Dr. Robert B. Bourne

Dr. Robert B. Bourne: Keeping Track of Orthopedic Medicine in Canada

August 01, 2002

Dr. Bourne is helping improve joint replacement surgery in Canada by his work founding and directing the Ontario Joint Replacement Registry and chairing the Canadian Joint Replacement Registry. He has focused his private practice on caring for patients with end-stage knee arthritis, using a variety if techniques to relieve patient pain and restore patient function. Dr. Bourne is currently Chairman for the Division of Orthopedic Surgery at the University of Western Ontario and practices at London Health Sciences Centre, University Campus.

Where is your current clinical work focused?
Dr. Bourne: First and foremost, I am an orthopedic surgeon and my practice is devoted to the care of patients with arthritic hips or knees. About half of my lower extremity arthritis practice is devoted to arthritic conditions of the knee joint. Arthritis surgery is very gratifying as the vast majority of people do extremely well. Patients feel that their life has been returned to them! I'm also an academic orthopedic surgeon, so I have a role in training our doctors of tomorrow, whether they be medical students, orthopaedic residents or Fellows. We have four graduate orthopedic surgeons who work with us as Fellows every year at London Health Sciences Centre. This year, our Fellows come from Japan, Australia, the United States and Britain. I also consider myself a clinician scientist with a keen interest in research. Most of my research is obviously involved with arthritic problems of the hip and knee joints. My main interest right now is developing a national joint replacement registry, such that we can follow the clinical results of all our hip and knee replacements in Canada. This is a formidable task, but we have had considerable support from orthopaedic surgeons in Canada, the Canadian Orthopaedic Association, Provincial Orthopaedic Associations and both federal and provincial levels of government. We're also been involved with helping the American Academy of Orthopaedic Surgeons develop a joint replacement registry in the United States. The American initiative is more complex owing to the larger population and a different medical environment.

What are the goals of the Canadian Joint Replacement Registry, and how are these important?
Dr. Bourne: The Canadian Joint Replacement Registry collects patient demographic, surgical technique and implant data of all total hip and knee replacements performed in Canada. The first annual report of the Canadian Joint Replacement Registry was recently published. In this report, we compared the number of hip and knee replacements performed in Canada in 1994-1995 compared to 1999-2000. We demonstrated that there was about a 40% growth in the number of total hip and knee replacements performed in that 5-year period. Somewhat surprisingly, we noted considerable growth in younger patients aged 45-54 years of age. For total knee replacements, there was an astounding 97% growth in total knee replacements performed in women and a 76% growth in men! Usually, patients less than 55 have been considered too young for total knee replacement, but many patients in this age group have end-stage arthritic conditions for which there is no other alternative other than putting up with the ongoing pain and disability,

What do this increase in the number of joint replacement operations and the decrease in patients' age say to you as a surgeon?
Dr. Bourne: Demographic studies of the post-war baby boom population have suggested that the number of patients greater than 60 years will at least double over the next 15-20 years. This increase in older patients will put a considerable stress on our medical system, particularly for high-volume medical interventions, such as total hip and knee replacement surgeries. I suspect that there will not be a lot of extra money to meet this patient demand, so we are going to be forced to find better ways of doing things in a more cost-effective manner. The Canadian Joint Replacement Registry will be extremely helpful in identifying which patients do best, which surgical techniques are associated with the optimum results and which implant provides the most durable results. The growth in an aging population will also stress our health care manpower needs. Already, we are facing a shortage of physicians and nurses. We will have to re-examine the distribution of our medical personnel. In Canada, the majority of our physicians are family practitioners, whereas in the US, the majority of these physicians are specialists. He proper balance is somewhere in between. In Canada, however, we do have a shortage of specialists who do technical procedures, such as total joint replacements. This has led to waiting times which are too long for patients in need of joint replacement surgery.

Is that is because of the structure of the medical community in Canada? Dr. Bourne: I think so. As I have alluded to, the perfect medical system is probably somewhere between the US and Canadian models. We do have some rationing of health care and long waiting lists in Canada. The Registry will be helpful in improving patient access by determining the number of people waiting, how long they wait and the severity of their symptoms. Because the Canadian Joint Replacement Registry is done in partnership with the Provincial Ministries of Health, which fund health care, the data on waiting times will have an influence on the health care providers. The second goal of the Canadian Joint Replacement Registry is to reduce the need for re-do operations by providing up-to-date timely information as to which patients, which surgical techniques and implants do the best. By pooling large numbers of patients and noting trends, patients, surgeons and health care providers can make evidence-based decisions. We know that this works in Sweden, where hip and knee registries began in the 1970s have shown stepwise reduction in complications, such as deep infection and the need for revision surgery. It is interesting to note that the cumulative revision rate in Sweden in the 1970s are similar to those in North America at this time. Today, cumulative revision surgery rates in Sweden are about half of these in North America! Finally, another goal of the Canadian Joint Replacement Registry is to provide post-market surveillance of new technologies which are being introduced into the field of hip and knee replacement surgery, For the most part, the introduction of these new technologies will be beneficial to patients, but occasionally something which looks very good in the laboratory does not work as well in the patient. We would like to be able to identify defective new technologies early, such that a minimum of patients are affected.

 Knee1: What are you looking at with your current research studies?
Dr. Bourne: Our other research focuses on clinical trials, ways to reduce wear following total joint replacement surgery, musculoskeletal imaging and the analysis of failed orthopaedic implants. In the field of clinical trials, we favour randomized clinical trials which are the most rigorous form of comparing one surgical intervention with another. In the field of musculoskeletal imaging, we have embarked upon a special technique developed in Sweden called RSA (Radiostereometric Analysis). By use of radio-dense markers placed in the bone, cement and/or implant, we are able to carefully assess implant fixation, wear and joint kinematics.

When you say put radio-dense markers in bone, how is that done?
Dr. Bourne: The first step in performing RSA studies is to obtain an informed patient consent. In consenting patients, small tantalum beads (less than 1mm) are placed in the bone, cement or on the implant using special introduction tools. Post-operatively, the joint to be studied is radiographed using two simultaneous radiographic pictures taken at angles of 40 or more degrees from each other. Based on this stereometric analysis, the movement of one part with regards to the other or the wear of one side of the joint replacement on another can be detected with great accuracy. This technique also has the potential of allowing us to study normal joint mechanics and to determine which type of implant, such as total knee replacement, best replicates normal human kinematics.

That's twice you have mentioned projects initiated in Sweden. Is that a coincidence or do you have a professional relationship with Sweden's medical community?
Dr. Bourne: Orthopaedic surgeons in Sweden are to be commended for many innovations, particularly in the fields of registry development and musculoskeletal imaging. We have had a close relationship with both the Swedish Knee Registry located in Lund, Sweden, and the Swedish Hip Registry located in Gotesborg, Sweden. Indeed, recently one of our Fellows spent half of his Fellowship in Sweden and half with us, obtaining a Ph.D. based on that experience. Our relationships with our Swedish colleagues are obviously very close.

 Knee1: Have you seen any work being done to create a joint replacement registry in the US?
 Dr. Bourne: Yes. The American Academy of Orthopedic Surgeons (AAOS) is exploring that right now. The leadership of the AAOS has sought input form both Sweden and Canada. As a member of the AAOS, I am happy to help with this endeavour. I think it will happen. There obviously will be some challenges to overcome, but the benefits of a US national joint replacement registry far outweigh any negative aspects of this endeavour. National joint replacement registries are a win-win-win endeavour for patients, orthopaedic surgeons and health care providers. Read more about the Ontario Joint Replacement Registry.

Last updated: 01-Aug-02

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