Sunlight And Your Bones

You need Vitamin D to stimulates the absorption of calcium and magnesium into your bones. Calcium alone is not responsible for bone strength–but a delicate combination of calcium and other elements like phosphorous and magnesium which are regulated by Vit D–a vitamin that is naturally produced when the sun hits your skin. In these dark and dreary northern hemisphere countries, we may need a dietary source of Vitamin D as found in fortified milk products, or via supplements.

Calcium is essential for bone health. In this chart from WebMD, you can see the daily requirements in mg for age:



Calcium (mg)

Birth to 6 months


6 months to 1 year


1-3 years


4-8 years


9-18 years


19-50 years


51-70 years


Over 70 years



As you can see, the older we are, the more calcium we need for the exception of the 9-18 age group when our bones are growing larger faster and the body is moving through puberty to adulthood.

Dietary calcium sources may not be enough. Green veggies, dairy products and fortified foods are a source of calcium. Supplements are another source of course. Too much calcium can lead to kidney stones. And if you have ever passed one, it’s certainly not fun.

Vitamin D requirements for bone health–which pushes the calcium into your bones– are in the realm of 600 to 1000 IU’s per day. Too much Vitamin D is toxic. Not enough can lead to a disease called Rickets where the bones are brittle and deformed.

Calcium sources: Here is a slide show of some amazing and delicious nutritious sources of calcium in your diet:

People with low levels of dietary calcium, Vitamin D, magnesium and phosphorus–but particularly calcium deficiencies– may end up with low levels of calcium in the bones which leads to a condition called osteoporosis (a decrease in density of the bone) which can lead to fragility fractures of the wrist, hip, spine or ankles. There are medications for osteoporosis which help increase bone density, some of which have their own side effects of bone fragility and brittleness (bisphophonates).

Patients with fractures often ask me what they can do from a dietary stand point to increase bone healing. Unfortunately, the calcium in your bones at the time of the fracture relates to dietary choices you made months and years ago. Eating more calcium today will not necessarily strengthen your bones tomorrow, and will have little to no effect on rate of fracture healing. However, a well balanced diet heavy in the leafy greens, lean meats and healthy fats, and low in carbohydrates and junk foods like sugar and processed crap, will help your overall health and well-being and promote healing while reducing the risk of future fragility fractures.

For more information on osteoporosis, please visit:

First Fully Digital Hospital in North America

The new Humber River Hospital…in Toronto, Canada

“It began as a dream… a desire to give our patients and our community the kind of hospital facility it deserved. On December 2, 2011 the dream began to take shape as we held our groundbreaking celebration: a wonderful day for our hospital, our patients and our community.


“Humber River Hospital proudly presents our new home: North America’s first fully digital hospital. A digital hospital utilizes the most current technologies possible to enhance all aspects of quality care delivery, improving efficiency, accuracy, reliability and safety. And currently no North American hospital is fully digital. There are systems interruptions in all of them that prevent full integration and full interoperability. We’re going to be the first in North America to close that gap to automate all of our processes.


“The centerpiece of our plans to revolutionize health care for our community, it is designed to maximize the benefits of technology, lean design and environmental planning. Our new building will enable our hospital team to further enhance the high quality, safe, efficient care they provide in our current facilities. It will allow care providers more time at the bedside, nurturing the personal interactions that form the basis of great hospital care. ”



Orthopaedic Surgery is a Team Sport!

It Takes a Community to Care for a Patient

At the recent American Academy of Orthopedic Surgeons (AAOS) meeting in Chicago, the word “collaboration” was being kicked around like a soccer ball.

Organizational behavior consultants, marketing consultants and business professionals having been emphasizing the importance of “teamwork” and “collaboration” in the literature for years!surgery

Although surgery itself takes a team to perform, many orthopaedic surgeons in Canada work as independent practitioners within a private practice and share hospital responsibilities with a small group of other surgeons, sharing the call schedule and collaborating on difficult surgical cases.

However, although we don’t practice in a bubble, we do tend to be the lone wolf in our subs-specialty areas unless we make a point of collaborating and consulting with peers.

In a recent post in the ezine “The Pipeline” by Katie Rief of the Advisory Board Company, take-away comments were presented from the AAOS meeting which emphasized the changing role of the orthopaedic surgeon as a team player.

Says Ms. Rief, “Surgeons are interested in building efficient, dedicated care teams. This is true in the OR as well as in the clinic.”

So what does my team look like?

My core team is me and my two office partners, Dr. Rodriguez-Elizalde who specializes in trauma and joint replacement surgery, and Dr. Cayen who specializes in sport IMG_65medicine and joint replacement surgery, as well as our administrative assistants. We share an office, our staff work side by side, and we all work at the same hospital–Humber River Regional (Church Street Site).

The next team layer include our cast techs in fracture clinic, operating room nurses, anesthesia colleagues, sales representatives from our surgical instrument and implant companies, surgical unit nurses and pre/post operative nursing staff as well as other orthopaedic surgical colleagues at both the Finch and Church sites whom we work with to provide orthopaedic surgical services to our 800,000 catchment area in North York.

Beyond this is the layer that encompasses all support services–hospital services, computer and networking services, laboratory and diagnostic radiology services and the companies who provide us implants and products we need to do our jobs. This layer also includes the insurance companies, including OHIP.

Each of Us Brings a Unique Skill to the Team

On any given day, at least 6 or 8 people are working with me to get my job done, as I work them to get their job tasks accomplished. This coordinated concerted effort constitutes the “inputs” and quality patient care is the “output”.

So although we might seem to practice independently, it takes a community to care for patient–each with a unique but interrelated job.



Cortisone Injections for Knee Pain

There is much controversy as to how to treat knee pain nonoperatively, and if cortisone injections are dangerous in the knee. The type of cortisone used, dose, number of injections and frequency of injections, as well as side effects are all controversial topics among orthopaedic surgeons.

The knee, being one of the largest joints in the body, is susceptible to the development of conditions that cause pain and swellng, like osteoarthritis, trauma and rheumatoid arthritis. Osteoarthritis is the most common of these conditions, representing 15% of most people over the age of 60 in developed countries. Symptomatic knee osteoarthritis has been found prevalent more commonly in women tcortisone_knee_dynhan men.

Initially, we treat early osteoarthritis of the knee with physical therapy, weight reduction, anti inflammatory medications like Advil and Aleve, and eventually move to prescription anti inflammatory medications, pain killers, braces, knee injections and sometimes surgery.

Cortisone has been one of the most common injections used in the knee for decades and benefits patients by relieving both pain and inflammation for weeks to months.

celsoluspanCortisone has been demonstrated in some studies to reduce the deterioration of knees and the development of more severe osteoarthritis, but concern has been raised about the potential side effects of long-term corticosteroid injection. There is evidence to suggest that frequent doses of cortisone may degrade joint cartilage and change the properties of meniscal cartilage by altering the cartilage cells. There are also numerous scientific studies demonstrating direct toxic effects of cortisone on joint structures including ligaments.

So how often is it safe to inject cortisone into the painful knee of someone with moderate osteoarthritis who is not yet ready for joint replacement surgery?

According to a study by Zuber in 2002, cortisone can be injected into a knee every 6 weeks with no more than 2 to 3 injections per year. There is no solid evidence to suggest repeat injections of cortisone lead to joint destruction and the 3 injections/year guideline is simply that–a guideline.(Zuber TJ. Knee joint aspiration and injection. Am Fam Physician 2002; 66: 1497–501).

In 1967, Salter, Gross and Hall concluded that:

“While it is unlikely that a single intra-articular injection of hydrocortisone is harmful, multiple intra-articular injections of hydrocortisone in a given joint are probably deleterious to the articular cartilage and should be avoided in order to prevent the iatrogenic complication of hydrocortisone arthropathy.” (Salter RB, Gross A, Hall JH. Hydrocortisone arthropathy: an experimental investigation. Can Med Assoc J 1967; 97: 374–7.)

This advice is still relevant today in spite of 45 additional years of research.

Personally, I concur with the author of today’s source article in Medscape who suggests cortisone injections are effective in patients who are not yet ready for knee replacement, who are on a waiting list for knee replacement, in young patients who knee replacement is to be avoided until later life if possible, and in patients who have medical or other reasons they cannot undergo knee replacement. I administer these injections 6 weeks apart for a total of 3, if required–and wait 6 months between treatment courses before repeating if necessary. Some point along the line,doctorhdshot2 the decision would be made whether to proceed with joint resurfacing or replacement based on the patient factors such as age and medical status, as well as disease factors such as severity and functional abilities.

For more information on Cortisone, please visit:

Cooking for Bone Health

The two main dietary bone health-promoting nutrients are Calcium, a mineral naturally found in bone; and Vitamin D, a vitamin required to absorb calcium from your intestine.

With enough sunlight, our bodies will synthesize Vitamin D in quantities great enough for adequate calcium absorption. Calcium, on the other hand, must come from external sources or your body will start to use up the calcium stored in bone for other body functions.

Calcium is a mineral essential for many cellular functions including bone mineralization and muscle contraction. Calcium deficiency leads to osteoporosis and neuromuscular disorders including convulstions, heart rythmn disturbances, numbness and even paralysis.

BroccoliThe best source of calcium is in foods. Calcium supplements, though effective at correcting low calcium states, may cause other side effects in the body including kidney or bile stones, bone pain, nausea and vomiting, and pancreatitis among other conditions.

Foods high in calcium include: milk, cheese, broccoli, fortified cereals and almonds. Vitamin D fortified milk helps increase the absorption of calcium from the intestine into the blood stream. MP5094

According to, the following recipes are calcium-rich and great for bone health: Black-eyed peas with Tofu, Chicken Cassoulet, Salmon Cakes, Manicotti, Lamb and Rice Casserole.

Check out Bone Healthy Desserts!

The Weekend Warrior Syndrome–Avoiding Injury

Weekend warriors: According to, a weekend warrior is a person who holds a regular job during the week which restricts their ability to partake in adventurous or physical activities, and thus plans epic weekend adventures to compensate leaving them susceptible to injuries as a result of lack of training, fitness or due to unconditioned physical training or skill.

For example, a busy executive spends 12 hours a day at work, Monday through Friday, and then on the weekend goes skiing, parachuting, plays in a hockey tournament, goes windsurfing or decides to do a marathon with minimal training.

Aside from the stiffness and muscle pain that will now take him the entire next week to recover from, a weekend warrior is at risk of certain injuries that may be debilitating and even require surgical treatments. lists eight typical weekend warrior injuries to be aware of:

1. Shoulder rotator cuff injuries

2. Elbow tendonitis IMG_9090

3. Knee arthritis

4. Hip arthritis

5. Knee cartilage tears

6. Anterior cruciate ligament tears of the knee

7. Achilles tendonitis

8. Low back strain

Over the next few blogs, I’ll address each of these common weekend warrior injuries. Sure, the same injuries happen to well trained and conditioned athletes, but avoidance of these conditions for an occasional adventure sports enthusiast is not as difficult as you might believe.

Regular sport-specific conditioning, a general exercise or core conditioning program, and stretching before and after physical activities may help prevent injury to joints, ligaments, tendons and muscles.