As you can see we have selected a newsletter name. "Fractoids" was suggested by Phil Spiegel and is a reference to the CNN program "Factoids". Other names considered included "Fracture Lines" and "The Acetabloid", from Kim Alexander. Thanks to Phil and Kim for their creativity.

Many thanks to the contributors to the first issue, including Alan Levine, Ken Johnson, Bob Winquist, Don Wiss, Bruce Browner, Jim Goulet, Chip Cornell, and Jim Kellam. We have received a lot of compliments from the membership on the newsletter, and lots of suggestions from the Board of Directors as to how the newsletter can be used to make our organization more effective and cohesive.

The orthopaedic trauma discussion list has been a little slower to take off. We presently have about three dozen members signed on to it. We still feel that this has great potential as a way to inform members about issues rapidly, generate discussion and debate, identify resources and interests, consult, inform and educate. Once you have signed on ("subscribed"), you get a copy of every message sent to the list ("posted") in your email, to read at your leisure. You can respond to agree, disagree, elaborate, or question, and your responses are automatically distributed to everyone one the list. Obviously, such a forum relies on participation of the members for its usefulness. To subscribe, send an email message to: Listproc@lists.missouri.edu. Leave the subject line blank, and in the body of the message write: "subscribe Ort-L your name", replacing "your name" with your name, first and last. (You may think that is obvious. So did I.) Please sign on and help us make this work.

There has been some interest in an OTA home page on the World Wide Web. In view of the fact that so few have been active in the email list, it is unclear how much demand there would be for a web site. I would be interested in hearing any thoughts anyone has on the topic, any other feedback on the list or the newsletter.

The recent annual meeting in Tampa successfully integrated a stellar scientific program, the members' business meeting, a new resident education course, and a delightful social schedule, all in the space of a few days. The Tampa Convention Center proved to be a wonderful setting for both the meeting and the resident's course. There were 424 participants pre-registered, and another 60 registered on-site.

The scientific program, put together by Dr. Wiss and the program committee, consisted of 61 papers and 107 poster presentations. The papers were grouped into topic sessions: basic science, tibia, polytrauma, pediatric/ spine, foot/ankle, upper extremity and pelvis/acetabulum. Each group of two or three papers was reviewed by an discussor, and time was allowed for floor comments. A symposium discussing the relative advantages of reamed and unreamed femoral nailing included Drs. Winquist, Duwelius, Templeman and Regel. The take-away message from that symposium, and confirmed by several papers in the scientific sessions, was that the recent concerns about reaming the femoral canal are not supported by clinical or experimental data. There does not seem to be a physiologic advantage, in terms of pulmonary function or in infection resistance, to unreamed nailing. The number of patients in some of the studies was small, however, and it is possible that larger studies with more statistical power will bring out some more subtle differences between reamed and unreamed nailing. Dr. Winquist gave an excellent discussion of the difficulties of removing broken intramedullary nails, and warned against the use of solid nails due to the difficulty of extracting broken parts.

Dr. Levine gave the first ever OTA presidential address, entitled "The Graying of the Orthopaedic Trauma Surgeon", in which he discussed problems in recruitment, retention, and maturation for orthopaedic traumatologists. He noted that trauma fellowships represent less than 4% of all orthopaedic fellowships, that there is a 15% annual attrition rate in the sub-specialty, and that ~25% of academic programs do not have a traumatologist on staff. The average duration of practice in orthopaedic traumatology is 5 years after fellowship. He listed many possible causes for this situation, including unpredictable schedules, reimbursement problems, malpractice risks, potential disease exposures, and a perceived lack of respect from colleagues. There is no predictable course of career development for the traumatologist, and limited opportunity for research and academic advancement. The solutions he proposed include better education of our residents and colleagues, alterations in fellowship training to include other areas such as reconstructive surgery, and continued efforts to improve reimbursement by making others aware of the difficulties and complexities of trauma surgery.

Other speakers included Dr. William Tipton from the AAOS, who discussed many social and economic trends in trauma care and the Academy's positions; and Dr. Bill Burman, who gave a fascinating multimedia presentation on the use of computers in orthopaedic education. Dr. Augusto Sarmiento, in a talk entitled "Is there a place for functional fracture bracing in the age of IM fixation?" discussed his experience with 1000 tibial shaft fractures treated closed He reported 1.1% nonunion rate and 1/3 the cost of surgical treatment. He noted a variety of forces which tended to promote surgical treatment, including industry-run CME, differential academic prestige, the content of training programs, and reimbursement factors.

The social highlight of the meeting was the reception at the new Tampa aquarium, organized by host committee chairman Dr. Roy Sanders. Members, guests and residents enjoyed music, food and drinks while taking the opportunity to wander around the aquarium, which was closed to other visitors for our event. Former Tampa residents and trauma fellows, along with the OTA Board of Directors and other guests had dinner at the Columbia Restaurant in historic Ybor city, also hosted by Dr. Sanders. Participants sampled the well-stocked humidor (particularly excellent was the Arturo Fuentes Hemingway Classico), and were treated to an exhibition of flamenco dancing.

For the first time, the OTA put on a resident's course in basic fracture care, organized by Dr. Winquist and the education committee. Attracted by the outstanding faculty (70 OTA members participated in teaching), 81 orthopaedic residents spent 4 days listening to lectures and working in the labs with OTA faculty. Workshops included everything from lag screw technique to placement of hybrid fixators to use of a halo jacket. The faculty talks, limited to 10 minutes per topic, were focussed and to the point. The Resident course will be repeated at next year's OTA meeting in Boston.

At the members business meeting, the members approved the minutes from the February business meeting, and received reports from Dr. Henley, Chief Financial Officer; Dr. Johnson, chairman of the Nominating Committee; and Dr. Wiss, chairman of the Program Committee. Dr. James Goulet, chairman of the Membership committee gave his report to the members and discussed an important issue presently being reviewed, the requirements for OTA membership. It has been suggested that we liberalize the criteria, specifically the requirement for being lead author on 1, or co-author on 3, published peer-reviewed articles regarding trauma in the last 4 years. Increasing our membership would be advantageous in terms of financial stability and political clout, but may risk changing the character of the organization. Dr. Goulet's committee has been charged with studying this question, and he passed out a survey to ascertain the feelings of the membership. Any members who wish to express an opinion on the matter should contact Dr. Goulet.

Meeting in Tampa, the Board of Directors received a report on a restructuring of the OTA committee system. The proposed restructuring provides that all appointments will run from specialty day at the AAOS meeting to the following year at the same time; all committees will have three year terms with one possible three year extension; and the chairman will be chosen from those eligible for renewal and will have a three year term. The following committees will be established:

• Research Committee - 9 members
• Program Committee - 9 members
• Bylaws Committee - 3 members
• Membership Committee - 5 members, elected
• Coding, Classification, and Outcomes Committee - 6 members
• Fellowship and Career Choices Committee - 5 members
• Archives Committee - 3 members
• Education Committee - 10 members
• Annual Meeting Arrangements committee - 10 members
• Health Policy and Planning Committee - 9 members
• Nominating Committee - 5 members, elected
• Recruitment, Retention and Maturation of Trauma Surgeons/Ad Hoc Committee - 5 members
• Policy and Procedures/Ad Hoc Committee - 5 members

All of the committees now have written charges which have been developed by the current chairmen, with Board input. Certain committees have specific makeups designated. Most of these changes require alteration of the OTA bylaws, and will be presented to the membership for approval at the Specialty Day meeting in February. Members interested in serving on committees should contact the President-elect (presently Dr. Larry Bone), who will compile a file of volunteers to be used to fill committee slots when they become available.

The Board of Directors received reports from the committee chairmen at the Tampa Board meeting. Excerpts of key reports are below:

Education
Chairman Bob Winquist reported that the two Trauma Update Courses of the past year had been successful, with 78 attendants in Reno and 74 in Buffalo. Surveys of the participants showed them to be mostly older orthopaedists in practice who considered the course as their one trauma course for the year. They identified "keeping current in fracture care" and "learning about recent innovations" as the primary goal of their attendance. There is one Update Course scheduled for the coming year, in Dallas on April 12-13, to be chaired by Dr. Bob Bucholz. The focus will be on "bread and butter" trauma surgery for the practicing orthopaedist.

Research
Chairman Chip Cornell reported that the committee reviewed 10 late applications from 1994, and 29 from the 1995 funding cycle. Eleven grants have been recommended for funding by the Board, totaling over $160,000. He noted that the committee should continue to favor start-up projects which will help launch young faculty, in the range of $20,000 or less.

Membership
Chairman James Goulet reported that 36 applications for active membership were received, of which 20 were complete, and 17 accepted. Thirteen applications for associate membership and 7 for corresponding membership were accepted. Two completed applications for research membership were submitted and accepted. A total of 38 new members were accepted out of 43 completed applications. He discussed with the Board the effects of the publication requirement on the recruitment of new members, and was directed to further study the potential outcome of easing that restriction, and the wishes of the membership on that issue.

Coding, Classification and Outcomes
Chairman Jim Kellam reported that the OTA Trauma Registry database software is ready to be distributed. He noted that 40 people attended the user's meeting in Tampa, and physicians outnumbered data entry personnel. There will be an application process to get the software, and a small licensing fee to cover the costs of royalties to the AMA for the use of CPT codes. Dr. Kellam also informed the Board that the Compendium of Fractures and Dislocations funded by the OTA will be sent as a supplement to the Journal of Orthopaedic Trauma soon after the annual meeting.

Fellowship and Career Choices
Chairman Chris Born reported that his committee had completed a survey of all orthopaedic trauma fellowship program directors and compiled a booklet containing the information. This will be distributed by the OTA to prospective applicants. Currently, there are 29 American programs with 50 positions and 5 Canadian programs with 7 positions. There are believed to be about 45 American applicants per year, and 6 programs currently have no fellows. Twenty five of 29 program directors thought that broadening the scope of training to include subjects ancillary to trauma would increase the applicant pool, and 20 have already begun to do so. He encourages all program directors to be sure that their program is listed in the AAOS fellowship directory, as that is the main source of information for applicants.

Health Policy and Planning
Chairman Bruce Browner and committee member Jeff Anglen discussed the results of the Academy's presentation to the RUC regarding CPT codes which we feel to be undervalued in the present relative value scale used by HCFA. Unfortunately, less than 30 out of 200 surveys sent to OTA members were completed and returned, weakening our argument for increases. The RUC accepted our recommendation to increase the value of 6 codes, did not accept with our arguments to increase 7, and referred 1 code to the CPT committee. The RUC recommendations now go to HCFA.

From the AO North America News, Issue no.5, may 1995:

Peter Trafton MD, President of AONA, wrote: "To preserve enough of our limited resources for educational efforts, and to improve our collaboration with the excellent peer reviewed research program carried out by the Orthopaedic Trauma Association, the Steering Committee chose to discontinue our independent research funding program for orthopaedic research, and instead to make a significant contribution to the Orthopaedic Trauma Association for this purpose." AONA initially designated $75,000 as a 1995 grant to the OTA, to be awarded as peer-reviewed research support. The OTA agreed that these funds would be available not only to OTA members, but also to AONA members who may not necessarily belong to the OTA.

From the AAOS Bulletin, vol.43 no.3, July 1995:

After a reviewof malpractice claims on the treatment of tibia fractures, the Academy's Committee on Professional Liability found the most common causes of suit were: nonunion, malunion, infection, length discrepancy, and skin injury. They suggested that including discussions of potential nonunion, malunion and length discrepancy in preoperative patient education may help forestall suits. Infection and skin injury suits are defensible if recognized early, documented and treated appropriately with culture and antibiotics. They encouraged early and frequent communication with patients, and noted that documentation of such communication is essential. The largest payouts involved vascular and compartment syndrome problems, although these were relatively infrequent.

From the American Association of Hip and Knee Surgeons Newsletter:

Dr. Larry Dorr, President of the AAHKS, has initiated the development of a legal defense team for AAHKS members. Members of the organization can submit details of a malpractice suit against them to the legal defense team, who will help determine if the suit is defensible. If it is, the team will participate in providing expert witnesses and information to educate the defense lawyers. The team is made up of volunteer members of the AAHKS. Dr. Dorr reports that, as of August 8, the concept has progressed to an action team, and has received its first case to evaluate.

The Orthopaedic Trauma Association has taken as one of it's projects the implementation of a standardized fracture classification system. This began six years ago spearheaded by Dr. Mark Swiontkowski. The concept was to develop a standardized commonly acceptable compendium for fracture documentation. This was combined with a minimal set data base so that initial documentation of the orthopaedic trauma patient and their injury could be done in a standardized manner. Beginning with the Muller Long Bone Classification System as the basis for itemizing long bone fractures, the Orthopaedic Trauma Association Coding and Classification Committee has extended this to include all other bones of the extremities. With the help of Drs. David Helfet, Emile Letournel, Joel Matta, and Marvin Tile, the pelvic and acetabular fractures have also been added.

This compendium of fractures and dislocations will be published as a supplement to the Journal of Orthopaedic Trauma. A data base was created to evaluate the patient injury characteristics and treatment in the initial phase. Subsequently, a functional outcome and long term follow-up aspect was added. This cumulated in a release of the first Orthopaedic Trauma Data Base, known as 4.2. With further advances in software development and the introduction of windows format, the Trauma Data Base has been re-written to become more user friendly.

It must be pointed out that under no circumstances has this data base or its fracture classification meant to prove or validate any given position. This is the beginning of an attempt to create a standardized fracture language so that in the future we will be able to correlate amongst ourselves more meaningful information.

To meet this need, the OTA's Coding and Classification Committee has a three year revision cycle. Once any program has been released, it will be revised over a three year period and then updated and released again. This will allow the membership to submit problems, changes, or verification of what is already present. This system cannot meet all needs, but it is an attempt to reach a minimum common ground. It is the Association's system, and therefore requires all of us to participate in its use so that it can be modified, changed and improved over the years.

The Bylaws and Hearings Committee will be proposing amendments to the Bylaws of the OTA at the next business meeting to be held at 12:30 p.m. on February 26, 1996, at the Omni Hotel in Atlanta, Georgia. A summary of the proposed Bylaw amendments is as follows:

Article V

Section I Classes of members have been changed to delete supporting members and to add a new category, corresponding research members.

Section VII Will be deleted. Loss of membership for missing two consecutive annual meetings will be eliminated.

Section XII Paragraph (a) Nomination to Honorary Membership may be made by a member of the Board of Directors or by the Chairman of the Membership Committee.

Section XIV Supporting membership will be deleted as a class of membership. A new class entitled, Corresponding Research Membership will be added. These individuals will spend a least 50% of their research effort in trauma, be an author of a minimum of 5 peer reviewed published articles dealing with orthopaedic trauma and have approval by 2/3 of the Research Committee who will forward his/her name to the Board of Directors.

Article VIII

Section III The Corporation's two representative to the AAOS Council of Musculoskeletal Specialty Societies will be selected from the Corporation's presidential line.

Article IX

Section II and III The Membership Committee shall Consist of five members of the Corporation, each of whom shall serve a single term of 3 years. Two committee members will be elected each year, except every third year when only one membership committee members shall be elected.

Article X

The proposed Bylaw revisions for appointed committees has been done to arrange the committees in alphabetical order and to make the term of each committee member 3 years. Committee members may be reappointed for one additional consecutive three year term. Members will not serve on appointed committees more than six consecutive years. A new committee called "Health Policy and Planning " has been added (Section VIII).

Article XV

Section VIII The fiscal year of the Corporation shall begin on the first day of January and end on the last day in December of each year. The Corporate year shall begin on Specialty Day a the annual meeting of the AAOS and will end at the conclusion of the subsequent Specialty Day.

Dr. Don Wiss, chairman of the Program Committee, introduced the scientific meeting by discussing the reasons why abstracts were rejected by the committee. He pointed out that the committee is composed of nine members who reviewed and graded the abstracts completely blinded to author and institution. There were 430 submissions this year and 62 were accepted for presentation. Some of the most common reasons for rejection were: the total series of patients was too small (case reports were felt to be inappropriate for presentation in this setting), or there were too many experimental groups, leading to inadequate numbers per group; the follow-up period was too short or too many cases were lost to follow-up; the study design was retrospective and nonrandomized or both; there was little or no meaningful data, or the data was inconsistent, not stratified, or simply didn't add up (arithmetic errors); there were study design flaws such as no controls or poorly defined groups; the conclusions were not supported or not stated; the information was not new or not useful for this audience. The committee wanted to remind investigators that no data equals no science. Tips for successful submission include: be brief, use plain English, make sure the spelling is correct, include clear and pertinent graphs and charts, don't try to impress the committee, have a more experienced colleague review and critique prior to submission, and, if you are still not successful, revise and re-submit. Abstracts should be clearly organized with the following sections: purpose, methods, results, discussion, and conclusions.

Over the past three years the Orthopaedic Trauma Association's research program has expanded significantly. Thanks to commercial sponsorship and pooling of funds with AO North America, the OTA research committee has more to work with. The mission of the research committee has been to provide funds for projects that will help the careers of young OTA members to get off the ground. Therefore, the committee is particularly interested in basic science projects submitted which involve modest budgets but address problems of interest to the Association as a whole. Recently, projects which study bone grafting, depot administration of antimicrobials, models of intra-articular fracture, and pulmonary effects of intramedullary nailing have been funded. In addition, several clinical projects which prospectively compare the outcomes of fracture treatment methods have been supported. The committee has tended to avoid funding simple biomechanical studies of devices and studies which explore new uses of existing commercial products. Biomechanical projects which involve studies of the stiffness of implant constructs have little clinical relevance unless they can be applied to a known clinical problem and can be shown to be relevant to the in-vivo mechanical loads expected in the injured patient. Studies which investigate commercial products should be funded by their manufacturers.

The OTA only funds projects in which an OTA member is an investigator, except for projects funded by monies from AO North America, which are available to AO members. Well written grants are more likely to be funded. A clear statement of the goals of the project and its relevance to current science or practice is needed. A hypothesis should be stated and the methods should be constructed to prove or disprove it. Each stated goal of the project must be clearly addressed by the methods and research plan. A thorough literature review should be submitted. Experimental models should be described in detail and any assumptions must be justified. The proposed analysis of the data must be described and numbers of animals or human subjects must be justified by appropriate power studies. Institutional review board approval of human or animal experimentation should be submitted with the projects. Having institutional support and endorsement at the time of submittal is a real advantage.

A thorough, realistic budget must also be submitted. Requests for funds to buy expensive equipment, to fund indirect institutional overhead, or to pay for travel will be denied. Fringe benefits for personnel who are assigned part-time to projects will probably not be funded. In general, one year projects are favored but good work which will require two or more years to complete will often receive multiple year support.

The committee encourages all OTA members to submit their grants for review. The committee is staffed by recognized experts with representatives from the fields of biomechanics, experimental biology, and outcomes research. Rest assured that your work will receive a thorough and constructive review.

An important achievement of the Coalition this Fall is recognition of trauma centers in the Medicare Reform legislation now being considered in the Congress. With the support of trauma professionals from around the country, the Coalition successfully included protections for trauma patients and trauma center reimbursement in a reformed health system.

The Coalition has also worked to preserve funding for the Injury Prevention and Control Center at the Centers for Disease Control, the National Institutes for Health and the Agency for Health Care Policy Research. At the time of this writing, the bill providing FY 96 appropriations for these programs is stalled in Congress.

But despite Coalition efforts, the Division of Trauma and EMS within the Health Services and Resources Administration of the Department of Health and Human Services was not funded, along with over 100 other discretionary spending programs. This program which provided grants to states to develop trauma systems has had the strong support of the trauma care community.

Membership in the Coalition continues to expand and individual as well as institutional membership applications are welcomed. For further information, please call 1-800-933-8226.

This year has been an exciting one for the Orthopedic Trauma Association. We have expanded our range of educational activities, broadened the scope and size of our annual meeting, increased our financial commitment to funding orthopeadic trauma research and begun efforts to educate those who influence our careers both financially and administratively. This has only been possible with the help of many of you who have volunteered your time selflessly to the organization. A few people deserve special mention. Both of our Trauma Update courses were successful educationally and financially, due largely to the efforts of Larry Bone and Tim Bray. Bob Winquist did a superb job of organizing our first resident fracture course and more than sixty society members participated in lectures and laboratories. I would be remiss if I did not mention the development of our newsletter and email discussion list by Jeff Anglen as important steps in disseminating information concerning a variety of issues facing members of our association.

The organization maintains a strong commitment to supporting research in the field of orthopeadic trauma. Our new relationship to the OREF has increased our ability to generate funds for the research endowment fund. When you donate to the OREF you can specify that a portion of your donation be used to fund research in the area of Trauma. The board of OTA has now separated all funds used for research funding from the general operating funds of the organization.

As I mentioned in my Presidential Address on "The Graying of the Orthopedic Trauma Surgeon", we have to improve the lifestyle and career development for the traumatologist. To that end, a distinguished panel composed of Andrew Burgess, Christopher Born and Peter Trafton presented a two hour symposium to the Academic Orthopedic Society in Washington on October 27th which generated a great deal of discussion and hopefully served to give program chairmen some useful ideas for retaining their traumatologists and improving their careers.

The final issue concerns the financial welfare of the organization. Although all of our educational activities have been self supporting and our research support comes from an independent fund, we will experience a financial shortfall in the coming year as a result of the dramatically increased management costs. The AAOS has revised its relationships with the specialty societies to a more strict cost accounting basis. With the new AAOS contract, our management costs have more than doubled in a single year. To partially offset that shortfall we have decided to increase the dues from $325 to $400 per year. In comparison to other societies this is still a bargain. OTA membership includes a subscription to JOT ($124), admission to specialty day ($125), member dinner on specialty day, a subsidized annual meeting registration (approx. $200), two newsletters, and, this year, a supplement to the JOT with the OTA fracture classification. With your support the organization will continue to grow and benefit all of us in the coming years.

As of our annual meeting in Tampa, OTA had assets in excess of $900,000. Principal sources of our net worth have been donations and excess revenues generated from our operations. OTA's assets are separated into two discreet funds: an Undesignated Fund, used for daily operations, and a Designated for Research Grant Fund. Corporate donations, investments, and interest derived from investment securities in this fund are used to support OTA's research activities. As of August 31, 1995, the Research Fund held approximately $650,000 of our net worth. Corporate donations for 1995 have exceeded $135,000. Major contributors have been Synthes, AO/ASIF, ACE/DePuy, Howmedica, Danek and Zimmer. The research awards for 1995 will be distributed by December 31 of this year.

In regard to OTA operations, a new management agreement was negotiated with the AAOS Society Speciality Services Department this year. This has caused our management fees to more than double, from approximately $60,000 in 1993 and 1994 to an anticipated $122,500 in 1995, and approximately $130,000 in 1996. These increased management expenses are offset in part by new management services which are now included in the contract. The AAOS's Specialty Society Services Department have included up to two regional courses, Specialty Day, and one residents' course held in conjunction with one annual meeting in the management contract. The Academy's new contract pricing is based on cost, and allegedly does not include profit or tax margins. Prior to 1995, the AAOS had been subsidizing the Specialty Society Services Department in order to strengthen the link between the specialty societies and AAOS. In 1994, it directed its Specialty Societies Services Department to break even, and hence instituted the new cost allocation methodology.

In summary, my goal is to maintain the financial vitality of our Association. My investment decisions have been to maximize return on our investments with a minimum of risk. The Board has approved investments in intermediate-term, high grade investment bonds, because our objective is relative stability of principal value, while maximizing return (the yield curve almost never rewards you for going beyond the ten-to-fifteen-year range).