We had a good response to the orthopaedic trauma service survey which was distributed in the last newsletter and via our E-mail discussion group. There were 56 North American centers which responded, 3 European, and one Chinese. Forty-one of the N.A. hospitals were level 1 trauma centers, 13 were level 2 and three were level 3. Twenty-seven respondents were in centers where orthopaedics was organized as a single academic department or division; 13 with multiple private groups, 5 with a single private group, and 9 situations had an academic group combined with private group(s). One left the "how are you organized" question blank, 1 said "yes" and 1 said "no". Forty-eight had residents; 12 did not.

There isn't enough space here to delve in detail into the results of this survey, but there were some differences I noticed in the handling of orthopaedic trauma, based upon how the orthopaedic service at the hospital was organized. Centers with an academic department were more likely to have a designated orthopaedic trauma service (24/36) than centers with multiple or single private groups (5/18), and were more likely to have a designated orthopaedic trauma director (20/36 vs. 6/18). Separate financial arrangements with the hospital for taking trauma call were more frequent in the private group setting (5/18 vs. 2/36) than in the purely academic or combo situation. Academic departments were more likely to have PAs, nurses, or Nurse Practitioners funded by the hospital or University for orthopaedic trauma care -11/36 vs. 2/18. While many centers had special call schedules for spine, hand and or pediatric trauma, hospitals with an academic group were more likely to divide trauma patients by subspecialty expertise, and to "hand -off" complex trauma as opposed to distributing patients strictly according to the call schedule.

The institutions who had orthopaedic trauma directors had a variety of duties for that person, from clinical (handle complex trauma cases, develop and monitor protocols), to administrative (call schedule, committee work, coordination of care, contracting, marketing, "keep partners in line"), to educational (CME, resident and fellow training, quality improvement) and research. We didn't address (but should in the future) how that person is selected and compensated for this service. I suspect for most it is a labor of love.

More details about the results of the survey will be put into a manuscript to submit to JOT, and in many ways the information is tantalizingly sketchy. More study will need to be put into this issue, but it seems to me that the organization of orthopaedic trauma care could greatly impact the quality of care delivered, especially given the development of traumatology as an orthopaedic subspecialty. The OTA should take the lead in developing minimum and optimal standards in this area. We could develop models of organization, similar to the model state society produced by the Academy, which would address issues of coordination, call, patient assignment, credentialing, outcome assessment and required hospital resources. Obviously, these would need to flexible and tailored to the specific local situation.

Your thoughts on these topics would be interesting. You can send them to the E-mail discussion list (ort-L@lists.missouri.edu or ) to me, and I'll post them.

Jeff Anglen
New E-mail address: anglenj@health.missouri.edu

The OTA Board of Directors met on Saturday, March 21, 1998 at the Marriott Hotel New Orleans. The following issues were discussed and actions taken:

Bill Burman and Ken Johnson discussed the Interactive CR-ROM project which the OTA is developing. Despite some problems with participation in the project, a demonstration topic of femoral neck has been completed and was shown at the meeting. It was felt to be an impressive accomplishment with tremendous teaching potential.

The Board reviewed the minutes from the COMSS meeting of 12/97, and discussed our representation. It was decided that the president-elect would be the alternate delegate.

Dr. Kellam discussed the role of the AAOS committee on trauma and our relationship with them. He suggested that the Chairman of that committee (Presently Dr. Barry Riemer) be invited to OTA Board meetings in the interest of better coordination. He reported that there will be a research direction consensus meeting called the "Bone and Joint Decade" in Lund, Sweden and suggested that the OTA research committee chairman, Dr. Bosse, be sent to represent us.

Old Business: The Specialty Day program was discussed. For the first time, the syllabus content and bibliography was available on our website before the meeting. It is anticipated that this will be an increasingly utilized means of distributing the content of our educational efforts. The effect on meeting attendance was discussed, with various opinions expressed. This year, pre-registration was down slightly (approx. 400), probably due to the off- site location of the meeting. The idea of having separate, simultaneous members-only sessions during Specialty Day was discussed.

The report of the nominating committee was presented and approved by the Board, the slate will be presented to the membership at this meeting.

Committee appointments and changes were presented by Dr. Helfet, president-elect. New committee chairmen were noted: Archives - Jeff Anglen; By-laws and Hearings - Raymond White; Education - Jim Kellam, Membership - Paul Tornetta. New members were appointed to fill vacancies: Archives - Meek; Bylaws - McAndrew; Coding - Borelli and Webb; Education - Helfet; Fellowship - Miller and Stephen; Policy - Finnegan and Henry; Program - Olson and Tornetta; Research - Lane.

A revised version of the musculoskeletal management section of the ACS Optimal Resource document was reviewed and approved. After discussion of this important issue, Andy Burgess and Larry Bone agreed to continue to work on the evolution of it.

The AAOS is producing a CD-ROM containing the contents of all the OKU's and the OTA will receive a portion of the royalties (12.5%) from this project.

Committee Reports:

Program: Dr. Tom Varecka reviewed the Annual Meeting program in Louisville, and some of the critiques from participants. Overall, the program was very well received, but there was a low response rate on surveys. The committee will be revising the paper discussor's role and providing some guidelines for paper discussion. It was also noted that there was poor availability for electronic presentation as opposed to slides, and it was felt that this is something to verify for future meetings. The 98 meeting plans were discussed.
Bylaws: The change in membership categories from "corresponding" to "international active" and "international research" was discussed and will be presented to the membership. International active members will have the same privileges (including voting rights, JOT, newsletter) and pay dues, and will get member rates for meeting registration.
Education: Dr. Winquist discussed the planned Trauma Update courses for the next two years, which would include Seattle and somewhere southeast for 1999, and Kansas City and possibly Calgary in 2000. The committee will plan to stick to 5 programs per year: 2 regional update courses, the resident fracture course, the annual meeting and Specialty Day.
Fellowship and Career Choices: Chris Born and Paul Tornetta presented some of the results of the committee's work over the past year - documents entitled "Guidelines for Orthopaedic Trauma Fellowships", "References for a Suggested Textbook Reading for Residents", "A Bibliography of Recommended Readings - OTA Resident Curriculum". These documents will be circulated to officers and committee chairmen as well as other interested members to elicit feedback prior to finalization at Vancouver. The Board thanked the committee for their hard work on these projects and good results.
Membership: Jim Goulet presented the recommendations of the committee which included -6 new active members, 9 associate to active members, 10 new associate members, 2 new research members and 6 new corresponding members. Out of 37 applications submitted, 33 were approved. Four members were changed to emeritus status, and two were recommended dropped because of dues nonpayment. There was a discussion of when to cut off JOT subscription for those not paying dues.
Research: Chairman Mike Bosse discussed the committee's plans to promote, coordinate and fund multi center clinical outcome studies. The intent would be to identify appropriate issues and then develop the project through chairman selection, site selection, planning, and initial funding. Some projects might be started with the goal of eventual NIH funding. The first two proposed topics are "Immediate vs. Delayed Closure of open type II and IIIA fractures" chaired by William DeLong and "Pulmonary embolism prophylaxis in the orthopaedic trauma patient" chaired by David Helfet. Dr. Bosse also reported that the committee had awarded $183,000 to eight projects in this funding cycle, and discussed a proposal to limit OTA funding to projects conducted in North America.

The OTA specialty Day Program " Controversies in Musculoskeletal Trauma" was held on March 22 at THE New Orleans Marriott Hotel. The attendance was in excess of 500. The program included "Yes and No" discussions of statements such as " Prophylaxis of PE in ortho trauma patients is unnecessary" and "Acute nonlifesaving ortho surgery is detrimental to the multiply injured patient". The highlight papers from the annual meeting were presented and the Edwin Bovill award for the best paper was presented to Douglas Dirschl from North Carolina. The afternoon session included Presidential guest speaker Edward Hanley, Jr., a panel discussion on Managed care and trauma, and symposia on upper extremity fractures and minimally invasive fracture surgery. Syllabus materials from the meeting are available on the OTA website, at http://www.ota.org.

The member's business meeting, held during the lunch break, included officer reports, committee reports, introduction of new members and elections. Andy Burgess was elected to the position of President-elect, Steve Olson was elected to an at-large position on the Board, and Michael Baumgartner and Emile Schemitch were elected to the membership committee. Members were advised to make hotel reservations early for Vancouver, as the number of hotel rooms available may be tight. The meeting hotel is the Waterfront Centre with the Pan Pacific and the Marriott Renaissance nearby.

Being elected President of the Orthopaedic Trauma Association was a wonderful surprise and unexpected honor. Once the euphoria had passed, the realization of having to assume the mantel of responsibility for this organization and its members was very humbling. However, I realized that this cannot, and should not, be done without the support and help of all members of OTA. I would like to open the lines of communication between the membership and the Board. Please feel free to contact any of the members of the Board or myself at any time you have suggestions, concerns, or if you would like to get more involved.

Just to give you an update of some initiatives, upcoming projects and future meetings:
(I) Michael Bosse, MD and the research committee have identified two multi center projects, which we would like to coordinate and fund. The first is a multi center study of DVT/PE in trauma patients. We have contacted the AAST and the EAST to work in concert with our general surgery colleagues to assure collaboration and compliance. The protocol is at present being finalized and hopefully will be available for distribution by the end of the summer. The second research project deals with open fractures. We will assess primary closure vs. secondary closure of open fractures. Again a multi center study. I will be the project coordinator for the DVT study and William Delong, MD, will be the project coordinator for the open fracture study. Both of these will be funded initially by OTA. If you have a significant volume of trauma patients, have a collaborating general surgery trauma team, and have the ability to perform research with a designated research data collector/coordinator, please notify OTA of your availability for one or both of these studies. Obviously, all the centers can not be involved if the response is overwhelming, but we will try to get as many involved as possible. I do believe that this type of prospective multi center study funded by our organization, performed by our members and reported as a result of the efforts of our own OTA will not only answer real unanswered questions, but also truly promote our organization.

(ii) We would like to expand our membership to include more international members. As the present time, international members are not full active dues paying members and do not have the same privileges as those from North America. I would like to propose changing the bylaws to make international members who are orthopaedic/general surgery traumatologists full active dues paying members with the same privileges as those from North America. We are investigating this as part of the membership committee.

(iii) Tom Varecka and the program committee have arranged a stellar program for the OTA annual meeting in Vancouver, October 7th through 10th of this year. The evening program will include a reception and dinner on top of Grouse Mountain, the Peak of Vancouver. The en bloc accommodation reservation is limited so make your plans early. Please also notify your orthopaedic residents of the OTA Resident Course (with didactic lectures, case presentations and hands-on sawbones laboratory exercises) which is being organized by the education committee and will run concurrently.

(iv) Christopher Born, MD and his Fellowship Committee have done yeoman's work and have created needed "Guidelines for Orthopaedic Trauma Fellowships". In addition, an Orthopaedic Residency Curriculum for Trauma is being finalized as is a Bibliography of Classic Fracture References for the OTA web site, all of which will be available soon.

I look forward to meeting again in Vancouver. This is our organization, we need your support and we expect you to be there! Please do not hesitate to contact myself or any other member of the organization if we can be of any help or assistance in the interim.

As of the end of our fiscal year, December 31, 1998, OTA had assets of approximately 1.38 million dollars. For 1997, we had a gain of 25% in our assets ($280,000) while funding $182,929 in research grants. Principal sources of our net worth have been donations and excess revenues generated from our operations in past years. OTA's assets are separated into two discreet funds: an "Undesignated Fund" used for daily operations, and a "Designated for Research Fund."

In regard to OTA operations, your CFO endeavors to keep approximately one year's cost of doing business in the "Undesignated Fund. We had revenue of approximately $290,000 and expenses of $205,000. Principle revenue sources included membership dues ($121,000) and proceeds from educational meetings ($158,000). Our major expenditures were for management and "overhead" expenses (AAOS Specialty Society Services Department - $150,000), OTA committees ($25,000), and publications - $30,000 (Journal of Orthopaedic Trauma Subscriptions and the Newsletter Fractoids).

Corporate donations, investments, royalties and interest derived from investment securities in the "Research fund" are used to support OTA's research activities. As of December 31st, 1997, the Research Fund held approximately $1.03 million of our net worth. Corporate and individual donations for 1997 were approximately $280,000. Major contributors were AO North America ($80,000), Synthes & H.J.Wyss ($56,250), ACE/DePuy ($25,000), Smith and Nephew Richards ($20,000), Howmedica ($20,000), Biomet ($10,000), Ortho Biotech ($10,000) and Zimmer ($10,000). Additionally, OTA received $22,933 in royalties on the AAOS publication OKU: Trauma edited by Alan Levine.

The majority of OTA's 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 invested in US equities in an attempt to match the return of the S&P500, using a dollar cost averaging approach. As of December 31, 1997, approximately 15% of the "Research fund's" portfolio was in US equities, 30% in corporate bonds and 55% in US agency securities.

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 so that our the return on our investments may benefit our missions of trauma research and education.

The 1998 meeting of the Orthopaedic Trauma Association will be held in Vancouver, British Columbia on October 8-10. The meeting will be held at the Vancouver Trade and Convention Center. The Resident's Fracture Course, organized by Dr. David Templeman will run from October 7-9 at the same location and will feature OTA members as faculty for lectures and practical labs. The annual meeting program, arranged by Dr. Tom Varecka and the program committee will feature the usual combinations of papers, posters, symposia and speakers. There are over 70 papers to be presented from the podium, 100 posters, bioskills labs, small group discussions, and 4 keynote speakers. The program is available on the OTA website for preview.

According to Dr. Peter O'Brien, local host committee, Vancouver has a wide range of cultural and recreational activities that attendees can enjoy. The welcoming reception will be held at the Grouse Mountain Ski chalet, which is across the Burrard inlet from the convention center. This venue provides a spectacular view of the mountains, the ocean and the city. The host committee encourages those attending the meeting to extend their visit and explore the many recreational opportunities in the mountains and ocean. British Columbia is Canada's Pacific Rim Province, stretching from the magnificent Canadian Rocky Mountains to the rugged beauty and unspoiled beaches of the Pacific Coastline. The province offers visitors a wide variety of experiences from the cultural and sporting events of a large modern city to wilderness fishing at remote lodges. Golfing, camping, hiking, fishing and luxury cruises are just a few of the opportunities available from Vancouver. Vancouver has been grouped with Rio de Janeiro and Hong Kong as the most beautiful settings in the world. In the past three years Vancouver has been voted one of the top ten "Best Destinations" in the world by readers of the Conde Nast Traveler magazine. The same reasons that make Vancouver a great city to live in - safe, clean, friendly, cosmopolitan, temperate and scenic - make it a great place to visit.

Vancouver is also relatively easy to get to. Because of the Alaska cruise business and the popularity of the Whistler/Blackcomb ski area, there are direct flights daily to Vancouver from most major U.S. cities. We are equidistant from Europe and Asia, so I think that we will attract a large international registration as well at this year's meeting.

It is important to remember that the Canadian Dollar is trading at well below 70 cents U.S. this year. That means that the prices that you are quoted in Canadian Dollars can be converted to U.S. at roughly a 2/3 ratio. If you would like more information about Vancouver and British Columbia, you can visit these internet sites: http://www.tbc.gov.bc.ca or http://www.tourism- vancouver.org.

The meeting hotel is the Waterfront Centre, and room space is limited due to other events, so reserve sleeping rooms early!

This column is a new effort to facilitate the rapid distribution of ideas amongst the membership concerning technical pointers and pitfalls in the performance of various procedures in orthopaedic traumatology. Although we recognize that as orthopaedic surgeons we need to care for the whole patient, the technical aspects of many orthopaedic procedures are formidable.

Each column will focus on a specific procedure for a specific application. We will outline some of the issues which in our opinion require intraoperative decision-making. It is intended that this outline will serve to stimulate discussion, dialogue, and the sharing of ideas. Any thoughts on all of the outlined issues or selected ones are encouraged and welcomed. We ask that these ideas be sent in so that they may be incorporated into future issues of Fractoids. Because of the limitations of space, we may have to resort to summarizing some of the submissions. However, we are currently contemplating a way to post all of them on the world wide web. Prior to doing so, we will be exploring medicolegal concerns about confidentiality and discoverability. The first topic selected is:

Intramedullary Nailing of Distal Third Tibia Fractures: Outline of Issues for Discussion

• Are preoperative radiographs of the contralateral tibia necessary for determining nail length?
• Is a fracture table necessary?
• Are larger diameter nails better than smaller diameter nails?
• Which end of the nail ought to be locked first?
• Should the distal screws be inserted from medial-to-lateral or lateral-to-medial?
• Is multiplanar fixation necessary in the configuration of distal interlocking screws?
• Does the fibula need to be plated in addition to nailing of the tibia? If so, which procedure ought to be performed first?
• Are neurovascular injuries a real concern either preoperatively or postoperatively?
• Is there a role for retrograde nailing of these injuries?
• When are "blocking screws" (screws beside the nail) useful?

We look forward to hearing your comments and presenting them in future issues of Fractoids.

Please send all letters to :

Craig S. Roberts, M.D.
Department of Orthopaedic Surgery
University of Louisville School of Medicine
HSC / ACB 3rd Floor Bridge
Louisville, KY 40292

The OTA does not endorse these technical points and formally disclaims any responsibility for their use.

OTA Web site: http://www.ota.org

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