repair with accelerated rupture of tendon of Achilles: A new clini- of acute Achilles tendon ruptures. A meta- rehabilitation versus nonsurgical treat- cal diagnostic test. J Trauma 1962;2: analysis of randomized, controlled trials. J ment for acute Achilles tendon ruptures: 126-129. Bone Joint Surg Am 2005;87:2202-2210. A randomized controlled study. Am J 8. O’Brien T. The needle test for complete 12. Soroceanu A, Sidhwa F, Aarabi S, et al. Sports Med 2013;41:2867-2876. rupture of the Achilles tendon. J Bone Surgical versus nonsurgical treatment of 15. Keating JF, Will EM. Operative versus non- Joint Surg Am 1984;66:1099-1101. acute Achilles tendon rupture: A meta- operative treatment of acute rupture of 9. Inglis AE, Sculco TP. Surgical repair of rup- analysis of randomized trials. J Bone Joint tendo Achillis: A prospective randomised tures of the tendo Achillis. Clin Orthop Surg Am 2012;94:2136-2143. evaluation of functional outcome. J Bone Relat Res 1981;(156):160-169. 13. Jones MP, Khan RJ, Carey Smith RL. Sur- Joint Surg Br 2011;93:1071-1078. 10. Bhandari M, Guyatt GH, Siddiqui F, et al. gical interventions for treating acute Treatment of acute Achilles tendon rup- Achilles tendon rupture: Key findings from

Table. Achilles tendon rupture rehabilitation protocol.

Time frame Activity 0–2 weeks Posterior slab/splint; non-weight-bearing with crutches: immediate post-op in surgical group, after injury in non-op group 2–4 weeks Aircast walking boot with 2-cm heel lift*† Protected weight-bearing with crutches Active plantar flexion and dorsiflexion to neutral, inversion/eversion below neutral Modalities to control swelling Incision mobilization modalities‡ Knee/hip exercises with no ankle involvement (e.g., leg lifts from sitting, prone, or side-lying position) Non-weight-bearing fitness/cardiovascular exercises (e.g., bicycling with one leg, deep-water running) Hydrotherapy (within motion and weight-bearing limitations) 4–6 weeks Weight-bearing as tolerated*† Continue 2–4 week protocol 6–8 weeks Remove heel lift Weight-bearing as tolerated*† Dorsiflexion stretching, slowly Graduated resistance exercises (open and closed kinetic chain as well as functional activities) Proprioceptive and gait retraining Modalities including ice, heat, and ultrasound, as indicated Incision mobilization‡ Fitness/cardiovascular exercises to include weight-bearing as tolerated (e.g., bicycling, elliptical machine, walking or running on treadmill, stair climber) Hydrotherapy 8–12 weeks Wean off boot Return to crutches or cane as necessary and gradually wean off Continue to progress range of motion, strength, proprioception >12 weeks Continue to progress range of motion, strength, proprioception Retrain strength, power, endurance Increase dynamic weight-bearing exercise, include plyometric training Sport-specific retraining

* Patients were required to wear the boot while sleeping. † Patients could remove the boot for bathing and dressing but were required to adhere to the weight-bearing restrictions according to the rehabilitation protocol. ‡ If, in the opinion of the physical therapist, scar mobilization was indicated (i.e., the scar was tight or not moving well), the physical therapist would attempt to mobilize using friction, ultrasound, or stretching (if appropriate). In many cases, heat was applied before beginning mobilization techniques.

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New procedure for Planning your family: Updated wills CL19 medical reports The insurance essentials Another priority is having an updated ICBC has adopted new policy and As physicians plan to start their fami- will. If a child under 18 is designated procedures for completing the CL19 lies in the province of BC, there are as a beneficiary, a trustee should be Medical Report. The new approach is important considerations to think designated to receive funds on the as follows: about. child’s behalf. Instructions that stipu- • ICBC agrees that a physician need late at what age, percentage, and cir- only complete and return a CL19 Life insurance cumstance the funds are to be trans- based on a review of the patient’s file. The first and foremost is to increase ferred to the child should be included. • A special or separate office visit is life insurance. Life insurance cover- If no trustee is elected, the funds will not required for the purpose of com- age is calculated to cover immediate be paid to the courts. pleting the CL19. needs such as a mortgage or other • ICBC currently pays a fee of loans to allow the surviving spouse to Health and dental coverage $193.54 (inclusive of bonus) for the live debt-free in the event of a death. If a physician has health and den- CL19, when completed. If there is a new dependent child, it tal coverage through the Doctors of • If a physician informs ICBC that is important that life insurance cov- BC Health Benefits Trust Fund, it is they intend to bill the CL19 at a ers costs of raising the child, includ- important to add the child to the plan rate higher than ICBC pays, ICBC ing education costs and a monthly within 90 days of birth/adoption. Dur- has indicated they will confirm the income for the child until he or she ing this period proof of health for the withdrawal of their request. reaches adulthood. Coverage increas- child is not needed. After 90 days has • The choice of whether to charge a es depend on the child’s age. For passed, proof of health is required higher rate is up to the individual example, if the child is 5 years old, and the child could be accepted or physician. you may need to account for 13 to 15 declined for coverage. Remember that when a request years of monthly income before the for records other than a CL19 occurs, child becomes financially indepen- Disability insurance as per the standards of the College of dent. The policyholder determines the Many physicians are not aware that Physicians and Surgeons of BC, you number of years of income the child disability insurance covers disability should obtain clear authorization from receives and the amount of income resulting from complications of preg- the patient or patient’s legal represen- received per month, and the insurance nancy. This includes complications tative to release that information. coverage is increased accordingly. from a cesarean section, whether the For questions or concerns around procedure was elective or otherwise. procedures, contact Ms Juanita Parental leave program Grant, Physician and External Affairs Insurance advisors also strongly rec- Critical illness insurance Department at [email protected] ommend that physicians look into the Physicians who have critical illness or 604 638-2829. parental leave program. Physicians insurance can consider adding a child paid by the Medical Services Plan on critical illness option to their cover- Congratulations a fee-for-service or sessional basis, or age. The plan includes an optional from the BCMJ paid under a nonsalaried service con- child rider offering up to $20 000 if At this year’s UBC Medical Student tract in the calendar year prior to the the child becomes ill or develops one Orientation Day, first-year students commencement of a leave, are eligi- of six specific childhood conditions had an opportunity to enter to win an ble for benefits. The program provides covered by the plan. If added, the iPad by signing up to receive each up to $1000 per week for 17 weeks chosen coverage amount will apply to issue’s table of contents by e-mail. over a 52-week period to BC physi- each child, and no matter how many Congratulations to Vionarica Gusti, cians who take a leave from practice children are in the family, there is winner of the draw, and thank you to as a result of the birth or adoption of only one low premium. everyone who entered. a child. In addition, physicians can To start receiving the BCMJ table have their Doctors of BC membership Accidental death and of contents by e-mail, visit bcmj.org dues reduced while on parental leave. dismemberment insurance and click on the Sign-up for e-alerts Adding a family option for the depen- button. dent child to accidental death and dis-

522 bc medical journal vol. 58 no. 9, november 2016 bcmj.org pulsimeter memberment insurance means that, in ing a new program to secure frail To predict future rates of COPD the unfortunate event of the death of and elderly seniors better access to disease, researchers at UBC con- the child, 10% to 15% of the policy family doctors. ducted forecasting analyses, com- holder’s coverage will be given to the • Dr Christopher Wong, an infectious bining population statistics and living parents. disease specialist at Royal Colum- health data for BC, and concluded For more information regarding bian Hospital, was celebrated for that between 2010 and 2030 the any of these recommendations, con- spending a lifetime innovating to number of COPD cases in the prov- tact a Doctors of BC advisor at 604 fight infectious disease. ince will increase by more than 735-5551, or learn more at www Two of the teams recognized 150%—despite decreased rates of .doctorsofbc.ca. with awards also included physician smoking. Among seniors over 75 —Ada Lo members: years of age, the number of cases UBC Medical Student, Year 2 • Dr Julian Pleydell-Pearce and the will increase by 220%. Researchers Doctors of BC Student Liaison Pediatric Observation Unit team at expect the BC-based predictions to Chilliwack General Hospital, who be applicable to Canada and other Practice Support: 1300 docs realized their dream of a dedicated industrialized countries. Nearly 1300 doctors participated in space for their smallest patients. Senior author Dr Mohsen Sadat- 80+ Practice Support Program learn- • Dr Shelley Tweedle and the Pre- safavi, assistant professor in the ing modules within the last year, Admission Clinic team at Royal Faculties of Pharmaceutical Sci- with many commenting in part that Columbian Hospital, who adapted ences and Medicine, identified that the modules improved their care for clinic procedures to end long waits people think COPD will soon be a people with mental health issues and and put patients first. problem of the past because smok- allowed them to provide more than ing is declining in the industrialized just meds. To learn more visit www Resource for treating obese world. But aging is playing a much .pspbc.ca. or overweight child patients Continued on page 524 MEND (Mind, Exercise, Nutrition… Physicians honored with Do it!) is a free, 10-week program that Above & Beyond Awards family physicians can recommend to Several Fraser Health physicians families with children age 7 to 13 The KEY to SUCCESS with have been honored with a Fraser who are moving away from a healthy SPEECH RECOGNITION Health Above & Beyond Award. weight trajectory and whose BMI is at Each year, Fraser Health recognizes or above the 85th percentile for age. ® the employees, physicians, and vol- Through group sessions that focus Certifi ed Dragon unteers who go above and beyond to on healthy eating and meal planning, Medical Software improve patient care and services in physical activity, and goal setting, the Sales & Training local communities. This year, Fraser early intervention program aims to Health celebrated 19 individuals and reduce the risk of children developing teams making a difference every day weight-related physical and mental One-on-one training sessions in health care. health problems later in life. Families Customized to your workfl ow Among the winners were four can contact the MEND coordinator in and specifi c needs individual physicians working at sites their community and find more infor- Complete initial, basic, and across Fraser Health: mation at www.bchealthykids.ca or advanced instruction available • Dr Shikha Minhas, a palliative care contact Leah Robertson, MEND pro- Exclusive and professionally physician at Surrey Memorial Hos- vincial manager, at leah.robertson@ written training materials pital, was honored for helping pa- cw.bc.ca. Follow up assistance and support tients pass peacefully. Dr Joelle Bradley, a hospitalist at Study: COPD • Solutions Royal Columbian Hospital, was epidemic looms awarded for enabling important dis- Despite a decline in smoking rates, an CONTACT US TODAY! cussions about advance care plan- epidemic of chronic obstructive pul- ning. monary disease (COPD) is expected Dr Nick Petropolis, a family physi- over the next 2 decades, according to speakeasysolutions.com • 1-888-964-9109 cian with the Fraser Northwest Di- a new study from the University of vision, was recognized for launch- British Columbia.

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 523 pulsimeter

Continued from page 523 perspective,” is published in the Using a synthetic peptide known as bigger role and that factor is often American Journal of Respiratory and DJK-5, they were able to interfere ignored. Lead author Amir Khak- Critical Care Medicine. with the bacteria’s stress response ban, health economist in the Faculty and heal abscesses in mice. The pep- of Pharmaceutical Sciences at UBC New weapon for hard-to- tide was effective against two classes and the Centre for Health Evalua- treat bacterial infections of bacteria, known as gram-positive tion and Outcome Sciences, notes Researchers at the University of Brit- and gram-negative bacteria, whose that age-adjusted COPD rates have ish Columbia have successfully pre- different cell wall structures make remained constant as smoking rates vented drug-resistant bacteria from them susceptible to different antibiot- have declined. forming abscesses using a peptide, ics. Professor Hancock hopes to begin Researchers suggest that COPD which worked by disrupting the bac- clinical trials on human infections will overtake all other diseases of teria’s stress response. Abscesses are within a year. aging over the coming decades, and responsible for 3.2 million emergency The study, “Bacterial abscess for- the associated health care costs of car- room visits every year in the United mation is controlled by the stringent ing for these patients will be signifi- States, and standard treatment for stress response and can be targeted cant. The study predicts that annual abscesses involves cutting out the therapeutically,” appears online in inpatient days related to COPD will infected tissue or draining it. EBioMedicine. grow by 185%. Senior author Bob Hancock, a The UBC team is focusing on professor in UBC’s Department of Uncovering cancer’s driving research and innovation to Microbiology, clarified that the pep- invisibility cloak change this trajectory with therapeu- tide offers a new strategy because its UBC researchers have discovered tic and biomarker solutions that pre- mechanism is completely different how cancer cells become invisible to vent and treat COPD. from every known antibiotic. Pro- the body’s immune system, a crucial The study, “The projected epi- fessor Hancock and his colleagues step that allows tumors to metastasize demic of COPD hospitalizations over discovered that bacteria in abscesses and spread. As cancer cells evolve the next 15 years: A population based are in a stress-triggered growth state. Continued on page 525 Haughton_SCF_BCMJ_1/2H_Jan2017_Haughton_SCF_BCMJ.qxd 2016-10-20 10:46 PM Page 1

Join the Section of Clinical Faculty (SCF) of Doctors of BC Your membership in the Section of Clinical Faculty allows us to inform you of progress on issues such as: • How to ensure clinicians are supported to provide excellent teaching. • What is the impact of teaching on patient wait-times and physician workload? • Does teaching affect the number of procedures performed in operating rooms? • Is teaching required for hospital privileging? • Is teaching required for access to O.R. time? • Does your UBC academic rank determine your clinical income? If so, why? If not, will it in the future? In order to help you, we need you to become a member of SCF. Your first year of membership is free, and $50/year thereafter. Sign up via the Doctors of BC website or the Section website: http://www.ucfa.ca/how-to-join

524 bc medical journal vol. 58 no. 9, november 2016 bcmj.org billing tips

Telephone fees: SSC fee items 10001, 10002, 10003, and 10004

t has come to the attention of the all of the requirements in the respec- ensuring that an appropriate commu- Patterns of Practice Committee tive fee notes, including the time of nication modality is used to meet the I that specialists may be billing fee the initiating request and the time of medical needs of the patient. items 10001, 10002, 10003, or 10004 response, as well as the advice given This fee applies to telephone and and not documenting correctly, or and to whom it was given. video technology communication misinterpreting how to apply a par- Section A. 2. Introduction to the (including other forms of electronic ticular fee item. General Preamble vii) requires “Mak- verbal communication) between the ing and maintaining an adequate specialist physician and patient, or a Lack of documentation medical record of the encounter that patient’s representative. It is not pay- If you are a specialist billing the Spe- appropriately supports the service able for written communication (i.e., cialist Services Committee (SSC) being claimed. A service for which an fax, letter, or e-mail). telephone fees (10001, 10002, 10003, adequate medical record has not been If you receive a normal test or 10004), you are required to create recorded and retained is considered result and would not normally book an adequate medical record for each not to be complete and is not a benefit an appointment with the patient to patient encounter as defined in the under the Plan.” inform them of the result, then the fee Preamble to the Doctors of BC Guide should not be billed for relaying the to Fees. This involves documenting Misinterpretation of fee item result over the phone. 10003 For fee items G10001, G10002, This article is the opinion of the Patterns of The purpose of fee item 10003 (spe- G10003, and G10004, please refer to Practice Committee and has not been peer cialist patient management) is for the section D. 1. (Telehealth Services) of reviewed by the BCMJ Editorial Board. For specialist to provide real-time advice the General Preamble. further information contact Juanita Grant, when the intent of communication is —Keith J. White, MD audit and billing advisor, Physician and Ex- to replace the need for the specialist Chair, Patterns of Practice ternal Affairs, at 604 638-2829 or jgrant@ to see the patient in person. The con- Committee doctorsofbc.ca. sulting specialist is responsible for

pulsimeter

Continued from page 524 over time they may lose the ability to and Immunology at UBC. Working create a protein known as interleuke- with researchers at the Vancouver in-33 (IL-33). When IL-33 disappears Prostate Centre to study several hun- in the tumor, the body’s immune sys- dred patients, study authors found that

tem has no way of recognizing the patients with prostate or renal cancers cancer cells and they can begin to whose tumors have lost IL-33 had metastasize. more rapid recurrence of their cancer Researchers found that the loss of over a 5-year period. They will now

IL-33 occurs in epithelial carcinomas, begin studying whether testing for

including prostate, kidney, breast, IL-33 is an effective way to monitor lung, uterine, cervical, pancreatic, the progression of certain cancers. skin, and many others. The study, “Discovery of a meta- Professor Wilfred Jefferies is a static immune escape mechanism ini- senior author of the study, working in tiated by the loss of expression of the the Michael Smith Laboratories and tumour biomarker interleukin-33,” as a professor in the Departments of was published in the journal Scien- Medical Genetics and Microbiology tific Reports.

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 525 in memoriam

Dr Eugene Giuseppe nature, and humor has put the prac- Vancouver as Dr DIC.) After return- Caira, 1918–2016 tice of art into the practice of surgery ing to Toronto for further training he to the benefit of his patients.” was subsequently recruited by Drs Dr Caira Eugene’s family would like to Mac Whitelaw and Wally Thomas to passed away extend their heartfelt gratitude to join UBC and the staff at VGH. With with his his dear friends and staff at Lake- Dr George Gray he directed the hema- family by side Manor, where he spent the last tology lab at VGH for many years. his side on 3 years with the help of We Care Dr Naiman became the province’s 5 September Home Health, and for the wonderful first full-time clinical hematologist 2016 at Shu care Eugene received from Dr Her- and subsequently the first head of the swap Lake man Venter and the exceptional staff UBC Division of Clinical Hematol- General at Shuswap Lake General Hospital, ogy. During this time he also joined Hospital in Salmon Arm, during his final weeks. the first examining board of the new Salmon Arm in his 98th year. Dr Cremation has taken place, and a Royal College of Physicians and Sur- Caira was the cherished father of celebration of Dr Caira’s life was held geons of Canada subspecialty of clini- Loren, Janine, Nadia (Dave), Daren at the Prestige Harbourfront Resort in cal hematology. (Jeff), Martene (Mark), Rachel (Tim), Salmon Arm on 23 September. Chari- During the 1970s and 1980s Dr and Leean; and dearly loved Nonno table donations may be made in lieu Naiman traveled with his popular (Granddad) of Anders, Kristian, Ste- of flowers to Shuswap Lake General hematology road shows around the fan, Katja, Drew, Caira, and Briar. Hospital. Online condolences may province where he educated and be- Dr Caira studied medicine at the be sent through Dr Caira’s obituary friended many practitioners. After 15 University of St. Andrews for Medi- at https://memoryleaf.net/dr--eugene years of frustration with the outcomes cine in Glasgow, Scotland, from 1943 -caira. of acute leukemia treatment in adults, to 1948, and in 1949 he was admitted —Nadia Caira Dr Naiman helped organize the Bone to the Royal College of Physicians of 100 Mile House Marrow Transplant Program at VGH Edinburgh. In 1956, after complet- in 1979. Overall, he practised hema- ing his master’s of science in experi- Dr Sheldon C. (Shelly) tology for over 40 years at both VGH mental surgery at the University of Naiman, 1937–2016 and St. Paul’s Hospital in Vancouver. McGill, Montreal, he was accepted Dr Naiman was a shining ex- into the Royal Faculty of Physicians Dr Sheldon ample—and one of the last—of a and Surgeons of Glasgow. In 1959 C. Naiman hybrid clinical and laboratory hema- Dr Caira obtained his certification passed away tologist and was widely regarded as as a general surgeon, and in 1972 he in July 2016 an outstanding educator. His lengthy became a Fellow of the Royal Col- following a consultation letters and impromptu lege of Surgeons of Canada. Dr Caira short illness. lectures on virtually any area of the dedicated his life to his profession Dr Naiman specialty were a testament to his vast as a respected general surgeon who was a be knowledge and experience. He re- was qualified in the United Kingdom, loved family ceived several master teacher awards, British Guiana (Guyana), and Cana- man and a and many students considered him to da. He was also instrumental in bring- mentor to many individuals in the be the best teacher they had ever had. ing the first nuclear medicine scintil- medical community in BC. Even as his sight was failing he was lation camera to Canada in 1970. Born in Toronto, Dr Naiman still considered the go-to person for Eugene will be remembered for graduated from the University of difficult blood film and bone marrow his lively personality, sense of humor, Toronto in 1962. After medical school interpretation. In 2009 he received the and his love for all things alive. He he moved to California and while at prestigious Dr Cam Coady Founda- was known as a mean painter and an the Los Angeles County Hospital he tion Medal of Excellence. able golfer by his friends. He was became interested in bleeding and Shelly was a true mensch, always described by a very dear friend as “an clotting problems and decided to finding time for family and friends astute diagnostician and a skilled gen- pursue a career in hematology. (Dr as well as for his patients. He and his eral surgeon whose humanity, good Naiman later became well known in wife, Dr Linda Vickars, were a true

526 bc medical journal vol. 58 no. 9, november 2016 bcmj.org in memoriam force, working together for over 20 Ted found his interests in theatre, cal practitioners, like Doctors of BC. years at St. Paul’s Hospital. They music, philosophy, and Christianity After several decades as a physi- were also passionate about traveling repeatedly drawing him into the circle cian, Ted sought a new career, feeling and visited all seven continents before of Phyllis Parham, the young woman that administrative and philosophi- Linda’s untimely death in 2014. While who became his wife. Married in cal changes had moved medicine and traveling they consulted for their 1958, Ted and Phyllis continued to academia away from his ideals. He friend, Dr George Deng, in Chengdu, debate these themes, then with their and Phyllis acquired Page’s Resort China, and contributed to the annual five children and, still later, seven & Marina on Gabriola Island where postgrad hematology course in India. grandchildren. Characterizing their he became as dedicated to the island Shelly and Linda created an en- relationship, Phyllis said they’d been community as he had been to his med- dowment at the UBC Centre for discussing Sartre for 60 years. ical practice. Together, Ted and Phyl- Blood Research, and the multipur- But Bishop’s University held fur- lis nurtured their business and sup- pose lab in the Life Sciences Centre ther attractions for Ted. It was there ported the arts, opening their home has been named after them. that he began in earnest the scien- for concerts, book launches, and art Shelly was particularly grateful tific career that would bring him to exhibitions. for the care given him by his lifetime organ transplantation’s leading edge. In his 60s, Ted was diagnosed personal physician and good friend, Following his bachelor’s degree in with hepatitis C, likely picked up dur- Dr Lyle Levy, and was overwhelmed mathematics and physics, Ted studied ing his medical career. As his battle by the compassionate attention shown medicine at McGill University before with the disease stiffened he was for- to him by the ICU staff at VGH during he and his young family moved west tunate to have had the sympathetic his last hospitalization. for a residency at St. Paul’s Hospital care of Dr Francois Bosman. Ted’s Dr Naiman is survived by his five in Vancouver and a postdoctoral fel- suffering, however, did not diminish children and their mother, Marcia lowship at UCLA. his compassion; rather than lamenting Schultz; his brother, Neil; and eight The science thrilled him, but so did that new treatments arrived too late grandchildren. the opportunity and responsibility of for him, he worried that their exorbi- —Gershon Growe, MD treating acutely ill patients, regardless tant pricing limited their accessibility. Vancouver of their background. It was a matter Ted is survived by Phyllis and their —The Naiman family of pride for Ted that when he and his children: Dorothy (Jacques), Charles Vancouver colleagues brought transplantation to (Amy), Gloria (Ken), Elizabeth, and British Columbia they didn’t just help Henry (Tiffani). His beloved family Dr Charles Edward (Ted) pioneer this therapy, they did so in an also includes grandchildren Christo- Reeve, 1936–2016 environment where it was available pher, Amandine, Nicolas, Stephanie, to unemployed cafeteria cooks and Michelle, Lioba, and Charlie. His sis- Directing self-made millionaires equally. This ter Helen, brother Norman, and par- British emphasis on quality of life led him ents Charles and Dorothy predeceased Columbia’s to branch out from nephrology and him. He was blessed with numerous kidney transplantation to related research in cherished friends who, along with his transplant immunology, hematology, and genet- wife and family, miss him dearly. program for ics, and to frequent involvement in —Charles Reeve, Jr., PhD 19 years the organizations and committees Toronto might seem that governed and lobbied for medi- an unexpected destiny for a skinny kid from small town Recently deceased physicians Alberta, but Dr Ted Reeve’s trajectory If a BC physician you knew well is recently deceased, consider submitting had a logical—albeit idiosyncratic— a piece for our “In Memoriam” section in the BCMJ. Include the path that made such an outcome all deceased’s dates of birth and death, full name and the name the deceased but inevitable. was best known by, key hospital and professional Born in Stettler, Alberta, to an affiliations, relevant biographical data, and a high- Anglican priest and his schoolteacher resolution photo. Please limit your submission to a wife, Ted grew up in Calgary before maximum of 500 words. Send the content and photo by attending Bishop’s University, as his e-mail to [email protected]. parents had before him. While there,

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 527 gpsc

Division-created patient resources: Empowering patients to make healthy choices

ducating patients about their for Me initiative, and in some cases Recognizing the value of this in- health and the health care sys- the learning materials created have formation to patients, the Chilliwack Etem can help to ensure that been repurposed by other divisions in Division adapted these materials for they make healthy, informed choices communities around the province. use in their own Appropriate Access and feel engaged in their own care. A to Care campaign. Chilliwack’s pro- growing number of divisions of fam- Primary care options gram also features a series of nine ily practice have developed patient Ensuring patients know where to go to videos that define primary care for education and awareness campaigns, receive appropriate care can strength- patients, advise them on preparing for giving GPs the opportunity to contrib- en GP-patient attachment and reduce a medical appointment, and provide ute their knowledge to the creation of low-acuity visits to the ER. These information on how to keep track of community-specific resources that were the goals of White Rock–South medications. The Kootenay Bound- can help improve the health and expe- Surrey Division’s Right Care, Right ary Division also adapted White riences of their patients. Place campaign, produced in collabo- Rock–South Surrey’s materials to cre- Division-organized patient educa- ration with Fraser Health and Peace ate their own Right Care, Right Place tion and awareness campaigns cover Arch Hospital. The campaign informs materials specific to their region. topics such as how to prepare for doc- patients of various primary health care The Richmond Division designed tors’ appointments, how and where to options available in the region that their own unique materials for their access appropriate care, and how to may be appropriate for their health Think Where for Care campaign, make healthy lifestyle choices. Many care needs. The campaign features a which they developed in partnership of these resources were developed rack card, video, and poster encourag- with VCH, the City of Richmond, through divisions’ work on the A GP ing patients to “call your doctor first” HealthLink BC, and SUCCESS. and suggesting when they might call Campaign materials include pam- This article is the opinion of the GPSC and 811 (HealthLink BC), speak with a phlets, posters, and rack cards titled has not been peer reviewed by the BCMJ pharmacist, access a walk-in clinic, “Why Have a Family Doctor?” and Editorial Board. or visit the ER (or call 911). “A Visit to Your GP,” and a health literacy puppet show video. All ma- Table. Division-created patient education resources. terials, including the informational video, are available in four languag- Division Resource Online access es—English, Cantonese, Punjabi, and Burnaby Empowering Patients www.divisionsbc.ca/burnaby/ Mandarin—to address the needs of empoweringpatients the community’s ethnic and immi- Central Healthy Initiatives http://healthyinitiatives.ca www. grant populations. Okanagan Get Regular with Your GP divisionsbc.ca/cod/posters

Chilliwack Appropriate Access to Care www.divisionsbc.ca/chilliwack/ Importance of the Mini Medical School agpformevideos physician-patient Healthy Kids Initiative: www.divisionsbc.ca/chilliwack/minimed relationship Live 5-2-1-0 www.divisionsbc.ca/chilliwack/hkilogin While some of the patient/public Kootenay Right Care, Right Place www.divisionsbc.ca/kb/careoptions campaigns outlined above incorpor- Boundary ate information that helps patients make the most of their time with their Richmond Think Where for Care www.divisionsbc.ca/richmond/ whereforcare doctor, two divisions have created campaigns specifically promoting the Sunshine Empowering Patients www.divisionsbc.ca/sunshine-coast/ Coast empoweringpatients physician-patient relationship. Cen- tral Okanagan Division’s Get Regular Vancouver Talk to Your GP www.divisionsbc.ca/vancouver/ with Your GP posters build awareness talktoyourgp about the ways in which a good rela- White Rock– Right Care. Right Place www.divisionsbc.ca/white-rock-south tionship with a GP can result in better South Surrey -surrey/rcrp health outcomes. The posters, which

528 bc medical journal vol. 58 no. 9, november 2016 bcmj.org gpsc remind patients to inform their doctor online resource for residents to find care, healthy kids, brain injury, public of all health concerns, be proactive in local fitness facilities and parks, health strategies, and more. their health, and prepare for their ap- fresh food choices, and doctors’ The Burnaby Division has creat- pointments, can be downloaded from offices and clinics. ed a public education program called the division’s website. Chilliwack Division’s Healthy Empowering Patients, comprising a The Vancouver Division has cre- Kids Initiative provides a number of wide array of presentations and infor- ated the Talk to Your GP campaign, a printable resources to educate kids mation sheets for a patient audience. series of FAQ videos that feature divi- and families about the Live 5-2-1-0 Topics include heart disease, blood sion members providing a physician’s health message. Materials include pressure, diabetes, healthy eating, perspective on topics such as why it’s a coloring sheet, rack card, support emotional wellness, healthy physical important to have a good relationship booklet, goal trackers, a poster, and activity, and information about hos- with a GP, how GPs can help their a Healthy Balance for Life Medicine pital stays. These materials are avail- patients when they’re admitted to Wheel produced in partnership with able for use by all other divisions, hospital, what kind of information is the Stó:lō Service Agency. and the Sunshine Coast Division has important for patients to tell GPs, and The Chilliwack Division also repurposed them for their own local what patients can do to enhance the provides local residents with a Mini audience. care they receive from their GP. Medical School information series, Please see the Table for a list of through which they can get informa- division-created patient education Healthy eating, tion on various health topics from resources, and contact divisions@ lifestyle, and general doctors, residents, and other health doctorsofbc.ca to learn more about health information professionals. The information series, adapting these materials for use in Many divisions have created patient put on by medical residents through your own community. education resources that encourage the local UBC Medical Residency —Afsaneh Moradi healthy choices and lifestyles. Cen- program, has created a repository of Initiatives Lead, Divisions of tral Okanagan Division’s Healthy presentations and resources on topics Family Practice Initiatives website serves as an relating to mental health, end-of-life

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530 bc medical journal vol. 58 no. 9, november 2016 bcmj.org calendar

FALL/WINTER CME CRUISES by students at all levels of training. based research and in the popularity FROM SEA COURSES Accreditation: RCPSC MOC Section of its use. Join us for this 3-day expe- November 2016–March 2017 1 credits (pending). Fees: $99 (pro- riential workshop on mindfulness and Travel with the CME cruise experts. fessionals); $49 (students). Registra- meditation as they relate to the unique Discover new destinations. Return to tion: http://cbr.ubc.ca/events/earl-w challenges and blessings of our work favorite ports. Costa Rica (Nov), Tahiti -davie-symposium/. as physicians. Learn about the latest & Marquesas (Nov), Caribbean (Dec, clinical evidence and neuroscience Mar & Apr), South America (Jan), ESSENTIAL MEDICAL-LEGAL on mindfulness in medicine, find out Australia/New Zealand (Feb), Mexi- TOOLKIT about programs offered throughout co (Feb), Bali–Singapore (Feb). Trips Vancouver, Various dates BC and Canada, and explore practical planned by physicians for physicians. This program is suitable for family meditation tools for yourself and for Sea Courses has provided almost 300 physicians and specialists and will be your patients. Accrediation: 32 cert + unique CME conferences onboard held at UBC Robson Square. Medical group learning credits. Visit drmark cruise ships over the past 20 years. Legal Reports: The Essentials, will be sherman.ca for more info or contact Programs are accredited for specialists held 9 a.m. to 4 p.m., 26 Nov (Sat), [email protected] to register. and family physicians, have no phar- and 25 Feb (Sat). If writing medical ma-sponsorship and include a compli- legal reports causes you stress, if you BCMJ CME CRUISE mentary enrichment program for trav- are not sure what to write when asked Mexico, 9–21 Feb (Thu–Fri) elling companions. All Sea Courses about prognosis, unsure of what to do 12-night Quintessential Mexican— trips offer group pricing, special air- about patients’ subjective complaints, Family Practice Refresher onboard the fares, and free cruising for compan- or how much you should be billing for Azamara Quest. San Diego round trip ions. Contact Sea Courses Cruises for your reports, then this is the course sailing the Baja California and the Sea more information and details of cur- you want to attend. Medical Legal of Cortez. Ports of call include Cabo rent promotions. Phone 604 684-7327 Reports Advanced and Testifying in San Lucas (water sports, nightlife, and or toll free 1-800-647-7327; e-mail Court: Becoming a Great Expert, will nature), La Paz (see jumping Mobula [email protected]. 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Cruise price tion, and cardiovascular and neurovas- .medlegaltoolkit.com. includes all gratuities, bottled water, cular disease, and facilitates knowl- soft drinks, specialty coffees and teas, edge exchange between researchers MINDFULNESS IN standard spirits, international beers and physicians. This symposium will MEDICINE—FOUNDATIONS and wines, shuttle service to and from focus on cutting-edge advances in the OF THEORY AND PRACTICE ports where available, and English but- understanding and treatment of hemo- Brentwood Bay Resort, 2–4 Dec ler service for suite guests. Escape the philia, thrombosis, and bleeding dis- (Fri–Sun) winter and book now for this exciting orders. Highlights of the symposium As chronic stress and its associated voyage. For registration and informa- include keynote presentations by Drs mental and physical health challenges tion contact Sea Courses at cruises@ Nigel S. Key and John W. Wiesel, a continue to rise in epidemic propor- seacourses.com. Tel: 1 888 647-7327. lineup of leading local and interna- tions, the application of mindfulness Continued on page 532 tional speakers, talks by patients, and in clinical practice settings has gained selected oral and poster presentations prominence both in terms of evidence-

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 531 calendar

Continued from page 531 award-winning CME in medical cog- SOUTH PACIFIC CRUISE GP IN ONCOLOGY TRAINING nitive behavior therapy—Medical 15–29 Apr 2017 (Sat–Sat) Vancouver, 20 Feb–3 Mar (Mon–Fri), CBT: Ultra-brief techniques for real The world’s most romantic destina- and 11 Sep–22 Sep 2017 (Mon–Fri) doctors. The Maui workshop (CBT tions, from French Polynesia to Fiji. The BC Cancer Agency’s Family for Depression/Happiness) will be Join us for a 13-night cruise exploring Practice Oncology Network offers an held at the idyllic Sheraton Maui on exotic Tahiti (where Captain Bligh’s 8-week General Practitioner in Oncol- Ka’anapali Beach. With 23 acres of men mutinied to stay put), Mo’orea ogy training program beginning with lush Hawaiian grounds, you’ll never (Arthur Frommer’s vote for “the most a 2-week introductory session every feel crowded! Maui has been voted beautiful island on earth”), Taha’a spring and fall at the Vancouver Cen- best island by the readers of Condé (French Polynesia’s vanilla-scented tre. This program provides an oppor- Nast Traveler for more than a dozen isle), Bora Bora (celebrities’ exclusive tunity for rural family physicians, years. Attractions include 10 000 foot hideaway), the Cook Islands (New with the support of their community, Hale’akala (Hawaiian for house of the Zealand’s private paradise), the King- to strengthen their oncology skills so sun), 14 golf courses (including some dom of Tonga (proudly never colo- that they may provide enhanced care of the world’s top-rated), the scenic nized), and three idyllic islands of Fiji for local cancer patients and their fam- road to Hana, the Seven Sacred Pools (Viti Levu, Vanua Levu, and postcard- ilies. Following the introductory ses- of Oheo, and over 500 restaurants. The perfect Beqa). You’ll be enchanted by sion, participants complete a further 6 Kauai workshop—CBT Tools, will be the South Pacific’s craggy volcanic weeks of customized clinic experience held at the spectacular Grand Hyatt on peaks, sugary beaches, warm lagoons at the cancer centre where their patients sunny Poipu Beach. The Grand Hyatt teaming with fish, glistening black are referred. These can be scheduled Kauai is ranked among the world’s pearls, and Tamure dancing sugges- flexibly over 6 months. Participants top resorts by both the Condé Nast tive enough to make you blush. The who complete the program are eligible Traveler and Travel+Leisure. Kauai CME provides a rock-solid founda- for credits from the College of Fam- is the most tranquil and pristine of the tion in medical CBT for depression, ily Physicians of Canada. Those who main Hawaiian Islands, with beach- reviewing a plethora of ultra-brief are REAP-eligible receive a stipend es fringing nearly 50% of its tropi- office techniques to defeat depression and expense coverage through UBC’s cal coastline. Attractions include the and be happy. CBT Canada, now 20 Enhanced Skills Program. For more world-famous Kalaulua Trail on the years old, is a national winner of the information or to apply, visit www Napali Coast, red-rocked Waimea CFPC’s CME Program Award, and .fpon.ca, or contact Jennifer Wolfe at Canyon, 17-mile Polihale Beach was the first organization authorized to 604 219-9579. (Hawaii’s longest), crescent-shaped provide 3-credit-per-hour CME. Lead Hanalei Bay, and Hawaii’s only navi- instructor Greg Dubord, MD, is a Uni- HAWAIIAN CME: MAUI/KAUAI gable river, the Wailua. See www.cbt. versity of Toronto CME Teacher of the Maui, 27–29 Mar 2017 (Mon– ca for details about both the Maui and Year. Assistant faculty includes Lori Wed), and Kauai, 10–12 Apr 2017 Kauai workshops. Warning: Our sig- Montgomery, MD, from the Univer- (Mon–Wed) nificantly discounted guestrooms for sity of Calgary, who will be present- Aloha! Please join us in the happi- these two workshops will sell out far ing on CBT for chronic pain. Super est American state next spring for in advance. early bird rates for ocean-view state- rooms aboard the spectacular m/s Paul Gauguin start at $12 850 (includes all beverages, all taxes, all gratuities, return airfares, and companion cruises free). Book with Canada’s largest cruise agency, CruiseShipCenters. See CBT Canada at www.cbt.ca or call 1 888 739-3117.

BC Medical Journal CME Cruise 12-Night Quintessential Mexican February 09–21 seacourses.com

532 bc medical journal vol. 58 no. 9, november 2016 bcmj.org classifieds

Classified advertising (limited to 700 characters) Rates: Deadlines: Ads must be submitted or can- Doctors of BC members $50 + GST per celled by the first of the month preceding month for each insertion of up to 350 the month of publication, e.g., by 1 Novem- characters. $75 + GST for insertions of ber for December publication. Please call if 351 to 700 characters. We will invoice on you have questions. Tel: 604 638-2858. publication. Submit requests at www.bcmj.org/classi Non-members $60 + GST per month for fied-advertising-submission-form. each insertion of up to 350 characters. Provincial legislation prohibits ads that dis- $90 + GST for insertions of 351 to 700 criminate on the basis of sex. The BCMJ characters. We will invoice on publication. may change wording of ads to comply.

skills. Clinic group focus is on balancing work practices available and lifestyle. Easy access to Lower Mainland, MERRITT—FP Whistler, and Interior of the province. Call is Rolling hills, sparkling lakes, and over 2030 KELOWNA—FP PRACTICE with hours of sunshine every year make Merritt a currently 1 in 5. Regular schedule includes 1 OBSTETRICS haven for four-season outdoor recreation. We Awesome practice available in collegial FP week off every fifth week. Full rural physician have a need for family physicians in their choice group that does obstetrics. Doc is retiring. recruitment and retention benefit eligibility, of clinic. Nicola Valley Hospital and Health Great shared call schedule. Supportive group. including 38 days of rural locum coverage for Centre is a 24-hour level-1 community hospital Vibrant community. Great place to raise a fam- holidays. World-class wilderness at your door- with a 24-hour emergency room. Royal Inland ily and be outdoors. Available now. Locums step for skiing, hiking, fishing, white-water Hospital in Kamloops is a tertiary-level hospi- also welcome. Contact Dr Rishi at jrishi@ tal located only 86 km away. Remuneration is telus.net or 250 718-4101. kayaking, and mountain biking. Full-service rural hospital with GP surgeon and anesthe- fee-for-service ($250 000 to $450 000-plus per tist on staff. For more information e-mail year), rural retention incentives and on-call LAKE COUNTRY, BC—FOUR availability payment. For more information [email protected] or PHYSICIANS NEEDED Continued on page 534 Lake Country Family Practice is expanding! visit www.betterhere.ca. Lake Country is a fast-growing community of 19 000, 15 km north of Kelowna. We are looking for four physicians to join our established group of four practices to allow very flexible working hours and a minimum of 8 weeks of vacation per year, yet maintain low overhead and full coverage without the need for locums. For more information visit our website lake- countryfamilypractice.com, or e-mail Bonnie at [email protected].

VANCOUVER—PEDIATRICS Busy pediatric practice available. Solid referral base. Recently renovated 1000 sq. ft. office, including four exam rooms and two MD rooms. EMR in place. Conveniently located near BC Children’s Hospital. Options to buy or rent com- mercial unit. E-mail [email protected] or call 778 233-6543 for more information.

employment ABBOTSFORD—LOCUMS Full-service East Abbotsford walk-in clinic requires locum physicians for a variety of shifts including weekends and evenings. Generous Sarah Morphy split: pleasant office staff and patient popula- 604 906 1940 tion. Please contact Cindy at 604 504-7145 if [email protected] you are interested in obtaining more info. sarahmorphy.com

LILLOOET—FP Five-physician, unopposed fee-for-service practice seeks sixth family physician with ER

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 533 classifieds

Continued from page 533 e-mail [email protected]. Visit e-mail [email protected] our website at www.caledonianclinic.ca. POWELL RIVER—PERMANENT FPs & LOCUMs or view online at www.betterhere.ca. Powell River is a rural community of 20 000 NEW WEST—FAMILY PHYSICIAN people on the Sunshine Coast of British Co- New Westminster: Columbia Square Medical N VANCOUVER—FAMILY PHYSICIANS lumbia, a 25-minute flight from Vancouver. Clinic is looking for a family physician for a WELCOME It’s known for its waterfront location, outdoor full- or part-time position. Partnership and Family practice/walk-in seeking F/T or P/T beauty, urban culture, and international music options to buy are available. Flexible hours, physicians. Spacious, Oscar EMR, Wi-Fi. Lo- festivals. Supported by a 33-bed general hospi- competitive split. The clinic is newly renovat- cated near SeaBus. Convenient to downtown tal, the close-knit medical community consists ed with bright rooms, Oscar EMR, excellent Vancouver. Offering highest splits on North of 26 general practitioners, 4 ER and anesthe- friendly and efficient staff, 20 minutes from Shore (up to 72.5%). No OB or ED mandatory. sia physicians, 2 NPs, and 7 specialists. We are downtown Vancouver. We have 800 families Flexible hours. Great staff. Contact Francis: looking for permanent general practitioners waiting for a family doctor who wants to es- e-mail [email protected]. and locums. Please visit divisionsbc.ca/powell tablish a permanent practice or work part-time. river/opportunities for details. Considering a change of location or practice N VANCOUVER—FP LOCUM style? Call Irina at 778 886-6511 or e-mail Physician required for the busiest clinic/fam- [email protected]. RICHMOND—FP & LOCUMs ily practice on the North Shore! Our MOAs Opportunities for physicians looking to do are known to be the best, helping your day run walk-in shifts, build a practice, or relocate in NORTH DELTA—GENERAL our busy modern clinic. EMR OSCAR. Great smoothly. Lucrative 6-hour shifts and no head- PRACTITIONER location next to a 24-hr Shoppers Drug Mart. aches! For more information, or to book shifts Very busy, established family practice located No hospital work, no call, 70/30 split—walk-in online, please contact Kim Graffi at kimgraffi on Scott Road. The practice consists mainly shifts at $100 per hour minimum—and bonus @hotmail.com or by phone at 604 987-0918. of Punjabi-speaking patients. Two spacious available. Contact us at healthvuemedical@ exam rooms plus a private office available for gmail.com, 604 270-9833/604 285-9888. NANAIMO—GP the physician. Underground parking. No set- General practitioner required for locum or up fees or equipment required. Everything is permanent positions. The Caledonian Clinic included in the billing split (80/20). Potential SURREY (WHALLEY)—METHADONE- is located in Nanaimo on beautiful Vancou- to earn 400K per year. Physician may decide LICENSED GP ver Island. Well-established, very busy clinic their own schedule. Each exam room is fully Methadone-licensed GP needed to joint an ad- with 26 general practitioners and 2 specialists. equipped with everything required. EMR: Med diction clinic. No overhead if available week- Two locations in Nanaimo; after-hours walk-in Access. Very friendly medical office assistant days other than Tuesday and Thursday. Patient clinic in the evening and on weekends. Com- and office manager. For more information con- loads guaranteed. Staffed with MOA and coun- puterized medical records, lab, and pharmacy tact Dr Jagtar Rai at raimedicalclinic@gmail selor. MSP billing available. Please apply by on site. Contact Ammy Pitt at 250 390-5228 or .com. e-mail to [email protected] or contact 604 715-6011 for more info.

SURREY/DELTA/ABBOTSFORD—GPs/ SPECIALISTS Considering a change of practice style or location? Or selling your practice? Group of seven locations has opportunities for family, walk-in, or specialists. Full-time, part-time, or locum doctors guaranteed to be busy. We provide administrative support. Paul Foster, 604 572- 4558 or [email protected].

VANCOUVER/RICHMOND—FP/ SPECIALIST We welcome all physicians, from new gradu- ates to semiretired, either part-time or full- time. Walk-in or full-service family medicine and all specialties. Excellent split at the busy South Vancouver and Richmond Superstore medical clinics. Efficient and customizable Oscar EMR. Well-organized clinics. Please contact Lisa at [email protected].

VANCOUVER—FAMILY DOCTOR Family doctor wanted for semiprivate Cope- man-style clinic on Vancouver’s west side. Excellent pay and working conditions. Please e-mail [email protected].

VANCOUVER—FP or SPECIALIST 80/20 Modern practice in King Edward Village, 10 minutes from downtown core. Tailor schedule to your lifestyle. Friendly staff, brand-new equipment. Full-time/part-time. You will have

534 bc medical journal vol. 58 no. 9, november 2016 bcmj.org classifieds access to two rooms and the split is 80/20 for 6 general surgery, OB/GYN, pediatrics, internal months. CDM 100%. Annual CDM 50K. Con- VICTORIA—WALK-IN med, radiology, anesthesia, and psychiatry. tact [email protected]. Walk-in clinic shifts available in the heart of Further specialist support available at our re- lovely Cook St. Village in Victoria, steps from ferral centre in Kamloops. Williams Lake is the ocean, Beacon Hill Park, and Starbucks. VANCOUVER—FP/BREASTFEEDING known for its outdoor opportunities and full For more information contact Dr Chris Watt at range of amenities (including local college and MEDicine [email protected]. Vancouver Breastfeeding Centre is looking for airport). Contact 1 877 522-9722 or physician [email protected]. a permanent, part-time family physician with WILLIAMS LAKE—FP EMERGENCY a special interest in breastfeeding medicine to Seeking CCFP-EM or CCFP with ER expe- join our group. Maternal and child health ex- rience. Cariboo Memorial Hospital services medical office space perience and IBCLC qualification preferred. a population of approximately 26 000 with Supervised clinical training is available. Visit LANGLEY—OFFICE SPACE AVALABLE 20 000 visits to the ER annually. ER is staffed Medical office for rent. Close to Langley Hos- www.breastfeedingclinic.com and contact by six full-time ER physicians and a variety [email protected] for more info. pital, one consulting room, two exam rooms, of part-time ER physicians (staffed 24/7). We one parking spot, available 1 November 2016. have a 28-bed hospital with 3-bed ICU. Ex- VANCOUVER—LOCUM cellent collegial specialist support including Continued on page 536 Busy walk-in shifts in Kitsilano at Khatsahlano Medical Clinic, three-time winner of Georgia Straight reader’s poll for Best Independent Medical Clinic in Vancouver. Split is 65%; 70% on evenings/weekends. Contact Dr Chris Powell River: Watt at [email protected].

VERNON—AESTHETICS/VEIN/LASER Doctors practice here! Outstanding opportunity to join a well- established and thriving GP derm/aesthetics/ vein/laser practice in one of the best places to live in Canada. We are looking for an associate/equity partners. The office has all the latest technology and an excellent, congenial staff. Training provided but a special interest in dermatology a definite asset. The Okanagan has some of the best weather, lakes, wineries, golf courses, ski hills, and overall lifestyle anywhere in Canada, if not the world. Contact Dr William Sanders: 250 558-9606, w.sanders@ shaw.ca.

VICTORIA (OAK BAY)—MD PARTNER Derma Spa is a well-established medical/cos- metic practice located in the charming seaside neighborhood of Oak Bay, Victoria. Our business is growing and we have an experienced medical, financial, and marketing team in place to support you. Please contact Alex at 250 580- 9428 or [email protected]. We are a rural community of 20,000 people on the Sunshine Coast of VICTORIA—GP/WALK-IN Shifts available at three beautiful, busy clinics: British Columbia, a 25-minute ight from Vancouver – known for its Burnside (www.burnsideclinic.ca), Tillicum waterfront location, outdoor beauty, urban culture, and international (www.tillicummedicalclinic.ca), and Uptown music festivals. Supported by a 33 bed general hospital, the close- (www.uptownmedicalclinic.ca). Regular and knit medical community consists of 26 general practitioners, 4 ER occasional walk-in shifts available. FT/PT GP post also available. Contact drianbridger@ and anesthesia physicians, two NPs, and 7 specialists. gmail.com. We are looking for permanent general practitioners and locums. Visit divisionsbc.ca/powellriver/opportunities for all our opportunities VICTORIA—SHARED PRACTICE Ideal opportunity for Mandarin/Cantonese– speaking physician to join a turnkey, EMR practice with a view to building the practice. Escape the high-cost accommodation in Van- couver and relocate to Victoria, known for its breathtaking natural beauty and enviable qual- [email protected] ity of life. Combine a rewarding career with a 604-485-4700 satisfying lifestyle. E-mail [email protected].

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 535 classifieds advertiser

Continued from page 535 index For more information please call 604 534- VANCOUVER (VGH AREA)—MED 7515. OFFICE SUBLEASE Office space for psychiatrists, psychologists, or Thanks to the following advertis- any other specialist MD. No secretary or other NEW WEST—MED OFFICE FOR RENT additional overhead expenses. Top floor. Great ers for their support of this issue One medical office available in Brewery Dis- view. Two offices for sublease. One office is of the BC Medical Journal. trict next to Royal Columbia Hospital for bigger and has a sink and space for an exami- lease. Three exam rooms with sinks; separate nation table. E-mail [email protected]. MOA area; large, carefree common waiting Cambie Surgery Centre/ area; private washroom. Current occupants on Specialist Referral Clinic ..... 495 same floor: urologist, surgeon, neurologist, GP, VAN (DWTN)—MED OFFICE SPACE Two established psychiatrists seeking a third etc. Available January 2017. E-mail london Johnson Inc. psychiatrist to share office space in the Rob- [email protected] for details. son Professional Building located on Robson Medoc ...... 534 Street. The space features two bright offices; PORT COQUITLAM—MED OFFICE reception/waiting room area; kitchen with sink, Macdonald Realty SPACE fridge, and microwave. Includes full secre- Sarah Morphy ...... 533 Two medical office spaces are available to join tarial services (reception, typing, and billing). a practice in Port Coquitlam. Both are avail- Opportunity for mentoring in assessment and Magnum Properties able immediately and are run by one doctor treatment of ADHD and comorbidities avail- Burrard Place ...... 493 looking for another to join. Fully furnished, able. Very reasonable rent. Available: January easy access, and ample parking. One is in a 2017. Call 604 687-0654 or e-mail inquiries to MedRay Imaging ...... 503 medical building and the other in a plaza. Per- [email protected]. fect for family practice. For more details please call Emad 604 941-5575. Mercedes-Benz ...... 529 VANcouver (KERRISDALE)—OFFICE Airy, spacious, and quiet office available for Pacific Centre for RICHMOND—MED OFFICE SPACE a psychiatrist or psychologist on Fridays. Reproductive Medicine ...... 500 New modern EMR clinic in Steveston Village Located in the Kerrisdale Prof. Bldg., an ex- looking for physicians to join our team. Oppor- ceptionally convenient location for access by Pollock Clinics ...... 494 tunities to start a practice or relocate existing public transit or car, with a large amount of free practice without worrying about administra- residential parking available. Close to numer- Powell River Division of tive headaches. We offer base 70/30 split and ous pharmacies, labs, a walk-in clinic, coffee higher for complex care and forms. Visit www. shops, and restaurants—all within walking dis- Family Practice ...... 535 HealthVue.ca or contact healthvuemedical@ Continued on page 537 gmail.com, 604 285-9888. QHR Technologies Accuro Medeo ...... 490 Record Storage and Retrieval Service ...... 536

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Continued from page 536 ports. Telephone or digital recorder. Fully years, and the tax and financial issues facing tance. The office is accessible by elevator or confidential, PIPEDA compliant. Dictation them at various career and professional stages. by stairs. Consists of a waiting area that seats tips at www.2ascribe.com/tips. Contact us at The tax area is complex and practitioners are two people; a large reception desk; file storage www.2ascribe.com, [email protected], or often not aware of solutions available to them room; and large, bright, and comfortable inter- toll free at 866 503-4003. and which avenues to take. My goal is to help view room/office. If interested please contact you navigate and keep more of what you earn Dr Lewis Pullmer at [email protected], FREE MEDICAL RECORD STORAGE by minimizing overall tax burdens where pos- or call the office directly at 604 872-3422. Retiring, moving, or closing your family prac- sible, while at the same time providing you tice? RSRS is Canada’s #1 and only physician- with personalized service. Website: www .rwmcga.com, e-mail: [email protected], VANCOUVER—WEST BROADWAY managed paper and EMR medical records stor- phone: 778 552-0229. Fully furnished space for one or multiple doc- age company. Since 1997. No hidden costs. tors. Space can be used part-time or full-time Call for your free practice closure package: with short- or long-term arrangement possible. everything you need to plan your practice clo- WHITE ROCK—BILLING SERVICE Use some or all of the large space. MOA pro- sure. Phone 1 866 348-8308 (ext. 2), e-mail AVAILABLE vided if needed. Extraordinary views. Con- [email protected], or visit www.RSRS.com. I provide billing service from my home. Pa- crete professional building with elevators, tient information is received by e-fax or pickup underground parking, and three restaurants. PATIENT RECORD STORAGE—FREE from hospitals. I use Mediclaim, but can also Available immediately. Please call Neil at 604 Retiring, moving, or closing your family or bill using Accuro, Plexia, or Osler. My work 644-5775. general practice physician’s estate? DOCU- includes rebilling unpaid claims, correcting davit Medical Solutions provides free storage and resubmitting pre-edit refusals, and submitting overage claims. Experience dealing with VANCOUVER—WEST SIDE for your active paper or electronic patient re- MSP and fee updates. Currently billing for Vancouver medical office space to rent. Very cords with no hidden costs, including a patient internal medicine, cardiology, endocrinology, nice office, ideal for GP or pediatrician. Child- mailing and doctor’s web page. Contact Sid gastroenterology, psychiatry, and GP, as well friendly neighborhood, great staff. Negotiable Soil at DOCUdavit Solutions today at 1 888 as locums working at hospital locations only. hours and low rate. Call Howie James at 604 781-9083, ext. 105, or e-mail ssoil@docudavit Reference available. I can be contacted at 778 263-7338. .com. We also provide great rates for closing specialists. 886-4993.

miscellaneous VANCOUVER—TAX & ACCOUNTING CURRENT ADS ONLINE SERVICES Ads are available online in an easily searchable CANADA-WIDE—MEDICAL format at bcmj.org/classifieds. TRANSCRIPTION Rod McNeil, CPA, CGA: Tax, accounting, Medical transcription specialists since 2002, and business solutions for medical and health Canada wide. Excellent quality and turnaround. professionals (corporate and personal). Spe- All specialties, family practice, and IME re- cializing in health professionals for the past 11

bc medical journal vol. 58 no. 9, november 2016 bcmj.org 537 back page

Proust questionnaire: Vishal Varshney, MD

geous, and immensely hardworking. I say “and whatnot” far more than I Each day I strive to reflect their values should, and whatnot. and teachings in my life. What characteristic do your What profession might you have What is your idea of perfect favorite patients share? pursued, if not medicine? happiness? An optimistic outlook on life—they Something in marketing or political Perfect happiness for me starts with refuse to be defined by illness, and science. I am fascinated by both. waking up to sunshine and the smell persevere to enjoy what is important of waffles, being surrounded by fam- to them. Which talent would you most ily and friends, drinking tea and eat- like to have? ing excellent Indian food, with some Where would you most like to I wish I had artistic talents, like amazing music playing in the back- practise? drawing or painting. I am in awe of ground. I am blessed to be able to live and those who so easily create beautiful work in Canada. Anywhere in this imagery. What is the trait you most amazing country would be a true deplore in yourself? privilege. What do you consider your Deplore might be a strong word, but greatest achievement? I am always seeking to improve my What is your most marked I’m hoping that my greatest achieve- time management skills. characteristic? ment is yet to come. For now, I feel I only engage in activities that I have incredibly fortunate to be able to pur- Which living physician do you true passion, energy, and enthusiasm sue a career in medicine, which start- most admire? for. Without that, it simply becomes ed when I was accepted into medical My sister, Dr Nishi Varshney, and tedious. school at the University of Calgary. brother-in-law, Dr Vineet Bhan, are both practising physicians in BC What do you most value in your Who are your heroes? (geriatrician and cardiologist, respect- colleagues? Without a doubt my heroes are my ively). I admire them most for their Honesty and passion. parents, Pratap and Kamlesh Varsh- ability to excel in their profession ney. They are compassionate, coura- while maintaining such strong family What is your greatest fear? values, as cherished by both me and Losing those who are closest to me. Dr Varshney is a fourth-year anesthesiol- their sons (a.k.a. my nephews!). ogy resident at UBC, the immediate past Who are your favorite writers? president of Resident Doctors of BC, and What is your favorite activity? There is something about William board chair of Resident Doctors of Canada. Anything social where I get an oppor- Shakespeare for me that is always Born and raised in Calgary, he completed tunity to learn from or spend time memorable and everlasting. medical school at the University of Calgary. with other interesting people. While his professional interests include What is your motto? pain management and medical administra- Which words or phrases do you “You CAN do this.” Reaching outside tion, his personal interests include music most overuse? of my comfort zone has led to some of and learning to play the ukulele. I’ve recently started to realize that my most cherished moments in life.

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bc medical journal vol. 58 no. 9, november 2016 bcmj.org 539 Essential Medical Legal Toolkit

For FAMILY PHYSICIANS and SPECIALISTS

Medical Legal Reports: Medical Legal Reports Advanced The Essentials and Testifying in Court: Saturday, November 26, 2016 or Becoming a Great Expert Saturday, February 25, 2017 (9 am–4 pm) Saturday, March 4, 2017 (9 am–4 pm) Does writing medical legal reports cause you Physicians and all health care professionals generally prefer stress? Not sure what to write when asked about not to testify in court. This course will provide advanced prognosis? Need help figuring out how much training on writing more complex medical legal reports as you should be billing for your reports? What to well as how to reduce the stress of testifying in court. do when patients have subjective complaints? This course will outline: This course will outline: • Advanced skills for successful medical legal report • The essential components of a medical legal writing report • How to address issues of patient compliance/adherence • How to clearly narrate the patient’s history, and possible secondary gain in a medical legal report physical examination findings, diagnosis and • How to answer complex questions related to Cost of prognosis Future Care and Future Treatment • The steps to complete a medical legal report • The role of the medical/health professional expert efficiently witness in court • How to streamline the payment/invoicing for • How to prepare for court testimony medical legal reports • How to succeed in the various parts of expert testimony: • How lawyers, juries and judges identify the Qualifying the expert, direct testimony, good, bad and ugly medical legal report cross examination, re-direct • Common challenges with medical legal • Common pitfalls and traps in court—and reports and how to easily resolve them how to avoid them

Teaching Faculty: Register at www.medlegaltoolkit.com These courses will be taught by medical and legal professionals Cost: $490/course who have extensive medical More information: 604-525-8604 or email legal experience and have taught [email protected] numerous courses for health care Presented by CORE Occupational Health Care Centre professionals and lawyers. The legal teaching faculty have busy personal injury practices and UBC Robson Square know exactly what they want from 800 Robson Street medical legal reports and expert Vancouver, BC V6Z 3B7 540Dr Gurdeepbc medical Parhar journal testimonyvol. 58 no. 9, novemberin court. 2016 bcmj.org