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Hand Program

The Hand Program is a tertiary centre for surgery and rehabilitation of the hand and upper extremity and is the national leader in comprehensive hand care by fully integrating orthopedic and plastic surgeons with expertise in hand surgery. The Hand Program has pioneered many firsts: the first functioning muscle transfer in North America, the first derotation osteotomy, the first pyrocarbon PIPJ arthroplasty, and, most recently, the first and only successful hand transplantation in Canada. The Program encompasses a multidisciplinary team of hand surgeons, physiotherapists, occupational therapists and orthopedic technicians to treat patients with arthritis, nerve injuries, trauma, and work-related injuries. The Hand Program is the upper extremity replant centre for the province of Ontario, and is the primary site for teaching in hand surgery for two divisions in the University of Toronto Department of Surgery: Plastic Surgery and Orthopedic Surgery, attracting postgraduate trainees from North America and abroad.

The research division of the Hand Program is an area with great potential for rapid growth. The program is poised to conduct novel and important research due to high clinical volumes, excellent facilities, and strategic research collaborations across UHN and abroad.

Within UHN, there are productive collaborations with researchers in the Schroeder Arthritis Institute and neurosciences program. The Schroeder Arthritis Institute collaboration supports ongoing longitudinal cohort studies for clinical and translational research among patients with thumb carpometacarpal osteoarthritis (CMC OA), which has led to acquisition of peer-reviewed funding within the last two years. Our group has curated a biobank of bio-fluids and joint tissues in this cohort of CMC OA patients; the first biobank of its kind internationally. Collaborative research with the Neurosciences Program focuses on exploring neuroplasticity following peripheral nerve injury and compression to better understand the role of the central nervous system in clinical outcomes. Further, ongoing studies are investigating the use of DTI/MRI imaging of peripheral nerve microanatomy as an innovative diagnostic tool. This collaborative effort has led to the acquisition of significant peer-reviewed funding. As a joint effort between investigators in the program, the Hand Program has recently initiated a project to facilitate data collection for a research data repository of varying hand conditions. This database will be invaluable for future prospective clinical studies and for retrospective analyses of different patient populations.

The Hand Program is strategically positioned for collaborations with renowned researchers in the Krembil Research Institute and has ready access to the resources needed to conduct leading basic science and clinical research in the field of hand pathology. We envision the Hand Program being at the forefront of translational research by understanding the interplay of pain and outcomes in hand surgery. We envision accomplishing this goal by developing personalized medicine approaches to treating all types of hand conditions. Our plan to expand research within the Hand Program will grow in tandem with our dedication to reshaping and improving the platform by which care is delivered to our patients.

Orthopedics

The Division of Orthopedics provides comprehensive surgical care of musculoskeletal diseases focusing on arthritis, provides the highest quality training and education for staff and future physicians, and seeks to improve the delivery of care for patients through research and innovation. The division is for complex orthopedic surgery of all joints (foot/ankle, shoulder/elbow, spine, hip/knee) and is a pioneer of innovative models of care. It also supports computer-assisted surgery, and is improving pain management techniques of outpatient care. Orthopedics is an integral part of the UHN Schroeder Arthritis Institute biobank that provides longitudinal data for prognostic markers of disease. Other research areas of focus include proteomic/genomics, epidemiology/health services research, diagnostic imaging, and predictive analytics.

Osteoarthritis (OA) is among the most prevalent human diseases and is the most common form of arthritis. It is among the leading causes of disability in Canada and worldwide, rising with increasing life expectancy. OA is a major socioeconomic burden for Ontario and all of Canada. In OA, cartilage progressively deteriorates and synovium gets inflamed, which together, cause joint stiffness, pain and disability. The disease progresses relatively unnoticed in its early stages. By the time it is diagnosed, it is often so severe that medical treatments are no longer effective. Specific mechanisms underlying the joint destruction are largely unknown. Due to the lack of biomarkers, it is not yet possible to identify patients exhibiting early stages of OA. Furthermore, due to poor understanding of the underlying disease mechanisms at present, no disease-modifying therapies exist. Early detection and curative interventions depend on improved diagnostic and prognostic markers and on better understanding of the biological basis of the disease.

Our team of orthopedic surgeons, clinical investigators, basic, translational, epidemiologists and health service research scientists are focusing on:

  • Osteoarthritis Molecular Phenotyping
    This program focuses on understanding different subtypes of Osteoarthritis phenotypes using clinical cohorts and molecular techniques.
  • Joint Restoration Therapeutics
    This program is focused on identifying disease modifying Osteoarthritis Drugs.
  • OA Regenerative Medicine/Cell Therapy
    This program is focused on creating cell-based therapeutics for joint regeneration and OA treatment. The core expertise include tissue engineering, cell therapies, and cell-derived therapies as well as translating bench research in regenerative medicine into clinical trials.
  • OA Predictive Analytics
    This program uses informatics/big data approach to create new predictive tools to determine the outcomes of treatments/interventions.
  • Centre for Health Transformation
    This program is focused on creating and implementing new patient-centred models of care that enable translation and integration of i-v to provide optimized access, personalized assessment, personalized care and ongoing community support.

The Osteoarthritis Research Program has an Academic Advisory Board comprising of 6 internationally recognized experts in the field of Osteoarthritis.


Osteoporosis

Osteoporosis is a systemic skeletal disease affecting 1 in 2 women and 1 in 5 men over the age of 50. It is silent until a fracture happens. Common osteoporotic fractures are wrist, spine and hip fractures. Hip fracture increases mortality, with worst outcomes than having breast cancer. Most fractures are associated with pain and disability, and reduced quality of life.

The Osteoporosis Program is a multidisciplinary group that focuses on improving musculoskeletal health of the population by developing innovative diagnostic tools, testing promising new therapies, personalizing care through genomics and proteomics, and integrating nutrition and exercise to achieve optimal outcomes. The vision of this program is to have a world without musculoskeletal impairment in which healthy mobility is a reality for all.

The osteoporosis Program has 3 main research themes:

The program has become a leader in bone and muscle research. It currently holds two CIHR grants, one to personalize osteoporosis care by defining genetic and non-genetic determinants of atypical femur fractures and the other one to examine subchondral bone properties and their association with pain and joint deterioration in postmenopausal women with knee OA and varying risk for fractures. In addition, the program currently has two projects testing novel biomarkers for fractures, and three projects testing innovative therapies (palovarotene and activin A inhibitor for fibrodysplasia ossificans progressiva, and sclerostin inhibitor for osteogenesis imperfecta).

The Osteoporosis Program has had many firsts translating cutting-edge research to clinical care: the first DXA unit in Canada, the first bisphosphonate trial in Canada, the first “virtual bone biopsy” with innovative imaging techniques, and the first centre to provide "Trabecular Bone Score" to improve fracture risk assessment. The Osteoporosis research group serves as advisor to Osteoporosis Canada, Canadian Institutes of Health Research, Endocrine Society, International Osteoporosis Foundation, Agency of Healthcare Research & Quality, Department of Defense, and NASA. We also lead national and international research initiatives such as the Canadian Multicentre Osteoporosis Study, the ASBMR Bone Strength Working Group, and the Quantitative Musculoskeletal Imaging international workshop.

Rheumatology

The Rheumatology Division is the site of the largest Rheumatology training program in North America and is internationally renowned for excellence in clinical care, clinical investigation and basic research. Specialized clinics provide multidisciplinary management of systemic lupus erythematosus, psoriatic arthritis, ankylosing spondylitis, Sjogren’s syndrome, scleroderma, and early autoimmune rheumatic diseases.

General Rheumatology clinics, including urgent assessment clinics, allow timely diagnoses and treatment of diverse rheumatic diseases. In recognition of its excellence, the division was designated the Arthritis Centre of Excellence for Ontario by the Arthritis Society.

A major focus of the Rheumatology Division is improvement of the outcomes for patients with rheumatic diseases through research. Rheumatology is the most research-intensive division in the Department of Medicine at UHN, with 73% of the division appointed as clinician scientists. The Rheumatology Division’s research spans basic science, translational research, clinical epidemiology, and health services. To facilitate this research, the division has made a major commitment to the establishment of longitudinal patient cohorts and expansion of biobanks to store tissue and blood samples.

The division now has the most comprehensively studied group of rheumatic disease patients in the world. Research advances into pathogenesis and in early diagnosis have meant timely, personalized treatments for patients, less accumulated damage, and better quality of life. Members of the division have continuously received peer-reviewed funding from local, national, and international funding organizations and a number of our investigators have received peer-reviewed competitive salary awards.

The major clinical sub-programs include

  • Systemic Lupus Erythematosus
    This longitudinal observation cohort has provided novel insights into prognosis of SLE and has been pivotal in defining optimal management of this complex disease. It is currently concentrating on phenotyping and genotyping patients with SLE to develop an approach to personalized medicine. There are collaborative studies with genetic researchers and basic scientists defining cytokine/chemokine and proteomic markers associated with clinical phenotypes.
  • Ankylosing Spondylitis
    This program bridges basic and clinical science and has provided new insights into the biological basis of this disease and predictors of clinical course. The program encompasses basic, translational, and clinical research. This program includes a novel Spondylitis Screening Clinic which evaluates large numbers of patients with undiagnosed back pain from around the province.
  • Psoriatic Arthritis
    This program has played a central role in clinically profiling the disease and in developing personalized treatment strategies. It includes patients with psoriatic arthritis as well as patients with psoriasis without arthritis followed prospectively to identify psoriatic arthritis early. Biomarkers for susceptibility and disease expression are being sought to facilitate early diagnosis and treatment.
  • Early autoimmune rheumatic disease cohort
    This is a novel clinic in which patients with serological abnormalities, but not yet clinical autoimmune disease, are registered and followed with clinical and immune profiling.
  • Scleroderma
    This program has developed a rigorous clinical database which identifies complications of the disease and is actively involved in clinical trials of new therapeutics.
  • Sjögren’s syndrome
    This program has created a multidisciplinary clinic which incorporates ENT, Ophthalmology and Rheumatology into a comprehensive care model.

The strength of these programs has made the Division of Rheumatology the hub of the National and International networks for clinical research. It also serves as a magnet for trainees, both national and international.

Krembil Programs

Basic & Clinical Research

Krembil Research Institute is the hub where basic, clinical and translational research in arthritis is conducted. Basic, clinical and translational research in arthritis at the Krembil focuses on basic understanding of diseases mechanism, identifying novel ways to detect the disease, as well as new therapeutic strategies to stop or prevent arthritis and musculoskeletal diseases including autoimmune rheumatic, bone, joint, and spine conditions.

In addition, the majority of the wet lab research of the 4 clinical programs is housed within the Buchan Arthritis Research Centre and comprises world class infrastructure and equipment to conduct basic, clinical and translational research.

Health Care and Outcomes Research

The priority of Health Care and Outcomes Research at Krembil is to reduce the impact of arthritis on individuals and the health care system. To achieve this, our research spans the range of biological to health and social policy factors, including clinical aspects and all types of arthritis. We investigate risk factors and their modification to prevent disease and disease progression. Major research foci include differences in manifestation of arthritis and differences in access and response to care. Aging and differences between men and women, social determinants of health and lifestyle factors (e.g., obesity, physical activity, sedentary behaviours etc.) are key considerations. Our research is translated and implemented by working with patient advisors, clinicians, policy makers and other stakeholders to develop, evaluate and implement programs and new models of care to enhance access, improve effective management and outcomes for people with arthritis.