British Columbia Medical Journal - November 2010

November 2010; 52: 9Pages 429- 492

www.bcmj.org

Surgical interventionsThe role of arthroscopy in thetreatment of degenerative jointdisease of the knee

Partial knee replacement

Total knee arthroplasty: Techniques and results

Total hip arthroplasty: Techniques and results

Proust: Erik Paterson

Good guys: Russell Palmer

BCCDC: Antibiotic resistance

WorkSafeBC: Asbestosis

OSTEOARTHRITIS OF THEHIP AND KNEE—PART 2

BC MEDICAL JOURNAL VOL. 52 NO. 9, NOVEMBER 2010 www.bcmj.org430

contentsA R T I C L E S

OSTEOARTHRITIS OF THE HIP AND KNEE—PART 2

438 Guest editorial: Surgical interventionsB.A. Masri, MD

439 The role of arthroscopy in the treatment of degenerativejoint disease of the kneeRobert McCormack, MD

442 Partial knee replacementRobert C. Schweigel, MD

447 Total knee arthroplasty: Techniques and resultsDaniel H. Williams, MSc, FRCS, Donald S. Garbuz, MD, B.A. Masri, MD

455 Total hip arthroplasty: Techniques and resultsR. Stephen J. Burnett, MD

O P I N I O N S

432 EditorialsInvasion of the body scanners, David R. Richardson, MD (432); The end ofan era, David B. Chapman, MD (433)

434 CommentDetermining fitness to drive: A troublesome taskIan Gillespie, MD

435 Personal ViewRe: Medical marijuana, Rielle Capler, MHA, Philippe Lucas, MA (435);

Dr Vroom responds, Willem R. Vroom, MD (436); CMPA position (436)

466 Good GuysRussell Palmer: Forgotten champion, Angus Rae, MB

490 Back PageProust questionnaire: Erik T. Paterson, MD

30%

Cert no. SW-COC-002226

Established 1959

ON THE COVER: Part 2 ofour special series on OA ofthe hip and knee focuseson surgical interventions.With the ongoing improve-ment in outcomes and theadvent of predictable anddurable surgical technique,younger patients are re -questing the pain relief andimproved quality of life af -forded by these operations.

Artwork by Jerry Wong.

ECO-AUDIT:Environmental benefits of using recycled paperUsing recycled paper made with post-consumer waste and bleached without the useof chlorine or chlorine compounds results inmeasurable environmental benefits. We arepleased to report the following savings.1399 pounds of post-consumer waste usedinstead of virgin fibre saves:• 8 trees• 760 pounds of solid waste• 837 gallons of water• 1091 kilowatt hours of electricity (equivalent:

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• 1382 pounds of greenhouse gases (equivalent: 1119 miles traveled in the average car)

• 6 pounds of HAPs, VOCs, and AOX combined• 2 cubic yards of landfill space

November 2010Volume 52• Number 9

Pages 429–492

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www.bcmj.org VOL. 52 NO. 9, NOVEMBER 2010 BC MEDICAL JOURNAL 431431

© British Columbia Medical Journal, 2010. All rights reserved. No part of this journal may be re-produced, stored in a retrieval system, or transmitted in any form or by any other means—elec-tronic, mechanical, photocopying, recording, or otherwise—without prior permission inwriting from the British Columbia Medical Journal. To seek permission to use BCMJ material in anyform for any purpose, send an e-mail to [email protected] or call 604 638-2815.

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Advertisements and enclosures carry no endorsement of the BCMA or BCMJ.

EDITORDavid R. Richardson, MD

EDITORIAL BOARDDavid B. Chapman, MBChB

Brian Day, MBSusan E. Haigh, MD

Lindsay M. Lawson, MDTimothy C. Rowe, MBCynthia Verchere, MD

EDITOR EMERITUSWillem R. Vroom, MD

MANAGING EDITORJay Draper

PRODUCTION COORDINATORKashmira Suraliwalla

EDITORIAL ASSISTANTTara Lyon

COPY EDITORBarbara Tomlin

PROOFREADERRuth Wilson

COVER CONCEPT & ARTPeaceful Warrior Arts

DESIGN AND PRODUCTIONOlive Design Inc.

PRINTINGMitchell Press

ADVERTISINGOnTrack Media

Tel: 604 [email protected]–70 E. 2nd Ave.

Vancouver, BC V5T 1B1

ISSN: 0007-0556

D E P A R T M E N T S

437 College LibraryBest evidence: The tip of the information icebergKaren MacDonnell, Judy Neill

465 BC Centre for Disease ControlYour irresistible personal portrait: A way to reduce antibiotic resistance?David M. Patrick, MD, Malcolm Maclure, ScD, Bill Mackie, MD, Rachel McKay, MSc

470 General Practice Services CommitteeDivisions of Family Practice address community needs, improve care atlocal level, Brian Evoy, PhD

472 In MemoriamDr Norman Wignall, Norman Wignall Jr.

472 PulsimeterNew BC-wide surgery booking system (472); Online stroke information(472); BC Genome Sciences Centre advances, Judy Hamill (473); BCPRA education course for GPs, Michael Schachter, MD (473); Don Rix leadershipaward announced (474); Call for nominations: BCMA and CMA specialawards (475); Signs of Stroke materials available for physicians, Susan

Pinton (479); Body Worlds and the Brain exhibition, Lloyd Oppel, MD (479)

476 WorkSafeBCAsbestosis: A persistent nemesis, Sami Youakim, MD

477 Council on Health PromotionEmergency departments: Are they considered a safe haven from prosecutionfor impaired drivers involved in fatal or personal injury crashes?Roy Purssell, MD, Luvdeep Mahli, Robert Solomon, LLB, Erika Chamberlain, LLB

480 Calendar

483 Classifieds

486 Advertiser Index

489 Club MD


Do you think it’s normal for your

dentist to check your prostate?”

I ask the new hygienist. “Be -

cause Dr Plaque checks mine every

time I come in.”

At this point, somewhat alarmed,

the hygienist glances at the last entry

in my chart, under which, while unat-

tended, I have written, “prostate nor-

mal.” After I explain my little joke to

the slightly creeped-out young woman,

all my appointments go pretty much

the following way.

“You haven’t had X-rays for a

while so we should do them.”

“Why?”

“Well, Dr Plaque likes to have

them done periodically to check on

things.”

“Well, then Dr Plaque can pay for

them.” I don’t think the dentist likes

me.

Imagine, doing a periodic X-ray to

check on things. This has always been

frowned upon in our profession. How-

ever, we are now on the crest of a brave

new scanning wave. Patients can pay

privately for almost any scan imagi-

nable. Then with the scans and reports

in hand they come to us for advice.

The problem is that nobody really

knows what to do with the results.

Randomized controlled trials that

investigate the impact of routine diag-

nostic imaging on mortality and mor-

bidity are scarce. So what does one do

with an otherwise healthy 50-year-old

man who pays privately for a coro-

nary CT that shows calcifications? Do

you order a stress test, exercise MIBI,

angiogram, or just monitor and en cour-

age risk-factor modification (which is

what was prescribed prior to the scan

anyways)? How about tiny renal or

lung lesions? What about small cere-

bral ischemic changes? The list goes

on. Private companies are happy to do

the scans, but what is the next step?

Patients are signing up for virtual col -

onoscopies, ultrasounds, CTs, PET

scans, carotid dopplers, and more in

ever-increasing numbers.

Let’s not forget magnetic resonance

imaging (MRI). Oh, how I hate those

three letters. It doesn’t seem to matter

what the patient’s problem is, eventu-

ally they always come to the conclu-

sion (based on the expert advice of

editorials

Invasion of the body scannerstheir lawyer, spouse, parents, physio,

massage therapist, barista, or garden-

er) that they need an MRI just in case

something is being missed. This hap-

pens despite my explanation that an

MRI won’t aid in the diagnosis of their

ingrown toenail or make their obesity-

related back pain go away. I am con-

sidering purchasing a big magnet to

glide over people while I make a

humming noise. I will then give them

a stick drawing of the appropriate

injured area and bill them for a dis-

count MRI.

Technological advances are often

a good thing, but some rational judg-

ment must be applied. There is still

an art to practising medicine, an art

that can be intriguing, satisfying, and

alluring. I’m calling for the use of

good old common sense. A good ques-

tion to ask is, “Is the management of

this patient likely to change depend-

ing on the outcome of this test?” If

not, don’t do it. If your patients remain

dissatisfied, send them to my newly

opened discount MRI clinic.

—DRR

“


W e are approaching the end

of an era at our community

hospital. As you read this

line, you may be expecting a lament

on the death of the full-service family

physician. The family doctor who has

an office practice, hospital privileges,

does house calls, does palliative care,

delivers babies, and perhaps also does

ER work. The dinosaur that has previ-

ously been described in these pages,

and whose imminent demise has been

much lamented. This would be a rea-

sonable thought.

It may also be reasonable to expect

an essay on the demise of the commu-

nity hospital. I expect that this may

happen soon in the new era of “pro-

gram management.” The new buzz-

words in our health authority seem to

be carving our once unified hospital

into separate silos of health care deliv-

ery. Our interdependent departments

such as obstetrics, pediatrics, anesthe-

sia, and surgery are being managed

and directed by individuals who are

not on site full-time because they have

too much on their plates and have to

manage and direct multiple hospital

sites and programs.

But, alas no. I am going on about

the imminent loss of an indispensible

person at our hospital, our medical

staff secretary who for approximately

the past 17 years has been doing her

job with amazing dedication. Unfor-

tunately, she is retiring and her posi-

tion is not going to be filled.

I must be getting old. I find myself

reflecting more and more about how

things used to be. I am becoming one

of the When we generation. You know

who you are. You start sentences with

When we, such as, “When we started

at this hospital…” It is true.

When I started at my hospital 20

years ago, I applied for hospital privi-

leges through the medical staff secre-

tary. It was the medical staff secretary

who organized my pager for me, as

well as the multiple replacements I

have needed over the years. She

reminded me that my annual dues

were overdue, as was my annual reap-

plication for hospital privileges. The

medical staff secretary took minutes

at our medical staff meetings (and

many other committee meetings); she

coordinated our on-call schedules and

notified others of the changes that we

seemed to make so frequently. The

medical staff secretary updated our

hospital’s physician directory, an

indispensible tool for us and our office

staff. She was the “go to” person at

our hospital when one had a question

or a problem. She coordinated weekly

education sessions for physicians. Our

medical staff secretary managed our

medical staff bank accounts and

administered the scholarships our

hospital medical staff gives to worthy

medical students each year.

Her job description has been chang -

ed by the hospital administration. She

editorials

The end of an erais no longer supposed to be doing the

things she has done for the medical

staff for the last 17 years. She has out-

lasted every other secretary in the hos-

pital. She has gone above and beyond

on many occasions, quietly and effi-

ciently. She is due to retire shortly.

The glue that holds our hospital’s

medical staff together is about to be

dissolved.

By the time we realize what we

have lost, it will be too late. From one

dinosaur to another: Have a well-

deserved retirement, Marcy. You have

certainly earned it. We will all miss

you. It won’t be same around here any

more. —DBC

Linda [email protected]

4550 Lougheed HwyBurnaby, BC

ALL makes and models! (Honda, BMW, GM, Ford, Subaru, etc.)

Lowest prices. No need to negotiate

Quick and convenient. Over the phone, by email or in person

Car shopping that’s stress free.

The glue that holds ourhospital’s medical staff

together is about to be dissolved.


A s long ago as 1999, the Sup -

reme Court of Canada decid-

ed in the case of Terry Gris-

mer to instruct all motor vehicle

licensing authorities to make fitness-

to-drive decisions on the basis of

functional capacity, not simply by

diagnosis, as had been done previous-

ly. Mr Grismer was the operator of a

mining truck and wanted to continue

his employment after a stroke pro-

duced a homonymous hemianopsia

that eliminated most of his left-side

peripheral vision in both eyes. Al -

though, sadly, Mr Grismer died while

the human rights legal challenge was

making its way through subsequent

levels of court, his estate pursued the

matter to this conclusion.

In our province, the Office of

the Superintendent of Motor Vehicles

(OSMV) then began a consultation

process and planned for the publica-

tion of a new BC Guide in Determin-ing Fitness to Drive to replace the

1997 edition. After a long consulta-

tion period, in which many doctors

volunteered their time, the new edi-

tion was published online in July

2010. It was always the intention to

also publish a condensed and user-

friendly guide for physicians, as the

full edition was aimed more toward

the needs of regulators. This task has

now been delayed until at least 2011,

with no announced plan for medical

editing and consultation.

At the time of this writing, the

BCMA does not know when and how

the new Guide will be implemented.

The first reading of Bill 14–The Motor

Vehicle Amendment Act, 2010, in part

21, provided for government to set out

by regulation the medical conditions

or functional impairments that oblige

a physician or other health profes-

sional to report.

Doctors can feel uncomfortable

balancing the mobility needs of a

patient against the potential risk to

public and patient safety when con-

sidering whether and what to report.

In my experience, a lot of the risk is

related to the driver’s level of insight.

A “safe enough driver” is aware of

any cognitive limitations and has the

judgment and willingness to adapt his

or her driving to these limitations. The

most dangerous situations are those in

which the driver denies or minimizes

the reduction in his or her functional

ca pacity and makes no accommoda-

tion for it.

When facing such complex deci-

sions it has been very helpful for BC

physicians to know they could contact

a medical consultant employed by the

OSMV. The OSMV used to have two

part-time medical consultants on staff.

For the past 10 years, Dr John Mc -

Cracken provided this valuable serv-

ice; however, his contract was not to

be renewed. The BCMA and the Col-

lege of Physicians and Surgeons of

BC have jointly written to the OSMV

to highlight this concern and request a

meeting. With the demographics of an

aging population and more crowded

roadways this is a time that we need

more medical consultation available

—not less.

Meanwhile, DriveABLE is the test

that the OSMV has contracted with

the BC Automobile Association to

provide objective information to assist

in decision making when there is

a concern about cognitive function.

The OSMV is also proposing to use

SIMARD-MD, a brief pencil-and-

paper test, to assist health care pro -

viders in rapid screening of patients.

This approach has been used in a lim-

ited way in Alberta. We await the start

of a proposed pilot study in BC.

Functional capacity is much more

than the score on a test—without a

mechanism for meaningful and trust-

ed consultation we run the risk of even

more rigidity in fitness to drive deter-

minations than existed when only

diagnosis was used.

The BCMA’s Board of Directors

was kept regularly informed during

the preparation of the OSMV’s cur-

rent Guide, but the BCMA was never

advised of plans to discontinue the

role of medical consultant or the use

of medical appeals. We need to find a

way to address this social and medical

issue together and not lose many years

of medical “corporate memory” and a

spirit of collaboration, as we move

ahead.

—Ian Gillespie, MD

BCMA President

Determining fitness to drive: A troublesome task

comment


Re: Medicalmarijuana

W hile Health Canada has

delegated responsibility to

physicians to recommend

the use of cannabis for access to their

legal program, it has clearly abdicated

its responsibility to educate doctors to

ensure their medical opinion is more

informed than that of Dr Vroom [Med-

ical marijuana. BCMJ 2010;52:329].

As a result, Dr Vroom is not alone

is his lack of knowledge about the

medical use of cannabis. During our

many years working and conducting

research at both the British Columbia

Compassion Club Society and the

Van couver Island Compassion So ci-

ety, we have heard the other side of

doctor-patient dynamic that Dr Vroom

describes.

Many patients report having an

extremely difficult time obtaining

support from their physicians for the

use of this medicine, or even dis-

cussing this legitimate health option.

This deeply affects the doctor-patient

relationship, causing patients unnec-

essary stress and creating an atmos-

phere of shame and distrust. Sadly,

many patients find themselves in the

role of having to educate their doctors.

Cannabis is a legal therapy option

officially sanctioned by the federal

government. It is not a physician’s role

to decide what is or isn’t a medicine,

but rather to discuss the suitability of

treatment options on a case-by-case

basis. In a previous editorial, Dr Vroom

stated, “I am not afraid to keep an open

mind about remedies I know nothing

about, but I research their scientific

evidence.”1 Dr Vroom seems to be mak-

ing an exception for medical cannabis.

Thousands of peer-reviewed sci-

entific studies have been published on

the use of cannabis to treat many dif-

ferent conditions and symptoms—as

personal view

Letters for Personal View are welcomed.They should be double-spaced and lessthan 300 words. The BCMJ reserves theright to edit letters for clarity and length.Letters may be e-mailed ([email protected]), faxed (604 638-2917), or sentthrough the post.

MARKET LOSS RECOVERY GROUPMARKETT LOSS RECOV Y GROUPRVE

Continued on page 436


both symptom relief for conditions

like chronic pain and to slow disease

progression. For starters, we suggest

that Dr Vroom might check out the

Canadians for Safe Access (CSA)

research page (http://safeaccess.ca/

research/), or consider attending an

upcoming accredited course by the

Canadian Consortium for the Investi-

gation of Cannabinoids (www.ccic

.net/registeronline).

—Rielle Capler, MHA

—Philippe Lucas, MA

Co-founders, Canadians

for Safe Access

Reference

1. Vroom WR. Naturopath prescribing: Thehill to die on. BC Med J 2009;51:101.

Dr Vroom respondsMs Capler and Mr Lucas are correct

about my lack of knowledge of mari-

juana pharmacology. Their recom-

mended web site has, unfortunately,

not educated me any further.

The whole crux of my editorial

was to acknowledge that I have no

knowledge about all of the actions of

the 60-plus cannabinoids contained in

a joint, nor of their potency or con-

centration. That makes endorsing, let

alone prescribing, a substance such as

this problematic for me. I pointed out

that the only legal way to access mar-

ijuana is by the recognized indications

contained in the Health Canada Form

B1 and palliative situations. Ms Capler

and Mr Lucas maintain that it is not

for physicians to decide what is or

isn’t medicine. Maybe so, but there

are many medicines that I won’t pre-

scribe. And that is my right. Just

because Health Canada has created

“medical marijuana” as an escape

from advocacy group pressure doesn’t

mean that I have to accept their prob-

lem as now being mine.

Marijuana has an excellent reputa-

tion for being a recreational drug. I am

sure that, some day, research will lead

us to completely understand all of its

actions. Perhaps we may even see it

legitimized for recreational use. In

the meantime call it “experimental

marijuana,” “research marijuana,” or

“palliative marijuana”—anything but

“medical marijuana.”

—WRV

CMPA positionWhen we asked for the Canadian Med-ical Protective Association’s positionon the topic of prescribing marijuana,Luce Lavoie, the director of commu-nications at the CMPA, directed us totheir statement entitled, “Marijuanafor medical reasons: The MedicalDeclaration form,” originally pub-lished October 2001, revised Septem-ber 2009. Here is the introduction:

“Marijuana is not approved for use

as a drug in Canada. Health Canada

states that “no marijuana product has

been issued a notice of compliance”

and notes that indications, safety and

risks have not been adequately stud-

personal view

“ MCI takes care of everything without telling me how to run my practice”.

Toronto – Calgary – Vancouver

MCI Medical Clinics Inc.

MCI means freedom:I remain independent

Continued from page 435


ied and the appropriate dosage is

unclear.

“Many regulatory authorities

(Colleges) have considered these

facts. Some have stated clearly that

physicians should not support an

application for the medical use of

marijuana, while others have cho-

sen to simply remind their mem-

bers of the importance of evidence-

based medicine and the lack of

evidence about the benefits and

risks of this substance.

“However, patients who believe

that marijuana is effective for treat-

ing certain symptoms from which

they suffer can apply to Health

Canada for authorization to pos-

sess and use marijuana under the

Marijuana Medical Access Regu-

lations (the Regulations). Those

Regulations require the applicant

(patient) to submit two declara-

tions, one of which is the appli-

cant’s and the other a Medical Dec-

laration signed by the applicant’s

medical practitioner.”

The full statement is availableat www.cmpaacpm.ca/cmpapd04/docs/resource_files/infosheets/2009/com_is09103-e.cfm.

—ED

personal view

By BC physicians, for BC physicians

GPAC clinical practice guidelines arenow available in iPod Touch andiPhone format — FREE! This free application contains over 30 clinical practice guidelines inabridged format. It serves as a condensed, portable companion to the full clinical practice guidelines found at www.BCGuidelines.ca, where over 50 guidelines are available in a range of formats. Download app from:http://itunes.apple.com/us/app/bc-guidelines/id377956292?mt=8

Incorporating high-quality evidence

into clinical decision making re -

quires systematic searching, apprais-

ing, and synthesizing of the literature.

Performing these complex and time-

consuming tasks on a regular basis

is beyond reasonable expectations

for busy physicians, so using existing

sources of evidence-based informa-

tion, particularly systematic reviews,

is helpful. Unlike traditional narrative

reviews that are generally written by a

few authors who subjectively select

literature to comment on a broad topic,

systematic reviews tend to be pro-

duced by a team that endeavors to

search the literature on a narrow clin-

ical question in an unbiased and repro-

ducible manner and analyze the search

results according to explicit criteria.

Two initiatives of note that produce

carefully synthesized and appraised

systematic reviews are Clinical Evi-dence from BMJ Publishing Group

and the Cochrane Collaboration. Both

tend to focus on the benefits and harms

of clinical interventions.

Clinical Evidence, created in 1999,

summarizes systematic reviews, RCTs,

and observational studies, and states

college library

Best evidence: The tip of the informationiceberg

the current view on what is known and

unknown about specific aspects of

disease management. Conveniently,

patient leaflets on general topics sup-

plement the more precisely focused

systematic reviews. Clinical Evidenceis both a stand-alone publication as

well as a component of BMJ Point ofCare. The Cochrane Collaboration, a

distinct and independent organization,

has been producing the CochraneDatabase of Systematic Reviews since

1993. The Collaboration is not-for-

profit, funded by agencies such as

universities, charities, and personal

donations. Like Clinical Evidence,

Cochrane reviews tend to focus on the

risks and benefits of therapeutic inter-

ventions. Both of these resources are

available for free to all College mem-

bers at www.cpsbc.ca/library.

In addition the College Library

offers workshops on identifying and

effectively searching high-quality

medi cal evidence, and we are also

happy to arrange one-on-one learning

sessions with College members.

—Karen MacDonell, Judy Neill

Librarians/Co-Managers, College of

Physicians and Surgeons of BC Library


In the first part of this two-parttheme issue, we discussed the etiology, diagnosis, and nonoper-ative treatment of osteoarthritis

(OA). While the majority of patients,particularly those with small joint OA,respond to nonoperative treatment,surgical treatment is required in anincreasing proportion of patients withlarge joint OA. With the ongoing im -provements in outcomes and with theadvent of very predictable and durablesurgical technique, younger patientswith OA are requesting the pain reliefand the improved quality of lifeafforded by these operations.

Hips and knees continue to be the

joints most commonly affected and

requiring surgical intervention. His-

torically, hip and knee joint replace-

ment were reserved for older patients,

and it was not uncommon to hear

patients complaining that they were

denied surgery because they were “too

young.” In the past, with the limited

durability of joint replacement, that

was a reasonable strategy to protect

patients from failed joint replacement

down the road. Today, however, tech-

niques for first-time joint replacement

have improved so significantly that

we can offer joint replacements with

predictable longevity, with fewer

complications, and with less severe

failures. Moreover, revision surgical

techniques have also improved to the

point where even when joint replace-

ments fail, they can be predictably

reconstructed in the majority of

patients.

In the articles that follow, we begin

with an overview by Dr McCormack,

who describes the role of arthroscopy

in early OA of the knee. Because knee

OA often presents with isolated dis-

ease in one of the three compartments

of the knee, we continue with Dr

Schweigel’s discussion of partial knee

replacement. Dr Williams, Dr Garbuz,

and I then consider total knee replace-

ment. We finish with Dr Burnett’s

article about hip replacement and

resurfacing.

With the increasing success of hip

and knee replacement, demand will

continue to increase. It is my hope that

the articles in this two-part theme

issue will put the topic of hip and knee

osteoarthritis in perspective. I am

extremely grateful for the contribu-

tions of the various authors who have

done an excellent job of summarizing

this vast topic in a clear and concise

manner.

—B.A. Masri, MD, FRCSC

Professor and Head

Department of Orthopaedics

University of British Columbia

Guest editorial: Osteoarthritis ofthe hip and knee, Part 2:Surgical interventions

Guest editorial

Dr B.A. Masri


ABSTRACT: Degenerative joint dis-

ease is a common cause of knee

symptoms and disability. The indica-

tion to proceed to surgery is usually

the failure of standard nonsurgical

treatments. Despite the success of

joint replacement surgery, many cli-

nicians choose to avoid this large,

complex surgery if a minimally inva-

sive ambulatory procedure can allow

a patient to improve function and

quality of life. This has led to the fre-

quent use of arthroscopy to treat

degenerative joints, especially knee

joints. While a “scope” does qualify

as minimally invasive, it is still im -

portant to consider the ratio of risks

to benefits and the efficacy of arthro-

scopic debridement for degenera-

tive joint disease of the knee.

The impact of osteoarthritison the health care system issignificant and continues togrow as our population ages.

As there is no cure for degenerativejoint disease (DJD), medical interven-tions have focused on symptom con-trol. Unfortunately, none of the non-operative measures are universallysuccessful and some have significantrisks. A minimally invasive day-careprocedure that improves patient func-tion and delays more extensive recon-struction is appealing. Arthroscopy isthe most commonly performed ortho -paedic procedure, one often associat-ed with knee ligament reconstructionand treatment of meniscal tears. Inaddition, some estimates suggest thatover 500 000 arthrosco pies are per-formed in North America each yearfor the treatment of degenerative jointdisease.1 Recent studies have ques-tioned the role of this procedure in thetreatment of osteoarthritis, and thereis a general consensus that it has beenoverused in the past. The goal of thisarticle is to address the role of arthro-scopic surgery in patients who havedegenerative joint disease in the knee.

Proposed benefitsIt has been proposed that arthroscopic

lavage (wash out) of the knee joint can

improve patient status by washing out

inflammatory cytokines, cartilage frag-

ments, and other debris from the joint.

Formal joint debridement has also

been reported to improve patient

status by smoothing off unstable flaps

of articular cartilage and possibly

improving the weight distribution of

the remaining articular cartilage.2

On the one hand, if there is an

unstable meniscal fragment that is

causing mechanical symptoms, such

as locking, pain with sudden turns, or

sharp intermittent pain, an arthrosco -

py can address that component of the

patient’s symptoms by trimming the

unstable fragment. On the other hand,

it is difficult to quantify the benefit of

arthroscopic repair of the arthritic

knee given the inability during arthro -

scopy to actually perform biological

resurfacing in the face of diffuse

degenerative changes and the ex -

tremely variable course of DJD.

Recent studiesMost of the orthopaedic studies re -

garding the role of arthroscopy in the

treatment of DJD are of low quality

and suffer from the same short com-

ings seen in many other areas of med-

icine: variable selection criteria, incon-

sistent outcome measures, different

surgical techniques, and publication

The role of arthroscopy in thetreatment of degenerative jointdisease of the kneeRecent studies question the benefits of arthroscopic debridement formanaging patients with osteoarthritis affecting a weight-bearing joint.

Robert McCormack, MD, FRCSC

Dr McCormack is an associate professor inthe Department of Orthopaedics at the Uni-versity of British Columbia.


attention because patients were ran-

domized to one of three arms: arthro-

scopic lavage, arthroscopic debride-

ment, or sham operation. The patients

were assessed by a blinded independ-

ent assessor and the key finding was

that there was no significant differ-

ence in pain or function between the

sham operation and either of the

arthroscopic surgery groups. As inter-

esting as the results were, the design

of the trial also captured a lot of atten-

tion. The placebo effect of surgery was

neutralized by giving the patients in

the sham operation an anaesthetic and

creating the standard arthroscopic

portals, without performing any sur-

gery inside the knee.

The Moseley study created a furor

among orthopaedic arthroscopists.

Many criticized the design of the

study and the fact that all subjects

were males (in a female-dominated

disease) and all came from a Veterans

Affairs hospital (equivalent to work-

ers’ compensation patients). There

were concerns that the patients had

more severe disease than average and

that the authors used a nonvalidated

outcome measure. Nevertheless, sev-

eral societies, including the American

Rheum a tological Association, came

out with position statements that

arthroscopy did not have a role in the

treatment of osteoarthritis.

This controversy spawned further

trials in a number of centres, and re -

cently a prospective randomized clin-

ical trial from the University of West-

ern Ontario was published, again in

the New England Journal of Medi-cine.6 This Canadian trial by Kirkley

and colleagues randomized patients to

optimal medical treatment or optimal

medical treatment plus arthroscopic

debridement. The researchers defined

the grade of arthritis more precisely

and ensured that limb malalignment

was not significant. The patients in

both groups had similar age, BMI, and

length of follow-up. Importantly, the

researchers excluded patients with

significant meniscal tears that were

causing mechanical symptoms. The

primary outcome was the validated,

disease-specific WOMAC score.7 The

bottom line is that the trial addressed

most of the criticisms of the Moseley

trial. Interestingly, at 2 years follow-

up, the WOMAC scores were not sta-

tistically different (P = .22) and with

an absolute difference of less than 1%

that did not meet the threshold of a

clinically significant difference.

Significance of findingsWhat do these findings mean to the

clinician? Degenerative joint disease

of the knee ( ) is common and

family physicians often decide to order

an MRI to assess the joint. Since the

same degenerative process affecting

the articular cartilage also affects the

menisci, it is not surprising that most

of these patients also have a degener-

ative tear of the meniscus ( ).

Unfortunately, the patient and physi-

cian frequently focus on the MRI

results and forget clinical correlation.

When there are significant degenera-

tive changes most of the symptoms

are related to the underlying degener-

ation. Asymptomatic meniscal tears

are very common in this clinical situ-

ation and men iscal resection does not

address the main pain generators. As

the Moseley and Kirkley trials show,

when there is significant degenera-

tion, arthroscopic debridement inclu -

ding resection of degenerative menis-

cal tears ( ) does not lead to

improvement in pa tient outcomes, and

may in fact lead to more rapid deteri-

oration.

The one caveat to this is that the

presence of significant mechanical

symptoms (locking, significant catch-

ing, or instability secondary to a torn

meniscus or loose body) is different

from isolated joint line pain. These

Figure 3

Figure 2

Figure 1

The role of arthroscopy in the treatment of degenerative joint disease of the knee

bias. Through the 1980s and 1990s a

variety of case reviews reported a rea-

sonable rate of improvement with

simple lavage or joint debridement in

knees affected by osteoarthritis. The

success rates ranged from 40% to

75%.2 As might be expected, the ben-

efits of simple lavage were, at best,

transient and one small prospective

randomized trial found that arthro-

scopic lavage was no more effective

than closed needle lavage of the joint.3

The evidence supporting arthro-

sco pic debridement was somewhat

better, but improvement was frequent-

ly of short duration and studies show -

ed that orthopaedic surgeons were

actually poor at predicting which

patients would improve.4 In 2002 this

technique came under close scrutiny

when the results of a prospective ran-

domized trial by Moseley and col-

leagues was published in the NewEngland Journal of Medicine.5 This

trial captured a tremendous amount of

Figure 1. Anteroposterior weightbearingradiograph showing degenerative jointdisease of the knee, particularly in themedial compartment.


mechanical problems are more pre-

dictably improved with arthroscopic

resection of the torn meniscus or loose

body. However, it is important to

remember that there may well be

residual symptoms, secondary to the

underlying DJD. The role of the pri-

mary care physician is to educate

patients that significant degenerative

changes are not helped by an arthro-

scopic “clean out.”

A second caveat is that occasion-

ally there is an indication for a diag-

nostic arthroscopy in a degenerative

joint, to better define the extent of

damage or to determine the role of

other procedures such as realignment

osteotomies or unicompartmental

arth roplasty. This may also apply to

patients whose symptom severity is

out of keeping with the radiographic

evidence. The patient can have changes

that appear mild on plain radiographs

but when examined arthroscopically

prove to be more severe with large

focal defects in articular cartilage.

Even if arthroscopic debridement

offers a small benefit, this needs to be

balanc ed against the risks of the pro-

cedure. Complications, including deep

venous thrombosis and pulmonary

embolism, are not to be underestimat-

ed and have ranged in some series

from 7% to 31%, with a higher preva-

lence in older patients.8

ConclusionsRecent high-quality trials suggest that

in the absence of mechanical symp-

toms, arthroscopic debridement of the

knee has a very limited role to play

when managing significant degenera-

tive joint disease.

Competing interests

None declared.

References

1. Owings MF, Kozak LJ. Ambulatory andinpatient procedures in the UnitedStates, 1996. National Center for HealthStatistics. Vital health Stat 13 (139). 1998.

2. Calvert GT, Wright R. The use of arth ro -scopy in the athlete with knee osteo arth -ritis. Clin Sports Med 2005;24:133-152.

3. Chang, RW, Falconer J, Stulberg SD, etal. A randomized, controlled trial of arthro-scopic surgery versus closed-needle joint

lavage for patients with osteoarthritis ofthe knee. Arthritis Rheum 1993;36:289-296.

4. Dervin GF, Stiell IG, Rody K, et al. Effectof arthroscopic debridement for osteoarth -ritis of the knee on health-related qualityof life. J Bone Joint Surg Am 2003;85A:10-19.

5. Moseley JB, O’Malley K, Petersen N, etal. A controlled trial of arthroscopic sur-gery for osteoarthritis of the knee. NewEngl J Med 2002;347:81-87.

6. Kirkley A, Birmingham TB, Litchfield RB,et al. A randomized trial of arthroscopicsurgery for osteoarthritis of the knee.New Engl J Med 2008;359:1097-1107.

7. Bellamy N, Buchanan WW, GoldsmithCH, et al. Validation study of WOMAC: Ahealth status instrument for measuringclinically important patient relevant out-comes to antirheumatic drug therapy inpatients with osteoarthritis of the hip orknee. J Rheumatol 1988;15:1833-1840.

8. Sherman OH, Fox JM, Snyder SJ, et al.Arthroscopy—“no-problem surgery.” Ananalysis of complications in two thou-sand six hundred and forty cases: J BoneJoint Surg Am 1986;68:256-265.

The role of arthroscopy in the treatment of degenerative joint disease of the knee

Figure 2. MRI showing degenerative tear of the medial meniscus.Degenerative joint disease can also be seen in the medialcompartment.

Figure 3. An intraoperative arthroscopic view showing loss ofarticular cartilage in the medial femoral condyle along with adegenerative medial meniscal tear.


ABSTRACT: Partial knee replace-

ments have come into and out of

favor over the past 60 years. There

has been renewed interest in partial

knee replacements in the armamen-

tarium for arthritic knees due to

increasingly good results. Partial

knee replacements include the uni-

condylar knee replacement and the

patellofemoral arthroplasty. These

partial knee replacements are indicat -

ed for specific, isolated arthritic por-

tions of the knee joint—specifically

the medial, lateral, or patellofemoral

portion of the joint. In carefully

selected patients outcomes are com-

parable to the results of total knee

replacements. Patient selection and

meticulous surgical technique are

likely the key to a good result in a par-

tial knee replacement.

Partial knee replacementsare a form of knee arthro-plasty that doesn’t replacethe entire knee (the femoral

condyles, tibial plateau, and patella).These surgical interventions includethe patellofemoral arthroplasty andthe more common unicondylar kneearthroplasty. Both procedures havebeen available since the 1950s andmay be options for patients who haveosteoarthritis in one compartment ofthe knee, do not have specific con-traindications for these more conser-vative procedures, and who havefailed to benefit from nonoperativemanagement of their osteoarthritis.

Unicondylar kneearthroplastyIn the past, unicondylar knee replace-

ments fell out of favor primarily be -

cause of the surgical technique of the

time, which made conversion to a full

knee replacement difficult. However,

with the advent of minimally invasive

approaches for unicondylar knee

replacement, there has been renewed

interest in this procedure over the past

decade.

A unicondylar knee replacement

( ) consists of a metal compo-Figure 1

nent that goes on the femoral condyle,

and another component that goes on

the tibial side. The tibial component

can be metal-backed with a fixed-

bearing or mobile-bearing polyethyl-

ene bearing surface, or it can be an all-

polyethylene fixed-bearing cemented

component. There is no evidence that

one approach is better than another.

The rationale for considering a

unicondylar knee arthroplasty is that

it is a more conservative operation

with faster recovery, less resection of

bone, conservation of the cruciate lig-

aments, and potentially better func-

tion. In addition, conversion to a total

knee replacement down the road is

simple using modern techniques, with

outcomes similar to a primary knee

replacement. When appropriate, par-

tial knee arthroplasty can be thought

of as a time-buying operation.

In addition, a unicondylar knee

replacement is an alternative to other

invasive procedures such as a high

tibial osteotomy or a total knee

replacement.

Partial knee replacementThe last decade has seen renewed interest in unicondylar kneearthroplasty and patellafemoral arthroplasty for patients with osteoarthritis affecting one compartment of the knee.

Robert C. Schweigel, MD, FRCSC

Dr Schweigel is a clinical instructor in theDepartment of Orthopaedics at the Univer-sity of British Columbia.


Patient selectionCareful patient selection is needed to

get the best possible results. This re -

quires a thorough history and physical

examination.

The history should include specif-

ic questions about the knee to deter-

mine whether there was a gradual

onset of pain or whether there was a

specific incident (i.e., trauma) that

caused the problem. This is particu-

larly important because anterior cru-

ciate ligament deficiency is a con-

traindication for a unicondylar knee

replacement. When considering a uni-

condylar knee replacement, the loca-

tion of the pain is very important. It

must be localized to only one com-

partment of the knee. For a medial uni-

condylar knee replacement, the pain

has to be medial and the patient has to

be able to point to the medial side of

the knee as the site of the pain. For a

lateral unicondylar knee replacement,

which is much less common as the

results are less predictable than a

medial unicondylar knee replacement,

the pain has to be lateral. For either a

lateral or medial unicondylar knee

replacement, the presence of substan-

tial patellofemoral pain is a con-

traindication. In addition, the pain has

to be of sufficient magnitude and to

interfere with activities of daily living

to warrant surgical intervention. It is

important to ensure that all reasonable

attempts at medical management have

been exhausted before considering

any surgical procedure.

IndicationsKozinn and Scott have outlined several

classic indications and contraindica-

tions for unicondylar knee replace-

ment.1 Indications include the diagno-

sis of unicondylar osteoarthritis or

osteonecrosis in either the medial or

lateral compartment of the knee. Ini-

tially, Kozinn and Scott stipulated that

patient age had to be greater than 60

years and weight had to be less than

82 kg. There had to be minimal pain at

rest and low demand of activity. The

ideal range of motion was an arc of

flexion of 90 degrees with a contrac-

ture of less than 5 degrees. The angu-

lar deformity had to be less than 15

degrees and be passively correctible

to neutral at the time of operation.

Specific contraindications to a uni-

condylar knee arthroplasty identified

by Kozinn and Scott included the

diagnosis of an inflammatory arthri-

tis, age younger than 60 years, high

patient activity level, pain at rest (which

may indicate an inflammatory com-

ponent), and patellofemoral pain or

exposed bone in the patellofemoral or

opposite compartment at the time of

the surgery. Asymptomatic chondro-

malacia in the patellofemoral joint

was not necessarily a contraindication.

More recently, some of these indi-

cations have been expanded. Various

authors have reported good results in

patients younger than 60 years2 and in

obese patients with BMIs over 30.3

Generally it is felt that both of the

cruciate ligaments have to be intact to

perform a unicondylar knee arthro-

plasty. Again however, studies have

suggested that a medial compartment

unicondylar arthroplasty is possible

in an ACL-deficient knee in certain


Figure 1. (A) Anteroposterior radiograph showing a medial unicondylar knee replacement. (B) Lateral radiograph showing a medialunicondylar knee replacement. Radiographs courtesy of Dr Bas Masri.

A B


circumstances;4 still, most surgeons

will not perform a unicondylar knee

re placement on a patient with a histo-

ry of torn ACL, and the presence of

a torn ACL should be considered a

contraindication to a unicondylar knee

replacement.

In summary, in addition to well-

localized pain with no patellofemoral

involvement, the indications for a uni-

condylar knee replacement include

the following:

• Range of motion of no less than

110 degrees with no more than a 5-

degree flexion deformity.

• A correctable varus on valgus defor-

mity of no more than 5 degrees of var -

us or 15 degrees of valgus, with the

correctability of the deformity to be

determined on physical examination.

• An intact anterior cruciate ligament.

• Osteoarthritis localized to either the

lateral or medial compartment, keep-

ing in mind that the vast majority of

unicondylar knee replacements are

medial.

• For some fixed-bearing tibial compo-

nent designs, a weight limit of 114 kg.

Based on the above, it is clear that

not every patient with knee osteo -

arthritis is a candidate for a unicondy-

lar knee replacement, and the final

decision is up to the orthopaedic sur-

geon. Typically, only 10% to 20% of

patients undergoing knee replacement

are candidates for unicondylar knee

arthroplasty.

ResultsIt is difficult to sort out the results for

unicondylar knee arthroplasty, as

there are different types of unicondy-

lar knee arthroplasties. Additionally,

it is difficult to distinguish between

medial side versus lateral side proce-

dures with respect to outcomes. Fur-

thermore, one has to compare the

results of a unicondylar knee replace-

ment with other options such as a high

tibial osteotomy and a standard total

knee replacement. Again, various au -

thors have reported varying degrees

of success with unicondylar knee

arthroplasty. Recently authors have

reported 96% survival of the implant

at a 10-year follow-up and excellent

or good outcome in 92% of patients.5

Most recently Newman and col-

leagues6 compared unicondylar knee

replacement with total knee replace-

ment in a prospective randomized

control trial. This report stated that the

15-year survivorship for a unicondy-

lar knee replacement was close to 90%

compared with 80% for a total knee

replacement. Additionally, the report

stated that the unicondylar knee

replacements had more “excellent”

results and a better range of motion

compared with the total knee replace-

ment. Registry data, however, such as

the Swedish Knee Replacement Reg-

istry, have shown a higher reoperation

rate for unicondylar knee replace-

ment, with the main reason for revi-

sion being progression of the arthritis.

The results for revision of a unicondy -

lar knee replacement to a full knee

replacement are similar to the results

for a primary total knee re placement,

and even though unicon dylar knee

replacements may not last as long, the

outcome of revision is better than that

of a revision of total knee replacement.


Figure 2: (A) Anteroposterior radiograph showing a patellofemoral replacement. (B) Lateral radiograph showing a patellofemoral replacement.Radiographs courtesy of Dr Bas Masri.

A B


ComplicationsThe complications after a unicondylar

knee replacement are similar to a total

knee replacement. These complica-

tions include inadequate pain relief,

deep venous thrombosis in 1% to 5%

of patients, infection in less than 1%

of patients, and unexplained pain

about the knee.

Late complications include loos-

ening of a component, subsidence of

the component, degeneration of the

other compartment resulting in pain,

infection, polyethylene wear, and pos-

sible dislocation of the polyethylene

component in a mobile-bearing knee

replacement.

PatellofemoralarthroplastyA patel lofemoral replacement

( ) is indicated for the man-

agement of isolated osteoarthritis of

the patellofemoral joint. It has to be

clear that this form of partial knee

replacement is not indicated for pat -

ellofemoral pain in the absence of rad -

iographically proven osteoarthritis.

Patient selectionPatellofemoral arthritis occurs in up

to 9% of patients over the age of 40

and 15% of patients over 60.7 Most

patellofemoral pain or arthritis can be

treated with nonoperative measures

such as activity modification, physi-

cal therapy, analgesics, braces, and/or

injections. Patellofemoral arthroplas-

ty may be an option for patellofemoral

arthritis when other treatment modal-

ities have failed.

Patients with chondromalacia of

the patella have been treated with

arthroscopic debridement with limit-

ed success.8 A patellectomy has been

used in the past as well. Unfortunate-

ly, a patellectomy has its own set of

problems, which include loss of exten-

sion power and increased risk of arth -

ritis in the tibiofemoral compartment.

Figure 2

IndicationsAccording to Lonner9 the indications

and contraindications for a patello -

femoral arthroplasty are isolated

patellofemoral osteoarthritis, post-

traumatic arthritis, or advanced chon-

dromalacia with eburnation on either

or both of the trochlear and patellar

surfaces. It is contraindicated in pa -

tients with medial or lateral joint line

pain or tibiofemoral arthritis or chon-

dromalacia. It is not felt to be appro-

priate for inflammatory arthritis or

crystalline arthropathy. It should be

used with extreme caution in a patient

who has a highly malaligned patello -

femoral articulation with a high Q

angle and is thus at risk for dislocation.

ResultsThe component for patellofemoral

arthroplasty consists of a metal troch -

lear component and a polyethylene

button that replaces the articular sur-

face of the patella. Good to excellent

results have been reported in short,

mid-term, and medium follow-up.

The results are reported as being 80%

to 90% good to excellent.9

ComplicationsThe complications after a patello -

femoral arthroplasty include patellar

snapping and instability. Additionally

the standard complications for uni-

condylar knee arthroplasty can be

included. There can be ongoing res -

idual anterior knee pain and dys-

function. There can be subsidence,

polyethylene wear, or loosening. Long-

term arthritis in the tibiaofemoral

joint can also occur.

ConclusionsPartial knee replacements may be an

option for a select group of patients.

There is renewed interest in partial

knee replacements with recently re -

ported good long-term outcomes,

complications similar to total knee

replacement, and the fall-back option

of a conversion to a total knee replace-

ment. For the unicondylar knee, it is a

more conservative option with a fast

recovery, good functional outcome,

and is a possible good option to a high

tibial osteotomy or total knee replace-

ment. The unicondylar knee is most

commonly done for isolated medial

compartment osteoarthritis and has

very specific indications. The patello -

femoral arthroplasty is possibly indi-

cated in patients with isolated patello -

femoral arthritic pain. The limited

reports on the patellofemoral arthro-

plasty suggest very good results.


There is renewed interest in partial

knee replacements with recently re ported

good long-term outcomes, complications

similar to total knee replacement, and the

fall-back option of a conversion to a

total knee replacement.



Competing interests

None declared.

References

1. Kozinn SC, Scott R. Unicondylar kneearthroplasty. J Bone Joint Surg Am 1989;71:145-150.

2. Pennington DW, Swienckowski JJ,Lutes WB, et al. Unicompartmental kneearthoplasty in patients sixty years of ageor younger. J Bone Joint Surg. 2003;85-A:1968-1973.

3. Tabor OB Jr, Tabor OB, Bernard M, et al.Unicompartmental knee arthroplasty:Long-term success in middle-age andobese patients. J Surg Orthop Adv2005;14:59-63.

4. Christensen NO. Unicompartmentalprosthesis for gonarthrosis. A nine-yearseries of 575 knees from a Swedish hos-pital. Clin Orthop Relat Res 1991;273:165-169.

5. Berger RA, Meneghini RM, Jacobs JJ, etal. Results of unicompartmental kneearthoplasty at a minimum of ten yearsfollow-up. J Bone Joint Surg Am 2005;87:999-1006.

6. Newman J, Pydisetty RV, Ackroyd C. Uni-compartmental or total knee replace-ment. The 15-year results of a prospec-tive randomized controlled trial. J BoneJoint Surg Br 2009;91:52-57.

7. Davies AP, Vince AS, Shepstone L, et al.The radiological prevalence of patello -femoral osteoarthritis. Clin Orthop RelatRes 2002;402:206-212.

8. Federico DJ, Reider B. Results of isolat-ed patellar debridement for patello -femoral pain in patients with normalpatellar alignment. Am J Sports Med1997;25:663-669.

9. Lonner JH. Patellofemoral arthroplasty.In: Lotke PA, Lonner JH (eds). Mastertechniques in orthpaedic surgery: Kneearthroplasty. 3rd ed. Philadelphia, PA: Lip-pincott Williams and Wilkins; 2009:343-359.


ABSTRACT: While osteoarthritis re -

mains the most common indication

for total knee replacement, the num-

ber of primary total knee arthroplas-

ties performed annually has increas -

ed exponentially over the last 55

years. Outcomes have improved

with the use of careful preoperative

assessment, a range of component

options, and operative technique

guided by clear surgical goals.

Informed consent of any patient con-

templating total knee arthroplasty

must be obtained by discussing the

risks and benefits and explaining that

between 80% and 85% of patients

are satisfied after the procedure.

Major joint arthroplasty isundoubtedly one of thesurgical success storiesof modern times. The

number of primary knee arthroplas-ties performed annually increasedexponentially over the last half of the20th century and increased between16% and 44% during the first 5 yearsof the 21st century.1,2 The history oftotal knee arthroplasty began back in 1860, when the German surgeonThemistocles Gluck implanted thefirst primitive hinge joints made ofivory. Development really took offfollowing the introduction of theWalldius hinge joint in 1951: initiallymanufactured from acrylic and later,in 1958, from cobalt and chrome.3

Unfortunately, this hinge joint suffer -ed from early failure.

In the early1960s, John Charnley’s

cemented metal-on-polyethylene total

hip arthroplasty inspired the develop-

ment of the modern total knee replace-

ment.4 Gunston, from the same centre

as Charnley, went on to design an

unhinged knee that replaced both the

medial and lateral sides of the joint

with separate condylar components.

Improved biomechanics resulted from

the preserved intact cruciate and col-

lateral ligaments, which maintained

the stability of unlinked femoral and

tibial components, and a design that

allowed the centre of rotation to change

with flexion of the knee.5 The metal-

on-polyethylene condylar design—

completely replacing the femoral and

tibial articulating surfaces—was pur-

sued throughout the early 1970s at

centres across the world.6-11 The result

was an implant relying on component

geometry and soft tissue balance to

provide stability, with a large articu-

lating surface area to spread load and

minimize polyethylene wear. Incre-

mental improvements in component

materials, geometry, and fixation

continued throughout the 1970s and

1980s. More accurate sizing, the

option of patellafemoral replacement,

better instrumentation, and compo-

nents that allowed an increased range

of motion and a lower wear rate have

since been developed.

Unicompartmental knee arthro-

plas ty developed in parallel with to tal

knee replacement from the early efforts

Total knee arthroplasty:Techniques and resultsProviding a patient with a pain-free, stable knee joint that will last along time can be achieved by focusing on five surgical goals.

Daniel H. Williams, MSc, FRCS (Tr & Orth), Donald S. Garbuz, MD, MPH, FRCSC, B.A.Masri, MD, FRCSC

Dr Williams is a fellow in the Division ofLower Limb Reconstruction and Oncologyin the Department of Orthopaedics at the University of British Columbia. Dr Gar-buz is an associate professor and head ofthe Division of Lower Limb Reconstructionand Oncology in the Department of Ortho -paedics at UBC. Dr Masri is a professor andhead of the Department of Orthopaedics atUBC.


of McKeever and Elliott in 1952.12

However, because the unicompartmen -

tal procedure replaces only the dis-

eased part of the joint with more nat-

ural kinematics or joint movement,13,14

the indications for its use are more

limited.

Indications andpreoperative assessmentOsteoarthritis, whether primary, post-

traumatic, or secondary to avascular

necrosis, osteochondritis, or sepsis, is

by far the most common indication for

total knee replacement. Inflammatory

arthritides make up the bulk of the

remaining indications. Diagnosis of

the underlying condition allows appli-

cation of appropriate nonoperative

treatment, while the functional impact

of disease upon the everyday life of

the patient determines the appropriate

timing of surgery. Mechanical symp-

toms—locking or giving way—may

be amenable to arthroscopic assess-

ment and treatment. The severity of

symptoms are assessed by noting

reduced walking distance, analgesic

use, and sleep disturbance. Ability to

climb stairs or inclines, use of walk-

ing aids or other orthotics, and exac-

erbating or relieving factors all build a

more detailed picture of disability.

Knee examination should include

assessment of gait, surgical scars, loc -

al ized tenderness, active and passive

range of motion, limb alignment, co -

ronal and sagittal plane ligament sta-

bility, and neurovascular status of the

limb. Other pathology contributing to

symptoms should be excluded by

examination of the back, hip, foot, and

ankle of the same limb.

Up-to-date and serial (if available)

radiographs of the knee should in -

clude an anteroposterior view as well

as true lateral and skyline patello -

femoral views of the involved knee

together with full long leg views if

there is significant deformity, previ-

ous fracture, or previous osteotomy of

the femur or tibia. An anteroposterior

pelvis and lateral radiograph of the

ipsilateral hip should be sought if there

are symptoms of groin pain or signs of

stiffness or pain on rotation of the hip.

Magnetic resonance imaging can be

used to assess for meniscal or liga-

mentous injury in appropriate cases,

but is generally not required for the

routine assessment of the painful

arthritic knee. Radiographs should

always be performed before MRI is

ordered; in many cases, the plain rad -

iographic findings will make MRI

unnecessary.

The option of total knee arthro-

plasty is typically discussed with pa -

tients at the point in their lives when

knee pain from arthritis is significant-

ly interfering with activities of daily

living. Informed consent requires a

full discussion of the risks and bene-

fits of surgery to ensure that patient

expectations are realistic. Generally,

between 80% and 85% of patients are

satisfied with their knee arthroplasty.

The most significant complication is

deep infection, which complicates

between 1% and 2% of operations and

may require further and repeated major

joint surgery. Arterial injury compli-

cates between 0.03% and 0.17% of

cases15 and peroneal nerve injury has

been reported in between 0.3% and

2.0% of patients.16 The 20-day post-

operative mortality rate of 0.2% is

increased above the age-matched pop-

ulation and is the same as that meas-

ured for total hip arthroplasty. The

mortality rate normalizes with the

age-matched population after the 70th

postoperative day.17 Mortality at 1

year following knee arthroplasty is

1.6%, which is half the mortality rate

of the age-matched population, demon-

strating that total knee arthroplasty

patients are a highly select group.18

Operative techniquePreoperative radiographic templating

for knee arthroplasty, while not as cru-

cial as for hip arthroplasty, does indi-

cate the size and shape of the tibial

bone to be removed and the compo-

nent type and size that is likely to be

required. It is particularly important

in cases requiring the extremes of

implant size to ensure that all likely

sizes are available, in cases of severe

deformity, and in cases where there is

severe bone loss.

ComponentsMost orthopaedic supply companies

manufacture a range of implant de -

signs, from cruciate ligament retain-

ing ( ) and posterior stabilized

( ) implants that usually pro-

vide sufficient stability in the primary

setting, through to megaprotheses for

replacing tumor or bone.

The level of built-in constraint, or

stability, required by a knee pros theses

depends upon whether the posterior

cruciate and collateral ligaments are

intact. If the posterior cruciate liga-

ment is compromised, as it is in most

rheumatoid knees, or there is fixed

Figure 2

Figure 1


Radiographs should

always be performed

before MRI is ordered;

in many cases, the

plain rad iographic

findings will make

MRI unnecessary.



coronal plane or significant flexion

deformity, then the PCL is replaced

by a cam and post, the design of which

controls sagittal plane kinematics.

A larger post can provide additional

side-to-side/coronal plane stability

( ). If the medial collateral lig-

ament is compromised, a hinged pros-

thesis is chosen to further improve

coronal plane stability ( ). In -

evitably this puts greater strain upon

the hinge itself and produces increas -

ed shear stresses at the implant inter-

face with the bone. A rotating hinge

allows movement in the axial plane

between the polyethylene and tibial

surface, decreasing these stresses but

producing a secondary surface for the

generation of wear debris. Modular

femoral and tibial stems are added to

the resurfacing implants in this scen -

ario to increase the area of fixation,

spreading load and decreasing stress-

es at the implant bone interface.

Femoral or tibial stems of varying

lengths may also be added if there are

significant uncontained bone defects.

Generally, a contained bony defect

with an intact cortical rim or an uncon-

tained defect of less than 5 mm can be

filled with cement upon implantation.

Contained defects greater than 5 mm

with an intact cortical rim can be treat-

ed with morcelized impaction bone

allografting. Uncontained defects re -

quire shaping to accommodate the

metal wedges that are added to the

implant. Larger defects are not com-

monly encountered in the primary set-

ting, but when present may require

bulk bone allograft. The addition of a

femoral or tibial stem provides addi-

tional stability and protects supple-

mented defects, minimizing the risk

of long-term implant subsidence.

Surgical goalsThe clinical aims of knee arthroplasty

are to provide the patient with a pain-

free, stable joint that will last a long

Figure 4

Figure 3

Figure 1. Cruciate ligament retainingimplant.

Figure 2. Posterior stabilized implant. Thepresence of a post (arrow) distinguishes thisdesign from the cruciate ligament retainingdesign in Figure 1, which has no such post.

Figure 3. Posterior stabilized implantwith larger post (arrow) for improvingcoronal plane stability.

Figure 4. Hinged implant for improvingcoronal plane stability. The hinge is linkedinto the femoral component as indicated bythe arrow.


time. To achieve this, the surgical team

focuses on five surgical goals:

• Mechanical alignment of the limb.

The proximal tibia and the distal

femur are cut so that the mechanical

axis of the limb—from the centre of

the hip to the centre of the ankle

joint—passes through the centre of

the knee arthroplasty. This ensures

that forces are transmitted equally

through each side of the new joint,

optimizing the lifetime of the joint.19

Aligning the limb correctly also pro-

vides the correct starting platform

for achieving subsequent surgical

goals.

• Joint line preservation. The depth of

bone removed from the tibia and the

femur should be equal to the height

of the respective components that

are implanted. By taking out what is

to be put back in, the position of the

original joint line is preserved. This

optimizes the function of the liga-

ments and muscles acting upon the

knee.

• Soft tissue balance in the coronal

plane. Balancing the knee to varus

and valgus stress maintains equal

load transmission through each side

of the knee. Following many years

of disease, deformity in the coronal

plane can become fixed by contrac-

ture of soft tissues. Osteoarthritis

most commonly leads to a varus

deformity and tight medial soft tis-

sues, which are released in the fol-

lowing order to attain satisfactory

balance:

1. Medial osteophyte removal.

2. Proximal subperiosteal stripping

of the deep medial collateral lig-

ament.

3. Posteromedial capsular release.

4. PCL sacrifice requiring the use of

a posterior stabilized component.

5. Distal tibial periosteal stripping

of the MCL (avoiding complete

release and subsequent valgus

instability).

Rheumatoid arthritis or lateral

fem oral condyle hypoplasia can lead

to a valgus deformity that requires the

following releases to attain satisfac -

tory balance:

1. Lateral osteophyte removal.

2. Subperiosteal dissection of the lat-

eral joint capsule.

3. Lateral patellofemoral ligament

release.

4. “Pie crusting” of the iliotibial band

if tight in extension.

5. Popliteus release if tight in flexion.

6. PCL sacrifice requiring the use of a

posterior stabilized component.

7. Lateral collateral ligament release

from its femoral insertion (avoid-

ing complete release and subse-

quent varus instability).

• Balance of the flexion and extension

gaps in the sagittal plane. This re -

sults in the knee maintaining stabil-

ity throughout its full range of mo -

tion. Flexion instability occurs when

the gap between the tibia and the

femur is wider in flexion than in

extension and must be corrected to

ensure the patient is asymptomatic.

Recurvatum or extension beyond

0 degrees may result from a “loose”

extension gap. A “tight” flexion or

extension gap may restrict the full

range of flexion or extension. Loss

of full range of motion at either

extreme can be disabling. Loss of

full flexion can make stair and hill

climbing difficult. Loss of full ex -

tension makes complete lockout of

the knee impossible and requires

prolonged quadriceps muscle en -

gagement—which is tiring for the

patient—when standing in one spot.

A tibiofemoral gap consistent

throughout a full range of motion

can be achieved by using an appro-

priately sized tibial insert combined

with a femoral component implant-

ed in the correct position.

• Q angle correction. This is the angle

between the quadriceps and the

patella tendon and is a function of

the positioning of the tibial, femoral,

and, if used, patella component. In

particular the femoral component

requires appropriate positioning in

all three planes to allow the patella

to track correctly.

Each of these goals may not nec-

essarily be addressed in strict order

during surgery. Indeed, some of the

steps involved during the procedure

may address more than one goal at the

same time. For instance, sizing and

positioning the femur ensures balance

of the flexion and extension gaps as

well as creating a Q angle that affords

correct patella tracking. What is vital

is that every goal be considered in

order to produce a pain-free, stable

joint that will last a long time.

The operationFollowing complete preoperative

assessment and planning to ensure

correct implant availability, a typical

total knee arthroplasty would proceed

as follows:

• Intravenous antibiotics are given

well before inflation of a proximal

thigh tourniquet to 300 mm Hg.

• The skin is prepped and draped to

allow an adequate midline longitu-

dinal incision to access the knee

joint, usually via a medial parapatel-

lar approach.

• Part of the anterior fat pad, remnants

of the medial and lateral menisci,

the anterior cruciate ligament and

the PCL (if a posterior stabilized

implant is to be used) are excised.

Osteophytes are excised and the

proximal medial soft tissues are

released to allow visualization of the

edge of the medial tibial plateau and

forward subluxation of the tibia in

full flexion and external rotation.

Further preliminary soft tissue re -

leases are performed at this stage as

appropriate.

• The tibia is cut at 90 degrees to its



mechanical axis using an extra -

medullary or intramedullary jig.

Tibial bone is removed from the

normal side of the joint to the same

depth—usually 10 mm—as the

height of the tibial component to be

implanted, with the aim of preserv-

ing the position of the original joint

line.

• The femoral intrameduallary canal

is entered and the appropriate jig

is used to cut the distal femur in

between 5 and 7 degrees of valgus

relative to the anatomical axis. This

ensures the bone is cut at 90 degrees

to the mechanical axis of the femur,

thus satisfying the first surgical

goal of knee arthroplasty. Femoral

bone is removed to the same depth—

again, usually 10 mm—as the height

of the femoral component to be im -

planted, with the aim of preserving

the position of the original joint line.

• The extension gap is checked to

ensure a 10-mm spacer can be insert-

ed. If it cannot, the tibia or femur, as

appropriate, are recut by an appro-

priate amount—usually 2 to 4 mm.

Overall alignment of the bony cuts

is checked to ensure the limb is

straight and the soft tissues balance

to varus and valgus stress. Further

adjustments of the bony cuts and

further soft tissue releases proceed

if required.

• The femoral size is measured (in

the anteroposterior and mediolateral

plane) and correct position of

the femoral cutting block in the

sagittal (anteroposterior transla-

tion), the coronal (mediolateral

translation), and axial plane (rota-

tion) is ensured.

• The posterior femoral condylar cut

is made to enable trialing of the 10-

mm spacer block at 90 degrees of

flexion to confirm that the flexion

gap matches the extension gap be -

tween the tibia and the femur.

• The remaining femoral bony cuts

are made to match the inside of the

femoral component, and a drill hole

is made in each condyle to accom-

modate the two femoral pegs.The

trial components are inserted with

the appropriate tibial spacer. The

patella is prepared if it requires

replacement, and is rechecked prior

to final implantation. The optimum

position of the tibial component is

marked and preparation of the tibial

keel is completed.

• The cancellous bone surface is clean -

ed and the real components cement-

ed with antibiotic-loaded cement.

Compression is applied with the knee

in extension through a trial insert.

Once the cement has hardened any

loose cement is removed and the

appropriate real polyethylene insert

is implanted.

• The tourniquet is released to con-

firm hemostasis. A single drain is

used and the retinacular-tendinous

layer is closed with interrupted sut -

ures. The subdermal tissues and skin

are closed and dressings applied.

Postoperative careTwo further intravenous doses of anti -

biotics are given to cover the first 24

hours. Low molecular weight heparin

or a similar suitable anticoagulant is

prescribed—according to patient risk

assessment—usually up until the 10th

day postoperatively to ensure optimal

thromboprophylaxis. The patient is

mobilized, fully weight bearing in the

majority of cases, as soon as the gross

effects of the anesthetic have worn off.

Patients are encouraged to maximize

knee extension and flexion at every

stage of their recovery to ensure opti-

mal outcome. Exercises are commen -

ced to ensure full recovery of quadri-

ceps tone and strength and analgesia

is provided to ensure the best possible

results from physiotherapy. Discharge

from hospital is allowed when the

wound is dry and the patient is safe

ascending and descending stairs.

Sutures or skin clips are removed at

10 to 14 days. A walking aid may be

required for several weeks following

surgery. The literature supports driv-

ing from 8 weeks, so long as the pa -

tient is clear of opiod analgesia and

can perform an emergency stop.20 Fol-

low-up appointments are scheduled at

6 to 8 weeks, 1 year, 5 years, and every

subsequent fifth year thereafter. Earli-

er follow-up should be requested if

there is any sign of infection or other

significant concern. Over 85% of total

knee arthroplasty patients will recover

knee function following a general

rehabilitation protocol. The remain-

ing 15% of patients will have difficul-


The patient is mobilized, fully weight

bearing in the majority of cases, as

soon as the gross effects of the

anesthetic have worn off.


ty obtaining proper knee function sec-

ondary to significant pain, limited pre-

operative motion, or the development

of arthrofibrosis. This subset of

patients will require a more specific

prolonged rehabilitation program that

may involve ongoing oral analgesia,

continued physical therapy, additional

diagnostic studies, and occasionally

manipulation. Controlling pain is the

mainstay of any such treatment plan.21

ResultsThe survivorship rate is the percent-

age of total knee arthroplasties that

have not been revised in any given

series of patients. It is generally the

most often quoted outcome in the joint

arthroplasty literature. Survivorship

is arguably the most useful outcome

when distinguishing between differ-

ent prosthetic designs and also helps

answer the patient question, “How

long will the knee last?”

The pioneers of total knee arthro-

plasty saw early failures that quickly

led to the use of more durable materi-

als, better fixation, and improved de -

sign.5-11 Published longer-term results

have shown markedly differing sur-

vivorship rates between more subtle

differences in arthroplasty design. In

a recent study looking at 3234 knee

arthroplasties performed between

survivorship rates of 100% at 10 years

are seen with the Miller-Galante II

knee, which was redesigned to solve

the high rate of patellofemoral com pli-

cations seen with the Miller-Galante I

(which still had an 84.1% survivorship

rate at 10 years).28 Studies comparing

the results of different design options

manufactured by the same company

are now also available: the 10-year

Genesis knee results for the (posteri-

or) cruciate retaining knee reveal 97%

survival compared with the Genesis

posterior stabilized knee, which has

96% survival—an insignificant differ-

ence.29 The results of unicompartmen-

tal knee arthroplasty have been as

good as total knee arthroplasty in pub-

lished individual series, with sur-

vivorship rates of 98% at 10 years.30,31

It is arguably the recent registry

data for newer generation knee im -

plants that apply most readily to the

average patient considering total knee

arthroplasty. The 8-year survivorship

rate for the eight most common knee

joints in current use in Norway is

between 89% and 95%1 and the 7-year

rate in Australia is 95.7%.2 Of note,

purely in terms of survival, these reg-

istries have found inferior results for

even the best-performing unicompart-

mental knee arthroplasties when these

are compared with total knee arthro-

plasty. The cumulative survival at 7

years for unicompartmental knees in

Australia is only 88.1% compared

with 95.7% for total knees.1,2 This may

relate to issues of patient selection or

reflect the increased technical expert-

ise required for this procedure. Con-

version of unicompartmental knee

arthroplasty to total knee replacement

is relatively straightforward, so appro-

priate patients seeking a partial knee

replacement should not be discour-

aged by the slightly lower long-term

survivorship seen in registry data.

Several knee scores have been

developed to assess outcome follow-


1969 and 1995, 89% of the condylar

designs had survived 10 years and

between 78% and 89% had surviv ed

15 years.22 Survivorship rates, how ever,

varied considerably among different

implant designs. The corresponding

rates for some, now discontinued,

designs in this same study were

between 43% and 63% at 10 years

and between 28% and 59% at 15

years.22 Further studies have confirm -

ed clinical survival of the total condy-

lar knee design of 94% at 15 years23

and be tween 77% and 91% at 21 to 23

years.24,25 For this reason the total

condylar design has endured. Perhaps

the best long-term published results

are for the Anatomic Graduated Con -

dy lar (AGC) knee arthroplasty, the

success of which is attributed to a

straightforward design that utilizes

carefully manufactured materials. The

AGC knee has a published survivor-

ship rate of 98.9% in 4583 knees at 15

years26 and a rate of 97.8% in 7760

knees at 20 years—quite impressive

survivorship. The number of knees

that reach long-term follow-up in such

series are, however, often small; only

36 of the 7760 knees in this study

made it to the 20-year point.27

Medium-term follow-up is becom-

ing available on updated versions of

the total condylar design. Improved

Improved survivorship rates of 100% at

10 years are seen with the Miller-Galante II

knee, which was redesigned to solve the

high rate of patellofemoral com pli cations

seen with the Miller-Galante I.


ing total knee arthroplasty. These tools

produce numbers that correspond to

excellent, good, fair, or poor outcome.

For example 92% of knees were as -

sessed as good or excellent in one

study, with 1.6% fair and 6.5% poor.23

Between 96% and 98% of knees were

assessed as good or excellent in anoth-

er study.29 However, more recently it

has been shown that the views of sur-

geons and their patients regarding the

outcome of surgical interventions do

not always correlate well—especially

with respect to function and pain.

Patient questionnaires are thought to

better assess patient outcome, and in a

recent study 81.8% of 8095 patients

were satisfied, 11.2% (906 of 8095)

were unsure, and 7.0% (566 of 8095)

were not satisfied with their new knee

joint.32

With regard to younger patients

under the age of 55 years, a survivor-

ship rate of 96% of 93 knees was

observed at 10 years,33 and of 90% of

108 knees at 18 years;34 94% of pa -

tients in the latter study had good or

excellent function and all but two

patients had improvement in their

activity score postoperatively. Fur-

thermore, 24% regularly participated

in activities such as tennis, skiing,

bicycling, or strenuous farm or con-

struction work.34 This suggests that

the traditional practice of withholding

knee replacement until patients are

over 65 or over is not warranted, and

replacement should proceed when

clinically appropriate.

It was traditionally thought that

obese patients do not fare as well as

normal-weight patients following

joint replacement. Postoperative out-

come scores for obese patients, how-

ever, were found to be comparable to

scores for patients who were not obese

in one recent study. Furthermore,

given the lower preoperative scores

measured in the obese group, the over-

all improvement was actually greater

than in the normal-weight group.

Additionally, survivorship rates in

obese patients were not significantly

lower than in patients who were not

obese at 10 years follow-up.35 There

was, however, a greater proportion of

lucent lines seen on the radiographs

around the implants of the obese

patients23,35 and in the morbidly obese

the complication rates are higher and

the implant survivorship rate is lower.

The final objective measure of

outcome perhaps most relevant to the

individual patient is range of flexion.

This has gradually improved from a

mean of 99 degrees23 to between 114

and 117 degrees with newer genera-

tion designs.29 Postoperative range of

motion largely depends on the preop-

erative range of motion. Generally,

what the patient has before the opera-

tion is what the patient can expect to

achieve after surgery and rehabilita-

tion.36 Patients seeking knee replace-

ment should be counseled that their

postoperative knee will not be “nor-

mal,” but it will feel and function

much better than their preoperative

arthritic knee.

ConclusionsOsteoarthritis remains the most com-

mon indication for total knee arthro-

plasty. Fortunately, technical devel-

opments over the last half century

have resulted in 10-year survivorship

rates of 90% and higher, and between

80% and 85% of patients have been

satisfied with their total knee replace-

ment. Further incremental improve-

ments in knee arthroplasty engineer-

ing, implant design, and material

science will continue to improve bear-

ing surface tribology, implant fixa-

tion, and implant longevity. These

advances will all help meet the main

surgical goals of total knee arthro-

plasty: to correct limb alignment, pre-

serve joint line position, balance the

soft tissues in the coronal plane, bal-

ance the flexion/extension gap in the

sagittal plan, and create a Q angle that

facilitates satisfactory patella track-

ing. Preoperative assessment and

planning will also help meet these

goals by ensuring patient expectations

are realistic and informed consent has

been obtained after a full discussion

of the risks and benefits of surgery.

Competing interests

None declared.

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Survivorship rates in obese patients

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ABSTRACT: Primary total hip arthro-

plasty has become one of the most

successful surgical procedures over

the past 50 years and is currently

performed worldwide with similar

techniques and excellent results.

Despite variations in technique and

implant selection, medium and long-

term outcome studies have demon-

strated over 90% implant survival at

15 to 20 years. Previous problems

with implant fixation have now been

reduced, and the focus has shifted

to the selection of improved bearing

surfaces to limit wear, hip replace-

ment options for younger patients,

and improved surgical and anesthet-

ic techniques. Current surgical ap -

proaches to the hip rely most often

on direct lateral or posterolateral

exposure. The most commonly uti-

lized bearing surface for both hip

replacement and hip resurfacing in

Canada is a metal (cobalt-chrome)

femoral head combined with a

second-generation cross-linked poly-

ethylene, combined with cementless

implant fixation. Alternative bear-

ings such as ceramic-on-ceramic

and metal-on-metal may be consid-

ered for hip replacement in younger

patients. Although it has not been

determined which surface will prove

best for younger patients in the long-

term, there is no question about the

benefits of total hip arthroplasty.

With current techniques, the results

are favorable, and patient satisfaction,

pain relief, and long-term implant

survival are excellent.

The current long-term suc-cess of total hip replacement(THR) surgery has led to theobservation by Coventry1

that “total hip replacement, indeed,might be the orthopaedic operation ofthe century.” The indications for THRhave expanded to such an extent thatthis surgery is no longer performedonly in the elderly or in those with de -bilitating hip pain, arthritis, and severefunctional restrictions. Rather, THR isnow performed in younger and higher-demand patients, with expectations,quality-of-life measures, and inten-tions to return to prior activity levelsthat challenge surgical techniques andimplant design technology. The ad -vantages of THR generally outweighthe disadvantages ( ), and atten-tion is now focused on improved fix-ation of the implants, reduction in therates of failure, and development ofbearing surfaces to reduce long-termwear and improve implant longevity.

Surgical exposureSeveral surgical exposures are utiliz -

ed for THR. The two most common

Table

Total hip arthroplasty: Techniques and resultsYounger, more active patients are now candidates for total hip re-placement with the advent of improved implant fixation and newlow-wearing bearing surfaces.

R. Stephen J. Burnett, MD, FRCSC, Dipl ABOS

Dr Burnett is a consultant orthopaedic surgeon in the Division of Orthopaedic Sur-gery, Adult Reconstructive Surgery of theHip and Knee, Vancouver Island Health–South Island.


ex posures ( ) are the anterolat -

eral2 and the posterolateral approach-

es to the hip.3 Patients may also be

offer ed one of the newer techniques of

surgical exposure referred to as muscle-

sparing or minimally invasive. The

decision of which surgical exposure

to use will depend upon surgeon expe-

rience and preference, patient body

habitus (i.e., obesity), patient ana tom-

ical factors, the location and type of

prior surgical incisions over the hip,

and implant selection. The most im -

portant factor to consider is surgeon

experience and preference.

The anterolateral exposure is an

abductor-splitting approach requiring

removal and repair of the anterior 30%

to 40% of the gluteus medius and min-

imus. This approach may also be uti-

lized for revision THR surgery. Many

surgeons select this approach based

upon the potential for a reduced dislo-

cation rate. Disadvantages of the an -

tero lateral approach include:

• An increase in limp due to splitting

of the abductor muscle (also likely due

Figure 1 to traction injury to anterior branch-

es of the superior gluteal nerve dur-

ing surgery). Often the limp is re -

ported as being asymptomatic, but

frequently it is a Trendelenburg gait.

• An increase in the formation of het-

erotopic bone within the abductor

muscles and anteriorly over the cap-

sule and greater trochanter.

• A greater incidence of trochanteric

complications (intraoperative frac-

ture, postoperative fracture, or es -

cape of the greater trochanter), and

trochanteric pain (often incorrectly

attributed to a diagnosis of tro -

chanteric bursitis), most likely due

to failure of the ab ductors to heal

following the repair.

• A tendency for the surgeon to insert

the femoral component angled from

anterior to posterior within the fem -

oral canal (i.e., nonanatomic femoral

component placement).

With the popularity of less inva-

sive surgery, the posterolateral expo-

sure has again gained prominence.

Disadvantages of the posterolateral

approach include:

• Perhaps a slightly higher risk of dis-

location, although with experience

this is minimized.

• The need for careful attention to

component orientation in order to

insert the implants in proper antev-

ersion.

In Canada between 2008 and 2009,

the direct lateral approach (60%) and

posterolateral approach (36%) com-

bined for over 95% of all surgical

exposures.4 When minimally inva-

sive surgery for THR is performed, it

is most commonly performed using

one of these two approaches. Other

minimally invasive surgical approach

options include the two-incision ap -

proach,5,6 the anterolateral (Watson-

Jones) approach, and the direct ant e-

rior (Hueter) approach.7 Often these

surgical approaches require the sur-

geon to change to a different OR

setup6 (i.e., one with a specialized

table, retractors, and lights, and access

to intraoperative X-ray) and to use an

implant he or she may be less familiar


Advantages• Predictable immediate pain relief and

return to function.• Predictable long-term implant survival.• Low risks and few complications for

healthy patients.• Contemporary bearing surfaces that

may reduce long-term wear.• Multiple indications (osteoarthritis,

inflammatory arthritis, osteonecrosis,posttraumatic hip conditions).

• Bone preservation options (hipresurfacing, tapered femoral stems).

Disadvantages• Prosthetic joint replacement limitations.• Activity limitations (nonimpact only).• Bearing surface wear in younger active

patients.• Revision surgery complications (three to

five times higher than for primary THR).• Major complications (infrequent).

Table. Advantages and disadvantages oftotal hip replacement.

Figure 1. Common surgical exposures. (A) Anterolateral incision. This incision is centredlongitudinally over the greater trochanter and permits an abductor-splitting approach. (B)Posterolateral incision. This approach is similar distally to the anterolateral, curving from thetip of the greater trochanter slightly posteriorly, entering the hip posterior to the abductormusculature.


with in order to make the procedure

feasible. While there may be a few

short-term advantages to minimally

invasive surgery, the early and mid-

term results have been associated with

significantly increased risks and sur-

gical complications,5 which have not

been seen in THR prior to the popu-

larity of these techniques. Thus, the

enthusiasm for minimally invasive

surgery has declined recently in favor

of surgery performed safely through

smaller incisions, and with the goal of

achieving an ideal implant orientation

and longevity. Computer-assisted

surgery (CAS) for total hip replace-

ment has gained popularity and is per-

formed in many centres. The advan-

tages and results of CAS have been

difficult to assess, and there does not

appear to be any significant advantage

to CAS at this time. The one area of

potential advantage is that CAS may

be useful in identifying “outlier”

acetabular component position/angu-

lation and leg length and hip offset

intraoperatively, which might help in

select situations, especially for sur-

geons with less experience perform-

ing THR and surgeons combining

CAS with minimally invasive surgery.

The main disadvantage is increased

OR time and increased cost. Overall,

CAS has not been shown to be cost-

effective to date.

Implant fixation:Cemented or cementless? Both cemented and cementless fixa-

tion are currently utilized in THR sur-

gery, although there has been a trend

in North America toward cementless

implants over the past 10 years. Total

hip replacement implants typically

consist of the acetabular component

(which is fitted into the patient’s

native acetabular pelvic bone with or

without cement), the femoral compo-

nent (inserted down the femoral

canal), and the bearing surfaces (the

articulating aspects of the implant).

When describing fixation methods,

we are referring to the femoral and

acetabular components.

Acetabular component implant fixationThe use of cemented acetabular com-

ponents has declined in recent years in

North America, although cemented

components are still used occasional-

ly in older and lower-demand patients.

When compared with cementless im -

plants, cemented acetabular compo-

nents have been associated with in -

creased rates of loosening at 10 to 20

years, especially in patients younger

than 50,8 when compared to cement-

less implants. Cementless acetabular

fixation was introduced to solve the

problem of loosening with cemented

acetabular cups. The most commonly

used composite for cementless acetab-

ular components is titanium alloy,

which is favorable for bone ingrowth.

Typically, a modular bearing surface

(the liner) is inserted into the inner

aspect of the acetabular component,

and locks into place via a mechanism

contained within the acetabular com-

ponent. The acetabular component

may accept bearing surfaces, including

liners made of polyethylene, ceramic,

or metal, to complete the acetabular

component composition ( ).

This modular bearing surface may be

exchanged in the future if wear or

other less common indications make

this necessary, leaving the intact

osseo-integrated acetabular compo-

nent in place. The long-term results of

cementless titanium acetabular fixa-

tion have been favorable. At a mini-

mum of 20 years, the implant survival

Figure 2


Figure 2. Cementless titanium acetabularcomponent. (A) The porous outer surfacepermits bone ingrowth and the cluster holesallow for adjunctive screw fixation. (B) Thepolished inner surface with circumferentiallocking mechanism accommodates amodular acetabular bearing surface. Themodular acetabular liners available for thiscomponent include: (C) Cross-linkedpolyethylene. (D) Ceramic. (E) Metal.

A B

C D

E


for titanium hemispherical cups has

recently been reported at over 95%.9

However, wear-related complications

of the polyethylene liner inside and on

the backside (and of the associated

modular locking mechanism) occur in

approximately 20% of patients by 20

years, a problem that has become the

focus of research in THR surgery.

Femoral component implant fixationCemented femoral component fixa-

tion has achieved excellent long-term

results in multiple studies at 17 to 30

years10-14 and continues to be the gold

standard against which the more pop-

ular cementless femoral fixation must

be measured. Contemporary cement-

ing techniques were refined in the

1970s and require attention to detail.

In addition to cement technique, there

are two implant designs: the cemented

tapered polished collarless stem (Ex -

eter, Stryker Orthopaedics, Mahwah

NJ) and the Spectron EF stem (Smith

& Nephew Orthopaedics, Memphis

TN) ( ) which have incor po-

rated differing design characteristics,

yet which have both proven very

successful in the long-term clinical

trials.15,16 Early failures of cemented

stems implanted with older cementing

technique included loosening, stem

fracture, and localized areas of bone

destruction (osteolysis) from cement

wear debris. Cementless implants were

developed to solve these problems.

Today, cementless femoral compo-

nents are produced in various designs

and shapes, and with different metal-

lic compositions and surface prepara-

Figure 3

tion to promote osseo-integration. All

uncemented femoral stem designs rely

on metaphyseal fixation, metaphy-

seal-diaphyseal junction fixation, dia-

physeal fixation, or a combination of

the three. The tapered titanium alloy

cementless stem ( ) has grown

in popularity17 and is becoming com-

monly used worldwide. Achieving

a press-fit via a single or dual taper -

ed wedge with subsequent proximal

osseo-integration of bone has proven

successful in multiple long-term stud-

ies18 of tapered titanium stems, with

over 95% survival at 10 to 20 years.

In summary, while cemented fem -

oral stem fixation remains the gold

standard in long-term studies, it is

highly dependent on cementing tech-

nique and implant design. Cemented

acetabular fixation is rarely utilized in

North America. Cementless fixation

on both the femoral and acetabular

sides is performed most commonly

and relies on an immediate press-fit

of the implant followed by osseo-

integration into host bone.

Hip resurfacing Total hip resurfacing, also known as

surface replacement arthroplasty or

hip resurfacing (HR), has gained in

popularity partly because of two

metal-on-metal HR implants approv -

ed by the FDA within the past 9 years.

HR has been performed for 15 years

in both North America and Europe

with favorable results.19,20 It is per-

formed using a cemented metal fem -

oral component shaped to the patient’s

native femoral head and a cementless

acetabular component with a polished

inner cobalt-chrome metal surface

( ). The two surfaces join to

create a metal-on-metal bearing

surface that has low-wear properties.

Relative indications for HR surgery21

include younger age, active occu-

pational and lifestyle requirements,

favorable bone anatomy and quality

Figure 5

Figure 4


Figure 3. Cemented femoral component. (A) Spectron EF component (Smith & Nephew,Memphis, TN). (B) Postoperative radiograph showing cemented femoral stem combined with acementless acetabular component, cross-linked polyethylene modular liner, and cobalt-chrome modular femoral head.

A B



Figure 4. Cementless femoral component. (A) Dual 3-degree tapered titanium component. The proximal portion of the stem has porous coatingfor bone ingrowth, while the middle of the stem is roughened by grit-blasting for bone ongrowth. (B) Postoperative radiograph showing acementless tapered stem, cementless titanium acetabular component with screw fixation, and modular metal-on-metal bearing surface.

Figure 5. Hip resurfacing. (A) Metal-on-metal bearing surface. (B) Postoperative radiograph showing left hip resurfacing.

A B

A B


(without cystic change, defects, or dys-

plasia), normal weight, and male sex.

Hip resurfacing may also be used ad -

junct when there is proximal femoral

deformity that would otherwise re -

quire an osteotomy to perform a THR

( ). Contraindications include

impaired renal function (or the poten-

tial for impairment with a diagnosis

such as diabetes) with an inability to

process serum metal ions, older age,

osteoporosis or osteopenia, unfavor-

able femoral head geometry, clinical

metal sensitivity history (usually a

nickel sensitivity), a leg-length discrep-

ancy greater than 1 cm, and women of

childbearing age. The primary con-

cern regarding HR in younger women

is how the increased ion levels of

cobalt and chromium normally asso-

ciated with a metal-on-metal bearings

could effect fetal development, as

these ions do cross the placenta. Two

recent studies suggest that although

these ions cross the placenta, a modu-

latory effect oc curs, decreasing their

concentration in the fetus. Still, such

Figure 6

results should be interpreted with

caution.22,23

Hip resurfacing surgery is perform -

ed with similar exposures to those

used in conventional THR. Contrary

to popular belief, hip resurfacing is

not a minimally invasive procedure.

Rather, it often requires a larger inci-

sion and surgical exposure, with addi-

tional soft tissue capsular releases that

are not typically performed in THR—

thus HR is often more invasive, not

less. Despite this, recovery following

hip resurfacing is similar to conven-

tional THR, likely due to generally

younger patient age. The proposed

advantages (which remain controver-

sial) of HR surgery include:

• Bone preservation on the femoral side.

• Ease of future revision surgery on

the femoral side.

• Large-head bearing surface with a

reduced dislocation rate.

• Use of a metal-on-metal low-wear

bearing surface.

• Patient findings that HR feels more

normal than THR.

These advantages, however, can

all be obtained from conventional

THR with the use of a metal-on-metal

bearing surface, particularly if a large

femoral head is used.

Surgeons who disfavor hip resur-

facing do so for several reasons:

• Bone preservation may not neces-

sarily occur, with occasionally more

bone being removed on the ace tab-

ular side to achieve a deepened sock-

et with a press-fit and no option for

screw fixation.

• The risk of notching the femoral neck

and subsequent femoral neck fracture

(risk 0.8%–1.5%)24,25 ( ).

• Elevated levels of serum and urine

cobalt, chromium, molybdenum, and

selenium ions that remain elevated

lifelong.

• The risk of lymphocyte-mediated

metal sensitivity reactions and/or

the development of pseudotumors,

recently highlighted in research at

UBC and McGill University.26

• It is a technically more demanding

surgical procedure for the surgeon

Figure 7


Figure 6. Hip resurfacing in case of proximal femoral deformity. (A) Preoperative radiograph used to investigate left hip pain. This patient hadpreviously undergone an intertrochanteric osteotomy. The residual femoral canal deformity seen on the radiograph means that an osteotomywould be required to perform a THR with a femoral component stem. (B) Postoperative radiograph showing left hip resurfacing performed toavoid the femoral osteotomy.

A B


and team, with a steep learning

curve27 and potentially increased

risks and complications when com-

pared with conventional THR.

While HR is an option to consider

in younger and more active patients, it

requires careful preoperative assess-

ment and a discussion with the patient

about all of the issues, including the

risk of increased metal ion levels and

metal sensitivity reactions, and the

low risk of psuedotumor.28 In addi-

tion, impact activities are not encour-

aged after HR, and the restrictions and

precautions following surgery are

similar to those for THR. Overall, the

short-term results of HR (up to 5

years) have been worse than for THR,

and therefore hip resurfacing should

be used with caution. THR remains

the gold standard.

Bearing surfacesWith current implant fixation meth-

ods demonstrating excellent long-

term results, the bearing surface

in THR is now the focus of much

research. The bearing surface is where

the movement of the two bearings

occurs and which provides the range

of motion and articulation of the pros-

thetic ball and socket joint. Within the

last 10 years, the use of traditional

ultrahigh molecular weight polyethyl-

ene (UHMWPE) acetabular liners has

declined with the development of new

kinds of polyethylene.

Highly cross-linkedpolyethylenesTo reduce wear rates and particulate

debris, highly cross-linked polyethyl-

ene (XLPE) has been used in total

hip arthroplasty for 8 years. The man-

ufacturing process for these materials

cross-links the molecules and im -

proves wear characteristics but slight-

ly reduces the strength of the polyeth-

ylene. Free radicals may be generated

in the process, potentially allowing

for oxidative changes in the polyeth-

ylene, unless these changes are appro-

priately managed in the manufactur-

ing process. Thus, the ideal XLPE

would be cross-linked at an appropri-

ate level of radiation, and then remelt-

ed to remove these free radicals and

thus reduce the oxidation process.

Cur rently, all of the THR implant

manu facturers produce either a first-

generation or second-generation XLPE.

When combined with a polished

cobalt-chrome head of multiple sizes,

these new XLPEs have shown prom-

ise in reducing in vivo and simulator

wear measurements significantly29

compared with traditional UHMWPE.

The increase in wear resistance is,

however, associated with a decrease

in fatigue strength and toughness. The

use of XLPE liners requires meti cu-

lous positioning of the acetabular

component to avoid vertical place-

ment of the implant, which reports

have associated with an increased risk

of fracture at the rim of the polyethyl-

ene liner ( ). The use of XLPE

has allowed the introduction of larger

femoral heads, which increase the sta-

bility of the hip with their greater dia -

meter and increased “jump distance.”

When XLPE is used, wear rates of the

polyethylene have not been shown to

be worse with larger femoral heads.

This is in contrast to older UHMWPE,

which demonstrates higher volumet-

ric polyethylene wear as the size of

the femoral head is in creased.

Alternative bearing surfacesOther bearing surfaces have been

developed and utilized in THR in an

attempt to reduce the wear-related

polyethylene complications. Polyeth-

ylene wear and debris formation result

in hip joint synovitis, joint instability,

osteolysis, and, potentially, prosthesis

loosening. Alternative bearing surfaces

such as metal-on-metal, ceramic-on-

ceramic, ceramic-on-XLPE, oxinium

(oxidized zirconium), and even the

new XLPEs themselves have been

developed in an attempt to reduce

wear and improve implant survival in

Figure 8


Figure 7. Radiograph showing a femoral neck fracture that occurred at 4 months following a left hip resurfacing procedure.


younger and more active patients.

Currently in Canada, the most com-

monly utilized bearing surface is a

cobalt-chrome head combined with

cross-linked polyethylene (59%),

while other alternative bearings such

as metal-on-metal (11% ; includes HR

use) and ceramics (13%) are used less

frequently, and usually in younger

patients.4

Ceramics. Alumina ceramics were

introduced in the 1970s. They have a

very low coefficient of friction and

demonstrate the lowest wear rates of

any implant bearing surface.30 They

are scratch resistant and may be com-

bined as a modular ceramic acetabular

liner with a ceramic head. There is no

potential for metal ion release, which

is attractive to younger patients, espe-

cially females of childbearing age.

Although ceramics can fracture be -

cause of their brittle composition, the

rate of fracture is very low (0.5%)31 in

most studies. Newer ceramic compos-

ites of alumina (Biolox Delta Ceram-

ic, CeramTec AG, Lauf, Germany)

have demonstrated increased strength

and fracture resistance, and offer

increased neck-length options intra-

operatively ( ). Ceramic-on-

ceramic bearing surfaces have been

associated with squeaking that is audi-

ble to the patient and others. Initially

believed to occur rarely (~1%) in

ceramic-on-ceramic THR, recent stud-

ies have shown that noise (squeaking,

grinding, rubbing, or other audible

Figure 9

sounds from the hip) occurs more fre-

quently than originally re ported, and

is experienced by 10% to 17% of

patients with a ceramic-on-ceramic

bearing surface.32,33 The causes and

implications of squeaking have yet to

be determined, but are likely to be

multifactorial: acetabular modular

implant design-specific factors, com-

ponent orientation and malposition,

instability, and femoral component

design have all been implicated. The

use of ceramic-on-ceramic bearings

offers many advantages in terms of

wear reduction, especially for young

and active patients. Nonetheless, pa -

tients considering ceramic-on-ceramic

bearings should be informed of this

phenomenon, and the surgeon and


Figure 8. Fractured rim of a cross-linked polyethylene liner. The acetabular component wasplaced in a vertical orientation, leading to a fatigue fracture at the superior aspect of thepolyethylene liner.

Figure 9. A ceramic-on-ceramic modularbearing surface.


patient should discuss avoiding cer -

amic implants associated with a high-

er incidence of squeaking. There are

no long-term clinical results to date

for the newer ceramic composites.

Oxinium. Oxidized zirconium (Smith

& Nephew, Memphis, TN) has been

developed for femoral head compo-

nents and has the wear-resistance of

ceramic without the brittle fracture

risk. Compared with the limited cera -

mic ball neck lengths available, oxini-

um allows for increased length op -

tions intraoperatively. No long-term

clinical studies of this material have

been published yet, and it is only avail-

able from one manufacturer.

Metal-on-metal. Metal-on-metal bear-

ing surfaces have been used widely

since the 1960s.34-36 Poor metallurgy,

poor design (equatorial head edge bear-

ing), and poor fixation led to early fail-

ures of many hip replacements using

metal bearings. However, a subset of

these were found to have a suitable

central-head bearing and minimal wear

when compared with hip replace-

ments using UHMWPE. This finding

led to a resurgence of interest in metal-

on-metal surface bearings, and an

attempt to create a bearing surface

with similar metallurgy and design to

that found in the subset with long-term

survival. Metal bearing surfaces dem -

onstrate very low wear rates—some-

where between rates for ceramic-on-

ceramic and metal-on-XLPE—and

much less wear than for conventional

UHWMPE. Metal bearings support

the use of a larger femoral head size,

which demonstrates better fluid-film

lubrication, and lower metal ion lev-

els than found with smaller head com-

binations, making metal-on-metal

ideally suited for hip resurfacing.

Metal is not brittle like ceramic, mak-

ing it attractive for younger patients.

Larger head sizes are also associated

with improved joint stability and a

reduced risk of dislocation. While

metal-on-metal bearing surfaces gen-

erally are associated with elevated

metal ion levels,37 no long-term effects

are known. Preoperatively, patients

must be informed that the low risk of

metal sensitivity and lymphocyte-

mediated reaction is similar to that for

hip resurfacing. Recently, inflamma-

tory granulomatous pseudotumors,

which are necrotic cystic soft tissue

tumors, have been seen following

large-head metal-on-metal hip replace-

ment with one or more implant de -

signs, and have been seen less often

following HR. For this reason, metal-

on-metal bearing surfaces should be

used with caution in THR, patients

should be followed closely at yearly

intervals, and patients should be coun-

seled about the possibility of metal-

related complications that will lead to

poor outcome if they occur, even after

revision surgery.

ConclusionsTotal hip arthroplasty has become the

treatment of choice for hip-related dis-

orders leading to arthritis in the adult

population. With improvements in

long-term clinical results, implant fix-

ation, and new low-wear bearing sur-

faces, THR surgery is now being per-

formed in younger and more active

patients. Using current implant design

and techniques, the implant survival

at 20 years is favorable, with over 90%

implant survival in multiple studies.

However, with younger and more

active patients undergoing total hip

replacement, the challenge will be the

bearing surface selection. It remains

to be determined which bearing sur-

faces will provide the lowest wear

rates and the fewest wear-related com-

plications in the long term.

Competing interests

None declared.

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15. Williams HD, Browne G, Gie GA, et al.The Exeter Universal cemented femoralcomponent at 8 to 12 years. A study ofthe first 325 hips. J Bone Joint Surg Br2002;84:324-334.

16. Garellick G, Malchau H, Herberts P. Sur-vival of hip replacements. A comparisonof a randomized trial and a registry. ClinOrthop Relat Res 2000;(375):157-167.

17. Danesh-Clough T, Bourne RB, RorabeckCH, et al. The mid-term results of a dualoffset uncemented stem for total hiparthroplasty. J Arthroplasty, 2007;22:195-203.

18. Lombardi AV Jr, Berend KR, Mallory TH,et al. Survivorship of 2000 tapered titani-um porous plasma-sprayed femoral com-ponents. Clin Orthop Relat Res 2009;467:146-154.

19. Treacy RB, McBryde CW, Pynsent PB.

Birmingham hip resurfacing arthroplasty.A minimum follow-up of five years. JBone Joint Surg Br 2005;87:167-170.

20. Amstutz HC, Le Duff MJ. Eleven years of experience with metal-on-metal hybrid hip resurfacing: A review of 1000conserve plus. J Arthroplasty 2008;23(suppl):36-43.

21. Della Valle CJ, Nunley RM, Barrack RL.When is the right time to resurface?Orthopedics 2008;31(suppl).

22. Ziaee H, Daniel J, Datta AK, et al.Transplacental transfer of cobalt and chro -mium in patients with metal-on-metal hiparthroplasty: A controlled study. J BoneJoint Surg Br 2007;89:301-305.

23. Amstutz HC, Antoniades JT, Le Duff MJ.Results of metal-on-metal hybrid hipresurfacing for Crowe type-I and II devel-opmental dysplasia. J Bone Joint SurgAm 2007;89:339-346.

24. Shimmin AJ, Back D. Femoral neck frac-tures following Birmingham hip resurfac-ing: A national review of 50 cases. J BoneJoint Surg Br 2005;87:463-464.

25. Amstutz HC, Campbell PA, Le Duff MJ.Fracture of the neck of the femur aftersurface arthroplasty of the hip. J BoneJoint Surg Am 2004;86-A:1874-1877.

26. Garbuz DS, Tanzer M, Greidanus NV, etal. The John Charnley Award: Metal-on-metal hip resurfacing versus large-diam-eter head metal-on-metal total hip arthro-plasty: A randomized clinical trial. ClinOrthop Relat Res 2009;468:318-325.

27. Nunley RM, Zhu J, Brooks PJ, et al. Thelearning curve for adopting hip resurfac-ing among hip specialists. Clin OrthopRelat Res 2009;468:382-391.

28. Counsell A, Heasley R, Arumilli B, et al. Agroin mass caused by metal particle


debris after hip resurfacing. Acta OrthopBelg 2008;74:870-874.

29. Bragdon CR, Kwon YM, Geller JA, et al. Minimum 6-year followup of highlycross-linked polyethylene in THA. ClinOrthop Relat Res 2007;465:122-127.

30. Semlitsch M, Willert HG. Clinical wearbehaviour of ultra-high molecular weightpolyethylene cups paired with metal andceramic ball heads in comparison tometal-on-metal pairings of hip jointreplacements. Proc Inst Mech Eng H1997;211:73-88.

31. Capello WN, D’Antonio JA, Feinberg JR,et al. Ceramic-on-ceramic total hip arthro-plasty: Update. J Arthroplasty 2008;23(suppl):39-43.

32. Jarrett CA, Ranawat AS, Bruzzone M, etal. The squeaking hip: A phenomenon ofceramic-on-ceramic total hip arthroplas-ty. J Bone Joint Surg Am, 2009;91:1344-1349.

33. Mai K, Verioti C, Ezzet KA, et al. Incidenceof “squeaking” after ceramic-on-cera mictotal hip arthroplasty. Clin Orthop RelatRes 2009;468:413-417.

34. McKee GK, Watson-Farrar J. Replace-ment of arthritic hips by the McKee-Far-rar prosthesis. J Bone Joint Surg Br1966;48:245-259.

35. Ring PA. Complete replacement arthro-plasty of the hip by the ring prosthesis. JBone Joint Surg Br 1968;50:720-731.

36. Muller ME. Total hip prostheses. ClinOrthop Relat Res 1970;72:46-68.

37. MacDonald SJ, McCalden RW, ChessDG, et al. Metal-on-metal versus poly-ethylene in hip arthroplasty: A random-ized clinical trial. Clin Orthop Relat Res2003;(406):282-296.


David M. Patrick, MD, FRCPC,MHSc, Malcolm Maclure, ScD,Bill Mackie, MD, RachelMcKay, MSc

Confidentially, could you resist

looking at your pattern of an -

ti biotic prescribing and com-

paring it with evidence? Without any-

one else knowing? If you are a GP in

active practice, you will soon receive

a sealed, coded envelope containing a

confidential portrait (seen by no one)

of your prescribing of antibiotics for

urinary tract infections (UTI). Its goal

is to reverse recent growth in antibi-

otic resistance. Yes, we can! Studies

have demonstrated the potential for

reduced antibiotic resistance follow-

ing reduced antibiotic prescribing.1

Ten years ago, BC’s provincial

health officer published a report on

antimicrobial resistance which con-

tained recommendations for areas of

action.2 It is fair to say that consider-

able progress has been made on most

of the recommendations related to the

piratory tract infections (URTI). The

portraits will be mailed out in a stag-

gered manner in coming months, so

impacts on prescribing can be asses -

sed comparing geographic areas that

receive the portraits early versus de -

layed areas.

Now that we are finally making

progress in putting our own house in

order, we should applaud BCMA’s

endorsement of investigation into the

deleterious effects on nonveterinary

use of antibiotics in agricultural opera -

tions.4 The effects on the environment

and the contribution to emergence

of antibiotic-resistant organisms in

humans must be understood and

addressed.5 While trends in human use

in BC are slowly improving, we have

made little or no progress on the issue

in agriculture and veterinary practice.

In several countries in northern Europe,

strict controls apply in agriculture.

References

1. Enne VI. Reducing antimicrobial resist-ance in the community by restricting pre-scribing: can it be done? J of AntimicrobChemother 2010;65:179-182.

2. Provincial Health Officer. AntimicrobialResistance: A Recommended ActionPlan for British Columbia. Office of theProvincial Health Officer, 2000. www.health.gov.bc.ca/library/publications/year /2000/ant imicrobia l f ina l .pdf(accessed 28 September 2010).

3. Ranji SR, Steinman MA, Shojania KG, etal. Interventions to reduce unnecessaryprescribing: A systematic review andquantitative analysis. Med Care 2008;48:847-862.

4. Gillespie I. BCMA leads country with 16resolutions at CMA. BC Med J 2010;52:330.

5. Mackie B. Antibiotic use in our livestock.BC Med J 2010;52:309.

bc centre fordisease control

Your irresistible personal portrait: A way to reduce antibiotic resistance?

Dr Patrick is the director of EpidemiologyServices at the BCCDC, and a professor inthe School of Population and Public Healthat the University of British Columbia. DrMaclure is professor and BC chair in PatientSafety in the Department of Anesthesiolo-gy, Pharmacology, and Therapeutics atUBC and co-director of Research and Evi-dence Development in PharmaceuticalServices Division of the BC Ministry ofHealth Services. Dr Mackie is current chairof the BCMA Environmental Health Com-mittee, past president of the BCMA, pastchair of the BCMA Council on Health Pro-motion, and clinical associate professorUBC Faculty of Medicine. Rachel McKay isa surveillance analyst in Epidemiology Serv-ices at the BCCDC.

practice of medicine. BCCDC and the

Do Bugs Need Drugs? program con-

duct regular surveillance on antibiotic

consumption and resistance in BC.

Our data show overall use of an ti -

biotics rose between 2002 and 2005,

and then levelled off. Between 2005

and 2008 we saw an 8.7% re duction in

antibiotic use with acute sinu sitis and

a 17% reduction with acute pharyn-

gitis. There has been a 35% to 57%

reduction in use of anti biotics in chil-

dren, with the largest reduction among

children less than 1 year of age.

Unfortunately, the use of antibi-

otics with acute bronchitis remains

high. Ominously, the overuse of fluo-

roquinolones now threatens to render

this class of antibiotic ineffective for

treating urinary tract infections (UTI)

as E. coli resistance surges. Despite

guidelines stating that moxifloxacin

should be used only after another

antibiotic, preliminary data suggest

the vast majority of prescriptions for

this drug in BC in 2009 were not pre-

ceded by another antibiotic.

Judicious use of antibiotics in

hum an medicine is imperative in con-

trolling the spread of antibiotic resist-

ant organisms. Evidence indicates that

personalized feedback to physicians

is an effective way to reduce unneces-

sary prescribing of antibiotics in out-

patients.3 The EQIP group, a joint

initiative of the BC Ministry of Health

Services, the BCMA, and UBC Fac-

ulty of Medicine’s Department of

Anesthesiology, Pharmacology, and

Therapeutics, creates individualized

de-identified prescribing portraits for

BC physicians on a variety of topics.

EQIP has recently collaborated with

the Do Bugs Need Drugs? program to

create portraits of antibiotic prescrib-

ing associated with UTI and upper res-


Angus Rae, MB, FRCPC,FRCP(UK), FACP

The Netherlands recently cele-

brated the 65th anniversary of

its liberation by Canadian Arm -

ed Forces on 5 May 1945 from Nazi

Germany. These celebrations were

attended by a dwindling number of

Canadian veterans present on that his-

toric day. It was a joyous occasion and

the Dutch turned out in force.

One Canadian veteran missing was

Lieutenant Colonel Russell Palmer

(Retired), who died 22 December

1999, aged 94.1 Dr Palmer’s major

contribution to the initiation and sub-

sequent growth of our renal failure

program, now the equal of any in

Canada, is seldom re membered in his

home pro vince of British Columbia.

Who was Russell Palmer?

Lt. Col. Russell Palmer obtained a

BA from UBC in 1926 and an MD

from McGill University in 1931, and

was serving with the Royal Canadian

Army Medical Corps in Kampen,

Netherlands, at the time of the libera-

tion. There he met by chance Dr Wil -

lem Kolff, a Dutch physician who had

been trying for some years to develop

a workable artificial kidney for pa -

tients with renal failure, something

which despite many attempts had not

been done successfully. After the Nazi

invasion of 1940, Dr Kolff joined the

Dutch resistance and was forced to

continue his work in secret and in

great danger, since some of his mate-

rial, metal derived from downed air-

craft, was wanted by the foe.

Palmer given blueprint ofKolff’s artificial kidneyWhen the Canadians arrived in 1945,

Dr Willem Kolff, anxious to discuss

his work with a physician from the lib-

erating forces, was introduced to Dr

Palmer who, as a general internist, had

no special interest in the kidney and

was unaware of attempts to create an

artificial one; there was no precedent

for a complex organ being replaced by

a machine. With the aid of an inter-

Russell Palmer: Forgotten championHow victory in Holland launched the BC renal failure program

Dr Rae is clinical professor emeritus ofmedicine, University of British Columbia.

good guys

preter, Dr Palmer immediately saw

the significance of Dr Kolff’s work

and gratefully accepted the offer of a

“reprint” (i.e., blueprint) of his rotat-

ing drum artificial kidney ( ).

Dr Kolff had used his invention as

early as 1943 in a variety of patients

with renal failure but, despite techni-

cal success with the equipment, none

of the patients survived; later several

were shown to have had chronic ir -

reversible disease, and Dr Kolff con-

Figure

Figure. Letter from Kolff to Palmer offering to supply a blueprint for the machine that wouldenable Palmer’s first life-saving hemodialysis in 1947.


cluded that this treatment was only

indicated in those with the potential

for recovery.

The first patient whose life Dr Kolff

saved with his artificial kidney in Sep-

tember 1945 was a Nazi collaborator

imprisoned in the local barracks.2 She

was moribund from uremia due to

sulphonamide anuria following treat-

ment for cholecystitis and septicemia;

her kidneys recovered after treatment,

and she lived for a further 7 years.

First successfulhemodialysis with Kolff’s machineOn return to Canada with Dr Kolff’s

blueprint, Dr Palmer had the rotating

drum built by his brother, an engineer

on Granville Island. Palmer’s first

life-saving hemodialysis using this

equipment was carried out at Shaugh-

nessy Hospital in Vancouver in Sep-

tember 1947.3

In 1946 Dr Kolff gave copies of

his rotating drum artificial kidney to

England, the United States, and Cana-

da.2 It was used several times in Lon-

don in that year with indifferent results

and abandoned in favor of dietary

management. Dr MacLean in Montre-

al used it in 1948, as did the Ameri-

cans in the same year;4 hence Dr Palm -

er was the first to succeed with Dr

Kolff’s rotating drum in North Amer-

ica, and the fourth in the world, includ-

ing Kolff’s case mentioned above.

Soon after, the new UBC Medical

School opened in 1950. Dr Palmer was

named head of the Metabolic Unit at

Vancouver General Hospital (VGH)

for a short while with the rank of clin-

ical assistant professor of medicine.

Dr Palmer used the rotating drum

artificial kidney briefly at Shaugh-

nessy Hospital and thereafter at VGH

until 1957 with the assistance of Dr

Edwin Henry, a research fellow in

clinical investigation. In that time they

obtained 10 years’ experience of 54

patients with acute renal failure, 23 of

whom were dialyzed with the rotating

drum, 12 of whom survived.5,6

In 1956 Dr Henry left to work in

Prince George and was replaced at

VGH by Dr John D.E. Price. Mean-

while Dr Kolff, having immigrated to

the US to work at the Cleveland Clin-

ic in 1950, improved on his earlier

device and developed the twin coil

artificial kidney. Dr Palmer promptly

arranged for Dr Price to spend a few

weeks in Cleveland to learn about it.

On Dr Price’s return to the VGH, and

at Dr Kolff’s invitation, a trial of the

twin coil was carried out and its supe-

rior functioning reported by Drs Palm -

er and Price in 1957.7

The treatment of acute renal fail-

ure by hemodialysis was now estab-

lished, but up until 1960 a major prob-

lem was the need for repeated vascular

puncture, which inevitably damaged

vessels leading to lack of access; when

that occurred the only alternative was

peritoneal dialysis, or death. This prob-

lem of vascular access was the major

reason why hemodialysis for chronic

renal failure was not even considered.

Dr Gordon Murray, a surgeon in

Toronto unaware of Kolff’s work,

built a machine with which he did a

hemodialysis in December 1946. Al -

though it was successful, his machine

never came to anything for reasons

given in an excellent 1999 article enti-

tled, “Gordon Murray and the artifi-

cial kidney in Canada.”8 This extra or-

dinary man was named a companion

of the Order of Canada in 1967.

Dr Kolff was inducted into the

Inventors’ Hall of Fame in 1985, and

in 1990 was named by Life magazine

in its list of the 100 Most Important

Americans of the 20th Century.

Peritoneal dialysis Peritoneal dialysis also had problems

with access. Repeated puncture of the

peritoneal cavity carried the danger of

leakage, infection, and the potential

for visceral damage. Nevertheless Dr

Palmer’s interest in it began in the

1950s while still at VGH, in part be -

cause of these problems with hemo -

dialysis but also to relieve pressure on

this limited resource. Drs Palmer and

Henry published their experiences in

1963 using repeated peritoneal punc-

ture in eight acute and four chronic

renal failure patients; six of the acute

but none of the chronic patients sur-

vived, confirming the value of peri-

toneal dialysis in acute patients but

giving little hope for those with chron-

ic renal failure.9

In 1962 Dr Palmer left VGH to join

St. Paul’s Hospital, partly to pursue

his interest in peritoneal dialysis, while

Dr John Price continued to supervise

dialysis at VGH. In 1964 the Vancou-

ver General Hospital Renal Unit for

Dialysis was opened and thereafter

thrived and expanded under Dr Price’s

leadership. In those early days nephro -

logy was not recognized as a special-

ty, and it was not until 1979 that the

UBC Medical School created a formal

Division of Nephrology under Dr John

Dirks.

Back at St. Paul’s Dr Palmer, with

assistance from Dr C.E. (Ed) Mac-

Donnell, another internist with an in -

terest in the kidney, concentrated on

peritoneal dialysis. Although it had

been known that the peritoneal mem-

brane had clinical potential as long

ago as 1877, the first successful peri-

toneal dialysis for acute renal failure

did not take place until 1923. Reports

of successes thereafter were few until

the 1950s.10 A major reason for the

good guys

Palmer’s first life-saving hemodialysis

using this equipmentwas carried out at

Shaughnessy Hospitalin Vancouver in

September 1947.



catheter. This, like the shunts for hemo-

dialysis, remained in place for access

when needed and peritoneal dialysis

for chronic kidney failure also became

a reality.11

Back at St. Paul’s, Drs Palmer

and McDonnell put the new Palmer-

Quinton catheter to good use. There

were no hemodialysis facilities then at

St. Paul’s, and since younger patients

were given priority for the limited

resource at VGH, the two doctors

focused their attention on patients

over 50 years of age with chronic kid-

ney failure. In 1968 they reported their

experiences with peritoneal dialysis

using the Palmer-Quinton catheter in

21 patients, including a nurse aged 53,

who survived for just under 2 years,

did much of her peritoneal dialysis at

home, and returned to work part-time.

In effect she became the first recorded

patient with chronic renal failure to do

home peritoneal dialysis.12

However neither the shunt nor

the catheter were without problems.

The Scribner-Quinton shunts had the

propensity to clot, requiring declotting

by a physician or revascularization by

a surgeon.

The Palmer-Quinton peritoneal

catheter was prone to leaks, and in -

fection could enter the track of the

catheter through the abdominal wall

and cause peritonitis. However, both

devices paved the way for later im -

provements that are now in widespread

use. The Scribner-Quinton shunt was

superseded by the Cimino-Brescia

fis tula2,4 and the Palmer-Quinton

catheter by the Tenckhoff catheter,

whose Dacron cuffs fibrosed in the

abdominal wall, reducing the chance

of infection.4 There was now the dis-

tinct possibility of using both hemo -

dialysis and peritoneal dialysis for

long-term treatment of patients with

chronic renal failure.

New Renal Unit at St. Paul’s In 1968 Dr Palmer was instrumental

in recruiting his successor, the author,

from the trial home hemodialysis unit

funded by the State of Washington in

Spokane, a unit funded only for home

hemodialysis.13 Thus 4 years after the

opening of the Renal Unit for Dialysis

at VGH, a second such unit opened

at St. Paul’s, each now equipped for

hemo dialysis and peritoneal dialysis;

Dr Palmer was the driving force in the

inauguration of both.

That was the end of Dr Palmer’s

active involvement in dialysis but he

remained interested and in 1982 pro-

duced his acclaimed history of peri-

toneal dialysis.10 In 1992 he received

an award at the 12th Annual Confer-

ence on Peritoneal Dialysis in Seattle,

where he made a brief presentation,

“Afterthoughts”—essentially his swan-

song.14

What did Palmer achieve?Dr Russell Palmer introduced both

hemodialysis and peritoneal dialysis

to British Columbia and by initiating

the two renal units in Vancouver intro-

duced, if unwittingly, an essential ele-

ment of competition that triggered the

rapid expansion that has resulted in

BC’s leading position in this field.

The first patients to do home hemo -

dialysis were trained at St. Paul’s in

196915 and at VGH soon after. Home

good guys

sluggish advance was the danger of

repeated peritoneal puncture. Hence

although both hemodialysis and peri-

toneal dialysis often saved lives in the

short term, both had major problems

with the need for repeated access.

In the end both hemodialysis and peri-

toneal access problems were solved by

the use of Teflon and silicone rubber.

In 1960 Professor Belding Scrib-

ner of the University of Washington

in Seattle, a leader in long-term hemo -

dialysis, had, together with his engi-

neer Mr Wayne Quinton, devised Tef -

lon catheters that were inserted in an

artery and an adjacent vein for long-

term vascular access. These catheters

were joined by a flexible silicone

rubber tube so that with anticoagula-

tion blood could flow continuously

between hemodialysis treatments, the

tubes being uncoupled for the proce-

dure. Hence repeated vascular punc-

ture was avoided and the prospect of

long-term hemodialysis for chronic

renal failure became a possibility us -

ing this Scribner-Quinton shunt.2,4

Dr Palmer, alert to these advances,

saw the potential of silicone rubber

for use as a permanent peritoneal

catheter, and described his idea to Mr

Quinton, who fashioned the Palmer-

Quinton silicone rubber peritoneal

Dr Russell Palmer, centre, after receiving a special recognition award in Seattle, February 1992.He is pictured with Mrs Palmer (far left), his daughters Noel Palmer (holding award), and LynnEyton (far right).



peritoneal dialysis was continued at

St. Paul’s16 and VGH was the first to

adopt continuous ambulatory peri-

toneal dialysis a major advance first

described in 1978.17

Several other cities in BC now

have dialysis units and train patients

to treat themselves at home; some

units were initiated and supported by

Dr John Price in the 1960s and others

later by St. Paul’s.

Several hundred patients in BC are

now dialyzing themselves independ-

ently at home; about 20% are doing

hemodialysis and the others periton -

eal.18 Hundreds more are dialyzing in

community centres with minimal assis-

tance from nurses. Well over 1000 are

receiving dialysis in hospital centres

and some in nursing homes because

they are elderly, infirm, or incapable

of learning the procedure.

The first renal transplant was done

at VGH in 1968, and when a second

team was warranted, St. Paul’s fol-

lowing in 1986. The advent of this sec-

ond team resulted in a surge in num-

bers and the transplant rate was tripled

in a few months. The total now trans-

planted approaches 4000. The paired

exchange program was started in BC

in 2009 and is increasing the pool of

eligible donors. The zenith of this

program to date is an exchange of kid-

neys among four couples.19

Is it too much to suggest that this

explosion of activity resulted from a

chance meeting in the Netherlands

65 years ago? I don’t think so. Histo-

ry is full of individuals who, marching

to the beat of their own drum, achieve

more than an army of conscripts to

another’s.

Dr Russell Palmer was better known

in the US than at home. In 1975 he

was elected to mastership of the Amer-

ican College of Physicians, an honor

granted only to “highly distinguished

physicians…who have achieved

recognition in medicine by…making

significant contributions to medical

science or the art of medicine…” Dr

Palmer qualified on both counts.

Dr Palmer was a modest man not

given to blowing his own trumpet.

Like most of those who together have

built our enviable renal failure pro-

gram, he was a member of clinical

faculty. Together with others in the

1940s and 1950s, and often opposed

by the academic and political estab-

lishment,20,21 he saw and seized on

possibilities that in the aggregate have

resulted in the well-being of millions

worldwide whose lives have been

saved and improved beyond measure

by dialysis while they await the ulti-

mate goal of a functioning kidney

transplant.

In the last paragraph of his swan-

song, “Afterthoughts,” Dr Palmer

reminds us that however necessary

and indeed seductive discovery can

be, it is of no value in the context of

our profession unless it serves our

main purpose to care for the sick and

injured.14

References

1. Rae A. Russell Alfred Palmer. BC Med J2000;42:142-143.

2. Cameron JS. History of the Treatment ofRenal Failure by Dialysis. Don Mills:Oxford University Press; 2002.

3. Palmer RS, Rutherford PS. Kidney sub-stitutes on uraemia; the use of Kolff’s dial-yser in two cases. CMAJ 1949;60:261-266.

4. McBride PT. Genesis of the Artificial Kid-ney. 2nd ed. Chicago: Baxter Healthcare;1987.

5. Palmer RA, Henry E, Eden J. The man-agement of renal failure. Observationson 54 cases. CMAJ 1957;77:11-19.

6. Palmer RA, Henry EW. The clinicalcourse of acute renal failure observationson 54 cases. CMAJ 1957;77:1078-1083.

7. Palmer RA, Price JDE, et al. Clinical trialswith the Kolff Twin Coil Artificial Kidney.CMAJ 1957;77:850-855.

8. McKellar S. Gordon Murray and the arti-ficial kidney in Canada. Nephrol DialTransplant 1999;14:2766-2770.

9. Palmer RA, Maybee TK, Henry EW, et al.Peritoneal dialysis in acute and chronicfailure. CMAJ 1963;88:920-927.

10. Palmer RA. As it was the beginning. A his-tory of peritoneal dialysis. Perit Dial Bull1982;2:16-23.

11. Palmer RA, Quinton WE, Gray JE, et al.Prolonged peritoneal dialysis for chronicrenal failure. Lancet 1964;1:700-702.

12. Palmer RA, McDonnell CE. Prolongedperitoneal dialysis for chronic renal fail-ure in patients over 50 years of age.CMAJ 1968;98:344-349.

13. Rae AI, Marr TA, et al. Hemodialysis inthe home. Its integration into generalmedical practice. JAMA 1968;206:92-96.

14. Palmer RA, Afterthoughts. AdvancesPeritoneal Dial 1992;8:xvii–xviii.

15. Rae A, Craig P, Miles G. Home dialysis:Its costs and problems. CMAJ 1972;106:1305-1316.

16. Rae A, Pendray M. Advantages of peri-toneal dialysis in chronic renal failure.JAMA 1973;225:937-941.

17. Popovitch RP, Moncrief JW, Nolph KD, etal. Continuous ambulatory peritoneal dial-ysis. Ann Int Med 1978;88:449.

18. Komenda P, Copland M, Makwana J, etal. The cost of starting and maintaining alarge home hemodialysis program. KidInter 2010;77:1039-1045.

19. Landsberg DN, Shapiro J. Kidney, pan-creas, and pancreatic islet transplanta-tion. BC Med J 2010;52:189-196.

20. Crowther SM, Reynolds LA, Tansey EM(eds). History of dialysis in the UK:c.1950–1980. Wellcome Witnesses toTwentieth Century Medicine. WellcomeTrust Centre for the History of Medicineat UCL. 2009;37:1-122.

21. Rae A. History of dialysis in the UK: c.1950–1980. Hemodial Int 2010;14:156-157.

good guys

Make your community healthier

www.divisionsbc.ca


The Divisions of Family Practice

initiative is clearly meeting the

needs of family physicians

across the province. Since its launch

almost 2 years ago, the initiative has

seen the creation of 18 divisions, rep-

resenting the interests of physicians in

68 communities. By year-end another

two divisions are expected to be added

to the total.

Although many of the issues being

addressed through the Divisions of

Family Practice—such as expanding

capacity for primary care and enabling

access to a family physician for all

British Columbians—are similar

across the province, the divisions also

focus on identifying and addressing

specific local community needs.

“Our Division gives us an oppor-

tunity to make positive changes in our

community,” says Dr Steve Larigakis,

physician lead for the White Rock–

South Surrey Division. “In the past

there wasn’t a mechanism for improv-

ing things. Now we can identify local

problems and through our Collabora-

tive Services Committee we can work

together toward solutions.”

One of the current priorities for the

White Rock–South Surrey Division is

the Attachment initiative, also called

“A GP for Me,” which is funded by the

General Practice Services Committee

(GPSC). The provincial goal for this

program is to ensure by 2015 that

every British Columbian who wants

access to a family physician has it.

“The solution to attachment is

multi-faceted,” says Dr Brenda Hef-

ford, lead physician for the Division’s

A GP for Me initiative. “It involves

helping family physicians in the work

they do, while also increasing com-

munity capacity.”

To expand capacity, the White

Rock–South Surrey Division is devel-

oping a recruitment strategy for attract-

ing new general practitioners to the

community, and hopes to recruit up to

four new family physicians within the

next 2 years.

The Division is also working with

Fraser Health to develop a multidisci-

plinary primary care access clinic,

slated for opening in early November,

to provide a “primary care transition-

al home” for local patients discharged

from hospital or emergency who do

not have a family physician. The

Division is providing operational sup-

port for the clinic, which will be staf -

fed by a community physician and by

nurse practitioners provided by Fras-

er Health.

Recruitment of new physicians

has also been a priority for the Abbots-

ford Division of Family Practice,

which in the past year has succeeded

in attracting seven new family physi-

cians to the community.

“We discovered that in the past

there were doctors making inquiries

about working here, but since recruit-

ment was handled by the health au -

thority and not locally, there wouldn’t

be any follow-up,” says Dr Holden

Chow, physician lead for the Division.

By hiring a coordinator and partner-

ing with Fraser Health and adminis-

trators at Abbotsford Regional Hospi-

tal, the Division was able to ensure

that every physician expressing inter-

est in moving to the region was con-

tacted and encouraged to choose

Abbotsford. The Division has a goal

of securing three additional GPs and

is currently in discussions with four

potential recruits.

Many of Abbotsford’s newly re -

cruit ed physicians have requested

hospital privileges and are participat-

ing in the Division’s Hospital Care

Physician Program.

“On any given day up to 15 admis-

sions to the hospital are unattached

patients who would be uncared for if

we didn’t have this program,” says Dr

Chow. The new physicians have revi-

talized the hospital care program and

helped reduce the stress for other

family physicians with hospital privi-

leges, says Dr Chow.

In Prince George, an in-patient

primary care program has been devel-

oped to support family physicians and

patients in hospital who don’t have

their own doctor, says Dr Garry Knoll,

Divisions of Family Practice address community needs,improve care at local level

gpsc

Make your voice heardwww.divisionsbc.ca

“We discovered that in the past there were

doctors making inquiriesabout working here, butsince recruitment washandled by the health

au thority and not locally,there wouldn’t be any

follow-up.”


gpsc

physician lead for the Prince

George Division. There is also an

unattached patient clinic to follow

up with these patients once they

are discharged from hospital.

Dr Knoll says the Division has

discussed partnering with North-

ern Health to provide a home for

up to 5000 unattached patients in

the community, many of whom

have special needs. By providing

primary care along with a multi-

disciplinary range of services in

areas such as social work, physio-

therapy, and mental health and

addictions counseling, Dr Knoll

says the needs of up to 30% of

Prince George’s unattached patients

could be met.

This summer the Chilliwack

Di vision of Family Practice launch -

ed a hospital care program. Ac -

cording to physician lead, Dr Scott

Markey, the program is working

out better than anticipated.

“We have had some success in

bringing back physicians who had

stopped working at the hospital,

and with some locum physicians

in the community who have cho-

sen to keep up their hospital skills

by working in the program,” says

Dr Markey.

Overall, among the divisions

there is a strong feeling of opti-

mism about the chance to make

local changes toward improving

primary care.

“It’s pretty exciting times for

family practice right now,” says

Dr Hefford. “The things going on

in the divisions have opened doors

and opportunities that didn’t exist

before.”

“There’s a recognition now that

family practice is where things can

be done to make a difference,”

says Dr Chow. “We’ve heard that

from all levels and now we’re

starting to see it.”

—Brian Evoy, PhD

Executive Lead, Divisions

of Family Practice

BCMA Board officers anddelegates contact list

President Ian Gillespie [email protected]

Past President Brian Brodie [email protected]

President-Elect Nasir Jetha [email protected]

Chair of the GeneralAssembly Shelley Ross [email protected]

Honorary SecretaryTreasurer William Cunningham [email protected]

Chair of the Board Alan Gow [email protected]

District #1 William Cavers [email protected]

District #1 Robin Saunders [email protected]

District #1 Carole Williams [email protected]

District #2 Robin Routledge [email protected]

District #2 Michael Morris [email protected]

District #3 James Busser [email protected]

District #3 Bradley Fritz [email protected]

District #3 Charles Webb [email protected]

District #3 Duncan Etches [email protected]

District #3 Lloyd Oppel [email protected]

District #3 David Wilton [email protected]

District #3 Mark Godley [email protected]

District #4 Kevin McLeod [email protected]

District #4 Nigel Walton [email protected]

District #5 Bruce Horne [email protected]

District #6 Todd Sorokan [email protected]

District #7 Yusuf Bawa [email protected]

District #7 Barry Turchen [email protected]

District #8 Gordon Mackie [email protected]

District #9 Jannie du Plessis [email protected]

District #10 Shirley Sze [email protected]

District #11 Jean-Pierre Viljoen [email protected]

District #12 Charl Badenhorst [email protected]

District #13 Mark Corbett [email protected]

District #13 Philip White [email protected]

District #15 Trina Larsen Soles [email protected]

District #16 Luay Dindo [email protected]

District #16 Evelyn Shukin [email protected]


one less form to complete as part of

the OR booking process. Surgeons

will still make the decision with their

patient when to have surgery.

Benefits for patientsThe standardized method used across

the province for prioritizing patients

will enable waitlists to be managed

fairly and barriers to reducing wait

times will be identified. This is intend-

ed ultimately to improve access for

BC’s surgical patients.

Watch for further information com-

ing your way soon from the BCMA,

the Provincial Surgical Advisory

Council, and your health authority.

Online strokeinformationHealth Education Solutions, an Amer-

ican continuing medical education

company, has released a new Stroke

Special Section within its online

research library, incorporating a series

of articles, vignettes, and facts about

the American Heart Association’s

pulsimeterin memoriam

Dr Norman Wignall1918–2010Dr Norman Wignall passed away

on 28 August after a lengthy illness.

Dr Wignall was born in Barrow-in-

Furness, England, and immigrat ed

to Canada in 1956. He was a mem-

ber of the Royal (British 8th) Army

Medical Corps serving in North

Africa and the Middle East. A grad-

uate of the University of Liverpool

Faculty of Medicine, Norman prac-

tised pathology with the qualifica-

tions of CD, MB, ChB, FRCPC in

Vancouver until his re tirement in

1991. He was also a mem ber of the

BC Regiment and Ro yal Canadi-

an Army Medical Corps.

He is survived by his wife,

Teiko, and son, Norman Jr. He will

be missed. His family is grateful

to his friends and colleagues for

their support and to the medical

professionals who always assisted

with compassion and effectiveness.

—Norman Wignall Jr.

Vancouver

CorrectionBCMJ regrets the inclusion of Dr

Helen Angela Penny in the list of

recently deceased physicians pub-

lished in our October 2010 issue.

We sincerely apologize to Dr Penny

for this publication error.

New BC-wide surgerybooking systemAfter 3 years of use, the Clinical

Assessment Tool has now been dis-

continued and replaced with a stan-

dard province-wide, diagnosis-based

prioritization system for all adult and

pediatric elective surgeries in BC (see

the ). As of 1 December 2010

three additional fields will be added

to all Health Authority OR booking

forms—two of those fields will be for

“Date of Decision for Surgery” and

“Cancer Status” and the third will be

mandatory completion of a “Condition/

Diagnostic code” field. More than 120

surgical leaders across the province

representing 14 surgical reference

groups and subspecialties provided

feedback on the development of a

comprehensive list of adult patient

condition/diagnosis codes.

The new system is designed to be

much simpler to use. Surgeons will

select the relevant patient condition/

diagnosis code from the list provided

by their health authority and enter it

on their existing OR booking form,

rather than filling in a separate form.

These codes link every patient’s diag-

nosis and clinical condition to one of

five priority levels and an associated

maximum wait time target.

Because these changes are being

incorporated into your health authori-

ty’s OR booking form, there will be

no fee attached for completing it.

Benefits for surgeonsBecause there is now an objective and

standardized methodology for desig-

nating patient diagnosis/condition

descriptions to a priority level, sur-

geons will be able to review their wait

listed patients by level of urgency and

see how long their patients have been

waiting relative to the maximum rec-

ommended target. The elimination of

the Clinical Assessment Tool means

Figure

Figure. Example of a revised OR bookingform. As of 1 December 2010 the ClinicalAssessment Tool form will be replaced withthe mandatory completion of these threefields in the OR booking form.

Norman Wignall, MD


CKD increases the normal risk of car-

diac morbidity by 10 times. Fully 40%

of patients on dialysis also have dia-

betes.

The ability of GPs to manage care

for patients with chronic conditions

often depends on effective communi-

cation and exchange of knowledge

with specialist colleagues. The BCMA

and Ministry of Health Services have

highlighted the importance of effec-

tive physician-to-physician commu-

nication through recent updates to fee

schedules that facilitate inter-provider

contact. Strategic alignment of com-

pensation with point-of-care health

care processes provides appropriate

in centives to enhance interaction

among participating physicians and

represents a philosophical shift toward

a shared care model.1

Shared care refers to a set of ideas

designed to facilitate collaboration

between GPs and specialists. The ben-

efits are thought to include reduced

patient wait times for specialist care

by minimizing the amount of primary

care provided by specialists, a de crease

in inappropriate consultations, less

duplication of testing and fewer un -

necessary prescriptions, and increased

communication and knowledge ex -

change between specialists and GPs.

Shared care also seeks to open

ongoing dialogue between specialists

and GPs to more effectively define

roles and mutual expectations and en -

sure that patients do not “fall through

the cracks.”

In support of shared care, the Bri -

tish Columbia Provincial Renal Agency

(BCPRA) has developed a program

to engage GPs and neph rologists to -

ward improving care for patients with

kidney disease. Within this program,

one initiative has focused on studying

stroke certification courses. The 10-

article special section is free for health

care providers, first responders, and

individuals who want to be prepared

to provide emergency care.

Titles include “Recognizing the

Signs of Stroke,” “Trends in Stroke,”

“Common Stroke Risk Factors,” “Dif-

ferentiating Stroke from Mimics,” and

“The Seven D’s of Stroke Survival.”

Health Education Solutions pro-

vides the cognitive portions of each

American Heart Association (AHA)

course, including Acute Stroke, Stroke

Prehospital Care, and Stroke Hospi-

tal-based Care, entirely online. The

courses’ web-based, self-paced mod-

ules provide a flexible training option

for health care providers. Students who

follow the online course are re quir ed

to meet with an AHA instructor to

complete a hands-on skills practice

session and test.

For more information or to access

the online research library, please visit

www.healthedsolutions.com.

BC Genome SciencesCentre advancesIn 1997, Nobel laureate Dr Michael

Smith created Canada’s first genomic

research centre dedicated to the study

of cancer in British Columbia.

At the time, genomics was still in

development—it would be another 3

years before scientists decoded the

human genome. British Columbians

invested $24 million through the BC

Cancer Foundation to establish Cana-

da’s Michael Smith Genome Sciences

Centre at the BC Cancer Agency.

Now one of the largest genome

centres in the world, the centre has

announced four major research break-

throughs in the past year revealing

specific genetic mutations underlying

the cause or development of cancers.

All these breakthroughs were made

possible by next-generation computer

sequencing technology, which has

the capacity to process and analyze

torrents of data at previously unimag-

inable rates and at a fraction of the

original cost.

Ten years ago, sifting through the

human DNA code to find individual

genetic mutations was the proverbial

hunt for the needle in a haystack. Up

until about 2 years ago, researchers

had no way to look through thousands

of kilometres of DNA in each of an

individual’s trillions of cells.

The Genome Sciences Centre’s

technology platform provides BC

Can cer Agency researchers with very

specific biological targets at which to

aim new treatments to improve pa -

tients’ outcomes. Now, personalized

medicine—once a distant possibility

—is within researchers’ grasp.

This was demonstrated by the

Centre’s latest breakthrough, recently

published in Genome Biology. Centre

director Dr Marco Marra and his team

sequenced the genome of a living

patient’s tumor for the first time,

which guided oncologists to a treat-

ment regime for his rare and aggres-

sive cancer. It worked—the cancer

was halted for several months.

Although there are many chal-

lenges to overcome before this type of

approach becomes routine, in the near

future researchers will be able to look

at tumors at the genetic level to deter-

mine whether it is possible to tailor a

patient’s treatment and ultimately

improve that patient’s outcome.

—Judy Hamill

BC Cancer Foundation

BCPRA educationcourse for GPs It is estimated that up to 8% of British

Columbians have potentially signifi-

cant chronic kidney disease (CKD).

Many of these patients are also affect-

ed by heart disease and diabetes as

pulsimeter

Make your professional life betterwww.divisionsbc.ca

Pulsimeter continued on page 474


Physicians of Canada for 6.5 Main-

pro-1 CME credits. It will be held Sat-

urday, 22 January 2010 at the Wosk

Centre for Dialogue in downtown Van-

couver. More in formation is available

at www.bcrenalagency.ca/default.htm.

—Michael Schachter, MD

Vancouver

References

1. Hickman M, Drummond N, Grinshaw J.A taxonomy of shared care for chronicdisease. J Public Health Med. 1994;16:447-454.

2. Stigant C, Stevens L, Levin A. Nephrolo-gy: 4. Strategies for the care of adultswith chronic kidney disease. CMAJ 2003;168:1553-1560.

3. Coresh J, Selvin E, Stevens LA. Preva-lence of chronic kidney disease in theUnited States. JAMA 2007;298:2038-2047.

Don Rix leadershipaward announcedThe BCMA will honor Dr Donald

Rix’s memory and his many achieve-

ments with the annual Dr Don Rix

Award for Physician Leadership (D.B.

Rix Award). This award recognizes

exemplary physician leadership, as

exhibited by the late Don Rix through-

out his life and career.

Lifetime achievement is the prime

requisite in determining the recipient

for this award. The achievement

should be so outstanding as to serve as

an inspiration and a challenge to the

medical profession in British Colum-

bia. Medalists may have achieved dis-

tinction in one or more of the follow-

ing ways:

• Supported lifelong learning oppor-

tunities.

• Promoted excellence in medical

education.

• Built consensus among physicians

and groups of physicians.

• Provided leadership for new initia-

tives both in business and clinical

practice.

• Provided leadership and service to

the general community or province

either by direct support or through

philanthropy.

• Provided service to the medical pro-

fession through participation in the

BCMA.

• Provided leadership to the broader

medical community.

• Participated in legislative and other

political activities in support of

health care.

The award will consist of a $2000

donation to a BC charity of the win-

ner’s choice, as well as a gold medal.

Nominees must be a member in good

standing of the BC Medical Associa-

tion. Nominations may be submitted,

accompanied by suitable documenta-

tion, by a BCMA member. Documen-

tation should include a completed

nomination form, a detailed letter of

nomination accompanied by two let-

ters of support, and the nominee’s cur-

riculum vitae. Nominations submitted

electronically will be considered so

long as the origin of the documenta-

tion can be verified. Handwritten sub-

missions will not be accepted.

The first award will be made in

2011 and presented at the 2011 BCMA

Annual General Meeting. If you know

pulsimeter

* Population projections for year-end, 2010 come from BC stats P.E.O.P.L.E (Population Extrapolationfor Organization Planning with Less Error): www.bcstats.gov.bc.ca/data/pop/pop/popproj.asp#bc.

† Prevalence of CKD I-IV comes from US NHANES estimates, 1999–2004.3

‡ HD or PD is the actual number of patients registered in PROMIS as of year end 2009.§ Assume patients with CKD III and IV constitute true provincial demand for out patient services.

wait times for outpatient nephrology

assessment, while a second is aimed

at providing opportunities for GPs to

up grade their knowledge of nephrolo-

gy care.

These initiatives are timely in view

of the epidemic prevalence of CKD,

which is estimated to affect more than

2 million Canadians.2 The shows

the projected CKD prevalence figures

for BC by health authority.

While the projected total out-

patient demand of approximately

360 000 patients may include some

non-progressers who do not need to

see a nephrologist, the most conserva-

tive estimate of true outpatient CKD

demand suggests close to 200 000

British Columbians live with high-

risk CKD stage 3 to 4. At the same

time, BC has only about 50 full-time

nephrologists. It is clear that provi-

sion of effective early CKD care by

primary care physicians is needed to

optimize outcomes for these patients.

To help GPs manage the increas-

ing number of CKD patients in their

practices, the BCPRA has developed

a nephrology curriculum with objec-

tives derived from a formal survey of

GP’s educational needs. The first

annual GP nephrology course has been

approved by the College of Family

Table

Table. Projected dialysis and CKD prevalence in BC for 2009 and 2010.

Population per health authority*

FHA VCH VIHA IH NH Total BC

1 606 149 1 123 407 759 319 736 264 285 328 4 510 467

NHANES Prevalence†

CKD I 1.78% 28 589 19 997 13 516 13 105 5079 80 286

CKD II 3.24% 52 039 36 398 24 602 23 855 9245 146 139

CKD III 7.69% 123 513 86 390 58 392 56 619 21 942 346 855

CKD IV 0.35% 5622 3932 2658 2 577 999 15 787

HD or PD‡ 843 886 440 385 166 2720

Total outpatient demand§ 129 134 90 322 61 049 59 196 22 940 362 642




BCMA Silver Medal of ServiceBCMA members are encouraged tonominate physicians or laypersons forthe BCMA Silver Medal of Serviceaward. The medal will be presented atthe BCMA’s Annual General Meetingin June 2011. Physician nominees musthave 25 years of membership in goodstanding in the BCMA, the CMA, andthe BC College of Physicians and Sur-geons of British Columbia. Nonmed-ical candidates may be laypersons ofCanadian or foreign citizenship. To beeligible for the award, nominees mustmeet at least one of the following cri-teria:• Long and distinguished service to the

BCMA.• Outstanding contributions to medicine

and/or medical/political involvement in British Columbia or Canada.

• Outstanding contributions by alayperson to medicine and/or to thewelfare of the people of BritishColumbia or Canada.Nominations for the BCMA Silver

Medal of Service may be made by anyBCMA member in good standing. Sub-mit the candidate’s curriculum vitaeand your reasons for nominating theindividual to the BCMA MembershipCommittee, #115–1665 West Broad-way, Vancouver, BC V6J 5A4 by 30November 2010.

CMA Honorary MembershipThe BCMA is able to submit nomina-tions to the CMA for individuals toreceive the honor of becoming a CMAHonorary Member (previously calledCMA Senior Member Award). Candi-dates must be age 65 or over and amember of both the BCMA and theCMA for the immediately preceding10 consecutive years, including theforthcoming year 2011. They musthave distinguished themselves in theirmedical careers by making a signifi-cant contribution to the community andto the medical profession. To nominatea candidate for CMA Honorary Mem-ber Award, send a letter outlining thereasons for your nomination along withthe individual’s curriculum vitae to theBCMA Membership Committee, #115–1665 West Broadway, Vancouver, BCV6J 5A4 by 30 November 2010.

Dr David M. Bachop GoldMedal for DistinguishedMedical ServiceThis award may be made annually to aBritish Columbia doctor who is judgedby the selection committee to havemade an extraordinary contribution in the field of organized medicineand/or community service. Achieve-ment should be so outstanding as toserve as an inspiration and a challengeto the medical profession in BritishColumbia. Only one award will bemade in any 1 year and there shall beno obligation on the fund to make theaward annually. A letter of nominationincluding a current curriculum vitae ofthe candidate should be sent to MsLorie Janzen at BCMA, #115–1665West Broadway, Vancouver, BC V6J5A4 by 5 April 2011.

CMA Special AwardsFurther information on criteria, includ-ing nomination forms for the CMASpecial Awards, can be obtained fromwww.cma.ca/index.cfm/ci_id/1368/la_id/1.htm (select “About CMA” and“Awards from CMA”). Alternatively,contact the CMA Awards CommitteeCoordinator by mail, 1867 Alta VistaDrive, Ottawa, ON K1G 3Y6, or bytelephone at 800 663-7336 extension2243. Nominations and the individ-ual’s curriculum vitae must be sent tothe CMA by 30 November 2010.

F.N.G. Starr AwardAwarded to a CMA member who hasachieved distinction in one of the fol-lowing ways: making an outstandingcontribution to science, the fine arts, orliterature (nonmedical); serving human-ity under conditions calling for courageor the endurance of hardship in the pro-motion of health or the saving of life;or advancing the humanitarian or cul-tural life of his or her community or inimproving medical service in Canada.

CMA Medal of HonourBestowed upon an individual who isnot a member of the medical profes-sion who has achieved excellence inone of the following areas: personalcontributions to the advancement ofmedical research, medical education,health care organization, or health edu-

cation of the public; service to the peo-ple of Canada in raising the standardsof health care delivery in Canada; serv-ice to the profession in the field of med-ical organization.

CMA Medal of ServicePresented to a CMA member for excel-lence in at least two of the followingareas: service to the profession in thefield of medical organization, serviceto the people of Canada in raising thestandards of medical practice in Canada,personal contributions to the advance-ment of the art and science of medicine.

Sir Charles Tupper Award forPolitical ActionAwarded to a member of the CMA’sMD-MP Contact Program who hasdemonstrated exemplary leadership,commitment, and dedication to the causeof advancing the policies, views, andgoals of the CMA at the federal levelthrough grassroots advocacy efforts.

May Cohen Award for WomenMentorsSubmitted by the mentee and presentedto a woman physician who has demon-strated outstanding mentoring abilities.

CMA Award for Excellence inHealth PromotionAwarded for individual efforts or anon-health sector organization to pro-mote the health of Canadians at thenational level or with a national posi-tive impact.

CMA Award for Young LeadersThe CMA will present the Award forYoung Leaders to one student, one res-ident, and one early-career physician(5 years post-residency) member whohas demonstrated exemplary dedica-tion, commitment, and leadership inone of the following domains: politi-cal, clinical, education, research, orcommunity service.

Dr William Marsden Award in Medical EthicsRecognizes a CMA member who hasdemonstrated exemplary leadership,commitment, and dedication to thecause of advancing and promotingexcellence in the field of medical ethicsin Canada.

Call for nominations: BCMA and CMA special awards

pulsimeter


A sbestos is a fibrous silicate

mineral with numerous desir-

able characteristics, such as

resistance to heat and chemicals, good

tensile strength, and flexibility. As a

result, it has been used in thousands of

products, including insulation (acous -

tic, heat, electrical), friction material

(brake pads), gaskets, concrete rein-

forcement (pipes, sheeting, tiles),

plaster compounds, and spackling. In

the past 40 years, as adverse health

effects were recognized, the use of

asbestos in Canada has been marked-

ly curtailed. Despite this, the inci-

dence of asbestos-related diseases has

not declined, because of the long

latency characteristic of these diseases

and the ubiquity of materials contain-

ing asbestos.

Asbestos can cause a variety of

pulmonary diseases, some generally

benign pleural changes, such as effu-

sion, plaques, calcification, and hy -

pertrophy, and some more pernicious,

such as asbestosis, bronchogenic car-

cinoma, and malignant mesothelioma.

Diagnosis of asbestosisAsbestosis is a diffuse interstitial fi -

brosis of the lung parenchyma caused

by prolonged repeated exposure to

high levels of asbestos fibres. The

fibrosis typically starts symmetrically

at the lung bases and, as the disease

progresses, can extend to all lung

fields, producing stiffer lungs and

reduced gas exchange ability. Advanc -

ed asbestosis can be debilitating, as

severe fibrosis can lead to pulmonary

hypertension and right-sided heart

failure.

Asbestosis typically has a long

latency period, with symptoms occur-

ring 20 years after the onset of expo-

sure. The severity and progression of

the disease is dose dependent. Among

workers with high cumulative lifetime

exposure, the disease can continue to

progress even with cessation of expo-

sure.

Initially, workers with asbestosis

complain of shortness of breath with

exertion and decreased exercise toler-

ance. A dry cough can develop and

rales can be heard at the lung bases. As

the disease progresses, dyspnea oc -

curs at rest and there may be clubbing,

cyanosis, and signs of right-sided

heart failure.

Lung function tests demonstrate a

restrictive pattern with reduced FVC,

lung volumes, lung compliance, and

diffusion capacity. Asbestos by itself

does not typically result in small air-

way disease or COPD, so obstructive

changes on lung function testing are

uncharacteristic. Oxygen saturation

can decline with exercise or, in more

severe cases, at rest. Small irregular

opacities are noted on chest X-rays.

Coincidental radiologic manifesta-

tions of asbestos-related pleural dis-

ease may be found.

Since asbestosis affects only the

lungs, this is one way to differentiate

it from other systemic diseases that

also cause pulmonary fibrosis. Differ-

entiating asbestosis from idiopathic

pulmonary fibrosis can be challeng-

ing. The presence of asbestos-related

pleural changes is very useful as a

marker of asbestos exposure. Howev-

er, the most essential diagnostic crite-

rion is a history of prolonged and

repeated exposure to asbestos. The

risk of developing asbestosis is low if

the cumulative exposure is less than

25 fibres/ml-years (the metric fibres/

ml-years is analogous to pack-years

for cigarette smokers).

Those at greatest risk for asbesto-

sis are individuals who were actively

working with asbestos in the past. In

British Columbia, this includes work-

ers generally older than 60 who were

employed prior to the early 1980s as

asbestos miners and millers, construc-

tion workers, insulators, pipefitters,

millwrights, naval yard workers,

power or chemical plant workers, or

ship or train mechanics. Today, these

types of workers are still at risk,

although the risk is mitigated by im -

proved work practices that reduce

exposure. Other workers at risk for

asbestos-related diseases are those

involved in asbestos abatement, older

building renovation and demolition,

or building maintenance. The risk,

however, is generally low because, in

most circumstances, the presence of

asbestos is recognized and exposure is

controlled.

Treatment and preventionSince there aren’t any good treatments

for asbestosis, the best approach is

disease prevention. The prevention

branch of WorkSafeBC has been

actively involved through worker and

employer education, workplace in -

spections, and overseeing abatement

procedures. WorkSafeBC requires

em ployers to maintain an asbestos

inventory identifying all locations

where asbestos is found and to control

access to those areas.

Physicians can participate in pre-

venting asbestosis by identifying pa -

tients at risk with a comprehensive

occupational history, and referring

suspected cases to WorkSafeBC. If

inappropriate workplace exposure is

suspected, please contact WorkSafe -

BC’s prevention branch at 1 888 621-

7233.

worksafebc

Asbestosis: A persistent nemesisA disease with a long latency that can easily be overlooked.



Impairment-related crashes are the

leading criminal cause of death in

Canada, accounting for approx-

imately 1239 deaths, 73 120 injuries,

and as much as $12.6 billion in finan-

cial and social costs annually.1 Sanc-

tions resulting from conviction are

effective in preventing impaired driv-

ing.2-6 However, the injured impaired

drivers treated in our emergency de -

partments are infrequently convicted

of impaired driving. Three Canadian

studies have been published. The

first found that only 11% of injured

alcohol-impaired drivers identified in

the British Columbia trauma registry

between 1992 and 2000 were convict-

ed of impaired driving.7 The second

study found that the conviction rate

for injured alcohol-impaired drivers

admitted to Calgary Health Region

trauma service between 1999 and

2003 was only 16%.8 The third study

reported a conviction rate of only

6.7% for all alcohol-impaired drivers

injured in a crash who presented to a

tertiary care emergency department in

British Columbia from 1999 to 2003.9

Follow-up over a 4 1/2 year period

indicated that 30.7% of the injured

impaired drivers were engaged in sub-

sequent impaired driving, notwith-

standing that they injured or killed

someone in more than 84% of initial

crashes.9 These studies suggest that

our emergency departments may have

become safe havens for the worst

drinking drivers, those drivers who

are involved in fatal or personal injury

crashes.

Three separate Criminal Code,

R.S.C. 1985, c. C-46, provisions allow

the police to demand or seize blood

samples from suspected impaired

drivers. First, under section 254(3)(b),

the police may demand blood samples

from a person if they have reasonable

grounds to believe (a) that he or she

committed an impaired driving offence

within the preceding three hours; and

(b) that, by reason of the person’s

physical condition, he or she is inca-

pable of providing a breath sample or

it is impracticable to obtain one. Sec-

ond, under section 256, the police may

apply to a justice for a warrant auth -

orizing them to seek blood samples

from a driver if they have reasonable

grounds to believe that (a) the driver

committed an impaired driving

offence within the previous 4 hours;

(b) the driver was involved in a crash

resulting in death or bodily harm; and

(c) a medical practitioner is of the

opinion that the driver is unable to

consent to the drawing of blood sam-

ples, and that the taking of the samples

would not endanger the driver. Third,

under section 487 of the Criminal

Code, the police may apply to a justice

for a general search warrant authoriz-

ing them to search for and seize any

relevant evidence, including blood

samples that have already been taken

from a suspected impaired driver for

treatment purposes. Before issuing

such a warrant, the justice must be sat-

isfied, based on information sworn

under oath, that there were reasonable

grounds to believe that such blood

sample evidence would be found on

the premises.

To satisfy these Criminal Code

provisions the police must establish

that they had “reasonable grounds to

believe that the driver committed an

impaired driving offence.” However,

in many cases the police will need

information about the suspect’s phys-

ical condition that can only be ob -

council onhealth promotion

Emergency departments: Are they considered a safe havenfrom prosecution for impaired drivers involved in fatal orpersonal injury crashes?

tained from the suspect’s physician.

For example in R. v. Clark, the accused

was involved in a head-on collision

that killed another driver. Gerein com-

mented that the sweet odor on the

accused’s breath may potentially have

been due to alcohol. However, the

police officer did not provide reason-

able grounds to obtain a blood sam-

ple, because the odor may have been

due to another source such as dia-

betes.10 The police officer could only

have determined if the patient had

diabetes by interviewing Mr Clark’s

physician.

However, health professionals

who release patient information with-

out consent or statutory authority

would be in breach of their common

law, professional, and statutory confi-

dentiality obligations. The Canadian

Medical Association Code of Ethics

permits “disclosure of patients’ per-

sonal health information to third par-

ties only with their consent, or as pro-

vided for by law, such as when the

maintenance of confidentiality would

result in a significant risk of substan-

tial harm to others or, in the case of

incompetent patients, to the patients


Health professionals who release patientinformation without

consent or statutoryauthority would be in

breach of their commonlaw, professional, and

statutory confidentialityobligations.


ple results were excluded, and the

charges against the accused for im -

paired driving causing death and im -

paired driving causing bodily harm

were dismissed.14

Complicating the issue further, the

present statutes require the collection

of evidentiary samples within 3 hours

of the impaired driving offence. Often

the police cannot establish grounds

for demanding these evidentiary

blood samples within this time. In

other comparable democracies, blood

samples are taken when the patient

enters the emergency department and

are held in a secure location within

the hospital until the police have in -

dependently established grounds for

their seizure.13

Moreover, the Criminal Code

effectively limits the taking of blood

samples in hospitals, where drawing

blood is routine and taking eviden-

tiary breath samples is simply not fea-

sible due to limited space and patient

care priorities. Before being allowed

to demand a blood sample, the police

must demonstrate that the patient is

unable to provide a breath sample due

to their physical condition or that it

is impracticable to do so. The courts

have generally held that police should

not make decisions about the driver’s

inability to provide a breath sample

unless they have consulted a medical

professional.13 For instance, in R. v.Brooke, the accused was wearing a

neck brace and strapped down at the

time of arrest. The officer demanded a

blood sample, but the court excluded

the blood sample evidence because

the officer had not specifically asked

the attending physician about the ac -

cused’s physical condition and whether

he was able to provide a breath sam-

ple.15 Thus, in most cases, police can-

not obtain evidentiary breath samples

for logistical reasons, and a physician

cannot give them the information they

require to demand blood samples with-

out violating his or her confidentiality

obligations.

Thus, the legal “catch-22.” The

police need a considerable amount of

information to comply with the legal

requirements for a blood sample de -

mand from a patient who is hospital-

ized. It is very difficult for the police

to independently gather this informa-

tion, given that the patient may be

lying on a stretcher or otherwise

unable to perform a standard field

sobriety test. Moreover, the courts

have indicated that tests on approved

screening devices may only be con-

ducted at roadside. Therefore, in the

vast majority of cases, the police will

only have authority to demand an evi-

dentiary blood sample if they obtain

the necessary information from the

patient’s physician. However, the phy -

sician cannot provide this information

to police without violating his or her

confidentiality obligations. Such a

breach of confidentiality will likely

result in the evidence being excluded

and the accused being acquitted.

The Canadian Medical Associa-

tion is also concerned about this issue.

In 2008, the CMA passed the follow-

ing resolution at General Council:

“The Canadian Medical Association

urges the federal Department of Jus-

tice to conduct a review of the appli-

cable sections of the Criminal Code

related to blood testing of intoxicated

drivers who are treated in hospital

following a motor vehicle crash.” The

authors of this paper are of the opinion

that the following four amendments

would improve the effectiveness of

these Criminal Code provisions.

1) The Criminal Code should be

amend ed to authorize police to

demand blood samples from any

hospitalized occupant of a motor

vehicle that has been involved in a

fatal or personal injury crash. The

evidentiary collection process could

be modeled after the systems that

have been in place in England, New

Zealand, and Australia for many

years.13

2) To facilitate the timely collection of

evidentiary blood samples, they

should be taken from all occupants

themselves.”11 The Canadian Medical

Protective Association advises: “While

physicians may have a desire to col-

laborate with police to foster public

safety and injury prevention, physi-

cians are bound by a duty of confi-

dentiality to their patients. As such,

physicians should not provide any

patient information to the police

unless the patient has consented to this

disclosure or where it is required by

law.”12 While section 257(2) of the

Criminal Code protects medical prac-

titioners from criminal and civil lia-

bility for taking a blood sample pur-

suant to a valid demand or search

warrant, it does not protect them from

liability for breaching confidentiality

in assisting police to make a valid

demand or obtain a search warrant.

If the police wrongfully obtained

confidential patient information, a

blood sample demand made or a war-

rant obtained based on this informa-

tion would be invalid. Any subsequent

seizure of the blood sample would be

found to violate section 8 of the Char-

ter and, depending on the specific

facts, may well be excluded at trial.13

For example, in R. v. Dersch, the

accused expressly refused a police

demand for blood samples and told

the doctor not to draw blood in any

circumstances. However, once the

sus pect was unconscious, the doctor

took blood samples for medical pur-

poses. At an officer’s request, the doc-

tor disclosed the accused’s BAC to the

police, who subsequently obtained a

warrant and seized the samples. The

Supreme Court of Canada held that

the samples should not have been

taken without the accused’s consent,

and that the doctor breached his con-

fidentiality obligation in disclosing

the accused’s BAC to the police, as

the police had not used appropriate

means to obtain this information. The

Court held that the police conduct in

obtaining the suspect’s BAC informa-

tion was analogous to a search and

seizure. Consequently, the blood sam-

cohp



of motor vehicles involved in

fatal or personal injury crashes

upon their entry into the hos-

pital. These samples should be

stored in a secure location and

only released if the police can

independently establish grounds

for their seizure.

3) The Criminal Code and all laws

governing patient confidentiali-

ty should specify what informa-

tion physicians must provide to

the police during an impaired

driving investigation. The police

cannot effectively investigate

impaired driving cases unless

they have been told that the

patient has been admitted to hos-

pital, the patient’s location, if the

patient can be interviewed, and

if drawing blood would endan-

ger the patient.

4) The Criminal Code should be

amended to remove the “prefer-

ence” for breath samples when

suspected impaired drivers are

taken to hospital.

—Roy Purssell, MD

Associate Professor, Department

of Emergency Medicine, UBC

—Luvdeep Mahli,

Faculty of Medicine, UBC

—Robert Solomon, LLB

Professor, Faculty of Law,

University of Western Ontario

—Erika Chamberlain, LLB

Assistant Professor,

Faculty of Law, UWO

References

References are available at www.bcmj.org.

of a suitable candidate, consider nom-

inating him or her for the honor of

receiving the first Dr Don Rix Award

for Physician Leadership. The dead-

line for nominations is 30 March

annually, and should be sent to the

CEO of the BCMA at 115–1665 West

Broadway, Vancouver BC V6J 5A4 or

[email protected].

Signs of Strokematerials available for physicians The Heart and Stroke Foundation of

BC & Yukon has launched a 2-year

campaign to educate BC residents

about the five warning signs of stroke

and the time-sensitive nature of tissue

plasminogen activator treatments.

The campaign will use a TV com-

mercial, radio, and print advertising,

and public relations. Posters, wallet

cards, and other materials have been

printed for physicians to display in

their offices. If you are interested in

ordering a few posters and other mate-

rials for your office, please e-mail

[email protected] with “Signs of Stroke”

in the subject line.

—Susan Pinton

Heart and Stroke Foundation of

BC & Yukon

Body Worlds and theBrain exhibition Telus World of Science is displaying

the Gunther von Hagens’ Body Worlds

and the Brain exhibition until early

January. The exhibit is renowned for

the human bodies, specially preserved

through a method called plastination,

that are displayed in life-like postures.

Different specimens allow visitors to

appreciate the functional anatomy of

the various body systems, including

fetal development.

Since debuting in 1995, over 30

million people in 50 cities have seen

Body Worlds. Dr von Hagens invent-

ed plastination in 1977 in an effort to

For more informationFor further information regarding

as bestosis, contact Sami Youakim,

MD, at 1 250 881-3490.

—Sami Youakim, MD, MSc,

FRCP, WorkSafeBC

Occupational Disease Services

improve the education of medical stu-

dents. He created the Body Worlds

exhibitions to bring anatomy to the

public. Understandably, an exhibit

that presents human material in such a

frank and vivid manner will attract

both positive and negative interest, but

such a valuable educational opportu-

nity clearly deserves the support of

the medical community. In addition to

a special focus on the anatomy and

function of the brain, the exhibit will

allow people to see the consequences

of a number of modifiable behaviors

such as smoking, obesity, and poor

eating habits. These are conditions

that are not only important considera-

tions for individuals, but are also

major public health concerns. Visitor

numbers are expected to be very high.

Educational materials for school

groups and adults are being prepared

and extensive community consulta-

tions are underway.

Physicians interested in more in -

formation can find it at www.science

world.ca/bodyworlds and www.body

worlds.com. Timed tickets are now

available from Science World, either

by phone at 604 443 7500 or online at

www.scienceworld.ca/bodyworlds.

—Lloyd Oppel, MD

Vancouver

cohp pulsimeter



worksafebc


CME AT BIG WHITE

Kelowna, 2010–2011 Ski season

SkiME is a daily CME program held

at the Big White Ski Resort for phy si-

cians and medical staff. High-quality

recent lectures from international

speakers are shown from 8 a.m. to

noon weekdays during the ski season

at the Whitefoot Medical Clinic at Big

White Resort. Lectures are free to

watch. Certificate of Attendance cer-

tificates is available for a fee. For

complete programming information

or to pre-register (required by some

tax jurisdictions) see http://mybig

white.com/business/cme/. For more

information call 250 765-0544; e-mail

[email protected].

FREE ACCREDITED

ONLINE CME

www.mdBriefCase.com

Looking for convenient and afford-

able ways to participate in accredited

CPD activities? Let mdBriefCase help!

Since 2002, www.mdBriefCase.com

has been the leading provider of online

continuing education for Canadian

physicians. Our courses are available

24/7, making it easy for busy physi-

cians to complete their requirements.

We develop more than 35 online learn-

ing programs each year in collabora-

tion with leading experts, profession-

al societies, and academic institutions.

All of our programs are Mainpro-M1

and Maintenance of Certification

(MOC) accredited and we offer easy-

to-print certificates. What are you

waiting for? Sign up today and start

getting your CME at www.mdBrief

Case.com!

CME ON THE RUN

Various dates, 1 Oct–6 May (Fri)

Please join us for the CME on the Run

conferences that are held at the Paet-

zold Lecture Hall, Vancouver General

Hospital. There are opportunities to

participate via videoconference from

Prince George, Royal Columbian, and

Surrey Memorial hospitals. Each pro-

gram runs on Friday afternoons from

1 p.m. to 5 p.m. and includes great

speakers and learning materials. Top-

ics and dates: 5 Nov (women’s and

men’s health including menopause,

breast cancer screening updates, man-

aging erectile dysfunction, etc.), 3 Dec

(geriatrics), 4 Feb (diagnostics and

radiology), 1 Apr (ophthalmology/

ENT), 6 May (general internal medicine/

best topics). To register and for more

information, visit www.ubccpd.ca, call

604 875-5101, or e-mail cpd.info@

ubc.ca.

ADHD CONFERENCE

Vancouver, 20–21 Nov (Sat–Sun)

The Canadian ADHD Resource

Alliance is returning to Vancouver for

their 6th Annual ADHD Conference.

This year’s conference will feature

topics dealing with the less frequently

presented faces of ADHD: ADHD in

girls, women, and preschoolers; pa -

tients with brain injury and those

involved with forensics; and patients

with mood and rage disorders. Re -

search on long-term outcomes, ADHD

and learning, adult ADHD in primary

care practice, and the latest informa-

tion on ADHD within the DSM-V will

be covered. Two free preconference

workshops on adult ADHD and ADHD

medication will be offered. Formats

will include plenaries, workshops, and

“meet the expert” sessions where cases

can be discussed. Featured speakers

include Laurence Greenhill, Gabri -

elle Carlson, Rachel Klein, Rosemary

Tannock, and Steve Hotz. Accredita-

tion for family physicians, specialists,

and American physicians, and approval

for psychologists, has been applied

for. For more information visit www

.caddra.ca or e-mail penny.scott@

caddra.ca.

COMBINED APLS/ACLS

Vancouver, 25–27 Nov (Thu–Sat)

APLS: The Pediatric Emergency

Medicine Course will run half-day,

Thursday, 25 November and full-day

Friday, 26 November. This course is

designed to train physicians to assess

and manage critically ill children dur-

ing their first hours in the emergency

department. Participants will take part

in a 2-day format of skills stations and

case discussion sessions and must

then successfully complete the APLS

Course Completion Examination.

Please note that this course is intend-

ed for experienced clinicians involved

in care of critically ill children. Par-

ticipants are required to have previ-

ously completed at least one PALS or

APLS course successfully. The ACLS:

Provider Update Course will run on

Saturday, 27 November. The ACLS

Provider Course provides the knowl-

edge and skills needed to evaluate

and manage the first 10 minutes of an

adult ventricular fibrillation/ventricular

tachy cardia (VF/VT) arrest. Providers

are expected to learn to manage 10

core ACLS cases: a respiratory emer-

calendar

CALENDAR ON THE WEB

The BCMJ Calendar section is availableon the BCMA web site at www.bcma.org.CME listings on the web are updatedonce a week (on Fridays), and once amonth (when preparing copy for the up -coming BCMJ) all listings that will be time-ly are gathered and printed in the Journal.

Rates: $75 for up to 150 words (maxi-mum), plus GST, for 1 to 30 days; there isno partial rate. If the course or event isover before an issue of the BCMJ comesout, there is no discount. VISA andMaster Card accepted.

Deadlines: Online: Every Thursday (list -ings are posted every Friday). Print: Thefirst of the month 1 month prior to theissue in which you want your notice toappear, e.g., 1 February for the Marchissue. We prefer that you send materialby e-mail to [email protected].


gency, four types of cardiac arrest

(simple VF/VT, complex VF/VT, PEA,

and asystole), four types of pre-arrest

emergencies (bradychardia, stable

tach ycardia, unstable tachycardia, and

acute coronary syndromes), and stroke.

This 1-day update course is intended

for experienced clinicians who have

previously completed at least one

ACLS course successfully. Resuscita-

tion simulations that are relevant and

realistic for the learner’s background

and current work environment will be

used as much as possible. To register

and for more information, visit

www.ubccpd.ca, call 604 875-5101,

or e-mail [email protected].

FP ONCOLOGY CME DAY

Vancouver, 27 Nov (Sat)

The BC Cancer Agency’s Family Prac-

tice Oncology Network invites family

physicians to take part in its annual

CME Day—an opportunity to strength-

en oncology skills and knowledge and

enhance cancer care for patients and

families. This session takes place at

the Westin Bayshore Hotel in Vancou-

ver and is part of the BC Cancer

Agency’s Annual Cancer Conference,

25–27 November. The program meets

the accreditation criteria of the Col-

lege of Family Physicians of Canada

and has been accredited for up to 1.5

Mainpro-C credits and 2 Mainpro-

M1 credits. This Family Practice On -

col ogy CME Day will provide an

effective means to learn about new

oncology resources and support, bet-

ter understand the BC Cancer Agency

and establish useful contacts, and ben-

efit from oncology updates, including

practical and current information. To

learn more about the network please

visit www.bccancer.bc.ca/hpi/fpon.

Register for this event at www.bc

canceragencyconference.com.

BRAIN 2010

Vancouver, 3 Dec (Fri)

Brain 2010 Conference: Transform-

ing Health Care, will be held at the

Coast Coal Harbour Hotel, and aims

to explore the impact of modern neu-

roscience and clinical neuroscience

on the health care system. The confer-

ence will cover a wide range of topics

relating to brain development, brain

function, and brain disorders with the

goal of understanding how findings in

each area are leading to fundamental

changes in how we think of and deliv-

er health care. Brain 2010 will be of

interest to health care professionals

who work in areas where brain func-

tion is either the central focus or a

vitally important aspect of care, as

well as to professionals who provide

lifestyle counseling, personal coach-

ing, and performance-enhancement

training. These areas include general

and specialized medical practice, psy-

chology, nursing, counseling, and

rehabilitation. To view the program,

list of speakers, registration, and ac -

commodation information, please

visit www.brain2010.com, call Con-

gressWorld Conferences Inc. at 604

685-0450, or e-mail info@congress

world.ca.

EMERGENCY MEDICINE

UPDATE

Whistler, 20–23 Jan (Thurs–Sun)

Sponsored by the University of

Toronto, the 24th Annual Update in

Emergency Medicine will be held at

the Hilton Whistler Resort, Whistler,

British Columbia. The Office of Con-

tinuing Education and Professional

Development (CEPD), Faculty of

Medicine, University of Toronto is

fully accredited by the Committee on

Accreditation of Continuing Medical

Education (CACME), a subcommit-

tee of the Committee on Accredita-

tion of Canadian Medical Schools

(CACMS). This standard allows the

Office of CEPD to assign credits for

educational activities based on the cri-

teria established by the College of

Family Physicians of Canada, the

Royal College of Physicians and Sur-

geons of Canada, the American Med-

ical Association, and the European

Accreditation Council for Continuing

Medical Education (EACCME). Fur-

ther information: The Office of Con-

tinuing Education & Professional

Development, Faculty of Medicine,

University of Toronto, 650-500 Uni-

versity Avenue, Toronto, ON, M5G

1V7. Tel 416 978-2719, toll free 1 888

512-8173, fax 416 946-7028, e-mail

[email protected],

website http://events.cepdtoronto.ca/

website/index/EMR1101.

EXOTIC CME CRUISES

Various dates and locations

16–30 Jan sailing to South America

(CME: respirology, cardiology, psy-

chiatry); 21–28 Mar, Dubai and UAE

(CME: anti-aging and aesthetics);

22–29 Apr, Rhine River cruise (CME:

primary care refresher); 29 Oct–12

Nov Istanbul to Luxor (CME: rheuma-

tology, neurology), and includes free

4-day post-cruise tour to Luxor and

Cairo. Group rates and your compan-

ion cruises free. Contact Sea Courses

Cruises at 604 684-7327, toll free 1

888 647-7327, e-mail cruises@sea-

courses.com. Visit www.seacourses

.com for more CME cruises.

NEPHROLOGY FOR FPs

Vancouver, 22 Jan (Sat)

Sponsored by the BC Renal Agency,

this 1-day course (7:30 a.m. to 3:30

p.m.) will be held at the Wosk Centre

for Dialogue. The conference aims to

help GPs improve care for their pa -

tients with kidney disease. In BC, an

estimated 200 000 people have some

level of kidney disease. Learn about

methods for estimating renal function,

guidelines for managing chronic kid-

ney disease, evidence-based treatment

for hypertension, when and how to

refer patients to a nephrologist, and

strategies for enhancing end-of-life

care. Cost: $100. Participants will

receive 6.5 CFPC Mainpro CME cred-

its. For information or to register, visit

www.bcrenalagency.ca or e-mail bcpra

@bcpra.ca. Registration limited to

first 50 respondents.

calendar



CLINICAL MEDICINE CRUISE

Caribbean, 19–27 Feb (Sun–Sun)

An 8-day cruise for the price of 7 days.

This CME is ideal for hospitalists,

internists, rural physicians, and as a

general update for all physicians.

Approved for 17 hours of CME cred-

its. Optional workshop: a primer on

quality improvement (approved for 4

hours CME). Sail onboard Royal Carib -

bean’s Liberty of the Seas from Miami

to St. Thomas, St. Maarten, Puerto

Rico, and a day at Labadee—a private

beach. Group rates and your compan-



888 647-7327, e-mail cruises@sea



FP ONCOLOGY PRECEPTOR

TRAINING

Vancouver, 28 Feb–11 Mar (Mon–

Fri), and 26 Sep–7 Oct (Mon–Fri)

The BC Cancer Agency’s Family

Practice Oncology Network offers an

8-week preceptor program beginning

with a 2-week introductory session

every spring and fall in the Vancouver

Centre. This program provides oppor-

tunity for rural family physicians, with

the support of their community, to

strengthen their oncology skills so that

they may provide enhanced care for

local cancer patients and their fami-

lies. Following the introductory ses-

sion, participants complete a further

6 weeks of customized clinic experi-

ence at the Cancer Centre where their

patients are referred. These can be

scheduled flexibly over 6 months. Par-

ticipants who complete the program

are eligible for credits from the Col-

lege of Family Physicians of Canada.

Those who are REAP eligible receive

a stipend and expense coverage through

UBC’s Enhanced Skills Program. For

more information or to apply visit

www.bccancer.bc.ca/hpi/fpon or con-

tact Gail Compton at 604 707-6367.

SPRING BREAK CRUISE

Caribbean, 12–19 Mar (Sat–Sat)

Spring break promotion of 2nd, 3rd,

and 4th person in room cruises free.

CME on this cruise focuses on dia-

betes management and is ideally suit-

ed to all physicians and allied health

care providers. Additional workshops

will be held on effective practice man-

agement by MD Physician Services.

Up to 18.50 hours of CME will be pro-

vided. Group rates and your compan-



888 647-7327, e-mail cruises@sea



SOMATIC MEDITATION

Victoria, 25–27 Mar (Fri–Sun)

To be held at Royal Roads University

and sponsored by the Association of

Complementary and Alternative Phy -

sicians of BC, The Art and Science of

Somatic Meditation with Reginald

Ray, PhD, is for physicians, health

care professionals, meditation stu-

dents, and those interested in body-

centered practices and the healing arts.

Dr Ray is the spiritual director of the

Dharma Ocean Foundation, Creston,

CO, US. Program participants will

benefit personally and professionally

from somatic meditation practices,

deepen the felt connection with the

energetic dimension of the human

body, and nourish and renew them-

selves while engaged in the healing

arts. Cost: $285. Registration: www

.royalroads.ca/continuing-studies.

Call 250 391-2600, ext. 4801, toll free

1 866 890-0220.

CDN GERIATRIC SOCIETY ASM

Vancouver, 14–16 Apr (Thu–Sat)

The 31st Annual Scientific Meeting of

the Canadian Geriatrics Society will

be held at the Four Seasons Hotel. This

year’s national conference in beauti-

ful Vancouver aims to attract geriatri-

cians, family physicians, fellows, res-

idents, students, and allied health care

professionals. A number of interna-

calendar

tional keynote presenters have been

secured, including Dr Edward R. Mar-

cantonio, associate professor of med-

icine, Harvard Medical School, Boston,

MA; Dr John E. Morley, Saint Louis

University; Dr Cheryl Phillips, Amer-

ican Geriatrics Society Board chair

and clinical professor, University of

California; Dr Kaveh G. Shojania,

University of Toronto; and Dr Roger

Y. Wong, University of British Col -

umbia. The meeting’s comprehensive

agenda has resulted in a keen interest

for this conference. Abstract closing

date is 1 December 2010, and notifi-

cations of acceptance will be sent via

e-mail in January 2011. To register

and for more information visit www

.CGS2011.ca, call 604 875-5101, or

e-mail [email protected].

BCMJ CRUISE CONFERENCE

Rhine River, 22–29 Apr, 2011

(Fri–Fri)

Cruise your way from Basel, Switzer-

land, to Amsterdam, Netherlands, on -

board the AMA Waterways ms Amale-gro. Enjoy castles, cobblestones, cafes,

and cathedrals on the free daily shore

excursions. Gourmet meals, free local

regional wine and beer with meals,

complimentary Internet, and use of

helmets and bikes as you explore these

fascinating medieval towns and cities!

Companion cruises free. Application

has been made for 13 hours of CME

credits. Faculty for this Primary Care

Refresher include Drs Matt Black-

wood, Shannon Lee Dutchyn, Lind-

say Lawson, Colin Rankin, and David

Richardson speaking on a true cross-

section of the issues seen in primary

care today, including opiate prescrib-

ing, ADHD, practical dermatology,

COPD and asthma, tuberculosis, chron-

ic back pain, humor in medicine, and

more. Book now as this cruise is

almost sold out. More information and

photos at www.seacourses.com; to

book call 604 684-7327, toll free 1

888 647-7327, or e-mail cruises@sea

courses.com.



practices availableFP—KAMLOOPS

Family practice available in Kamloops. Locat-ed two blocks from hospital. Lease in renovat-ed house with two congenial colleagues.Excellent support staff. Availability flexible—late 2010 to early 2011. Phone 250 372-8568or e-mail [email protected].

FP/GP—VERNON

Established full-time solo family practiceavailable in Vernon in a modern, spacious two-GP office with shared overhead. No OBS orER. Office hours are flexible; currently share 1in 6 weekend in-patient call. Enjoy biking, ski-ing, boating, and Okanagan sunshine. ContactDr Bill Charlton at 250 542-2887 or [email protected].

FP—VICTORIA

Family practice available in Victoria’s westerncommunities. Turnkey operation, no charge.Half-time but can go to full-time. Can applyfor partnership in doctor-run treatment centre.Contact Paul at [email protected] or 250479-0548.

positions availablePHYSICIAN—NORTH VANCOUVER

Physician required for the busiest clinic/familypractice on the North Shore! Our MOAs areknown to be the best, helping your day runsmoothly. Lucrative 6-hour shifts and no head -aches! For more information, or to book shiftsonline, please contact Kim Graffi at [email protected] or by phone at 604 987-0918.

GPs/SPECIALISTS—LOWER

MAINLAND

Considering a change of practice style or loca-tion, or considering selling your practice?Group of eight established locations withinSurrey, Delta, and Abbotsford with opportuni-ties for family, walk-in, or specialist physi-cians. Full-time, part-time, or locum doctorsare guaranteed to be busy. We provide all the

administrative and operational support. En -quiries to Paul Foster, 604 592-5527, or [email protected].

LOCUM—VANCOUVER

Busy walk-in clinic shifts available in Yale-town and the heart of Kitsilano at KhatsahlanoMedical Clinic—voted best independent med-ical clinic in Vancouver in the GeorgiaStraight readers’ poll. Contact Dr Chris Watt [email protected].

WALK-IN—VICTORIA

Walk-in clinic shifts available in the heart oflovely Cook St. Village in Victoria, steps fromthe ocean, Beacon Hill Park, and Starbucks.For more information contact Dr Chris Watt [email protected].

LOCUM—ABBOTSFORD

East Abbotsford walk-in clinic with congenialstaff and pleasant patient population is lookingfor a flexible locum physician interested inpossible long-term opportunity with excellentremuneration. Please call Cindy at 604 504-7145 between 9 a.m. and 2 p.m., Monday toFriday.

GP—FORT ST. JAMES

GP required for busy family practice. Sur-rounded by beautiful scenery and hundreds oflakes, Fort St. James has recreational opportu-nities for everyone! We are recruiting two full-time physicians to consult in the clinic andshare ER on-call services and hospital in-patient care. High-income potential! For moreinformation please contact our office manager,Kathy, at [email protected] or call 250 996-8291. Visit our web site atwww.fsjamesmedicalclinic.com.

DOCTOR—SURREY

If the overhead cost is stopping you from hav-ing your own practice, or if you are looking tohave a very busy practice with guaranteedincome, we have the right office for you!Located in Surrey, On King George Blvd, twoblocks from SkyTrain station, next to a phar-macy and a dental clinic. Four exam rooms,

physician’s office, reception, waiting area,storage, signage, computer networking, plentyof free parking, and more. Lease terms areflexible, and the rent is very low and nego-tiable. For more information please call MrZehtab at 604 306-4706, or e-mail [email protected].

GPs/LOCUMS—SURREY

Very busy walk-in clinic looking for physi-cians/locums to do Monday and Friday morn-ing shifts from 9 a.m. to 3 p.m. Coverage alsoneeded for April Sunday morning shifts from 9 a.m. to 3 p.m. or 10 a.m. to 3 p.m. Eveningsfrom Monday to Friday from 3 p.m. to 8 p.m.The split is 70/30 with $95 minimum. Alsolooking for physicians to move their practice.We can do it by a percentage or just flat fee.Please contact the manager at 778 688-5898,or e-mail [email protected].

FP—SURREY/GUILDFORD

Lucrative family practice/walk-in in Surrey,near Guildford. Physician needed full-time orpart-time. Split 75%. Busy practice. Mostlyyoung families. High-income potential. Call Dr R. Manchanda at 604 580-5541, or [email protected].

GP—NANAIMO

General practitioner required for locum or per-manent positions. The Caledonian Clinic islocated in Nanaimo on beautiful VancouverIsland. Well-established, very busy clinic with24 general practitioners and four specialists.Two locations in Nanaimo; after-hours walk-inclinic in the evening and on weekends. Com-puterized medical records, lab, X-ray, andpharmacy on site. Contact Doris Gross at 250716-5360, or e-mail [email protected].

FP/WALK-IN—SURREY

Physician required for shifts in a busy, happy,and colorful clinic located inside the GuildfordTown Centre Mall. Please feel welcome todrop by, or contact Andrew at 604 588-8764,fax 604 588-8761, or e-mail [email protected].

classifieds

Rates: BCMA members $50 + GST perissue for each insertion of up to 50 words.Each additional word, 50¢ + GST per issue.Box number $5 + GST. We will invoice onpublication.Non-members $60+GST per issue for eachinsertion of up to 50 words. Each additionalword, 50¢ + GST. Box number $5 + GST perissue. Payment must accompany submission.Deadlines: Ads must be submitted or can-celled in writing by the first of the month pre-

ceding the month of publication, e.g., by 1 November for December publication. Pleasecall if you have questions.

Send material to: Kashmira Suraliwalla •BC Medical Journal • #115-1665 WestBroadway • Vancouver, BC V6J 5A4Canada • Tel: 604 638-2815; fax: 604 638-2917 • E-mail: [email protected] Provincial legislation prohibits ads that dis-criminate on the basis of sex. The BCMJ maychange wording of ads to comply.

C L A S S I F I E D A D V E RT I S I N G ( l i m i t e d t o 1 0 0 w o rd s )



hill, cross-country, and heli-skiing; mountainhiking and biking; unsurpassed ocean and riverfishing; wildlife watching; golf; and whitewa-ter rafting. Tremendous sporting facilities.Good schools. Affordable housing. No traffic!www.healthmatchbc.com. www.mdwork.com.www.kitimat.com. Apply to [email protected].

LOCUM/ASSOC—

BURNABY/NEW WEST

Tired of waiting for your locum cheque? Getpaid the next day. Long-term/short-term, part-time/full-time, locum/associate needed in amulti-physician office with family physicians,pediatrician, internal medicine specialist, hear-ing specialist, sleep specialist, etc. Supportivecolleagues in beautiful medical centre withonsite pharmacy, laboratory, optometry clinic,dental clinic, and rehab centre with physiother-apists, massage therapists, and chiropractors.Extremely safe, bright, and pleasant workenvironment. Convenient cafe across the hall-way from the medical clinic. Clinic is locatedcentrally on the Burnaby/New Westminster bor-der, 25 minutes from Vancouver. Contact Devonat [email protected] or 604 771-1081.

PHYSICIAN—BURNABY

Simon Fraser University Health and Coun-selling Services is looking for a physician towork 1 or 2 days a week. We are a clinic locat-ed at SFU’s Burnaby campus offering medicaland counseling services to SFU students fromMonday to Friday, 9 a.m. to 4:30 p.m. Ourstaff also includes RNs, counselors, psycholo-gists, congenial and efficient MOAs, and spe-cialist consults by an allergist and psychiatrist.This position could begin as a locum andprogress to a contract position with benefits.Contact Dr Patrice Ranger at [email protected] 778 782-4615.

FP—OAKRIDGE

Interested in cutting back on your hours? Twofamily physicians looking for a third FP toshare two practices; i.e., you would work 8months per year. These practices are located inthe Oakridge area in prime office space, withlab and X-ray in same building. Reply [email protected].

LOCUM—PENTICTON

Locum/vacation position in Penticton. Two-doctor office, EMR. Five days per week hospi-tal rounds (1 hour), 3 days per week office. No nights, weekends. Enjoy the beaches, golf,wine tours. Various times available in 2011.Contact Dr Glen Burgoyne at 250 492-4066.

RADIOLOGIST—VAN

Our unique private MRI facility is searchingfor an on-site locum radiologist to join ourinnovative team! We are committed to provid-ing the highest quality medical care in a com-fortable, private, safe environment. On-siteradiologist to report primarily MSK/neurologypatients. Successful candidate must be in goodstanding, have CMPA coverage, and be regis-

tered with the College of Physicians and Sur-geons of BC. Excellent opportunity in a leadingcutting-edge facility! Please contact Lisa Gar- cia at 604 733-4007 or [email protected].

LOCUM—NORTH VAN

North Vancouver, locum for December-January.Busy FP using EMR in a group setting. Canwork 4 or 5 days a week. Also an opening forsomeone to take over a practice available. Calloffice at 604 904-8804 or e-mail [email protected].

LOCUM—METRO VAN

Available Jan to Oct 2011 with possible exten-sion. This radiology practice involves tertiary,community, and clinic work, including generalX-ray, ultrasound, CT, MRI, mammography,and IR. Vascular interventional skills preferredbut not required. Excellent remuneration in aprogressive, dynamic group practice. For moreinformation, please contact Dr Ken Wong [email protected] or 778 231-5809.

PHYSICIANS—KELOWNA

Medi-Kel Clinics Ltd. seeks physicians fromacross Canada for well-established familypractice and walk-in clinic for full-time, part-time, and locum positions. Clinic is computer-ized (Osler EMR). Obstetrics and hospitalprivileges optional but not required. We pro-vide all the administrative and operational sup-port. Kelowna offers lots of recreational activ-ities. Please contact office manager MariaVarga at [email protected] or call250 863-9555.

FP—ASHCROFT

Enjoy the vibrant community of Ashcroft—famous for sunny skies, mild temperatures,and picturesque countryside. Join the experi-enced family physicians who provide medicalcare from the Ashcroft Hospital, Health CareCentre, and 24-hour ER. Full specialist supportat Royal Inland Hospital in nearby Kamloops.Weekday clinic hours 9–5. ER is manned 24/7.Call 1 in 3. Generous remuneration, on-call pay-ment, rural recruitment funding, and retentionallowance as well as a community-supportedrecruitment package. Contact 250 453-9353,toll free 1 877 522-9722, e-mail [email protected], or visit betterhere.ca.

FP—DELTA

Locum/associate for a large family practicewith after hours and weekend services. FullEMR. Flexible hours. For information, contactDr R. Clarke at [email protected].

FP—CASTLEGAR

Join a team of four family physicians and a

nurse in their new office equipped with EMR.

No in-patients. ER shifts from 8 a.m. to 8 p.m.

Office/clinic is in the process of becoming

computerized. Full specialist support at re -

gional hospital. Will consider locums. Castle-

classifieds

PHYSICIANS—LETHBRIDGE

Would you like to live in the best place inAlberta, close to mountains and lakes? Camp-bell Clinic is seeking P/T and F/T physicians;new graduates welcome. Currently we have 16family physicians, one pediatrician, and aninternist. Multidisciplinary health care teamsinclude a pharmacist, clinical educators, andmental health worker. Fully integrated elec-tronic medical records and on-site X-ray, labo-ratory service, and pharmacy. Friendly supportstaff and professional management. Excellentstart-up conditions and above-average incomewith very competitive overhead. We welcomeyour inquiries. Contact Chris Harty at 403381-2263 or [email protected].

GP—TSAWWASSEN

The Tsawwassen Medical Clinic, a friendlysix-doctor group, has an opening for a familyphysician in July 2011. This position will appealto someone looking for an excellent medicalgroup with superior facilities and an excellentstaff in a great community just 30 to 35 min-utes south of Vancouver. Schools and recre-ational facilities are excellent as well as easyaccess to nearby marinas. On-call schedule isone in six and hospital and OB involvementare available but not necessary. This is a greatopportunity for a young doctor to build up hisor her practice quickly, as well as taking overthe practice of a retiring doctor. Interestedapplicants please contact Susan at 604 943-9922 or e-mail [email protected].

GP—KITIMAT

Brilliant family opportunity for doc to join GPin stunning northwest BC. Kitimat, a marvel ofindustry and nature, needs a fifth GP. New 22-bed hospital. Refurbished clinic. Great staff.Wide variety of work. Specialist cover. Lots ofgovernment incentive payments. Excellentgross income. Friendly, purpose-built town is asafe, healthy environment, and offers theyoung family an exciting new start. Lots ofocean and mountain activities including down-


Credit cards accepted by the BCMJ

The BC Medical Journal acceptspayments by Visa and Master-Card for advertising. If your ac-count is overdue please call 604638-2815 or 604 638-2858 and we

will clear it im mediately with acredit card payment—

saving you the time and trouble ofproducing a cheque.


gar offers an enjoyable lifestyle with unlimited

year-round recreational activities including

championship golf courses, two world-class

ski resorts, and groomed cross-county ski

trails. Generous remuneration. MOCAP fund-

ing available. Contact 1 877 522-9722, e-mail

[email protected], or

visit betterhere.ca.

FP—CHASE

Join three other physicians in the multidiscipli-

nary clinic where set hours, weekends off, and

no call mean that you will be able to enjoy the

famous Shuswap lifestyle. With a guaranteed

minimum income, full practice support, and

ef ficiency incentives you will be able to focus on

patient care while building your thriving prac-

tice. Set weekday hours 8 a.m. to 5:30 p.m. One

emergency/outpatient day per week. No call.

Call 1 877 522-9722, e-mail physician recruit

[email protected], or visit betterhere.ca.

FP—CLEARWATER

Permanent, full-time GP with emergency room

skills to perform clinic work with four other

physicians in an unopposed group practice.

On-call rota at the new community hospital is

1 in 4 and is not onerous. Obstetrical skills

appreciated, but not required. Clearwater offers

a relaxed pace, good remuneration, congenial

colleagues, and many desirable recreational op -

portunities. On-call stipend and retention bonus

paid directly to physician. Contact Jennifer

Thur at 250 674-2244, e-mail physicianrecruit

[email protected], or visit betterhere.ca.

FP—LYTTON

Group family practice clinic in new health care

centre located adjacent to ER, lab/X-ray, and

pharmacy. Congenial, well organized, low

overhead, fee-for-service practice with flexible

scheduling for either full- or part-time. Week-

day hours 9 a.m. to 5 p.m., with 1 in 3 call. ER

skills required. Generous remuneration and

retention incentives. Lytton is a friendly com-

munity with a great climate, and is the white-

water rafting capital of Canada. Contact 1 877

522-9722, e-mail physicianrecruitment@

interiorhealth.ca, or visit betterhere.ca.

FP—SORRENTO

Sorrento is located on the south shore of

Shuswap Lake and serves approximately 8000

residents. Physicians in Sorrento receive full

specialist support from tertiary care centres in

Kamloops and Kelowna. Family practice, week-

days only. No call required. Physician may join

the ER rotation in nearby Salmon Arm. Excep-

tional remuneration and lifestyle. Contact

Denise Moore at 250 675-3903, toll free 1 877

522-9722, e-mail physicianrecruitment@


FP—100 MILE HOUSE

We are looking for FPs for clinic, walk-in, and

ER shifts. Part-time and full-time positions

classifieds

General PathologistRichmond, BC

A permanent full-time position for a General Pathologist at Rich-mond Hospital will be available November 2010. You will jointhree other General Pathologists providing services to RichmondHealth Services, and potentially Sea-to-Sky Highway, SunshineCoast and BC Central Coast. The Richmond Hospital Laboratoryprovides anatomic pathology, hematopathology, blood tranfusionservices, chemistry and infection control, and is part of the inte-grated Regional Laboratory which provides subspecialist supportin all disciplines. Participation in medical student and residenttraining is strongly encouraged.

The Richmond Hospital is fully accredited, serving a communityof 193,000 and a further 75,000 in the adjacent catchment area.Opportunity and flexibility may be considered within the regionallaboratory system.

In accordance with Canadian immigration requirements, this ad-vertisement is directed toward Canadian citizens and permanentresidents of Canada. The Vancouver Coastal Health Authority andits affiliates hire on the basis of merit and are committed to em-ployment equity. Candidates should be eligible for licensure bythe College of Physicians and Surgeons of BC.

Send a CV and letter of intent to Medical Administration, Rich-mond Health Services, 7000 Westminster Highway, Richmond,BC. V6X 1A2. Fax: 604-244-5552. Email: [email protected] formore information. Position will remain open until filled. Pleasenote, only applicants of interest will be contacted.

Visit metropolitan.com formeeting planning tools andgreat corporate promotions.

1.800.667.2300 metropolitan.com/vanc

DELICIOUS

ENERGIZING

PRODUCTIVE

available. Obstetrics, GP surgery, and GP anes-

thesia are optional. Located in the Cariboo-

Chilcotin region of British Columbia; the

warm, dry summers are ideal for hiking and

fishing while snow in the winter offers cross-

country skiing and snowmobiling. Recruit-

ment and retention incentives available. Con-

tact Dr Franky Mah, 250 395-2271, toll free 1

877 522-9722, e-mail physicianrecruitment@


GP ANESTHETIST & GP SURGEON—

FERNIE

GP surgeon needed to work with another

FRCP general surgeon to share on-call respon-

sibilities for C-sections, long-term care, and

in-patient care. Also looking for a GP anes-

thetist for one to two OR mornings per week as

well as half-time family practice. ER shifts and

obstetrics optional. There is a local FRCP gen-

eral surgeon as well as visiting dentists and

orthopaedics. Located in the Elk Valley in

southeast British Columbia, Fernie offers

exceptional recreation including fly-fishing,

alpine skiing, and golf. Contact 1 877 522-

9722, e-mail physicianrecruitment@interior

health.ca, or visit betterhere.ca.

PEDIATRICS—BURNABY

Busy pediatric and multidisciplinary office

offering walk-in and referral based practice.

Excellent location and competitive remunera-

tion. Please contact Jeremy at 604 299-9769.Continued on page 486


FP—NAKSUP

FPs required in Nakusp to provide medicalservices from private clinic and 6-bed hospital.MOCAP funding, rural recruitment and reten-tion incentives, and enhanced CME available.Call 1 in 6. Nakusp is located between theMonashee and Selkirk Mountains in BC’sKootenay region. Residents enjoy relaxing hotsprings, terrific golf and fishing, excellent hik-ing trails, and a multitude of other outdoor andindoor activities. Contact Miriam Ramsden at250 354-2318, toll free 1 877 522-9722, [email protected], orvisit betterhere.ca.

FP—PRINCETON

Work with four physicians who provide a fullrange of medical services in a six-bed commu-nity hospital that provides emergency, generalmedicine, and basic laboratory and diagnosticimaging services. Full specialist support avail-able at nearby Penticton Regional Hospital.On-site ambulance. 9 a.m. to 5 p.m. plus 1:6 on call for 24/7 ER. Princeton is a family-oriented, well-serviced community at thefoothills of the Cascade Mountains—the gate-way to exceptional four-season recreation.Con tact 1 877 522-9722, e-mail [email protected], or visit betterhere.ca.

GPs/SPECIALISTS—VANCOUVER

Multidisciplinary Integrative Medical Centreideally located at Broadway and Cambie hasopenings for GPs and specialty practitioners.Clinic has an educational center for seminars,etc. Great support staff, beautiful ambience.Exceptional clinic/centre, the first in Canada.Open extended hours. Flat rental room rate.Call Sharon at 604 708-3600 or [email protected].

medical office spaceSPACE—VANCOUVER

Third person wanted for shared three-officespace. Suitable for psychiatrist or psycholo-gist. Pooled expenses. North view, FairmontMedical Building, 750 W. Broadway, 12thfloor. Close to VGH and public transportation.Call 604 872-3422.

SPACE—VANCOUVER

Two psychiatrists looking for a third to sharesuite 902–601 W. Broadway. The office is gor-geous with a stunning floor-to-ceiling viewfacing north and west. The space is availableMon, Wed, and Fri (and weekends if desired).Call Trish Long at 604 872-3235 (Mon–Thur).

SPACE—SURREY

Office space available right across the streetfrom the main entrance to Surrey MemorialHospital. Space is 2000 sq. ft., set up for up tofive doctors. Available immediately for rea-sonable rent. For viewing please e-mail Lee [email protected].

classifieds


advertiserindexThe BC Medical Association thanks the following advertisers for their

support of this issue of the BC Medical Journal.

All new bcmj.org launches this month

BCMJ.org is turning into a true online publication,with fresh content throughout the month.• Early access to articles• Instant article commenting• Video (interviews with authors and others)• Blog on BC medical matters• New “People” section• Patient information sheets• Links to related articles

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AIM Medical Imaging ............................................................................................................. 488

BC Association of Clinical Counsellors ....................................................................... 434

Breivik and Company .............................................................................................................. 435

Cambie Surgery Centre/Specialist Referral Clinic ................................................ 432

Carter Auto ...................................................................................................................................... 433

General Practice Service Committee ............................................ 469, 470, 473, 491

Guidelines and Protocols Advisory Committee ...................................................... 437

MCI Medical Clinics Inc. ...................................................................................................... 436

Metropolitan Hotel ..................................................................................................................... 485

Optimed ............................................................................................................................................. 487

Richmond Health Services .................................................................................................... 485

Society of Specialist Physicians and Surgeons ........................................................ 488

Speakeasy Solutions .................................................................................................................. 487

Wickaninnish Inn ........................................................................................................................ 436


SPACE—VANCOUVER

Position/space available for a family doctor or

walk-in clinic doctor to join our multidiscipli-

nary clinic on the ground floor of the brand

new Vancouver Coastal Health building locat-

ed at 1669 E. Broadway. The ideal doctor

would be willing to refer patients for treat-

ments of their injuries/accidents, etc. Terms

are negotiable and flexible. Our team consists

of an experienced chiropractor, physiothera-

pist, massage therapist, acupuncturist, and pain

medicine specialist physician. If interested

please contact Dr Samji at 604 760-0230 or

[email protected].

SPACE—ABBOTSFORD

Fully renovated medical clinic in Abbotsford is

looking for family physicians for walk-in or

private practice. The 1300 sq. ft. location is in

a busy area. 15/85 split if we set up. Otherwise,

free rent for up to 1 year. Contact 604 537-

4464. E-mail [email protected].

LEASE—PORT MOODY

St. Johns St., Main St. Level walk-in. Long-

term lease available for medical practice.

Choose 1100 sq. ft. space, or large 2200 sq. ft.

unit for multi-practitioner clinic. Rear parking

lot. Future pharmacy or practice expansion

will be available. Extensive exterior/interior

renovations in progress. All medical use build-

ing. Separate meters and HVAC. Package

available. Call Andrew R. Taylor at 604 939-

4325, or e-mail [email protected].

SPACE—SURREY

Fully renovated medical clinic in Fleetwood is


private practice. Large 3000 sq. ft. central loca-

tion in a high-traffic area is adjacent to ample

free parking and a lab. 15/85 split if we set up.

Otherwise, free rent for up to 1 year. Contact

604 537-4464. E-mail kamalsandhu6@gmail

.com.

SPACE—NORTH VAN

Physician leaving province. Spacious five-

doctor office. Beautiful location in profession-

al building facing Grouse Mountain. Close to

Lions Gate Hospital. Equipped with electronic

medical records. Adequate space for full-time

or part-time consultant/family physician prac-

tice. Excellent, experienced medical office

assistant. Awesome colleagues. Contact 778

888-7251 or [email protected].

SPACE—VICTORIA

Excellent downtown Victoria medical office

space now available. Approximately 1000 sq.

ft. Base rent is $12. Located at 531 Yates St.

Call Kabir at 1 250 479-6480 ext. 23.

classifieds

The EMR for BC Specialists

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miscellaneousBILLING SOFTWARE—$199

It’s true. Windows XP Practice Software, $199

per computer. Klinix Assess. You get the com-

plete software package of billing, scheduling,

and medical records plus product support and

updates for an annual licence fee of $199 per

computer. Your satisfaction guaranteed in the

first 120 days or return Klinix Assess for your

money back. No fine print. Demos at

www.klinix.com. Toll free 1 877 SAVE-199.

BOOK OF POEMS AVAILABLE

Instinct-Science and Other Poems by Gurdev

S. Boparai is available through Chapters book-

store, at www.chapters.ca.

PATIENT RECORD STORAGE—FREE

Retiring, moving, or closing your family or

general practice, physician’s estate? DOCU-

davit Medical Solutions provides free storage

for your paper or electronic patient records

with no hidden costs. Contact Sid Soil at

DOCUdavit Solutions today at 1 888 711-0083,

ext. 105 or e-mail [email protected]. We

also provide great rates for closing specialists.

FREE CME SPACE—VANCOUVER

New state-of-the-art facility with boardrooms

available for CME events. No charge for phy -

sicians; seats up to 35 guests. Easy access to

underground parking. For further information

contact Lisa at 604 733-4407 or lgarcia@

aimmedicalimaging.com.

FOR SALE—HYSTEROSCOPY UNIT

Never used Storz Office Hysteroscopy Unit.

Autoclavable 2 mm 30 degree telescope with

enlarged view, 2.8 mm outer sheath. Tricam

Zoom 3-chip camera head. 175 watt xenon

light source and light cable. CO2 insufflator.

14" monitor. Storz endoscopy cart (36" high).

Purchased in 2004 but never used. In excellent

condition. Asking $20 000 OBO; must sell as

practice is now closed. E-mail sroffice@

telus.net or leave message at 604 872-2003.

classifieds

Your forum to advance…

Specialist IssuesRepresentingBCMA specialists

SPACE—VANCOUVER

Fully renovated medical clinic in Vancouver is


private practice. Large 2000 sq. ft. central

location in a high-traffic area. Free parking in

back. 15/85 split if we set up. Otherwise, free

rent for up to 1 year. Contact 604 537-4464.

E-mail [email protected].

vacation propertiesNEED A HOLIDAY IN PARADISE?

One bedroom beachfront condo in Puerto Val-

larta, Mexico, overlooking Mismaloya Bay.

Sleeps four. Full kitchen, fully furnished, A/C,

satellite TV. Available weekly or monthly. Call

604 542-1928, or e-mail [email protected].

FRENCH VILLA

France/Provence. Les Geraniums, a 3-bedroom,

3-bath villa. Terrace with pool and panoramic

views. Walk to market town. One hour to Aix

and Nice. New, independent studio with ter-

race also available. 604 522-5196, villavar

@telus.net.

FOR RENT—WHISTLER

Plan your next holiday, beautiful four-bedroom

house, 5 minutes from Whistler Village. Quiet,

private, ideal for groups of 8 to 10. All the

comforts of home. Contact Beth Watt or Peter

Vieira at [email protected] or 604 882-1965.

FOR RENT—MAUI

Our oceanview 1 BR, 2 bath condominium unit

can accommodate up to four people in relaxed

surroundings. It is located in Kihei across the

road from the Kamaole III Beach Park. Facili-

ties include two swimming pools, two hot tubs,

two tennis courts, BBQ, and high-speed Inter-

net access. Rates US $120–$180 per day. Call

250 248-9527 or e-mail [email protected].



BCMA MEMBER DISCOUNTS CLUB MD

E: [email protected] P: 604.638.2838 TF: 1 800 665.2262 ext 2838

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Best prices on Whistler ski passes in town!Peak 2 Peak lift!

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What profession might youhave pursued, if not formedicine?Aerospace engineering.

Which talent would you mostlike to have?Playing bagpipes.

What do you consider yourgreatest achievement?Initiating and bringing the public cam-

paign against BC Hydro’s Kootenay

Diversion Project to a successful con-

clusion.

Who are your heroes?Isaac Newton, Charles Darwin,

Steven Hawking, and Abram Hoffer.

Dr Paterson is a GP in Creston.

What is your idea of perfecthappiness?Now that’s way too personal.

What is your greatest fear?Human extinction.

What is the trait you mostdeplore in yourself?“Why do today what you can put off

until tomorrow?”

What characteristic do yourfavorite patients share?They are open with their problems.

Which living physician do youmost admire?Dr John O’Brien-Bell.

On what occasion do you lie?When truth would do more harm.

Which words or phrases do youmost overuse?“Tell me about it.”

The Proust Questionnaire has its origins in a parlor game popularizedby Marcel Proust, the French essay-ist and novelist, who believed that, inanswering these questions, an indivi -dual reveals his or her true nature.

Tell us a bit about yourself. Please complete and submit aProust Questionnaire—your colleagues will appreciate it.

Onlinewww.bcmj.org/proust-questionnaire. Complete andsubmit it online.

[email protected]. E-mailus and we’ll send you ablank MS Word document to complete and return.

Printwww.bcmj.org/proust-questionnaire. Print a copy fromour web site, complete it, andeither fax (604 638-2917) or mailit (BCMJ 115-1665 West Broad-way, Vancouver BC V6J 5A4).

Mail604 638-2858. Call us andwe’ll mail you a copy to com-plete and return by mail (BCMJ115-1665 West Broad way,Vancouver BC V6J 5A4).

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What medical advance do youmost anticipate?Acceptance of the efficacy of nutrients.

What is your most markedcharacteristic?Tenacity.

What do you most value in yourcolleagues?Acceptance of my idiosyncrasies.

Who are your favorite writers?John Buchan, Arthur Conan Doyle,

Arthur C. Clarke, Ian Rankin.

What is your greatest regret?Selling our first house when we did. If

we had kept it, I could have retired

upon its proceeds years later.

How would you like to die?Like Alfred Nobel, laughing.

What is your motto?Never give up.

Proust questionnaire: Erik T. Paterson, MD


Make a difference in your communityDivisions of Family Practice, an initiative of the General Practice Services Committee, are community-based affiliations of family physicians working together to improve patient care, to increase family physicians’ influence on health care delivery and policy, and to provide professional satisfaction for physicians.

The first of its kind in Canada, the Divisions initiative provides physicians with a stronger collective voice in their community while supporting them to improve their clinical practices and offer comprehensive patient services. The initiative is founded in the belief that our communities are best served when we seek to improve the health of all residents in the region.

Being a member of a Division offers a number of benefits, such as:

services around a Division practice area

and wellness programs

We invite you to join your local Division and make a difference in the delivery of primary health care in your community. www.divisionsbc.ca

in youMake

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22–29 April 2011 • Basel, Switzerland to Amsterdam, NetherlandsBasel • Breisach • Colmar • Freiburg • Strasbourg • Mannheim • Heidelberg • Rudesheim • Kolbenz • Cologne • Amsterdam

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Itinerary, features, faculty, topics,and more: www.seacourses.com

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Primary Care Refresher Excellent accredited CME

BC Medical Journal Cruise Conference

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Health & Medicine