The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 91, Issue 9

The Orthopaedic Forum | September 01, 2009

Orthopaedics in 2020: Predictors of Musculoskeletal Need*

Michael J. Dunbar, MD, FRCSC, PhD¹; Andrew Howard, MD, FRCSC, MSc²; Earl R. Bogoch, MD, FRCSC³; Javad Parvizi, MD, FRCS⁴; Hans J. Kreder, MD⁵

¹ Halifax Infirmary Hospital, 1796 Summer Street, Suite 4822, Halifax, NS B3H 3A7, Canada. E-mail address for M.J. Dunbar: Michael.dunbar@dal.ca
² Hospital for Sick Children, Room S-107, 555 University Avenue, Toronto, ON M5G 1X8, Canada
³ St. Michael's Hospital, Suite 800, 55 Queen Street East, Toronto, ON M5C 1R6, Canada
⁴ Department of Surgery, The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107
⁵ Division of Orthopaedic Surgery, Sunnybrook Health Sciences Centre, 2075 Bayview Avenue—MG 365, Toronto, ON M4N 3M5, Canada

View Disclosures and Other Information

This report is based on a symposium presented at the Combined Meeting of the American Orthopaedic Association (AOA) and the Canadian Orthopaedic Association (COA) on June 5, 2008, in Quebec City, Quebec, Canada.

Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Proctor and Gamble Pharmaceuticals Incorporated and Merck Frosst Canada Incorporated. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.

J Bone Joint Surg Am, 2009 Sep 01;91(9):2276-2286. doi: 10.2106/JBJS.H.01521

5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Article

Comments (0)

text A A A

Extract

Although the year 2020 is just over a decade away, changes in population demographics as well as advancements in knowledge, techniques, and treatments will likely lead to substantial changes in the delivery of orthopaedic care. One specific driver of the projected change is the fact that the North American population is aging. Projections show that, by 2020, 16.3% of the U.S. population and approximately 25% of the Canadian population will be sixty-five years of age or older, double the current number^1,2. This has led to projections for an increased incidence and prevalence of age-related musculoskeletal conditions, such as fragility fractures and osteoarthritis^3-8. Concurrent with the projections showing an increased need for orthopaedic services in 2020 is a projection showing a decreased number of full-time-equivalent orthopaedic surgeons, mostly due to retirement⁹.

Figures in this Article

Introduction

In light of these factors, a symposium was held, in June 2008, at the Combined Annual Meeting of the American Orthopaedic Association and the Canadian Orthopaedic Association in Quebec City to discuss the implications of an aging population and workforce, as well as changing disease patterns and treatment options, on core orthopaedic services in the year 2020. This article is a summary of that symposium and covers four specific aspects of orthopaedics in 2020: (1) pediatric orthopaedics, (2) fragility fractures, (3) hip and knee replacement surgery, and (4) care models for the delivery of orthopaedic services.

Pediatric Orthopaedics in 2020

Demographic Changes

The projected population of children in North America over the next ten to twenty years is expected to remain relatively constant. However, the family circumstances of these children will change considerably^3,4. More children will be single children, and their family trees will be vertical rather than horizontal, with many older relatives, fewer or no siblings, and fewer cousins (because their parents have fewer or no siblings). The number of children globally will continue to grow³.

Changes in national population demographics related to immigration can have an effect on pediatric musculoskeletal conditions. This has been experienced in Scandinavia, where an increase in the prevalence of clubfoot has been postulated to be related to progressive immigration policies^10,11. Continued shifts in population demographics through immigration can be expected to have continued effects on disease incidence and prevalence.

Disease Prevalence

Some pediatric conditions that were important in the past have virtually disappeared because of biological innovations. The poliovirus vaccine has eliminated the need for an entire area of traditional pediatric orthopaedics. Other infectious diseases, such as osteomyelitis, are much less prevalent because of improvements in nutrition, earlier presentation, and some effects of vaccination, such as the disappearance of Haemophilus influenzae-related septic arthritis and osteomyelitis in Canada¹². Myelomeningocele has become considerably less common as a birth defect because of the combined effects of public health measures (folate supplementation in grains) and routine ultrasound screening of pregnancies that lead to increased elective terminations for fetuses with major malformations¹³ (Table I).

View Larger

TABLE I Examples of the Expected Change in the Incidence and/or Prevalence of Pediatric Musculoskeletal Conditions in 2020

Decrease	Unchanged	Increase
Osteomyelitis	Clubfoot	Blount disease
Septic arthritis	Scoliosis	Slipped capital femoral epiphysis
Myelomeningocele	Cerebral palsy
	Developmental dysplasia of the hip

Add to My JBJS

TABLE I Examples of the Expected Change in the Incidence and/or Prevalence of Pediatric Musculoskeletal Conditions in 2020

Decrease	Unchanged	Increase
Osteomyelitis	Clubfoot	Blount disease
Septic arthritis	Scoliosis	Slipped capital femoral epiphysis
Myelomeningocele	Cerebral palsy
	Developmental dysplasia of the hip

Other pediatric musculoskeletal conditions have had a relatively constant prevalence. Developmental hip dysplasia, scoliosis, and cerebral palsy are large categories of childhood diseases that have remained constant in the recent past and seem likely to continue with a similar prevalence for the foreseeable future (Table I). In addition, clubfoot, despite an increased prevalence in Scandinavia, has otherwise remained relatively unchanged.

Some pediatric conditions are expected to increase. Obesity is the most noticeable example, and it is likely that the conditions for which obesity is a known risk factor will increase. These include Blount disease in infants and adolescents and slipped capital femoral epiphysis in adolescents¹⁴ (Table I).

Trauma is an important cause of morbidity and mortality in children. The public health and preventive response to trauma could be stronger as injury from motor-vehicle accidents is the leading cause of death of children in Canada¹⁵. Although the past several decades have shown a consistent decrease in deaths from motor-vehicle accidents across all age groups, the data for 2005 demonstrated an increase again—mostly as a result of alcohol-related single-vehicle accidents. Children are the least well-protected age group among North American passengers, particularly those between four and eight years old for whom the rate of booster-seat use is very low. While there are promising interventions and a track record of success, continued efforts are necessary.

Disease Treatment

Recently, there has been considerable progress, and success, in the nonoperative management of pediatric musculoskeletal diseases. Most children with developmental hip dysplasia in 2008 were managed nonoperatively. Ultrasound diagnosis and Pavlik harness treatment are the standard of care, and the success rate for the Pavlik harness is >95%^16-18. Ponseti management of clubfoot has meant that the rate of primary operative treatment for clubfoot has decreased from >80% to <5%¹⁹. Importantly, the results seem to be at least as good, but perhaps substantially better, than surgery in terms of both the risk of recurrence and the function and comfort of the foot.

Steroid management for Duchenne muscular dystrophy has been so successful in delaying the onset of muscle weakness that the spine can now grow without collapsing into scoliosis²⁰. A drastic reduction in the need for operative management with a corresponding improvement in quality of life has been the result.

Idiopathic scoliosis has been much more challenging. Nonoperative treatment, while a mainstay of management for years, has not been successful in preventing progression to surgery. A convincing biological key to this disease is lacking, but attempts to understand the etiology and natural history of the condition may lead to breakthroughs. Scoliosis remains perhaps the last common musculoskeletal condition for which the standard of care is an arthrodesis.

In trauma, disease treatment trends are solidly toward increasing operative intervention. Traction for the treatment of femoral fractures in children has almost disappeared from North American practice, and it has few remaining indications. Devices specific to pediatric patients allow for better fixation, smaller incisions, earlier mobilization, and quicker functional recovery following many childhood fractures. Similarly, pediatric sports medicine is rapidly growing as a subspecialty field. Thoughtful outcomes research in these fields is required as demand is not always synonymous with appropriateness^21-23. The appropriate rates for operative interventions in pediatric trauma and sports medicine have yet to be determined.

Pediatric orthopaedic trauma surgery has, by tradition, frequently occurred at night. However, there is evidence that procedures take longer at night and are accompanied by a higher error rate^24-26. There is evidence that most supracondylar fractures can be reduced and fixed the next day, with no negative outcomes on patient results, and the same finding applies for grade-I open fractures^27,28. By 2020, organizational mechanisms in hospitals that allow most fracture care to be performed during regular hours should be in place.

The children being treated now are expected to live well into their eighties and perhaps beyond³. Pediatric orthopaedics has always considered lifelong musculoskeletal health. It is possible that the biggest impact would be to ensure that the current cohort of children attain their genetically determined maximum potential for bone mass and skeletal strength. It is likely that many of them do not, perhaps in large part because of poor nutrition, obesity, lack of exercise, marginal vitamin-D status, and other factors^29,30. If today's children are expected to live long lives, then deficiencies in the acquisition of optimal bone health in childhood will have longer to manifest as adult disease, such as osteoporosis.

Fragility Fractures in 2020

Changing Incidence of Fragility Fractures

When we look back twenty years, there was little effective care for osteoporosis, no proof that prevention of hip fracture was possible, and no accurate and convenient way to measure bone density. Ten years ago, there had been major improvements in these domains, but <20% of Canadian patients with a fragility fracture (i.e., those manifestly at high risk of hip fracture) were receiving appropriate osteoporosis investigation and treatment from any of their health-care providers. It was unusual to see osteoporosis investigation or treatment in Canadian fracture clinics or hospital wards.

In the past ten years, international awareness has grown regarding the need for osteoporosis management in the group at highest risk—the patients with a prevalent (preexisting) fragility fracture—which is the group that we encounter daily as orthopaedists. The evidence that osteoporosis interventions are worthwhile in this group has engaged orthopaedic surgeons around the world, and North American physicians and surgeons have been in the vanguard of this trend^31-35.

There has been tremendous progress in the last twenty years, and today we have glimpses of a future when the hip fracture epidemic is possibly waning in countries with advanced medical systems. Analyses published during the 1990s predicted a fourfold increase in hip fracture rates by 2041 and raised the specter that hospitals filled with fracture patients would have insufficient resources for elective practice^36-39. Newer data have suggested that incidence rates for hip fracture in Canada, Finland, and Denmark have, in contrast, been decreasing since 1997, particularly in women, and despite the growing population of elderly individuals, the absolute number of hip fractures has been leveling off^40-42. In Switzerland, the age-adjusted incidence of hip fracture decreased by 1.4% per year in women (p = 0.021), but remained stable in men⁴³. A new study presented at the European League Against Rheumatism Annual Congress in June 2008 indicated that hospitalization rates for nontraumatic hip fracture in the United States have decreased by almost 50%, from 123.3 per 100,000 population in 1988 to 61.4 in 2005, notwithstanding an increase in all-cause hospitalizations during the same period⁴⁴. The absolute number of hip fractures in the coming years may stabilize rather than diminish, as increases in the size of the older population may balance the decreasing incidence rates.

This decrease has not been seen in all locations. In Germany, between 1995 and 2004, crude incidences of hip fracture per 100,000 increased from 121.2 to 140.9. Age and sex-adjusted annual incidence ratios showed a significant, but only slight, increase (1.01; p < 0.01), compared with higher increases in the past⁴⁵. In Japan, the estimated number of patients with a hip fracture from 1986 to 2006 showed a substantial increase over time for both sexes⁴⁶.

Explanations as to why hip fracture rates seem to be stabilizing or declining in populations served by advanced health-care systems remain speculative. Potential explanations include a healthier elderly population, increased average body weight, improved functionality among elderly women and men, and early diagnosis and treatment of osteoporosis^41,44. There has been an increase in medication use. From 1996 to 2003, prescription of antiresorptive therapy has increased eighteenfold in Canada, and 22% of Canadian women who have an indication for osteoporosis treatment (a hip or wrist fracture at the age of sixty-five years or older) are prescribed bisphosphonates⁴⁰. National guidelines for osteoporosis diagnosis and treatment have been defined and revised. There is an increased awareness around osteoporosis by the public and physicians. Furthermore, there is a new understanding that every low-energy fracture (wrist, ankle, clavicle, or pelvis) may be a fragility fracture, indicative of osteoporosis, thereby broadening our search for osteoporosis in vulnerable patients. There are even indications that high-energy fracture patients admitted to a level-I trauma unit frequently have underlying osteoporosis⁴⁷.

The available options for safe and effective treatment of osteoporosis following a fragility fracture are increasing. For example, in the HORIZON (Health Outcomes and Reduced Incidence with Zoledronic Acid Once Yearly Pivotal Fracture Trial) randomized trial, yearly intravenous administration of the bisphosphonate, zoledronic acid, within ninety days following hip fracture surgery was associated with a reduced relative risk of a new clinical fracture and reduced mortality from all causes compared with placebo⁴⁸. A once-yearly infusion of zoledronate largely overcomes issues of patient compliance with oral bisphosphonates⁴⁹. Strontium ranelate has dual effects on bone remodeling, both increasing bone formation and decreasing bone resorption. Over five years, daily administration of strontium ranelate reduced the relative risk for all nonvertebral fractures by 15% and the relative risk for hip fracture by 43%⁵⁰. Denosumab is the first of a new class of biological agents, which act as RANK (receptor activator of nuclear factor-?B)-ligand inhibitors. Subcutaneous denosumab, administered every three months (30 mg) or six months (60 mg), has been demonstrated to increase bone mineral density at the lumbar spine at twenty-four months, with no difference in adverse effects compared with oral bisphosphonates⁵¹.

Identifying Patients at Risk

In the orthopaedic environment, we are becoming better at identifying patients with osteoporosis after the first fragility fracture. In the first studies in the late 1990s, <20% of patients presenting with a fragility fracture were already receiving osteoporosis care^52-54. Currently, at the fracture clinic in an urban teaching hospital, 33% of patients presenting with a fragility fracture had been previously diagnosed and were receiving osteoporosis care⁵⁵. In the Ontario Osteoporosis Strategy province-wide fracture clinic program, the number of patients with a fragility fracture who were already being treated for osteoporosis was also >30%, and, in a nearby regional community, Peterborough, this rate exceeded 32%⁵⁶. In other jurisdictions, reported rates of patients presenting with fragility fracture who were already receiving osteoporosis care remained somewhat lower, with approximately 26% in Australia⁵⁷ and <22% in the United Kingdom^58,59 and the United States^60,61.

There is a society-wide change in the management of osteoporosis risk in patients with a fragility fracture. Several initiatives have been introduced in Canada to improve the rates of osteoporosis diagnosis and treatment^34,62-65. In the United States, the American Orthopaedic Association launched "Own the Bone," a postfracture osteoporosis care program, whereby patient information is entered into an interactive web-based quality-improvement registry, which generates patient-specific indications for care and customized patient education materials, and sends a personalized electronic letter to the family physician⁶⁶. In southern California, a multifaceted osteoporosis management program includes targeting patients for bone-mineral-density testing and a postfracture osteoporosis treatment program, a fall-reduction program, and a home health (safety) program⁶⁷. There are numerous other examples.

Orthopaedic surgeons have stated that they are prepared to deal with osteoporosis³². But screening programs are finding that there can be a gap between what orthopaedists are willing to do and what is actually being done, as broad implementation is challenging. Efforts are underway to find the right model(s) for postfracture osteoporosis care. A current literature search identified more than forty studies of postfracture models of osteoporosis care; half of these had been published in 2006 or later. Bone mineral density is a powerful motivator for the initiation of osteoporosis treatment, both for the family physician and for the patient. Patients with osteopenia or osteoporosis who are aware of and understand their bone-mineral-density results are more likely to be treated with osteoporosis medications and adhere to treatment than are the patients who do not know their bone-mineral-density results^60,68-70.

The Changing Incidence of Arthroplasty and the Burden of Revision in 2020

There has been a considerable change in the demographics of the population around the world. Major trends, such as the increase in life expectancy, the rising number of elderly patients, and epidemics of obesity, will continue to place an immense economic burden on health-care resources in general and total joint arthroplasty in particular.

Life Expectancy

According to statistics from the World Health Organization, there has been a steady increase in life expectancy over the last decade⁷¹. Currently, life expectancy in North America is 75.9 years for men and eighty-one years for women. People are living nearly twice as long today as they lived in the year 1900, when life expectancy was 47.3 years. The most profound trend has been the disproportionate increase in the number of elderly patients. For example, the number of octogenarians rose 274% between 1960 and 1994, with three million (1%) of the population in 1994 who were eighty years of age or older. This trend will continue. It is expected that, by the year 2050, 5% of the population will be octogenarians or older. In fact, people who are eighty-five years of age and older are the most rapidly growing elderly age group in the population.

Life expectancy is germane to joint replacement surgery as the prevalence of osteoarthritis of the hip and knee is related to aging^72-74. That is, the older a population is, the greater the prevalence of osteoarthritis.

Problem of Obesity

Obesity is an epidemic in North America. According to recent statistics, there has been a marked and sustained increase in the number of obese people in North America^75,76. Further, a disproportionate number of obese patients have been seen to require joint arthroplasty, confirming an association between obesity and the development of arthritis. In 2005, 24% of the general population in the United States was obese (defined as a body mass index of >25 kg/m²), whereas 52.1% of arthroplasty patients were obese⁷⁷. Data released from the Canadian Joint Replacement Registry indicated that, in Canada in 2004-2005, 87% of all patients receiving total knee arthroplasty and 74% of patients receiving total hip replacement were obese or overweight⁷⁸. Additional studies from the registry data have indicated that a morbidly obese individual is thirty-three times more likely to require a total knee replacement than is a patient with a normal body mass index⁷⁸. The sheer increase in the number of obese patients and the proven association between a higher prevalence of complications and obesity is likely to place a huge burden on the health-care system in the future. It has been demonstrated that obese people incur higher health-care costs at a given point in time. Increases in obesity prevalence alone have been shown to account for 12% of the growth in health-care spending in the United States⁷⁹.

Need for Total Joint Arthroplasty

Total joint arthroplasty continues to confer immense benefits upon patients with joint disease, and it is considered as one of the most cost-effective surgical procedures. Due to its success and the change in the demographics of the patient population, demand for the procedure is on the rise. Projections based on data from the Nationwide Inpatient Sample and other sources suggest that the number of total hip arthroplasties being performed will continue to increase steadily, reaching around 500,000 per year in the United States by 2030⁸⁰. The demand for total knee arthroplasty, on the other hand, will be much more pronounced. An increasingly large number of total knee arthroplasties are being performed in young patients, particularly women. This has been strikingly demonstrated in data from the Canadian Joint Replacement Registry that showed an increase of >300% in the incidence of total knee arthroplasty over a seven-year period in women forty-five to fifty-four years of age⁵. On the other end of the spectrum is a less dramatic but still impressive increase of >100% in the incidence of total knee replacement in patients more than eighty-five years old over the same time period.

The spike in the number of obese young patients receiving a joint replacement necessitates the consideration of the appropriateness or need for surgery. Appropriate rates for hip and knee arthroplasty have not been well defined.

Burden of Revision

With the rise in the number of primary arthroplasties being performed, particularly in young and obese patients, and the increase in life expectancy, more patients will outlive their prosthesis. The number of revision arthroplasties has already increased 79% over the last decade alone⁸¹. Currently, the failure rate of total hip arthroplasty is 16.9% per year in patients over the age of sixty-five years⁸¹. However, the cumulative revision rates for hip and knee arthroplasties increase with younger age⁸². This is problematic given the increased prevalence of joint replacement in young patients in North America. While it is possible that new joint replacement technology will be beneficial in reducing the revision burden, the empirical data for this are still lacking.

Although the majority of the primary arthroplasties are performed by low-volume surgeons, with >80% of the joint replacements being performed by surgeons doing less than twenty per year⁸³, the burden of revision is largely borne by academic institutions, somewhat by necessity given the complexity of the cases. Associated with this is an increased cost to the institution—a financial situation that has not been satisfactorily resolved with respect to remuneration. This will likely be an escalating problem into the year 2020.

Most importantly, revision creates a major burden for the patients. Satisfaction rates for revision knee arthroplasty have been shown to be significantly lower than those for primary arthroplasty⁸⁴.

Burden of Infection

The prevalence of infection following joint arthroplasty remains around 1% to 4%⁸⁵. Although this is a substantial reduction compared with higher rates that were seen during the early era of arthroplasty, the social and economic burden associated with periprosthetic infection is immense. Studies have also suggested that the prevalence of prosthetic joint infections may be on the rise, particularly those caused by resistant organisms such as methicillin-resistant Staphylococcus aureus. Although the prevalence of infection is likely to be less in high-volume centers, a disproportionately larger number of infections following arthroplasty are treated at academic high-volume centers⁸⁵. On the basis of the projections of the National Inpatient Survey data, the relative cost of treatment for such infections is 1.4-fold higher and the length of hospital stay is 1.7-fold longer than that of patients who have a revision without development of a periprosthetic infection⁸⁰. Satisfaction rates for patients undergoing revision total knee arthroplasty for infection are <50%, an undeniably dismal number⁸⁴.

Care Models for the Delivery of Orthopaedic Services in 2020

It is essential to ensure that an appropriate supply of orthopaedic practitioners will be available to meet the population demand for care in the future. Unfortunately, there are no accurate data regarding the capacity of the current orthopaedic workforce supply, and there is no consistent way of defining current population need, let alone accurate models of predicting how these variables might change in the future^86-88. Difficulties in forecasting supply relate to the lack of data regarding (1) the practice profiles and distribution of specialists and subspecialists; (2) the integration and scope of practice of other health-care professionals, such as osteopaths, chiropractors, physician assistants, advanced practice therapists, and nurses; and (3) the availability of resources, such as technology and operating-room access, a lack of which has been shown to limit the efficiency of the orthopaedic workforce^9,89,90. Numerous factors may affect the future efficiency and capacity of the orthopaedic surgical workforce, leading to modeling errors and uncertainty (Table II).

View Larger

TABLE II Supply Uncertainty and Workforce Capacity Issues

Decreased Capacity	Increased Capacity
• Aging workforce	• New models of care and/or care teams (offloading orthopaedic surgical capacity)
• Practice lifestyle changes for new surgeons (including more women)	• New technology (with improved efficiency)
• Lack of resources (operating room time, technology, and personnel)	• More resources (operating room time, technology, and personnel)
• Workforce emigration	• Workforce immigration

Add to My JBJS

TABLE II Supply Uncertainty and Workforce Capacity Issues

Decreased Capacity	Increased Capacity
• Aging workforce	• New models of care and/or care teams (offloading orthopaedic surgical capacity)
• Practice lifestyle changes for new surgeons (including more women)	• New technology (with improved efficiency)
• Lack of resources (operating room time, technology, and personnel)	• More resources (operating room time, technology, and personnel)
• Workforce emigration	• Workforce immigration

In addition to the orthopaedic surgeon, traditional delivery of orthopaedic care requires collaboration with other health-care practitioners and physical resources, such as offices, beds, operating rooms, and equipment, which are all organized into a health-care delivery system that allows the patient who is seeking care to interact with the appropriate practitioner who will deliver it. Although the role of orthopaedic surgeons is changing in the context of this system, the simplistic conventional view might consider the surgeon as the key provider of orthopaedic care, with the other human and system resources acting as enablers to support the surgeon's role. Thus, future supply-modeling would merely require predicting the number of orthopaedic specialists needed to provide care to the population of the future.

It would seem a simple thing to determine how many orthopaedic surgeons there are in a region or in a country to use as a basis for modeling the growth required to meet future population demand. However, the practice profiles of individual orthopaedic surgeons vary tremendously in terms of clinical caseload. Some provide after-hours call and a broad range of pediatric and adult services, while others provide only highly subspecialized services; some take no call; and some have major academic commitments and provide limited clinical service. Comparisons of the number of orthopaedic surgeons per population reveal differences of more than threefold across countries such as Sweden and France, where access to care is similar. The probable explanation relates to the amount of time surgeons in each country spend in clinical activities compared with administrative, teaching, research, and other nonclinical work (Fig. 1). In recognition of this fact, the full-time-equivalent clinician is usually considered a better measure of service availability and is expressed as the number of full-time equivalents available per 100,000 population. Even the full-time-equivalent concept remains problematic in practice. How many full-time-equivalent orthopaedic surgeons do we need in a region? It depends on what clinical service they will be providing to make up the full-time equivalent. How many cancer or trauma full-time-equivalent orthopaedic surgeons do we need in a region? How many full-time-equivalent pediatric orthopaedists? Ideally, one would calculate clinical full-time equivalents for each general and subspecialty care area, calculate another set of full-time equivalents for call and yet another set of full-time equivalents for consultation services. These data would need to be available to regional planners in real time to account for changes in surgeon practice patterns over time due to personal choice, including parental or other leave of absence, and new manpower additions and subtractions. Unfortunately, this information simply is not available.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 1: The number of orthopaedic surgeons per 100,000 population in 2002 in eleven countries. Access to care refers in general to the waiting times to see an orthopaedic surgeon and subsequently undergo surgery, if it is necessary. Increasing the number of orthopaedic surgeons per 100,000 population does not necessarily equate to improved access to care, as France and Sweden have similar wait lists, despite the fact that France has fewer orthopaedic surgeons per 100,000 population. This example illustrates that improving access to care is not as simple as merely increasing the number of surgeons in a given country. (Modified from: The National Standards Committee of the Canadian Orthopaedic Association. National workforce and services report 2004. 2004 Jun. http://beta.coa-aco.org/images/stories/news/NSC_Report_2004_final.pdf. Reprinted with permission.)

There is no single agreed-on method for calculating a full-time equivalent. In Canada, full-time equivalents are usually calculated by surgeon billings. In the United States, a surgeon with 2200 hours of patient care annually is considered one full-time equivalent. Data from the U.S. Department of Health and Human Services report "Physician Supply and Demand: Projection to 2020" in October 2006 indicated that, in 2000, the United States had approximately 8.7 orthopaedic surgeons per 100,000 population and roughly 7.1 full-time equivalents per 100,000 population⁹¹. In 2002, Canada had 3.7 orthopaedic surgeons per 100,000 population and 3.1 full-time equivalents⁹.

A simple projection of the number of full-time-equivalent orthopaedic surgeons per 100,000 population in the future could be interpreted to show a reduction in full-time equivalents in both the United States and Canada (Fig. 2). However, when one considers the increased demand for service from an aging population, an aging orthopaedic workforce, and the changing demographics of the surgical workforce, the decline in capacity may be much greater than that predicted^2,4,9,91. Caution is warranted when interpreting these data, as there is a lack of reliable and relevant data to make firm conclusions about future modeling.

View Large | Download Slide(.ppt)
Add to My JBJS

Fig. 2: The projected trends from 2000 through 2020 for orthopaedic surgeon full-time equivalents per 100,000 population in the United States and Canada, assuming the current clinical activity profile per surgeon. The Y-axis scale is tenths of full-time equivalents.

The Association of American Medical Colleges (AAMC) stated in 2006 that an appropriate supply of well-educated and trained physicians is an essential element to ensure access to quality health-care services⁹². By 2020, the AAMC suggests that physician shortages may affect access. As such, the association is calling for a 30% increase in enrollment in United States medical schools by 2015 and an increase in residency positions to accommodate the increased enrollment. However, surgeon supply adjustment involving national trainees is a slow process, given the length of time it takes to fully train an orthopaedic surgeon.

Older physicians tend to provide less clinical care than their younger counterparts. A recent survey has suggested that only 60% of orthopaedic surgeons planned to retire at the age of sixty-five⁹³. Many planned to practice part time, and some would retire because the part-time option was not available. By 2020, approximately 38% of the U.S. physician workforce will be over the age of fifty-five years compared with 26% in 2000⁹¹. Providing clinical practice opportunities and incentives for surgeons close to retirement to continue working could increase physician supply and should be considered.

The demographics of surgeons entering practice are changing. While the trend for women entering orthopaedics is lagging behind most other surgical specialties, there has been a steady increase in the percentage of female orthopaedic trainees over the last three decades⁹⁴. Overall, it has been suggested that female surgeons provide 15% less clinical care activity than do male surgeons⁹⁴, although there are no data for orthopaedics in isolation. Recent advances in restricting working hours for surgical trainees may well affect the future practice patterns of both male and female surgical graduates^95,96 who may be less willing than surgeons of previous generations to provide excessive hours of clinical care, although this has not yet been evaluated.

The clinical activity of surgeons can be substantially affected by access to resources^9,90. Thus, one part of the solution to a shortage of full-time equivalents in a region might not be to bring in more surgeons but to increase operating-room time and other resources⁹.

In 2004, the National Standards Committee of the Canadian Orthopaedic Association produced a report on the Canadian orthopaedic workforce and service capacity⁹. The report concluded that (1) Canadian orthopaedic service capacity was not able to meet population demand for surgical care, (2) an increase in operating-room time and associated resources would improve the capacity of the existing workforce immediately by allowing surgeons to spend more time providing surgical services, and (3) integrating other health-care professionals (such as physician assistants, advanced practice therapists, and nurse practitioners) into a surgical care team for patient screening, triage, and routine perioperative care was required to free up the surgeons' time so that they could use the additional operating-room resources if they were made available. Over the last few years, various Canadian provinces have facilitated implementation of this strategy with the result that access to care has dramatically improved for certain procedures in some jurisdictions^97,98. While this is a relatively new initiative in Canada, orthopaedic surgeons in the United States have long employed physician assistants to extend their capacity to provide service. Some of the patient-management tasks associated with longitudinal care are better performed by nonphysician members of the team. For example, in some settings, specially trained physical therapy practitioners routinely perform Ponseti casting⁹⁹.

Demand projections have traditionally been made by considering future changes in population demographics and by applying current disease and treatment rates to these projections. There are several problems with this approach. First, population demographics may change unexpectedly, depending on immigration patterns and refugee influx. Second, demand may be changed suddenly and dramatically by the introduction of new technology and innovation or through successful programs aimed at preventing disease or injury. The third problem, and one often associated with the introduction of new technology, is the definition of the most appropriate rate for a given procedure in a given community. Accurate demand forecasting is problematic because of the large number of unknown and uncertain factors (Table III). This situation is compounded when applying demand projections at the local level as regions may vary considerably from the national average^{1,23,86,87,100}.

View Larger

TABLE III Demand Uncertainty: Patient Demographics, Treatment Indications, Innovation, and Disease Rates

Decreased Demand	Increased Demand
• Immigration and/or refugees (young healthy individuals)	• Aging population
• Social and/or lifestyle improvements (nutrition, exercise, healthy weight, and abandoning high-risk behavior)	• Immigration and/or refugees (individuals with health-care needs)
• Contracting treatment indications (e.g., decreased surgery for low-back pain)	• Social and/or lifestyle deterioration (obesity, lack of exercise, and adopting high-risk behavior)
• Innovation (resulting in more medical compared with surgical treatment, less invasive surgery, or shorter length of stay)	• Expanding treatment indications (e.g., total joint replacement for patients at both young and old extremes of age)
• Disease and injury prevention (e.g., automobile accidents, industrial safety, interpersonal violence, arthritis, and cancer)	• Innovation (resulting in more surgical compared with medical treatment, more complex surgery, or longer length of stay to achieve improved patient outcomes)
	• Increased disease and injury rates (new infectious and other diseases, economic downturn, and high-risk social and lifestyle choices)

Add to My JBJS

TABLE III Demand Uncertainty: Patient Demographics, Treatment Indications, Innovation, and Disease Rates

Decreased Demand	Increased Demand
• Immigration and/or refugees (young healthy individuals)	• Aging population
• Social and/or lifestyle improvements (nutrition, exercise, healthy weight, and abandoning high-risk behavior)	• Immigration and/or refugees (individuals with health-care needs)
• Contracting treatment indications (e.g., decreased surgery for low-back pain)	• Social and/or lifestyle deterioration (obesity, lack of exercise, and adopting high-risk behavior)
• Innovation (resulting in more medical compared with surgical treatment, less invasive surgery, or shorter length of stay)	• Expanding treatment indications (e.g., total joint replacement for patients at both young and old extremes of age)
• Disease and injury prevention (e.g., automobile accidents, industrial safety, interpersonal violence, arthritis, and cancer)	• Innovation (resulting in more surgical compared with medical treatment, more complex surgery, or longer length of stay to achieve improved patient outcomes)
	• Increased disease and injury rates (new infectious and other diseases, economic downturn, and high-risk social and lifestyle choices)

Overview

In the year 2020, substantial changes will be seen in the demographics of the patients we treat and in the health-care providers providing services. Considerable challenges lie ahead.

Pediatric orthopaedics faces unique challenges. Operative care will not disappear, but it will change as the incidence and prevalence of certain pediatric musculoskeletal conditions change. The continued evolution of nonoperative management of some conditions, such as clubfoot, may be balanced by an increase in surgical indications for trauma and sports-related injuries. Successes in musculoskeletal health for children will occur because of advances in biology and public health.

Encouragingly, current evidence strongly suggests that the prevalence of hip fractures is decreasing. The numerous improvements in diagnosis, screening, and therapy may be at least partly responsible. Orthopaedic surgeons treating patients with a fragility fracture have played a major role in osteoporosis management and will continue to lead in this area.

The cost-effectiveness and success of total joint arthroplasty and the changing demographics of the patient population have resulted in an immense increase in demand for this procedure. This demand will continue to grow because of the aging population but also because of the increased prevalence of joint replacement in those under fifty-five years of age and those over eighty-five years of age. Furthermore, the effect of obesity on joint health is expected to further drive demand. It is likely that the increased rate in young and/or obese patients will also have a considerable impact on the revision burden for joint replacement. Infections around joint replacements will unfortunately account for a substantial percentage of these revisions.

Future projections show a decline in overall orthopaedic service capacity across North America and an increase in demand for orthopaedic services. However, precise modeling is not possible because of numerous factors. Care is required when projecting demand into the future, as demand does not always equate to need.

References

Loh S, George MV. Projected population size and age structure for Canada and provinces: with and without international migration. Can Stud Popul.2007;34:103-27.34103 2007

US Census Bureau. US interim projections by age, sex, race, and Hispanic origin: 2000-2050. . Accessed 2009 June 24.
http://www.census.gov/population/www/projections/usinterimproj/

United Nations Population Division. World population prospects: the 2002 revision. 2002. . Accessed 2009 June 24. 2002
http://www.un.org/esa/population/publications/wpp2002/WPP2002-HIGHLIGHTSrev1.PDF

Population projections for Canada, provinces and territories 2005-2031. Statistics Canada. . Accessed 2009 June 24.
http://www.statcan.gc.ca/pub/91-520-x/00105/4095188-eng.htm

Canadian Joint Replacement Registry (CJRR) 2007 annual report—hip and knee replacements in Canada. Ottawa: Canadian Institute for Health Information; 2008. . Accessed 2009 June 24. 2007
http://secure.cihi.ca/cihiweb/dispPage.jsp?cw_page=AR_30_E

Beveridge M, Howard A. The burden of orthopaedic disease in developing countries. J Bone Joint Surg Am.2004;86:1819-22.861819 2004 [PubMed]

Spiegel DA, Gosselin RA. Surgical services in low-income and middle-income countries. Lancet.2007;370:1013-5.3701013 2007 [CrossRef]

Spiegel DA, Gosselin RA, Coughlin RR, Joshipura M, Browner BD, Dormans JP. The burden of musculoskeletal injury in low and middle-income countries: challenges and opportunities. J Bone Joint Surg Am.2008;90:915-23.90915 2008 [CrossRef]

The National Standards Committee of the Canadian Orthopaedic Association. National workforce and services report 2004. 2004 Jun. . 2004
http://beta.coa-aco.org/images/stories/news/NSC_Report_2004_final.pdf

Engesaeter LB. Increasing incidence of clubfoot: changes in the genes or the environment? Acta Orthop.2006;77:837-8.77837 2006 [CrossRef]

Wallander H, Hovelius L, Michaelsson K. Incidence of congenital clubfoot in Sweden. Acta Orthop.2006;77:847-52.77847 2006 [CrossRef]

Howard AW, Viskontas D, Sabbagh C. Reduction in osteomyelitis and septic arthritis related to Haemophilus influenzae type B vaccination. J Pediatr Orthop.1999;19:705-9.19705 1999 [CrossRef]

Shaer CM, Chescheir N, Schulkin J. Myelomeningocele: a review of the epidemiology, genetics, risk factors for conception, prenatal diagnosis, and prognosis for affected individuals. Obstet Gynecol Surv.2007;62:471-9.62471 2007 [CrossRef]

Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet.2002;360:473-82.360473 2002 [CrossRef]

Transport Canada. Canadian motor vehicle traffic collision statistics: 2006. . Accessed 2009 June 24.
http://www.tc.gc.ca/roadsafety/tp/tp3322/2006/menu.htm

Peled E, Bialik V, Katzman A, Eidelman M, Norman D. Treatment of Graf's ultrasound class III and IV hips using Pavlik's method. Clin Orthop Relat Res.2008;466:825-9.466825 2008 [CrossRef]

Vane AG, Gwynne Jones DP, Dunbar JD, Theis JC. The diagnosis and management of neonatal hip instability: results of a clinical and targeted ultrasound screening program. J Pediatr Orthop.2005;25:292-5.25292 2005 [CrossRef]

Vukasinovic Z, Vucetic C, Cobeljic G, Bascarevic Z, Slavkovic N. [Developmental dislocation of the hip is still important problem—therapeutic guidelines]. Acta Chir Iugosl.2006;53:17-9. Serbian.5317 2006

Morcuende JA, Dolan LA, Dietz FR, Ponseti IV. Radical reduction in the rate of extensive corrective surgery for clubfoot using the Ponseti method. Pediatrics.2004;113:376-80.113376 2004 [CrossRef]

Alman BA, Raza SN, Biggar WD. Steroid treatment and the development of scoliosis in males with Duchenne muscular dystrophy. J Bone Joint Surg Am.2004;86:519-24.86519 2004

Salsberg ES, Grover A, Simon MA, Frick SL, Kuremsky MA, Goodman DC. An AOA critical issue. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am.2008;90:1143-59.901143 2008 [CrossRef]

Wennberg D, Dickens J Jr, Soule D, Kellett M Jr, Malenka D, Robb J, Ryan T Jr, Bradley W, Vaitkus P, Hearne M, O'Connor G, Hillman R. The relationship between the supply of cardiac catheterization laboratories, cardiologists and the use of invasive cardiac procedures in northern New England. J Health Serv Res Policy.1997;2:75-80.275 1997

Wennberg J, Gittelsohn J. Small area variations in health care delivery. Science.1973;182:1102-8.1821102 1973 [CrossRef]

Gawande AA, Studdert DM, Orav EJ, Brennan TA, Zinner MJ. Risk factors for retained instruments and sponges after surgery. N Engl J Med.2003;348:229-35.348229 2003 [CrossRef]

Gawande AA, Zinner MJ, Studdert DM, Brennan TA. Analysis of errors reported by surgeons at three teaching hospitals. Surgery.2003;133:614-21.133614 2003 [CrossRef]

Regenbogen SE, Greenberg CC, Studdert DM, Lipsitz SR, Zinner MJ, Gawande AA. Patterns of technical error among surgical malpractice claims: an analysis of strategies to prevent injury to surgical patients. Ann Surg.2007;246:705-11.246705 2007 [CrossRef]

Carmichael KD, Joyner K. Quality of reduction versus timing of surgical intervention for pediatric supracondylar humerus fractures. Orthopedics.2006;29:628-32.29628 2006

Walmsley PJ, Kelly MB, Robb JE, Annan IH, Porter DE. Delay increases the need for open reduction of type-III supracondylar fractures of the humerus. J Bone Joint Surg Br.2006;88:528-30.88528 2006 [CrossRef]

Gordon CM, DePeter KC, Feldman HA, Grace E, Emans SJ. Prevalence of vitamin D deficiency among healthy adolescents. Arch Pediatr Adolesc Med.2004;158:531-7.158531 2004 [CrossRef]

El-Hajj Fuleihan G, Nabulsi M, Tamim H, Maalouf J, Salamoun M, Khalife H, Choucair M, Arabi A, Vieth R. Effect of vitamin D replacement on musculoskeletal parameters in school children: a randomized controlled trial. J Clin Endocrinol Metab.2006;91:405-12.91405 2006

Bogoch ER. Canadian orthopedic surgeons and postfracture osteoporosis care: moving from persuasion toward facilitation. Can J Surg.2008;51:6-7.516 2008

Bogoch ER, Snowden E. A sample of Canadian orthopedic surgeons expressed willingness to participate in osteoporosis management for fragility fracture patients. Can J Surg.2008;51:8-14.518 2008

Brown JP, Fortier M, Frame H, Lalonde A, Papaioannou A, Senikas V, Yuen CK. Canadian consensus conference on osteoporosis, 2006 update. J Obstet Gynaecol Can.2006;28(2 Suppl 1):S95-S112.28S95 2006

Majumdar SR, Beaupre LA, Harley CH, Hanley DA, Lier DA, Juby AG, Maksymowych WP, Cinats JG, Bell NR, Morrish DW. Use of a case manager to improve osteoporosis treatment after hip fracture: results of a randomized controlled trial. Arch Intern Med.2007;167:2110-5.1672110 2007 [CrossRef]

Papaioannou A, Joseph L, Ioannidis G, Berger C, Anastassiades T, Brown JP, Hanley DA, Hopman W, Josse RG, Kirkland S, Murray TM, Olszynski WP, Pickard L, Prior JC, Siminoski K, Adachi JD. Risk factors associated with incident clinical vertebral and nonvertebral fractures in postmenopausal women: the Canadian Multicentre Osteoporosis Study (CaMos). Osteoporos Int.2005;16:568-78.16568 2005 [CrossRef]

Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int.1997;7:407-13.7407 1997 [CrossRef]

Jaglal SB, Sherry PG, Schatzker J. The impact and consequences of hip fracture in Ontario. Can J Surg.1996;39:105-11.39105 1996

Kannus P, Parkkari J, Sievanen H, Heinonen A, Vuori I, Jarvinen M. Epidemiology of hip fractures. Bone.1996;18(1 Suppl):57S-63S.1857S 1996 [CrossRef]

Papadimitropoulos EA, Coyte PC, Josse RG, Greenwood CE. Current and projected rates of hip fracture in Canada. CMAJ.1997;157:1357-63.1571357 1997

Jaglal SB, Weller I, Mamdani M, Hawker G, Kreder H, Jaakkimainen L, Adachi JD. Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong? J Bone Miner Res.2005;20:898-905.20898 2005 [CrossRef]

Kannus P, Niemi S, Parkkari J, Palvanen M, Vuori I, Jarvinen M. Nationwide decline in incidence of hip fracture. J Bone Miner Res.2006;21:1836-8.211836 2006 [CrossRef]

Nymark T, Lauritsen JM, Ovesen O, Rock ND, Jeune B. Decreasing incidence of hip fracture in the Funen County, Denmark. Acta Orthop.2006;77:109-13.77109 2006 [CrossRef]

Chevalley T, Guilley E, Herrmann FR, Hoffmeyer P, Rapin CH, Rizzoli R. Incidence of hip fracture over a 10-year period (1991-2000): reversal of a secular trend. Bone.2007;40:1284-9.401284 2007 [CrossRef]

Sehgal A, Vadhavkar S, Mithal A, Singh GSI. A victory in the war on osteoporosis? Declining prevalence of hospitalizations for non-traumatic hip fractures in the US. Ann Rheum Dis.2008;67(Suppl II):55.6755 2008

Icks A, Haastert B, Wildner M, Becker C, Meyer G. Trend of hip fracture incidence in Germany 1995-2004: a population-based study. Osteoporos Int.2008;19:1139-45.191139 2008 [CrossRef]

Hagino H, Furukawa K, Fujiwara S, Okano T, Katagiri H, Yamamoto K, Teshima R. Recent trends in the incidence and lifetime risk of hip fracture in Tottori, Japan. Osteoporos Int.2009;20:543-8.20543 2009 [CrossRef]

Sanders KM, Pasco JA, Ugoni AM, Nicholson GC, Seeman E, Martin TJ, Skoric B, Panahi S, Kotowicz MA. The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: the Geelong Osteoporosis Study. J Bone Miner Res.1998;13:1337-42.131337 1998 [CrossRef]

Black DM, Delmas PD, Eastell R, Reid IR, Boonen S, Cauley JA, Cosman F, Lakatos P, Leung PC, Man Z, Mautalen C, Mesenbrink P, Hu H, Caminis J, Tong K, Rosario-Jansen T, Krasnow J, Hue TF, Sellmeyer D, Eriksen EF, Cummings SR; HORIZON Pivotal Fracture Trial. Once-yearly zoledronic acid for treatment of postmenopausal osteoporosis. N Engl J Med.2007;356:1809-22.3561809 2007 [CrossRef]

Lewiecki EM. Intravenous zoledronic acid for the treatment of osteoporosis. Curr Osteoporos Rep.2008;6:17-23.617 2008 [CrossRef]

Reginster JY, Felsenberg D, Boonen S, Diez-Perez A, Rizzoli R, Brandi ML, Spector TD, Brixen K, Goemaere S, Cormier C, Balogh A, Delmas PD, Meunier PJ. Effects of long-term strontium ranelate treatment on the risk of nonvertebral and vertebral fractures in postmenopausal osteoporosis: results of a five-year, randomized, placebo-controlled trial. Arthritis Rheum.2008;58:1687-95.581687 2008 [CrossRef]

Lewiecki EM, Miller PD, McClung MR, Cohen SB, Bolognese MA, Liu Y, Wang A, Siddhanti S, Fitzpatrick LA; AMG 162 Bone Loss Study Group. Two-year treatment with denosumab (AMG 162) in a randomized phase 2 study of postmenopausal women with low BMD. J Bone Miner Res.2007;22:1832-41.221832 2007 [CrossRef]

al-Allaf AW, Pal B, Reid N. An audit of post fracture rehabilitation with special emphasis on osteoporosis assessment and treatment. Clin Exp Rheumatol.1998;16:451-3.16451 1998

Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann Rheum Dis.1998;57:378-9.57378 1998 [CrossRef]

Ulahannan TJ, Lavelle LA. Is systematic osteoporosis prevention and detection possible in a district hospital? J Clin Effectiveness.1997;2:43-6.243 1997

Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am.2006;88:25-34.8825 2006

Bogoch ER, Elliot-Gibson V, Escott BG, Beaton DE. The osteoporosis needs of patients with wrist fracture. J Orthop Trauma.2008;22(8 Suppl):S73-8.22S73 2008 [CrossRef]

Kuo I, Ong C, Simmons L, Bliuc D, Eisman J, Center J. Successful direct intervention for osteoporosis in patients with minimal trauma fractures. Osteoporos Int.2007;18:1633-9.181633 2007 [CrossRef]

Nixon MF, Ibrahim T, Johari Y, Eltayef S, Hariharan D, Taylor GJ. Managing osteoporosis in patients with fragility fractures: did the British Orthopaedic Association guidelines have any impact? Ann R Coll Surg Engl.2007;89:504-9.89504 2007 [CrossRef]

Talbot JC, Elener C, Praveen P, Shaw DL. Secondary prevention of osteoporosis: calcium, vitamin D and bisphosphonate prescribing following distal radial fracture. Injury.2007;38:1236-40.381236 2007 [CrossRef]

Rozental TD, Makhni EC, Day CS, Bouxsein ML. Improving evaluation and treatment for osteoporosis following distal radial fractures. A prospective randomized intervention. J Bone Joint Surg Am.2008;90:953-61.90953 2008 [CrossRef]

Warriner A, Curtis JR, Saag KG. Challenges in defining and improving osteoporosis quality of care. Clin Exp Rheumatol.2007;25(6 Suppl 47):142-6.25142 2007

Ashe M, Khan K, Guy P, Kruse K, Hughes K, O'Brien P, Janssen P, McKay H. Wristwatch-distal radial fracture as a marker for osteoporosis investigation: a controlled trial of patient education and a physician alerting system. J Hand Ther.2004;17:324-8.17324 2004 [CrossRef]

Bessette L, Ste-Marie LG, Jean S, Davison KS, Beaulieu M, Baranci M, Bessant J, Brown JP. Recognizing osteoporosis and its consequences in Quebec (ROCQ): background, rationale, and methods of an anti-fracture patient health-management programme. Contemp Clin Trials.2008;29:194-210.29194 2008 [CrossRef]

Elliot-Gibson VIM, Jain R, Jiwa F, Beaton DE, Bogoch ER, Richie S, Samji F. Osteoporosis post-fracture screening program. J Orthop Nurs.2009;13:38.1338 2009

Majumdar SR, Johnson JA, McAlister FA, Bellerose D, Russell AS, Hanley DA, Morrish DW, Maksymowych WP, Rowe BH. Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial. CMAJ.2008;178:569-75.178569 2008

Tosi LL, Gliklich R, Kannan K, Koval KJ. The American Orthopaedic Association's "own the bone" initiative to prevent secondary fractures. J Bone Joint Surg Am.2008;90:163-73.90163 2008

Dell R, Greene D, Schelkun SR, Williams K. Role of the orthopaedic surgeon in osteoporosis disease management. Read at the 75th Annual Meeting of the American Academy of Orthopaedic Surgeons; 2008 Mar 5-9; San Francisco, CA. 2008

Cadarette SM, Gignac MA, Jaglal SB, Beaton DE, Hawker GA. Access to osteoporosis treatment is critically linked to access to dual-energy x-ray absorptiometry testing. Med Care.2007;45:896-901.45896 2007 [CrossRef]

Pickney CS, Arnason JA. Correlation between patient recall of bone densitometry results and subsequent treatment adherence. Osteoporos Int.2005;16:1156-60.161156 2005 [CrossRef]

Tosteson AN, Grove MR, Hammond CS, Moncur MM, Ray GT, Hebert GM, Pressman AR, Ettinger B. Early discontinuation of treatment for osteoporosis. Am J Med.2003;115:209-16.115209 2003 [CrossRef]

Pan American Health Organization Health Analysis and Statistics Unit. Health situation in the Americas: basic indicators 2007. . Accessed 2009 June 24. 2007
http://www.paho.org/english/dd/ais/BI_2007_ENG.pdf

Quintana JM, Arostegui I, Escobar A, Azkarate J, Goenaga JI, Lafuente I. Prevalence of knee and hip osteoarthritis and the appropriateness of joint replacement in an older population. Arch Intern Med.2008;168:1576-84.1681576 2008 [CrossRef]

Grotle M, Hagen KB, Natvig B, Dahl FA, Kvien TK. Prevalence and burden of osteoarthritis: results from a population survey in Norway. J Rheumatol.2008;35:677-84.35677 2008

Andrianakos AA, Kontelis LK, Karamitsos DG, Aslanidis SI, Georgountzos AI, Kaziolas GO, Pantelidou KV, Vafiadou EV, Dantis PC; ESORDIG Study Group. Prevalence of symptomatic knee, hand, and hip osteoarthritis in Greece. The ESORDIG study. J Rheumatol.2006;33:2507-13.332507 2006

Lobstein T, Jackson-Leach R. Child overweight and obesity in the USA: prevalence rates according to IOTF definitions. Int J Pediatr Obes.2007;2:62-4.262 2007 [CrossRef]

Vandegrift D, Yoked T. Obesity rates, income, and suburban sprawl: an analysis of US states. Health Place.2004;10:221-9.10221 2004 [CrossRef]

Fehring TK, Odum SM, Griffin WL, Mason JB, McCoy TH. The obesity epidemic: its effect on total joint arthroplasty. J Arthroplasty.2007;22(6 Suppl 2):71-6.2271 2007

Bourne R, Mukhi S, Zhu N, Keresteci M, Marin M. Role of obesity on the risk for total hip or knee arthroplasty. Clin Orthop Relat Res.2007;465:185-8.465185 2007

Thorpe KE, Florence CS, Howard DH, Joski P. The impact of obesity on rising medical spending. Health Aff (Millwood). 2004;Suppl Web Exclusives:W4-480-6. 2004

Kurtz SM, Lau E, Schmier J, Ong KL, Zhao K, Parvizi J. Infection burden for hip and knee arthroplasty in the United States. J Arthroplasty.2008;23:984-91.23984 2008 [CrossRef]

Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am.2005;87:1487-97.871487 1990 [CrossRef]

The Swedish National Hip Arthroplasty Register. Annual report 2004. 2005 May. . 2004
http://www.jru.orthop.gu.se/archive/AnnualReport-2004-eng.pdf

Katz JN, Phillips CB, Baron JA, Fossel AH, Mahomed NN, Barrett J, Lingard EA, Harris WH, Poss R, Lew RA, Guadagnoli E, Wright EA, Losina E. Association of hospital and surgeon volume of total hip replacement with functional status and satisfaction three years following surgery. Arthritis Rheum.2003;48:560-8.48560 2003 [CrossRef]

Robertsson O, Dunbar M, Pehrsson T, Knutson K, Lidgren L. Patient satisfaction after knee arthroplasty: a report on 27,372 knees operated on between 1981 and 1995 in Sweden. Acta Orthop Scand.2000;71:262-7.71262 2000 [CrossRef]

Bozic KJ, Ries MD. The impact of infection after total hip arthroplasty on hospital and surgeon resource utilization. J Bone Joint Surg Am.2005;87:1746-51.871746 2005 [CrossRef]

Dauphinee WD, Buske L. Medical workforce policy-making in Canada, 1993-2003: reconnecting the disconnected. Acad Med.2006;81:830-6.81830 2006 [CrossRef]

Farley FA, Weinstein JN, Aamoth GM, Shapiro MS, Jacobs J, McCarthy JC, Kramer J; Orthopaedic Workforce Taskforce to Board of Directors, American Academy of Orthopaedic Surgeons, 2005-2006. Workforce analysis in orthopaedic surgery: how can we improve the accuracy of our predictions? J Am Acad Orthop Surg.2007;15:268-73.15268 2007

Greer RB 3rd. Orthopaedic workforce studies: 1980 to 1985. Clin Orthop Relat Res.2001;385:76-81.38576 2001 [CrossRef]

Shipton D, Badley EM, Mahomed NN. Critical shortage of orthopaedic services in Ontario, Canada. J Bone Joint Surg Am.2003;85:1710-5.851710 2003

Task Force Two. A physician human resource strategy for Canada. Physician HR progress report; 2006. . Accessed 2009 Jun 24. 2006
http://www.physicianhr.ca/news/newsletter/TF2NewsletterSpring2006-e.pdf

U.S. Department of Health and Human Services. Health Resources and Services Administration. Physician supply and demand: projections to 2020; 2006. . Accessed 2009 Jun 24. 2020
http://bhpr.hrsa.gov/healthworkforce/reports/physiciansupplydemand/default.htm

Association of American Medical Colleges. AAMC statement on the physician workforce. 2006 Jun. . 2006
http://www.aamc.org/workforce/workforceposition.pdf

Farley FA, Kramer J, Watkins-Castillo S. Work satisfaction and retirement plans of orthopaedic surgeons 50 years of age and older. Clin Orthop Relat Res.2008;466:231-8.466231 2008 [CrossRef]

Blakemore LC, Hall JM, Biermann JS. Women in surgical residency training programs. J Bone Joint Surg Am.2003;85:2477-80.852477 2003

Baskies MA, Ruchelsman DE, Capeci CM, Zuckerman JD, Egol KA. Operative experience in an orthopaedic surgery residency program: the effect of work-hour restrictions. J Bone Joint Surg Am.2008;90:924-7.90924 2008 [CrossRef]

Feanny MA, Scott BG, Mattox KL, Hirshberg A. Impact of the 80-hour work week on resident emergency operative experience. Am J Surg.2005;190:947-9.190947 2005

Davis AM, MacKay C, Badley EM. Access to care for people with arthritis: enhancing care across the continuum using advanced practitioners / extended role practitioners. Arthritis Community Research and Evaluation Unit (ACREU); 2008. . Accessed 2009 Jun 24. 2008
http://www.acreu.ca/pdf/pub5/08-01.pdf

Robarts S, Kennedy D, MacLeod AM, Findlay H, Gollish J. A framework for the development and implementation of an advanced practice role for physiotherapists that improves access and quality of care for patients. Healthc Q.2008;11:67-75.1167 2008

Shack N, Eastwood DM. Early results of a physiotherapist-delivered Ponseti service for the management of idiopathic congenital talipes equinovarus foot deformity. J Bone Joint Surg Br.2006;88:1085-9.881085 2006 [CrossRef]

100

Lurie JD, Weinstein JN. Shared decision-making and the orthopaedic workforce. Clin Orthop Relat Res.2001;385:68-75.38568 2001 [CrossRef]

Topics

aging ; obesity ; osteoporosis ; fracture ; hip fractures ; demography ; life expectancy ; musculoskeletal diseases ; pediatrics ; wounds and injuries

First Page Preview

View Large

Username

Password

Access for Patients

Forgot Password?

Have a subscription to the print edition?

Not a Subscriber?

Buy this Article

Get online access for 30 days for $35

New to JBJS?

Subscribe to the online edition for 30 days for $75

Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.

Have a subscription to the print edition?

Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.

Activate your online account now

Forgot your password?

Enter your username and email address. We'll send you a reminder to the email address on record.

Username:*

Email Address:*

Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
by your institution, please contact you librarian or administrator for username and password information. Institutional
administrators, to reset your institution's master username or password, please contact subs@jbjs.org

References

Accreditation Statement

These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.

CME Activities Associated with This Article

Submit a Comment

Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

* = Required Field

Comment Author(s) * (if multiple authors, separate names by comma)

Example: John Doe

Affiliation & Institution*

Comment Title*

Comment*

Cancel

Print
PDF
Email

Recipient(s) will receive an email with a link (good for 5 days) to 'Orthopaedics in 2020: Predictors of Musculoskeletal Need*'.
Your Name:*
Example: John Doe

Email Address:* CC Me:
Enter your valid email address. Example: jdoe@example.com

Recipient's Email Address:*

Separate multiple email address with semi-colons (up to 5).

Subject:* 's The Journal of Bone & Joint Surgery: 'Orthopaedics in 2020: Predictors of Musculoskeletal Need*'
Subject for your email.

Message:

(Optional, message will truncate at 1000 characters)

Processing your request... Please Wait...

Copyright © in the material you requested is held by The Journal of Bone & Joint Surgery, Inc. (unless otherwise noted). This email ability is provided as a courtesy, and by using it you agree that that you are requesting the material solely for personal, non-commercial use, and that it is subject to Journal of Bone & Joint Surgery, Inc.'s Terms of Use. The information provided in order to email this topic will not be used to send unsolicited email, nor will it be furnished to third parties. Please refer to The Journal of Bone & Joint Surgery Inc.'s Privacy Policy for further information.

Copyright © The Journal of Bone & Joint Surgery Inc. All rights reserved.
Share
Get Citation

Michael J. Dunbar, Andrew Howard, Earl R. Bogoch, Javad Parvizi, Hans J. Kreder; Orthopaedics in 2020: Predictors of Musculoskeletal Need*. The Journal of Bone & Joint Surgery. 2009 Sep;91(9):2276-2286.

Download citation file:

RIS (Zotero)

EndNote

BibTex

Medlars

ProCite

RefWorks

Reference Manager

Copyright © The Journal of Bone and Joint Surgery, Inc.
Rights & Permissions
Article Alerts

Processing your request... Please Wait.
Submit a Comment