British Columbia Medical Journal, October 2010 issue: Full Issue

OSTEOARTHRITIS OF THE October 2010; 52: 8
Pages 381- 428
HIP AND KNEE—PART 1
Pathogenesis and
nonsurgical management
Clinical features and pathogenetic
mechanisms
Evidence-based guidelines for
nonpharmacological treatment
Pharmacological treatment

Good Guys: Hammy and Hector

Proust: Ari Giligson

Research team explores new bone
and tendon-related treatments

Health Canada allows 10 000
unproven remedies onto shelves

Screening renal failure
patients for tuberculosis

www.bcmj.org

contents
October 2010
Volume 52 • Number 8
Pages 381–428

A R T I C L E S

OSTEOARTHRITIS OF THE HIP AND KNEE—PART 1

392 Guest editorial
Pathogenesis and nonsurgical management
Established 1959
B.A. Masri, MD

393 Clinical features and pathogenetic mechanisms
of osteoarthritis of the hip and knee
Manal Hasan, MD, Rhonda Shuckett, MD

399 Evidence-based guidelines for the nonpharmacological
treatment of osteoarthritis of the hip and knee
J. Hawkeswood, MD, R. Reebye, MD

ON THE COVER: Hip and
404 Pharmacological treatment of osteoarthritis
of the hip and knee
knee osteoarthritis places Stephen Kennedy, MD, Michael Moran, MBBS
a huge burden on society
because of the disability
associated with it. In Part 1 O P I N I O N S
of this double-issue series,
we explore the pathogene-
sis and nonsurgical man-
agement of OA of the hip
384 Editorials
Patient self-management, David R. Richardson, MD (384); Type 2 diabetes
and knee. In Part 2 (Novem-
ber), we examine the surgi-
in youth, Susan E. Haigh, MD (385)
cal options.

Artwork by Jerry Wong. 386 Personal View
Nosocomial or iatrogenic infections, Jim Battershill, MD (386); Re: Driver
assessment, Robert Shepherd, MD (386); Re: AGM article, Jim Busser, MD
(387); Re: Potential allergic drug reaction from residual antibiotics present
30% in livestock, H.C. George Wong, MD (388)

389 Comment
All in a day’s work (or perhaps a couple of weeks), Ian Gillespie, MD

Cert no. SW-COC-002226
410 Good Guys
Hammy and Hector, Sterling Haynes, MD

ECO-AUDIT:
Environmental benefits of using recycled paper
Using recycled paper made with post-
426 Back Page
Proust questionnaire: Ari Giligson, MD
consumer waste and bleached without the use
of chlorine or chlorine compounds results in
measurable environmental benefits. We are
pleased to report the following savings.
1399 pounds of post-consumer waste used
instead of virgin fibre saves:
• 8 trees
• 760 pounds of solid waste
• 837 gallons of water Enter to Win an iPad from
• 1091 kilowatt hours of electricity (equivalent:
1.4 months of electric power required by the
average home)
• 1382 pounds of greenhouse gases (equivalent: www.bcmj.org
1119 miles traveled in the average car)
• 6 pounds of HAPs, VOCs, and AOX combined
• 2 cubic yards of landfill space

382 BC MEDICAL JOURNAL VOL. 52 NO. 8, OCTOBER 2010 www.bcmj.org

contents
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D E P A R T M E N T S

390 Recently Deceased Physicians

391 WorkSafeBC
Research team explores new bone and tendon-related treatments
EDITOR
David R. Richardson, MD Kukuh Noertjojo, MD, Craig Martin, MD

EDITORIAL BOARD
David B. Chapman, MBChB
Brian Day, MB 411 Council on Health Promotion
Health Canada allows 10 000 unproven remedies onto shelves
Susan E. Haigh, MD
Lindsay M. Lawson, MD Lloyd Oppel, MD
Timothy C. Rowe, MB
Cynthia Verchere, MD

EDITOR EMERITUS
Willem R. Vroom, MD
412 Guidelines for Authors

MANAGING EDITOR
Jay Draper
413 BC Centre for Disease Control
Screening renal failure patients for tuberculosis
PRODUCTION COORDINATOR James Johnston, MD, Kevin Elwood, MB
Kashmira Suraliwalla

EDITORIAL ASSISTANT
Tara Lyon 414 Pulsimeter
Stephen Lewis AIDS Foundation AfriGrand Caravan (414)
COPY EDITOR
Barbara Tomlin
MWIA conference, Pamela Verma, BSc, Kristin DeGirolamo, BSc Pharm (414)
Call for nominations: BCMA and CMA special awards (415)
PROOFREADER
Ruth Wilson Core-Plus Plan reminder (416)
COVER CONCEPT & ART
Peaceful Warrior Arts
416 Advertiser Index
DESIGN AND PRODUCTION
Olive Design Inc.

PRINTING
417 Calendar

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www.bcmj.org VOL. 52 NO. 8, OCTOBER 2010 BC MEDICAL JOURNAL 383

editorials

Patient self-management

recently attended a patient self- for your health and I am concerned

I management seminar. The idea is
to involve patients in their own
care, thereby increasing the chance
about you.”) Next, I got Bob thinking
about the issue while encouraging him
to be an active part of the solution.
I wanted to tell Bob
that they will actually make appropri- “Bob, there are two basic factors that he was the only
ate lifestyle changes. After complet- involved in weight control. Do you living creature on the
ing the course, filled with religious know what they are?”
self-management fervor, I was unleash- “No.” planet capable of
ed upon my unsuspecting patients. I was taken aback, but sometimes creating mass . . .
I found the most applicable issue more groundwork is required. “Well,
in my practice to be weight control, so Bob, the two factors are how many
when faced with an obese middle- calories you consume—diet—and
aged man I launched into action. First how many you burn off—exercise.”
I established rapport. “Bob, you are Now it was time to give control back ing, is there any other type of exercise
really fat and are going to die.” (I actu- to the patient. “Which of these would you like?”
ally started with, “Bob, there is lots of you like to talk about?” “I love to exercise.”
evidence that being overweight is bad “We can talk about diet but I don’t “I notice you live by the pool. How
eat anything.” about swimming?”
“Bob, you’re 5'9" and 300 pounds “I don’t like to get wet.”
but you don’t eat anything?” “There’s a gym at the pool, how
“That’s right Doc. You would be about using the stationary bike?”
surprised by how little I eat and what “My thighs rub.”
I do eat is all healthy.” “Elliptical trainer?”
I think Bob and I would both be “I get dizzy.”
surprised by what he eats. If the patient “Rowing machine?”
isn’t ready to talk reasonably about “I don’t like the sound they make,
one item then it’s probably better to it creeps me out.”
try a different approach, “Well, Bob, In the seminar they did say that
since your diet is so good how about sometimes you have to accept that some
we talk about your activity level?” patients just aren’t ready to change.
“I walk everywhere.” However, I have a problem with this
“Everywhere?” whole self-management thing. It feels
“Yes, everywhere.” a little like babysitting. Who doesn’t
“So let’s get this straight. You know that being overweight isn’t good
don’t eat anything and walk every- for you? Have any of you ever had a
where but continue to gain weight?” I conversation with a patient like this?
wanted to tell Bob that he was the only “Hey Bob, probably no one ever told
living creature on the planet capable you this before but being overweight
of creating mass and that I wanted to is bad for you.”
study him in the lab, but I remember “Really, you’re kidding. Shut the
the kind people at the seminar stating front door! Bad for you? I’ve been see-
that ridicule isn’t an effective self- ing doctors for years and you’re the
management technique. “Well, Bob, first one to tell me. Well, if it’s bad for
if you can’t improve your diet and me then I’ll lose weight and take bet-
you’re already walking everywhere, ter care of myself. Thanks Doc.”
the only solution is to increase your Another life saved.
activity a little more. Other than walk- —DRR


editorials

Type 2 diabetes in youth
ntil recently, type 2 diabetes today’s children will become the first ing the importance of preventing obe-

U mellitus was almost unheard
of in children, but over the
past few years there has been a signif-
generation in some time to potentially
have a shorter life expectancy than
their parents!
sity and promoting health. It was esta-
blished in 2005 as a cross-government
health promotion initiative and their
icant increase in incidence of this con- Currently, the economic costs re- mandate involved achieving five goals
dition in children and adolescents. It lated to obesity and its consequences by 2010. Three of these related to
has occurred too rapidly to be solely are not insignificant but relatively healthier food and exercise habits and
attributable to genetic predisposition, small. Without effective intervention, resulted in new guidelines for food
indicating that environmental factors though, they may well become stag- and beverage sales in public schools
are likely to play a key role in its devel- gering in the future. in BC. These were developed with
opment. Preventing childhood obesity in registered dietitians and implemented
The hallmark of type 2 diabetes is the first place is obviously the goal in 2008. New recommendations for
insulin resistance and the most com- and comes down to a need for com- physical activity in schools were also
mon cause of this is overweight and prehensive changes in dietary and introduced in 2008. Their web sites
obesity (overweight is defined by a lifestyle habits. This is a very complex and links for parents and families try-
body mass index of 25 to 29.9 or waist issue and intervention must take place ing to adopt a healthier lifestyle are
circumference of > 80 cm in females at a number of levels—the family, excellent tools.
and > 94 cm in males and obesity as a schools and community, the food and There is promise that we can begin
BMI > 30 or waist circumference of entertainment industry, policymakers, to stem the tide of childhood obesity,
> 88 cm in females and > 102 cm in and government agencies. but it will take a massive shift in our
males). About 50% of the Canadian The fast food industry in particu- current habits. Little steps can start at
population is overweight or obese. lar needs to get on side and make rad- home!
The proportion of obese children has ical changes. For the most part, unfor- —SEH
almost tripled in the last 25 years in tunately, they offer “bad” foods. Bad
both females and males in all age foods are cheap, heavily promoted,
groups except preschoolers. Children and engineered to taste good. They are Liquid Nitrogen
of obese parents have a 66% risk of loaded with calories, sugars or refined for Medical Use
being obese before adulthood. It is carbohydrate, fat, and salt. Portion Westgen has been providing Liquid Nitrogen
estimated that 26% of Canadians age sizes have exploded. “Supersized” to doctors for the past 10 years. We have
2 to 17 (more than 1 in 4) are over- portions of fries, burgers, and pop established a reputation for prompt, quality
weight or obese, up from 15% in 1978. are typically two to five times larger service at a reasonable price.
We also offer MVE Cryogenic Refrigera-
Ninety-five percent of children with than when first introduced. Some fast
tors in 10 and 20 litre sizes. These can be
type 2 diabetes are obese. food chains have introduced healthier acquired on a one year LEASE TO OWN
With the seemingly unabated in- meals, but they are generally more option, a system that allows you to own your
crease in prevalence of obesity, type 2 expensive than the standard burger tank after a year of low monthly payments
diabetes in youth is emerging as a seri- and fries. which includes free liquid nitrogen for the
ous public health concern. It is associ- Regular physical activity is key to lease period.
ated with increases in morbidity and achieving and maintaining a healthy MVE Cryogenic
mortality from both microvascular weight. It’s recommended that chil- Refrigerators
and macrovascular disease, and we dren get at least 60 minutes of physi- • No Stop Charge
are now seeing these complications, cal activity daily, and sadly this is • No Cartage Fees
• No Dangerous
particularly coronary artery disease, often not achieved. Goods Handling
appearing in young adults. This child- On a positive note, the ActNowBC Charges
hood obesity epidemic means that initiative has led the way in recogniz- • Lease to own
option
Service provided to practitioners on Vancouver
Island, Lower Mainland and Okanagan area.
For more information contact Westgen at:
1-800-563-5603 Ext. 150 or 778-549-2761


personal view

“wash your hands in front of each
Letters for Personal View are welcomed. patient before examining them.” Also
They should be double-spaced and less “get offices on the main floor so older
than 300 words. The BCMJ reserves the
patients are considered.” Many of our
right to edit letters for clarity and length.
teachers had seen the 1918 influenza
Letters may be e-mailed (journal@bcma
.bc.ca), faxed (604 638-2917), or sent
epidemic and were still scared stiff of it.
through the post. I fully realize that the world moves
on, but perhaps we should look back
once in a while at what we are leaving
Nosocomial or behind.
iatrogenic infections For example, we all had a small —Jim Battershill, MD, FRCPC
booklet called The Control of Com- North Vancouver
ne hears frequently through the municable Disease, which listed meas-

O press about nosocomial (hos-
pital) or iatrogenic (doctor-
induced) diseases these days. I find
ures for the practitioner such as immu-
nization, placarding, or isolation.
Surgical infection (it used to be called
Re: Driver
assessment
this frustrating because when I entered “surgical scarlet fever”) was a cause doctor who never examines
medicine in 1946 the antibiotic era
was just beginning and we were still
indoctrinated in the older measures
for horror and embarrassment by all
the staff of the hospital.
One of my fondest memories is of
A his or her patients is doing a
poor job. The Office of the
Superintendent of Motor Vehicles
for disease control. One wonders if practical advice such as “the first thing (OSMV) tests young drivers repeat-
some may have been abandoned too the patient does when he/she enters edly. The OSMV does not test older
quickly. the office is to look to your hands” and drivers. Dr Jensen wrote, “The physi-

The EMR for BC Specialists
7% of General Surgeons
7% of Internists
8% of Dermatologists
Implement Accuro®EMR 8% of Neurosurgeons
9% of Otolaryngologists
Alternative Specialist Funding Program 10% of Neurologists
13% of Surgical Specialists
13% of Urologists
13% of Ophthalmologists
Accuro® EMR will enable physicians to meet the 19% of Endocrinologists
21% of Thoracic Surgeons
22% of Obstetricians & Gynecologists
25% of Orthopaedic Surgeons
Alternative Specialist Funding Program (ASFP) 29% of Plastic Surgeons
of $5,000 one-time and $250/month 35% of Gastroenterologists
42% of Nephrologists

info@optimedsoftware.com 1-866-454-4681 * percentage of BC Specialists
www.optimedsoftware.com for Accuro® Demonstration using Accuro®EMR


personal view

cian has no authority to have the dri- plaining about the doctor who took ers, the driver’s medical examination,
ver’s licence cancelled. The decision away his driver’s licence. He almost destroys the trust between patient and
to… deny a licence to operate a motor never comes to see me, so I cannot doctor. The OSMV should require
vehicle rests solely with OSMV” examine him. older drivers to have their vision
[“Driver assessment and the duty to On the OSMV “Driver’s medical checked by an optometrist by the auto-
report.” BCMJ 2010;52:122]. examination” is a request that the doc- mated static perimetry. The OSMV
Patients do not understand this. tor check a box “cognitive impairment should examine older drivers and do a
The only contact older patients have MMSE score.” The Folstein Mini screen of cognitive ability. The only
with the OSMV is a letter requiring Mental Status Examination does not test that assures that a person can drive
them to get a medical exam. As far as evaluate executive function. It is pos- safely is a road test.
the patients are concerned, this exam sible for a person to score well on the —Robert Shepherd, MD
is a routine visit that they happen to MMSE, but have sufficient loss of Victoria
have to pay for. Several patients have executive function that he or she
left my practice because I required should not drive. References
them to have an evaluation at Drive- The OSMV “Driver’s medical 1. Kerr NM, Chew SS, Eady EK, et al. Diag-
ABLE (www.driveable.com). examination” requires the doctor to nostic accuracy of confrontation visual
One such patient is Mr B., a gen- evaluate visual field. Kerr and col- field tests. Neurology 2010;74:1184-
tleman who enjoyed driving. I used to leagues demonstrated that “most 1190.
look forward to his visits, and he en- confrontation visual field tests were
joyed his visits with me when he insensitive to the identification of Re: AGM article
would tell me about the history books field loss.”1
he had been reading. When I asked The current method by which the he Journal’s feature on the An-
him to go to DriveABLE, he scored
far below normal on “Identification of
driving situations.” Now his wife tells
OSMV evaluates older drivers is inad-
equate to assure safe driving. The cur-
rent method by which the OSMV
T nual General Meeting [BCMJ
2010;52:290-293] hinted at
problems that warrant expansion.
me that he sits around at home com- gathers information about older driv- Continued on page 388

“MCI takes care of everything
without telling me how to
run my practice”. heal thyself.
MCI means freedom:
I remain independent

MCI Medical Clinics Inc.
Toronto – Calgary – Vancouver


personal view

Continued from page 387 spent $375 000 to date in direct costs Re: Potential allergic
While the segue to Zafar Essak and pertaining to Dr Wang. No reference was drug reaction from
Caroline Wang bears no comment, to made to her provision of facts, which
write that their business took “a lot of she clearly wished accessible to mem-
residual antibiotics
time” risks losing the merit of the busi- bers. No mention was made of Past present in livestock
ness inside its treatment. Highly signifi- President Ian Courtice’s appeal to the agree with the concern about anti-
cant to my view were repeated ad homi-
nem objections levied by one director
at Dr Essak. Those objections, later
Board to quickly resolve this matter.
On low attendance, Dr Lloyd Op-
pel asserted that it was the norm for
I biotic use in our livestock ex-
pressed in Dr Bill Mackie’s COHP
column [BCMJ 2010;52:309].
built upon by other directors, were coun- associations everywhere. The BCMJ’s In addition to the problem of
tered by Past President John Turner. managing editor proposed that given antibiotic-resistant organisms, there
I found it was this fruitless antag- the many opportunities for input that is a potential of sensitization from
onism, more than anything else, that people now have (phone, e-mail, reg- the residual antibiotics in the livestock
frustrated remaining attendees. To my ular surveys, elections), the AGM has resulting in subsequent antibiotic
view, the standing rules of our AGMs become obsolete, “a dinosaur on the allergy in patients. There could be a
should provide that the demeanor of brink of extinction.” With all due res- potential cause of chronic urticaria or
any speaker and any items they raise, pect to such opinion holders, the Asso- idiopathic anaphylaxis due to ingestion
once criticized, not be subject to repeat ciation might better take low atten- of the livestock containing the resid-
objection by the same person. Further dance as a failure to convince members ual antibiotics by sensitive patients
objection should have to be levied by that attending matters. This hinges on later on. Research in this area should
some other attendee. whether and how well those in charge be carried out.
It was learnt that the Association show themselves to be open, account- Antibiotic-resistant organisms and
able, and responsive, and to accord potential allergic drug reaction from
regular members a meaningful voice. the residual antibiotics in our live-
The social program, while important, stock should be of great concern to
cannot compensate for the entrenched Health Canada.
business portion that I maintain us to —H.C. George Wong, MD
have evolved. Vancouver
Our recent AGMs return to ques-
tions of transparency, accountability,
and function. I shall have asked the Enter to Win
Board to answer these squarely at its an iPad from
September meeting.
www.bcmj.org
—Jim Busser, MD
BCMA Delegate, District 3

Your forum to advance…
Specialist Issues
Representing
BCMA specialists


comment

All in a day’s work (or perhaps a couple of weeks)
“ o, are you enjoying being short notice because of reporter dead- see more brain injury prevention pro-

S BCMA president? What is it
like?”
To frequent questions such as this,
lines. It can be quiet for several weeks
and then there will be a flurry of act-
ivity all in one day, usually when an
grams and more effective methods of
assessing brain injury in our emer-
gency departments. Regarding the lat-
I would say “fascinating, satisfying, issue grabs the media’s attention. ter, I am working on a pilot project
challenging, and more.” The BCMA Most reporters are respectful, howev- intended to improve the quality and
is a well-integrated group of teams er they do like to polarize the news to consistency of the assessment patients
including the Executive Office, Pro- increase the level of audience interest. receive when they present in BC hospi-
fessional Relations, Policy and Eco- tal emergency departments after trau-
nomics, Negotiations, Communica- matic brain injury. Our small group
tions, Finance, Benefits, and Member Most reporters are has met with interested and knowl-
Services. The work is varied and can respectful, however they edgeable experts, including represen-
change on very short notice. tatives from ICBC, and a second meet-
do like to polarize the
My practice is compressed into 2 ing is forthcoming to discuss a draft
days per week with the remaining time news to increase the assessment flowchart, intake forms,
spent at the BCMA office. My patients level of audience patient information forms, and how to
and my office assistant, Rosemary, ensure good communication with the
interest.
have been very understanding and patient’s family doctor. We will then
supportive of my taking a turn at this decide on the appropriate terms of ref-
leadership. While president-elect, I was invit- erence for any committee work that
Once weekly, I meet with the sen- ed to speak to the BCMA staff. During will be carried forward and report that
ior staff of the BCMA to keep abreast the question period, someone asked if to the Board of Directors.
of Association issues, plus I have other I had a special project to undertake With respect to brain injury pre-
meetings with staff, physician mem- during my presidency. For some time vention, the BCMA’s resolution sup-
bers, government officials, and indi- I have had an interest in the comput- porting a ban on mixed martial arts
viduals from stakeholder organiza- erized assessment of cognitive ability (MMA) fighting in Canada somehow
tions. Responding to e-mail and phone and have noticed that there is a wide came to the attention of a Vancouver
calls usually has to fit in around the variation in findings and that there are newspaper 2 weeks before it was to
other tasks. Media interview requests often long delays in the identification be brought to CMA’s General Council
can bump other plans and are often on of significant impairment. I’d like to Continued on page 390

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By BC physicians, for BC physicians


comment

Continued from page 389 brain injury. All sport has its own inher-
meeting. The story (and subsequent ent risks; however the intent of these
ones) generated a visceral reaction from competitive team sports is very differ- Recently
many MMA fans and a request to meet ent than the intent of MMA, plus these deceased
with an MMA representative. After players are padded and helmeted. And
our meeting, in which he wanted us to even though many sanctioned MMA physicians
withdraw our resolution, all we could fights have a physician ringside, his or he following physicians
agree upon was the common goal that
the incidence of brain injuries must be
reduced.
her presence will not fundamentally
reduce the risk of long-term brain
damage to a fighter, even if the physi-
T have died over the past
9 months; please consid-
er submitting a piece for our
cian does provide other worthwhile “In Memoriam” section in the
The sole intent in an ringside medical care. BCMJ if you knew the deceased
With the passing of this resolution well.
MMA fight is to disable at CMA’s general council meeting by
your opponent, which an 84% majority, it is now up to the Andrews, Dr William John
includes by inducing CMA to advocate for a ban with fed- Baldwin, Dr John Henry
eral legislators. In Canada, under Sec- Bartok, Dr Katalina
a brain injury. tion 83 of the Criminal Code, prize Boxall, Dr Ernest Alfred
fighting is illegal with exceptions made Brunton, Dr Lawrence Jackson
Not surprisingly, there was debate for boxing (which the CMA voted to Chen, Dr Ferdinand
at the BCMA caucus meeting when call for a national ban in 2002) and Chetwynd, Dr John Brian
this resolution was first introduced, events authorized by provincial sports Dudley, Dr John Howard
and even more debate at CMA’s Gen- commissions. MMA itself has been Duffy, Dr John Peter
eral Council when it was presented banned in six provinces and territo- Findlay, Dr Ian Douglas
for discussion. My argument among ries, however Ontario reversed its ban Goh, Dr Anthony Poh Seng
media, physicians, and interest groups in August after strong lobbying. Our Kalyanpur, Dr Vasant Raghav
has always been the concern with the role will be to provide expert opinion Lewis, Dr David John
degree of violence in this sport and the to government about the risks to brain MacDonald, Dr Alan Angus
risk for brain injury. The sole intent in health, if and when government de- Mackenzie, Dr Conrad
an MMA fight is to disable your oppo- cides to consider the Canadian Med- McAdam, Dr Ronald
nent, which includes by inducing a ical Association’s recommendation. McCannel, Dr John Arthur
brain injury. We know that repeated Debating this issue has been chal- McDaniel, Dr Bernard Minshull
brain injuries have long-term debilitat- lenging, eye opening, and at times Milobar, Dr Tony
ing effects. Continuing research also frustrating. But being president of the Penny, Dr Helen Angela
confirms the increased risk of neuro- BCMA means you don’t back down Percheson, Dr Peter Brady
degenerative disease, and at an earlier when the going gets tough. I am proud Pinkerton, Dr Alexander Clyde
age, after repeated concussion. We that I stuck to my principles and per- Puttick, Dr Michael Paul Ernest
would not be doing our job if we sisted in working with those who had Queree, Dr Terence Candlish
didn’t speak up on behalf of the brain objections, and in the end the position Selwood, Dr Michael
health of Canadians. of our caucus was validated by a large Smaill, Dr William Donald
Critics have wondered (somewhat majority of physician delegates at the Thomas, Dr Ifor Mackay
sardonically) why we haven’t also CMA’s annual meeting. Tucker, Dr Frederick Gordon
called for a ban on football, hockey, —Ian Gillespie, MD Van Schie, Dr Lisa
or baseball, as they too have a risk of BCMA President


worksafebc

Research team explores new bone and tendon-related treatments

Platelet-rich plasma offers Shock therapy thought to One cause of shoulder
mixed success in treating ease pain from calcified pain is calcific rotator cuff
tendinopathies supraspinatus tendinopathy
tendinopathy, which occurs
The concept of using growth factors One cause of shoulder pain is calcific
contained in activated platelets to rotator cuff tendinopathy, which occurs in 7% to 17% of rotator
help wound healing dates back to the in 7% to 17% of rotator cuff tendinopa- cuff tendinopathies.
early 1980s. More recently, the use of thies. Extracorporeal shock wave ther-
platelet-rich plasma (PRP) to treat apy (ESWT) has been promoted as an
various musculo skeletal disorders, alternative to surgical intervention in experts have demonstrated a lack of
including tendinopathies, has increas- treating rotator cuff tendinopathy that agreement regarding the diagnosis of
ed tremendously. fails to respond to conventional and fracture nonunions.
Tendon healing is a complex pro- more conservative therapies. While While ultrasound has been applied
cess involving many growth factors, the mechanism is still unclear, this in treating fractures for half a century,
such as platelet-derived, transform- outpatient procedure is thought to pro- its role in fracture healing is not
ing, vascular endothelial, insulin-like, vide long-lasting analgesia and stimu- well understood. In January 2010, the
and epidermal growth factors, which late the healing process. WorkSafeBC Evidence-Based Prac-
are detected in higher concentrations In June 2010, the WorkSafeBC tice Group investigated the effective-
in PRP. To date, the respective role of Evidence-Based Practice Group inves- ness of Exogen low-intensity ultra-
each type of growth factor requires tigated the effectiveness of ESWT, sound in treating fracture nonunion
further exploration. As well, recent using low- and high-level energy shock and found three high-quality system-
evidence suggests varying concentra- waves to treat calcific supraspinatus atic reviews12-14 and one large case
tion levels of these growth factors in or rotator cuff tendinopathy in gener- series (n = 1317)15 that showed as fol-
PRP, depending on the protocol and al. Their findings included two sys- lows:
devices used to spin the blood. tematic reviews, one of high quality6 • No high-level primary studies exist
In April 2010, the WorkSafeBC and one of low quality,7 three low- to provide evidence of the effective-
Evidence-Based Practice Group con- quality RCTs,8-10 and one low-quality ness of low-level ultrasound.
ducted a systematic literature review case-control study.11 This included • Low-level evidence, including large
of the effectiveness of PRP in treat- some high- and low-quality evidence case series, showed that low-level
ing tendinopathies. They found five to suggest high energy ESWT can ultrasound is effective as an adjunct
studies of varying quality and design provide pain relief and increased func- to good immobilization, especially
investigating the application of PRP tion, as measured by the Constant- when provided by an external
in treating chronic patellar tendinosis1 Murley score, among patients suffering immobilizer.
and chronic elbow tendinosis,2 during from calcific rotator cuff tendinopa- • Low-level ultrasound may be effec-
arthroscopic rotator cuff repair,3 dur- thy. There was no evidence on the tive among patients aged 31 to 60
ing Achilles tendon surgery to pro- effectiveness of ESWT in treating with long bone or scaphoid frac-
mote healing,4 and treating Achilles noncalcific rotator cuff tendinopathy. tures; who had comorbid illnesses;
tend ino pathy. 5 Lower-quality and who had been treated with other
lower-level studies 1-4 showed the Low-intensity ultrasound for drugs, such as steroids, NSAIDs,
effectiveness of PRP in treating vari- nonunion fractures appears anticoagulants; or who are current
ous tendinopathies. However, the only effective for some smokers.
available high-quality evidence show- Fracture healing is a complex process Other adjunct treatments, yet to
ed that PRP injection compared to involving various factors that need to be tested for effectiveness, are also
saline injection did not result in sig- occur at a specific time and place. available. These include pulsed elec-
nificant improvement in pain and US data show up to 10% of healing tromagnetic field stimulation, direct
activity.5 These studies could not dis- fractures develop delayed union, current or capacitative coupling, ex-
count the value of co-interventions. and a significant proportion of these tracorporeal shockwave stimulation,
become nonunions. At present, some Continued on page 416


Guest editorial

Osteoarthritis of the hip and
knee, Part 1: Pathogenesis
and nonsurgical management

ease and the journey of patients with evidence behind these modalities.
OA of the hip or knee from diagnosis This article serves not only as a guide
to nonoperative treatment and finally for practitioners, but also as a summa-
to surgical intervention. This first part ry for patients who are considering
in a two-part theme issue on OA of the each of these modalities. The article
hip and knee explores the patholge- demystifies these modalities and
netic mechanisms and several aspects allows the physician and patient to
of nonsurgical management. understand the relative merits of each
In the first article here, Drs Hasan treatment, from footwear and weight
and Shuckett discuss the epidemiolo- loss to the use of canes.
gy of hip and knee OA and factors in In the third article here, Drs Ken-
its genesis. The figures that they in- nedy and Moran continue the discus-
clude about the burden of disease are sion of nonoperative management, but
indeed sobering. The authors discuss this time from the pharmacological
the risk factors for OA, allowing us as point of view. They discuss the role of
Dr B.A. Masri practitioners to potentially change oral medications as well as joint injec-
patients’ behavior at a young age and tions. This sets the stage for their dis-
lessen the likelihood of this disease cussion of the indications for surgical
with aging. They also discuss clinical intervention, and when to consider
steoarthritis (OA) is the presentation and radiographic find- referral to an orthopaedic surgeon.

O most common chronic dis-
ease affecting British Col-
umbians. Family physicians
manage patients with osteoarthritis on
a daily basis using strategies that range
ings, allowing an easier understand-
ing of when to suspect OA in a patient
and when to proceed to a radiographic
review. The authors clearly delineate
the indications for plain radiographs
By focusing on the earlier stages
of OA and considering diagnosis
and nonoperative management, all
the articles in Part 1 of this theme
issue pave the way for the articles in
from reassurance to surgical interven- and MRI. With improved access to Part 2, which will discuss surgical
tion. Large joint OA, as exemplified MRI, we often see patients presenting modalities.
by hip and knee osteoarthritis, places with OA with an MRI as the initial —B.A. Masri, MD, FRCSC
a significant burden on society be- radiographic investigation. The take- Professor and Head,
cause of the disability associated with home message is that an MRI should Department of Orthopaedics
it. Patients affected by OA of the hip be reserved for use when X-rays do University of British Columbia
and knee often require surgical inter- not indicate OA.
vention. Many modalities for nonoperative
With the increasing emphasis on treatment for OA of the hip and knee
joint replacement, it is important to exist. In the second article here, Drs
consider the entire spectrum of dis- Hawkeswood and Reebye discuss the


Manal Hasan, MBBS, MD, Rhonda Shuckett, MD, FRCPC, Diplomate ABIM

Clinical features and patho-
genetic mechanisms of osteo-
arthritis of the hip and knee
Understanding how osteoarthritis develops is critical to treating this
disabling disease.

steoarthritis (OA) is a non- tween X-ray findings and symptoms

O
ABSTRACT: Osteoarthritis is a non-
inflammatory form of arthritis that inflammatory form of arth- of OA.1
accounts for 25% of visits to primary ritis. A common miscon- OA accounts for 25% of visits to
care physicians. When osteoarthritis ception is that OA is due primary care physicians, and 50% of
affects the hip and knee, it can lead solely to wear and tear, since OA is NSAID prescriptions.2 It is estimated
to major disability and compromised typically a disease of persons in the that up to 80% of the population will
quality of life. Diagnosis relies on sixth decade and beyond. “Degenera- have radiographic evidence of OA by
clinical symptoms, physical find- tive arthritis” is often used as a syno- age 65, with 60% of those showing
ings, and radiographic findings. The nym for OA, but OA is not the result of symptoms and thereby having clinical
interplay between mechanical and a bland degenerative process; rather, OA.3 Another study found that by age
systemic factors such as congenital OA involves both degenerative and 70 to 74 years, about 33% of men and
abnormalities, obesity, and malalign- regenerative processes. 40% of women will have OA with
ment may predispose individuals to OA is common and serves as the clinical and X-ray features.4 The life-
osteoarthritis of the hip and knee. main source of chronic joint com- time risk of developing symptomatic
We must identify these factors and plaints in adults. The morbidity con- knee OA is about 45%, rising to 66%
the underlying causes of osteoarth- ferred by OA of the knee and hip in an in obese persons. While there is vari-
ritis if we are to develop more pro- ever-aging population is major. Its ation in these numbers, it is clear that
gressive early interventions for this high prevalence and huge impact on the morbidity and disability conferred
common affliction. quality of life demand that we engage by OA of the hip and knee is enormous
in better understanding of OA by con- and demands our attention.5
sidering diagnostic, epidemiological,
clinical, and radiographic features. An Symptoms and
understanding of how OA is classified physical findings
and OA risk factors is also critical. The main symptoms of OA of the knee
or hip are pain, stiffness, and altered
Diagnosis and function. Initially this tends to be
epidemiology worse with weight bearing and ambu-
The diagnosis of OA relies on clinical lation. Eventually this can progress to
symptoms, physical findings, and
radiographic findings. Not all persons Dr Hasan is a rheumatology fellow in the
who have radiographic OA have clin- Division of Rheumatology at the University
ical disease. Conversely, not all per- of British Columbia, sponsored by the King-
sons who have joint pain demonstrate dom of Saudia Arabia. Dr Shuckett is a clin-
plain radiographic findings of OA. ical associate professor in the Division of
Thus, there is often discordance be- Rheumatology at UBC.


Clinical features and pathogenetic mechanisms of osteoarthritis of the hips and knees

pain day and night once cartilage loss al compartment OA of the knees. Less
leads to bone-on-bone contact. True commonly, patients may present with
hip pain is felt in the groin most com- a valgus or knock-knee deformity,
monly, but can also present in the but- indicative of more advanced disease
tock and often down the anteromedial in the lateral compartment of the knee.
thigh to the knee. Not uncommonly, On occasion, and much less common-
patients may present solely with knee ly, patients may present with isolated
pain when the problem is in the hip. OA in the patellofemoral joint, which
Pain arising from osteoarthritis of the can of itself be very symptomatic.
knee is felt right around the knee joint, In the case of the hip, a true cap-
and unlike pain caused by hip OA, this sular pattern of limitation is found
pain does not typically radiate. with groin or buttock pain (or both)
In contrast to inflammatory arthri- and particular pain with internal rota-
tides such as rheumatoid arthritis, with tion of the hip. Flexion deformity of
their prolonged morning stiffness and the involved hip can be present with
worsened pain in the morning, OA advanced OA. Patients will often walk
Figure 1. Radiograph of osteoarthritis of tends to worsen as the day progresses. with a limp, and a waddling Trende-
the hip showing predominant superolateral The stiffness in OA is termed “inac- lenburg gait may be evident in late
joint space narrowing, subchondral
sclerosis of whitening of the bone adjacent tivity stiffness” and contrasts with stages.
to the joint space, and some marginal the prolonged “morning stiffness” of
osteophytes. rheumatoid arthritis. Inactivity stiff- X-ray findings
ness in osteoarthritic lower limb joints Standard knee X-rays should include
lasts about 5 to 10 minutes and occurs a standing anteroposterior (AP) view
when the patient gets up and bears of both knees, plus lateral views. In
weight after prolonged immobility. patients with suspected posterolateral
On physical examination, a small OA with a mild valgus deformity, a
effusion with a fluid bulge sign can be 30 degree flexed standing posteroan-
present in OA of the knee. Larger effu- terior (PA) view with the beam
sions can occur but are less frequent directed 15 degrees from cephalad to
than in the inflammatory arthropathies. caudad may be valuable in showing
Synovial fluid analysis after aspira- the disease in the posterior aspect of
tion of an OA knee effusion reveals the lateral compartment of the knee.6,7
that the fluid is thick and viscous with In early cases, a standard standing AP
a low synovial white blood cell count, view may appear normal or indicate
most of which are mononuclear cells. very mild OA, whereas the standing
On examination, there may be carti- flexed PA view may show bone-
laginous crepitus or a crackling feel- on-bone contact. Patellofemoral OA
ing on palpation of the knee with mo- of the knee cap is also a common
tion. Eventually there may be coarse finding, best diagnosed on a skyline
bone-on-bone crepitus whereby the X-ray view.
opposing bone ends, denuded of carti- X-rays of the hips to evaluate for
lage, seem to grate against one anoth- OA should include a standing AP
er. There is often a loss of range of pelvis view and frog-leg views of the
motion of the involved knee or hip, suspected hip joint. It is important to
Figure 2. Medial compartment particularly with progression of OA. always order standing X-rays of both
osteoarthritis of the knee with medial Loss of cartilage of the knee can knees in the case of suspected knee
compartment joint space loss.This marked
narrowing is between the medial tibial
lead to malalignment of the leg with a OA and an X-ray of the pelvis and not
plateau and the medial femoral condyle. varus deformity or bow-legged posi- just the affected hip in the case of sus-
The fibula can be seen in its lateral tioning of the leg being evident. This pected hip OA. This will allow for
location.
angulation of the knee applies to medi- comparison between sides and im-



proves the ability to diagnose mild to application. MRI has emerged as an Table 1. Traditional classification of OA
moderate disease. excellent modality for detection of OA
On plain X-ray evaluation, loss of when the plain radiographs indicate Primary osteoarthritis
the radiolucent cartilage, termed joint no disease or mild disease, and the • Idiopathic
space narrowing, is seen in OA. In the patient’s symptoms are out of keeping • Generalized
hip joint the joint space narrowing with the apparent severity of disease. • Erosive
tends to be more in the weight-bearing MRI can detect large focal articular
Secondary osteoarthritis
superolateral aspect of the joint, again cartilage lesions that cannot be detect-
• Due to mechanical incongruity of joint,
highlighting the role of mechanics in ed on plain films.6-8 congenital or acquired (e.g., acetabular
OA ( Figure 1 ). However, there are dysplasia of hip or internal knee
different patterns of OA of the hip, and Classification of OA derangement)
it is possible to get more central wear, Traditionally OA has been classified • Due to prior inflammatory disease (e.g.,
rheumatoid arthritis)
particularly in patients with deep sock- as primary or secondary ( Table 1 ).9
• Due to endocrine disorders (e.g.,
ets or protrusio acetabuli. In the knee, Primary OA denotes generalized or diabetes, acromegaly)
main involvement is often in the medi- erosive OA with no identifiable cause. • Due to metabolic disorders (e.g., calcium
al joint compartment ( Figure 2 ), but Secondary OA denotes OA caused by pyrrophosphate dihydrate crystals,
involvement of other compartments an underlying condition, including hemochromatosis)
or of the entire joint is also common. those caused by inflammatory dis- • Miscellaneous (e.g., avascular necrosis)
On plain X-ray of an osteoarthrit- eases, trauma, and mechanical factors.
Source: Adapted from Brandt KD.9
ic joint, in addition to joint space nar- In a large series of cases of so-
rowing, there tends to be subchondral called primary osteoarthritis of the
sclerosis or an appearance of whiten- hip, some underlying mechanical Table 2. Classification of OA by cause
ing of the subchondral bone. Osteo- developmental variation could be found
A. Abnormal concentrations of force on
phytes, which reflect a regenerative in most cases to account for the onset normal cartilage
process with formation of fibrocarti- of the disease.10 For instance, the sub- • Cartilage surface irregularities (e.g.,
laginous extensions or hooks at the tle presence of a shallow cup of the intra-articular fractures, meniscal tear)
joint margins, are common. Interest- hip, called acetabular dysplasia, is a • Malalignment of the joint (e.g., leg length
ingly, the presence of osteophytes in common precursor to OA of the hip. disparity, acetabular dysplasia,
congenital hip dislocation)
one compartment, such as the lateral In middle-aged men, femoroacetabu-
• Loss of ligamentous stability (e.g.,
compartment in a patient with medial lar impingement (FAI) is thought to anterior cruciate ligament tear)
compartment OA, is not indicative of be the most common cause of OA of • Loss of protective sensory feedback (e.g.,
disease in that compartment. It is sim- the hip. FAI of the pincer type occurs diabetic neuropathy)
ply indicative of the body’s reparative most often in middle-aged women. On • Other causes (e.g., obesity, occupational)
response to the abnormal stresses and occasion, patients may present with
B. Normal concentrations of force on
presence of disease in the medial com- symptoms of impingement prior to abnormal cartilage
partment. the development of advanced OA. It • Pre-existing arthritis (e.g., rheumatoid
The identification of OA on plain thus appears that the term “primary or arthritis)
X-rays means there is already full idiopathic OA” is probably a mis- • Metabolic abnormalities (e.g., crystal
thickness cartilage loss and even nomer as it applies to the hip or knee, arthropathy)
bone-on-bone contact. These radi- and that if we look hard enough an • Genetic (e.g., generalized osteoarthritis
of hands)
ographic findings occur relatively late underlying structural cause will often
in the course of OA. It would be ideal be apparent. C. Normal concentrations of force on
to be able to identify OA before gross In the 1970s Mitchell and Cruess normal cartilage supported by stiffened
subchondral bone
changes are apparent on radiographs. proposed a more pathogenetic classi-
• Paget disease
Earlier OA detection is important in fication of OA ( Table 2 ). This classi-
identifying disease before the pro- fication system assumes that osteo- D. Normal concentrations of force on
gressive bone-on-bone stage. Joint arthritis can arise from an intrinsic normal cartilage supported by weakened
subchondral bone
ultrasound has been applied in studies problem of the cartilage as encoun-
• Avascular necrosis
to identify OA earlier, but this is more tered after years of chronic inflamma-
a research tool than a routine clinical tory arthritis.11 Thus, OA can occur Source: Adapted from Mitchell NS, Cruess RL.11



is gaining increasing recognition as a
major structural precursor to hip OA.
These are usually asymptomatic before
possible progression to OA and can be
seen on a screening AP pelvis radi-
ograph. Such pre-symptomatic X-
rays, however, are not ordered rou-
Subtle and asymptomatic anatomic tinely.
variations have been associated
Genetic factors
with hip osteoarthritis. The strongest association between
genetic factors and OA applies to gen-
eralized osteoarthritis of the hands.
Evidence for a correlation between
genetics and knee or hip OA is less
conclusive.15,16

Physical activity
Although the health of cartilage and
with (A) normal force on abnormal Gender and the other joint tissues requires regular
cartilage. Alternatively, it can occur estrogen connection joint loading, excessive loading may
with (B) abnormal concentrations of Women are more likely than men to contribute to OA. While some studies
force on normal cartilage. This would have OA, be it generalized OA of the suggest a strong positive relationship
implicate mechanical aberrations such hands or OA of the hips and knees.12 between work-related knee bending
as malalignment, the post-meniscecto- The increase in OA in menopausal exposure and knee OA, others have
my knee, or a cruciate deficient knee. women has led to numerous investi- failed to find a direct relationship
The abnormally formed hip mention- gations into the relationship between between the presence of knee OA
ed above would fall into this category hormonal factors and OA. The results and habitual physical activity or rec-
as well. have been conflicting and inconclu- reational running. 17 A relationship
Mitchell and Cruess’s classifica- sive.13,14 Clearly, other health issues between heavy manual work, farming
tion system also includes situations are of concern when determining in particular, and hip OA was found in
where there is (C) stiffened subchon- whether hormone replacement thera- different studies, but the association is
dral bone, as in the case of the rare py is to be considered in the post- still considered a weak one.18
Paget disease, which does indeed pre- menopausal patient. Although it makes sense that high
dispose to OA of an involved joint. levels of impact and repeated torsion-
Alternatively, they describe situations Congenital/developmental al loading could increase the risk of
where (D) weakened subchondreal abnormalities articular cartilage degeneration, this
bone, as in avascular necrosis, predis- Local factors that affect the shape of is not borne out consistently in stud-
poses to OA. the joint may increase local stress on ies. Still, it would appear prudent to
cartilage and contribute to the devel- suggest that anyone with a known
Risk factors for OA opment of osteoarthritis, especially in underlying predisposition to OA, such
OA is best viewed as the end result of the hip joint. As already mentioned, as abnormal hip or joint anatomy or
an interplay between local and sys- subtle and asymptomatic anatomic excessive body weight, avoid repeti-
temic factors. Such factors are well variations have been associated with tive impact-loading activities such as
outlined in the classification schema hip osteoarthritis. These include ace- jogging.
of mechanical factors proposed by tabular dysplasia or epiphysiolysis,
Mitchell and Cruess. Several local which are common milder variants of Obesity
systemic factors may be operative in congenital hip dislocation and slipped Every step taken in a normal gait places
predisposing patients to OA of the hip capital femoral epiphysis, respective- about three times an individual’s body
or knee. ly.10 Femoralacetabular impingement weight on lower limb joints. Thus it



should not be surprising that obesity tis. An exception to this is the pres- deformity that will challenge accurate
and high body mass index have long ence of intra-articular fractures, that leg length measurement. It is key to
been recognized as potent risk factors is, fractures that extend though the place the patient’s legs in proper align-
for OA, especially medial compart- joint line. The disruption of the carti- ment. There should be an equal dis-
ment OA of the knee in females. lage and subchondral bone with an tance between the medial malleoli
The Framingham Study found that intra-articular fracture does portend a of the ankles, and the feet should be
women who lost about 5 kg had a 50% heightened risk of OA of the involved centred in a neutral position under the
reduction in the risk of developing joint in future decades. Trauma of corresponding hips. The apparent leg
new symptomatic knee OA.19 Weight- the knees leading to internal knee length is measured from the umbilicus
loss interventions have been shown to derangement such as a mensical or to the medial malleolus on each side.
decrease pain and disability in estab- major ligamentous tear will predis- A discrepancy usually signals a scol-
lished knee OA. The Arthritis, Diet, pose to osteoarthritis. In the case of iosis. The true leg length is measured
and Activity Promotion Trial showed the hip, acetabular labral tears, which from the anterior superior iliac spine
that weight loss combined with exer- can only be seen on MRI combined to the medial malleolus, and a discrep-
cise, but not either weight loss or exer- with an arthrogram, will increase the ancy suggests a true variation between
cise alone, was effective in decreasing risk of future OA of the involved hip the two legs. For a true leg length dis-
pain and improving function in obese joint. An acetabular labral tear is often crepancy of more than 1 cm, a shoe lift
elders who already had symptomatic an indication for hip arthroscopy to or built-up orthotic that adjusts for half
knee OA.20 trim the torn fragment. Hip arthros- of the leg length difference is typical-
When patients ask their physicians copy is not often done for diagnostic ly recommended. For a large discrep-
how they can prevent OA of the knees, purposes because MRI is so effective ancy this may not be readily attainable.
weight control is paramount. Unfortu- at picking up lesions. Varus deformities, valgus deform-
nately weight loss is challenging in It is thought that blunt trauma such ities, and cruciate ligament tears are
established OA of the knee due to the as contact with a dashboard in a motor other factors that can predispose to the
limited physical activity possible. vehicle accident can lead to patello- development and progression of knee
The relationship between excess femoral syndrome and chondromala- OA. Detailed discussion of such fac-
weight and hip OA is less clear. The cia patella. However, whether these tors is beyond the scope of this article.
evidence in hip OA is not as compel- pre-OA lesions will progress in future Like the medial compartment and
ling as with knee OA.21,22 decades to full thickness confluent the lateral compartment, the patello-
In addition, there is evidence that cartilage loss signifying OA has not femoral compartment of the knee is
obesity predisposes to osteoarthritis been determined. often afflicted with OA. While injury
in non-weight-bearing joints such as is a common factor in medial and lat-
the joints of the hand. Clearly excess Alignment, including leg length eral compartment OA, malalignment
weight in a biomechanical sense alone Strong evidence suggests that altered is a more common factor in patel-
does not explain this finding. Recent mechanics play a role in OA incidence lafemoral OA. Most cases of chon-
studies have shown that body fat, par- and progression, and recent studies dromalacia patella that result from
ticularly central fat deposits, are bio- are beginning to isolate specific malalignment are nonprogressive, but
chemically active and produce sub- mechanical factors that may be of par- some can progress to OA.24
stances such as leptin and adiponectin.23 ticular importance. Such alignment
It has also been shown that leptin can problems include a leg length discrep- Conclusions
induce the formation of cytokines, ancy of more than 1 cm, which con- OA of the hip and knee is a major
such as interleukin-6, which can have fers an increased risk of OA of the hip health care issue in an ever-aging pop-
a deleterious effect on chondrocytes on the long leg side. All patients ulation. OA of weight-bearing joints
of the cartilage. should be assessed for this. confers major disability and compro-
Leg length measurements include mised quality of life. At this time,
Trauma the apparent and the true leg length. medical treatment of OA is not as
In general, there is a paucity of good To measure leg length, you should sophisticated as the treatment of
documentation to support the con- have the patient lie flat on his or her rheumatoid arthritis. All too often we
tention that blunt trauma to a joint back on the examining table and en- fail with conservative treatment, and
increases the risk of future osteoarthri- sure that there is no hip or knee flexion patients with hip and knee OA progress


British Columbia Medical Journal, October 2010 issue: Full Issue

British Columbia Medical Journal, October 2010 issue: Full Issue

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British Columbia Medical Journal, October 2010 issue: Full Issue