The flight back from San Francisco to Missouri offered the opportunity to catch up on some magazines that I threw into my briefcase for the trip. After exhausting Rolling Stone and the swimsuit issue, I noted that the cover story of Scientific American was about the controversy over animal research. The topic brought up two particular papers from the Academy meeting, both having to do with trauma research done on baboons. Now, I am no animal rights activist, and I have dispatched my share of rodents to the great beyond in the name of science, and, in fact, am doing so on a regular basis. None the less, both of these studies raised questions in my mind. One had to do with measuring the pressure in the baboon femur during reamed and unreamed nailing using custom designed baboon nails and reamers. Is there any reason to think that the pressures in the baboon femur are determined by anything other than the size and shape characteristics of the bone and of the reamers? Why would these be translatable to the bones of another species with different implants? Is it really relevant to the human situation? Why couldn't it be done in humans to begin with? The other study involved the creation of a compartment syndrome in the baboon calf which was then treated with pneumatic foot pumps, and examination of calf muscle tissue was done after a week. The goal seemed to be more or less to see what happened, and whether pulsatile plantar compression would lessen muscle damage. A compartment syndrome is something we know to be painful, crippling and permanent, and moreover has a well defined and accepted treatment. The authors are careful to state that they are not suggesting, or even looking for, any change in treatment protocols. Is the research question asked in this study of sufficient importance to justify the animal treatment that accompanied this project? In my opinion, the answer is no.

In the Scientific American article, those arguing against animal research make their points on purely scientific merit. They point out the artificiality of some experiments and the often poor correlation between animal models and the human situation, as in the first baboon study mentioned above . They wisely avoid the emotional or philosophical arguments often seen in the lay press. The authors on the other side have an easier job, and argue from historical evidence on the importance of animal studies to modern medicine. Both sides point out the use of modern methods such as computer modeling, cell and tissue culture and statistical methods to decrease the use of animals, but they differ in how much they think such techniques can decrease animal use. The most effective way ultimately involves the researcher asking him or herself whether the project is really relevant and well-designed enough to give an important answer, and whether there might be other ways to answer the question. This can't easily be delegated to institutional animal use committees.

Most people are (perhaps illogically) bothered less by research on lower forms like worms, insects and politicians than that done on intelligent primates, but the scientific validity is less farther away from our own species. In any event, it is an issue with ethical and scientific aspects worth taking seriously, particularly in trauma research. Our response to extremism among animal rights activists should not be an extremism in the other direction, but a rational aknowledgement of the legitimacy of the question.

On a different topic, some other papers from from recent meetings genreated some thoughts about potential roles for our organization. There were several papers at the AAOS meeting comparing different methods for the prevention of relatively rare complications ( infection after open fracture - systemic vs. local antibiotics; pulmonary complications of reamed or unreamed nailing, heterotopic bone prophylaxis with Indocin or radiation) and all suffered from lack of statistical significance due to low numbers. Perhaps the identification of these sorts of questions and the development of multicenter study groups to answer them would be an appropriate function for a national organization such as OTA. Protocols could be developed and investigators recruited under the auspices and using the resources of our group. E-mail would lend itself well to such an endeavor.

At the Mid-America Orthopaedic Association meeting I saw a paper from Barry Munn and colleagues in New Orleans reviewing all the FDA Medical Device Reports (MDRs) over a 9 year period related to total hip and knee arthroplasty. It turns out that hospitals are supposed to be reporting all medical device related complications to the FDA, but these authors estimate that less than 5% of such events are reported. They also found that device related complications or failures were even more significantly underreported in the medical literature. Device problems which appeared a handful of times in the literature had actually been reported dozens or hundreds of times to the FDA. Most of the time this information is spread by word of mouth. Given all the new internal and external fixation devices that are making it to market with little clinical experience, could we develop a national registry of device-related problems and complications, focussing on fracture fixation devices, in which our members could pool their experiences? All identifying information would be removed, but adequate clinical details retained to understand the complication and contributing factors. Participation would be voluntary, and might include some analysis by the reporting member about what went wrong. Would this help us to identify problems earlier, and protect some patients from preventable complications, or would it be a political and legal quagmire?

In our initial issue, I promised to share reader mail and comments with all of you. To date, the modesty of your humble editor has precluded that, as all correspondence has been embarrasingly congratulatory. However, in this issue I have included some reader comments which may be instructive and/or amusing.

Dr. B. R. Moed of Detroit, Michigan writes: I recently received my copy of "Fractoids". I could not help but notice the listing of who won or lost the controversy debates at the last OTA Annual meeting. Since I know of no formal poll or grading of these presentations, I would like to know how you came to these conclusions....Perhaps this was our own private poll. Or perhaps this was just your own personal response. In either case, I think that you are totally full of crap.

Whoa, dude. Time to switch to decaf!
Okay, for the record: All subjective opinions expressed in this newsletter (including but not limited to debate winners, sushi bar reviews, cigar evaluations and stock market predictions) are solely those of the Editorial Board, and do not represent the official opinions of the OTA or its officers, although if they had any sense they would mostly agree. Any person taking exception to those opinions has the option of filing a formal appeal with the Editorial Board, or writing your own newsletter, or better yet write something for this one and inflict your own half-baked impressions on the readership along with ours.

The OTA Board of Directors met in San Francisco prior to the Specialty Day business meeting. Due to the absence of Dr. Bone, President-Elect Kellam presided over the meeting. The minutes from the previous Board meeting in Boston were reviewed and accepted after minor corrections. Other business conducted by the Board included:

Received the report of CFO Brad Henley. As of 12/31/96, the operating expense budget showed an excess of revenue over expenses of approximately $3000.00. Dr. Henley reviewed the financial status of several OTA programs. The annual meeting produced a profit of approximately $100,000, the residents' course yielded $2,028, Specialty Day produced $29,988, and Trauma Update Courses lost $13,940 this year due to cancellation of the Dallas course.

The research fund received $265,456 in contributions during fiscal 1996 including $19,350 from individual contributions (see related story), and $164,500 in corporate donations. Profits from the OKU-Trauma brought $41,000 to the research fund and AO North America provided research support of $81,106.

Received the report of COMSS representative Alan Levine and reviewed the minutes from the COMSS meeting in November. Two areas of current special interest for COMSS are the problems specific to the aging population and family violence. Specialty societies are being asked to think about these two areas and how they can be involved through education or research, and through including these topics in programming.

A number of documents were distributed at the COMSS meeting concerning legal issues surrounding society educational activities. In particular, emphasis was placed on the importance of identifying the FDA status of all devices in the program, at workshops and at all exhibits at meetings.

Dr. Levine also stressed the importance of support for the Orthopaedic PAC, as our voice in Washington. The level of support in the orthopaedic community for this vital activity has been disappointing.

The Board discussed the proposal from Lippincott-Raven Publishers regarding publication of the annual meeting program. It was decided that we would allow the annual meeting abstracts to be printed in Journal of Orthopaedic Trauma, perhaps as a supplemental issue.

Discussed the Specialty Day program for this and next year, and the overall philosophy of Specialty Day. It was reported that pre-registration was 581 this year, which is an increase of over 200 from last year. The concept of having a "members only" scientific meeting in some manner was discussed. It was felt that this would be a chance for members to get together with other orthopaedic traumatologists and talk in greater depth and detail, explore controversies, coordinate research, etc.

Received notice of a 2 year grant in "blood conservation" research that has been funded by Ortho Biotech. The grant is available to members of 4 specialty societies, one of which is OTA.

Discussed the issue of spine trauma training and the role of the orthopaedic traumatologist in care of spinal injuries, which had been raised in a letter to the Board by Dr. Timothy Bray.

Received the report of President-Elect Kellam, who discussed his plans for the year, in particular, his interest in making the OTA an international leader by involving our corresponding members more. One way to do this may be by organizing national "chapters" of the OTA in non- North American countries to encourage participation.

Committee reports:

Coding, Classification and Outcomes:
AO North America has agreed to fund a position for 2 years to work with the database Ortho Trauma 95. At present, the project is focused on collecting and image database.

Education:
The Newport and Pittsburgh Trauma Update courses are set up and fliers mailed. (See OTA web site for the program). Next year courses are planned for Seattle and Atlanta, chaired by Chip Routt and Mary Jo Albert, respectively. The residents' course under the direction of Dave Templeman will soon have it's final schedule. The goal for this year is to improve the workshops by involving more OTA members as table instructors. There will be a syllabus with the course this year.

Fellowships and career choices:
Paul Tornetta is working on producing a residency trauma curriculum for use by program directors. The question of necessity of a fellowship curriculum is unclear. A discussion of the issue of physician unionization was presented (see associated story).

Research:
Letters from Mike Bosse were reviewed outlining a new procedure for evaluation of research grant requests. All investigators will be requested to provide a pre-proposal to the committee by April 1, which will be graded (in a blinded manner) on anticipated scientific merit, impact and general interest. Selected investigators will be invited to submit a full proposal by the August 1 deadline.

The last decade has witnessed a tremendous loss of physician autonomy and erosion of the doctor-patient relationship fostered by the incursion of insurance companies and managed care organizations into the healthcare decision making process. The physician response has generally been "reactive". As alliances and consolidations occur between hospitals, insurers, and HMO's, the physicians have found themselves scrambling in a musical chairs-like game of diminishing financial reimbursement. Panic decisions are made by practitioners who find themselves aligning with an alphabet soup of PPO's, MSO's, IPA's, etc. for fear of being locked out of a region's patient base. More time gets spent meeting with administrators than with patients, practices become unhinged, and patient care suffers.

This state of affairs is inherently ripe for the concept of "unionization". In early February of this year, the Philadelphia County Medical Society hosted a meeting attended by nearly 200 physicians to hear speakers discuss the rationale behind a physician's union. Raymond Lodise, the Society president, has stated, "I'm for whatever can work for physicians . . . that has teeth, and I don't know of anything that has teeth outside of a union".(1) (Philadelphia Inquirer, 2/3/97).

Unionization in the healthcare field is not new. Physicians, however, have been constrained from organizing because they are viewed as being "independent contractors". As such, they are prohibited by antitrust laws from engaging in collective bargaining or other activities which may be perceived as restraining competition. However, these laws affirm the right of workers to organize and engage in collective bargaining as long as they fall within the common law definition of "employees".As more physicians become "employees, the impediments to unionization diminish. Currently, 43% of physicians in the United States are now employees, up 20% in ten years. More significantly, nearly 65% of physicians who are less than five years out of their training are employees. This group will have the greatest need for the protections afforded by unionization.

Currently, there are two major physician unions, both in states with a high penetration of managed care, Florida and California. Recently, podiatrists in Pennsylvania have organized into a guild which already has members in eight states and has been invited to make presentations in 35 others. They are clearly targeting M.D.'s in their organizing plans. It is estimated that less that 20,000 of the 720,000 physicians in the United States currently belong to unions (American Council on Medical Services); however, it is anticipated that this number will increase as labor organizers become more aggressive and physicians become increasingly disaffected by loss of control.

Many Orthopaedic traumatologist are employed by their institutions. The concept of unionization may have an impact on our futures as the issues of job security and compensation continue to intensify. Whether the courts would view any attempt at organizing as legal is unknown. At issue is whether such a group is regarded as a genuine effort to improve the terms and conditions of employment rather than a vehicle to enjoin competition among independent contractors. Further, a union's ultimate power lies in its ability to strike. For physicians, striking seems to run counter to the oath we took and to the very reasons we have chosen our profession. The OTA will continue to monitor this situation with more than a little interest.

As of the end of our fiscal year, December 31, 1996, OTA had assets in excess of 1.1 million dollars. Principal sources of our net worth have been donations and excess revenues generated from our operations in past years. OTA assets are separated into two discreet funds: an Undesignated Fund used for daily operations, and a Designated for Research Fund. Corporate donations, investments, royalties and interest derived from investment securities in the Research fund are used to support OTA research activities. As of December 31st, 1996, the Research Fund held approximately $840,000 of our net worth. Organizational donations for 1996 exceeded $250,000. Major contributors have been AO North America ($81,106), ACE/DePuy ($50,000), Synthes ($45,000), Smith and Nephew Richards ($25,000), Howmedica ($20,000), Sofamor Danek ($15,000) and Zimmer ($10,000). Additionally, OTA received over $40,000 from royalties on the AAOS publication OKU: Trauma edited by Alan Levine.

In regard to OTA operations, your CFO endeavors to keep approximately one year's cost of doing business in the Undesignated Fund. At year end, this account balance was about $271,000. For 1996, Society operations just exceeded the break-even point. We had revenue of approximately $235,000 and expenses of $232,000. Principle revenue sources included membership dues ($110,000) and proceeds from educational meetings ($121,000). Our major expenditures were for management "overhead"expenses (AAOS Specialty Society Services Department - $136,000), committees ($36,000) and publications (Orthopaedic Trauma Subscriptions, publication of the OTA Fracture Classification and Newsletter Fractoids - $44,000)

The majority of OTA assets are in intermediate-term, high grade investment bonds, because our objective is relative stability of principal value, while maximizing return. In 1996 the Board of Directors approved diversification into equities not to exceed 25% of the assets in the Research Fund. This decision was made to improve the return on our investment portfolio, above that afforded by debt securities. We have begun to invest in the equity markets using a dollar cost averaging approach, and we will attempt to match the return of the S&P500.

In summary, my investment decisions have been to maximize return on our investments without incurring excessive risk. My goal is to maintain the financial vitality of our Association using a fiscally responsible approach.

OTA Specialty Day Program in San Francisco was attended by 835 people, a record attendance. The program was organized and coordinated by President Larry Bone with the assistance of Robert Brumback, David Helfet, Jim Kellam, and Don Wiss. The program began with a section on evaluation of the injured extremity with particular emphasis on soft tissue assessment. Bob Winquist moderated a panel discussion on the pros and cons of reaming in open and closed fractures of the tibia and femur. The nine papers selected by the program committee as "Highlight Papers" from our annual meeting in Boston were presented. Jeff Mast gave the Presidential Guest Lecture on "Osteotomy about the Hip". The afternoon program included sessions on intraarticular fractures, indirect reduction, and complex femoral fractures. Many OTA members were involved in the program and are to be congratulated on a popular and excellent effort, which seemed to have presentations of value to the orthopaedic traumatologist as well as the general orthopaedic surgeon.

At the annual member's business meeting held in conjunction with the specialty day program, new officers were elected. President-elect is David Helfet, Secretary is Jim Goulet, new at-large board members are Ross Leighton, Andy Burgess, and David Templeman. Brad Henley continues as CFO, and Barry Riemer and William DeLong were elected to the membership committee. New members were welcomed to the organization; there were 16 active, 16 associate, 8 corresponding and 1 new research member. Five members advanced from associate to active.

I would like to take this opportunity to express my appreciation to all of the members of the OrthopaedicTrauma Association for entrusting the guidance of the Association to me for the next year. I hope I will be able to carry forth the ideas of our past presidents and also forge new ideas that are important for us as we move towards the twenty-first century. It is my pleasure to officially thank Larry Bone, our past president. Larry was very active throughout the year in guiding the organization. Unfortunately, Larry was forced to miss our Specialty Day and his final duties. Consequently, on behalf of all of the membership, I would like to take this opportunity to thank Larry for all he has done and to let the membership know that he is fully recovered and back working as hard as ever.

There are several areas that the membership should think about over the next year, and perhaps through our email discussion list, members can let the board know of their feelings. First, what is the Association doing for its membership? There is no doubt we have become leaders in education. However, are we meeting your needs with regards to orthopaedic trauma? The Association does not provide its membership with a closed meeting in which we may present to each other new, innovative, and current state of the art research or techniques. These are areas from which we would like to have input from others, but not in the general meeting. Does the membership feel that we should consider the development of such a closed meeting on an annual basis for our members to interact with each other? Second is the development of clinical practice guidelines. There has been a flurry of interest on the orthopaedic trauma web. As we see more and more emphasis on practice guidelines, I think it is important that the Association become the leader in this area. I would like to know your comments and thoughts. There is a downside to practice guidelines, but I think there is a more important, positive side if the Association is the one giving the stamp of approval to practice guidelines with regard to the care in orthopaedic trauma.

Finally, what about the increasing development of subspecialty care within orthopaedic trauma? The development of subspecialty areas in shoulder, elbow, wrist, foot and ankle has led these groups to espouse their expertise in fracture management. My concern is: where does the orthopaedic traumatologist fit in? Are we going to be left with only the pelvis, or diaphyseal fractures, and how should we react to this? We, as orthopaedic traumatologists have prided ourselves in an understanding of the physiology and mechanisms of trauma, the insults to and the responses of the total patient, and how this is modified, then applied to the patient in fracture care. We are also constantly involved in the assessment and handling of the soft tissues, and how important this is towards fractures care! I think it is time that the Orthopaedic Trauma Association began to develop cooperative relationships with these subspeciality societies, so that a common area can be developed and perhaps cooperative studies and protocols formed.

Please let the board know of your feelings. I look forward to a very successful, stimulating and fruitful year for the Orthopaedic Trauma Association and yourselves.

Thirty-nine individuals used their 1997 OREF donation to help support the OTA's research program. They are listed below. Donations to the OREF at the level of the "Order of Merit" ($1,000) or above can have up to half of the amount directed to specialty societies such as OTA. All members are encouraged to remember this method of supporting our research mission.

• Jeffrey O. Anglen, MD
• Dr. & Mrs. Michael R. Baumgaertner
• Dr. & Mrs. Alfred F. Behrens
• Dr. & Mrs. Phil H Berry, Jr.
• Dr. & Mrs. James C. Binski
• James P. Blasingame, MD
• Charles N. Cornell, MD
• Dr. & Mrs. Thomas A. DeCoster
• Dr. & Mrs. Paul J. Duwelius
• Dr. & Mrs. John R. Edwards
• James F. Fahey, MD
• James A. Goulet, MD
• Dr. & Mrs. Douglas P. Hartzler
• Dr. & Mrs. J. Paul Harvey
• David L. Helfet, MD
• Dr. & Mrs. Edward T. James
• Dr. & Mrs. Kenneth D. Johnson
• Joseph M. Lane, MD
• Gerald J. Lang, MD
• Richard H. Lange, MD
• David W. Lhowe, MD
• Kevin W. Luke, MD
• John P. Lyden, MD
• Dr. & Mrs. Frank W. Maletz
• Dr. & Mrs. Glenn E. Oren
• David M. Ott, MD
• Michael J. Patzakis, MD
• James A. Pollard, MD
• Dr. & Mrs. Uwe R. Pontius
• Drs. Matthew and Ann Putnam
• Patrick B. Respet, MD
• Howard Rosen, MD
• Christopher Stack, MD
• Dr. & Mrs. Marc F. Swiontkowski
• George R. Tanner, MD
• Mrs. Patricia G. Thorne
• Thomas F. Varecka, MD
• Charles N. Versteeg, Jr., MD
• Robert A. Winquist, MD

The 1997 annual Meeting of the Orthopaedic Trauma Association will be held in Louisville, Kentucky on October 17 through 19. The meeting will be held in conjuction with a meeting of the Kuntscher Society, an international organization of orthopaedic traumatologists, and the programs of both organizations will be open to mebers of either group. Thomas Varecka, program chair for the OTA meeting, reports that over 460 abstracts were submitted for presentation at the meeting, and the committee has selected approximately 65 of the best studies for the program. In addition, guest speakers, controversy panels, symposia and an extensive poster presentation area are being organized. The resident's basic fracture care course will be run concurrently, organized by David Templeman. Make plans now to attend the meeting!

The OTA and AO North America will jointly sponsor the first annual John Border Lectureship in Orthopaedic Traumatology, to be given at the annual meeting in Lousville. This lectureship has been established to honor the memory of Dr. John Border, who was instrumental in development of modern trauma care. He was the pioneer in the concept of total care and the implications of musculoskeletal injuries on the overall management of the trauma patient. The lecture will be given each year at the fall meeting of the OTA. The recipient will be a mutual selection made by the Chairman of AONA and the President of OTA, and will be a recognized world expert in orthopaedic trauma care.