Once again it is time to begin the process of reviewing the Relative Value Units (RVUs) that are assigned to the work we do. For those of you who don't know, RVUs is how the Health Care Finance Administration (HCFA) compares the work involved in various CPT codes - for example, is nailing a femur more or less work than scoping a knee or delivering a baby or working up chest pain? This, of course, ultimately translates in to how much a person gets paid for various activities.

Every 5 years, the Resource Based Relative Value Scale (RBRVS) gets revised or re-evaluated. This scale is the listing of all the CPT codes and how many RVUs they are worth. The five year review is our opportunity to increase the RVUs assigned to any procedure or activity that has gotten harder, due to changes in the way the procedure is done or in the patient population. We have now started on that process.

The first step is to collect a list of codes which are possibly in need of RVU revision. Then we survey our members to verify that the work is indeed harder than it was 5 years ago. We next attempt to convince the AMA/Specialty Society RVS Update Committee (RUC), through the AAOS RUC Advisory committee. If we are successful, then RUC tries to convince HCFA. If that is successful, the RVUs assigned to each code will be adjusted.

The last time we went through this, we had very low participation rates for the surveys we sent out to collect data on how much work is associated with the codes we chose to try to upgrade. Out of 200 surveys, only 20 or 30 were returned. This leads to low quality data, and weak arguments. Nonetheless, we were able to win upgrades of the RVUs for several fracture care codes. With more participation, we would have done better.

So, please give this some thought. Remember, everyone else will be out there trying to convince them that their work is harder and they deserve more RVUs, so if we do nothing, we will lose ground. Since the whole process is budget-neutral, if some codes go up in RVUs, the others go down.

Send me a list of CPT codes (or of procedures) which may have changed since 1995 in the amount of physician work required either due to changes in the patient population ( more complicated patients, older patients, more high energy patients), or changes in technique (e.g. new techniques or technology). There are of course many codes we feel are undervalued from the start, but unless we can convince them that something has changed in the work content of a code, it will probably not get re-evaluated.

Thanks for your help with this.

Jeff Anglen, MD
Department of Orthopaedics MC213
1 Hospital Drive
Columbia, MO 65212
anglenj@health.missouri.edu
573-882-1654

The Board met in the Pan Pacific Hotel on October 8, 1998. Here are some Highlights from the meeting:

After call to order and approval of the minutes from the Board meeting of 3/21/98, the Board heard a report from Bill Burman and Ken Johnson regarding the development of an educational CD-ROM. Some difficulty was encountered in getting the project going due to lack of author involvement in the Pelvis and Acetabulum Case forum, but they are now focusing on trying to capture the Resident's Basic Fracture Course. Demonstration of the potentialities of the project impressed the Board.

CFO Brad Henley reviewed the balance sheets and financial reports for the Board. He reported we are doing well; expenses are going up, due to management fee increases from the AAOS, increased costs for computer time, increase to 4.0 FTE employees. He is endeavoring to keep approximately 1 year's operating expenses on hand, and anticipates a break-even year. The annual meeting is expected to be profitable (90-100K); the Resident's course is approximately a break -even project; the one Trauma Update course in 1999 is expected to be profitable (last year Pittsburgh and Newport each earned about 13-14K). The Research Endowment fund is right on budget with a balance of approximately $1.1 million. Last year's contributions of $281,250 was a "banner year" and this year's pledges are higher. Discussion was made of a proposal to add a solicitation of direct contributions to the annual meeting program.

Jim Kellam gave a report from COMSS. He noted that Specialty Day will be on Saturday at the Academy meeting beginning in the year 2000. There is work going on to connect our ortho trauma database software with the MODEMS program. Dr. Heckman has set up a corporate Advisory council to increase communication between the Aademy and Industry, and has pointed a public relations task force to work on improving the public image of orthopaedics. There was discussion of the feasibility and advisability of coordination with AAOS for trauma courses. The Board thought that this idea may have merit in terms of efficiency and avoiding conflict/duplication, but wouldhave to be structured to protect the OTA's interests, as more and more of our revenue comes from programming income. Full minutes from the COMSS meeting were distributed to the Board.

Barry Riemer, chairman of the AAOS committee on trauma was present and reported on the committee. The Board suggested that Dr. Riemer and Kellam explore the possibility of coordination for trauma courses. The AAOS subcommittee on trauma evaluation is preparing a self assessment test on musculoskeletal trauma, and it was felt that the OTA may have a role to play in development. The board directed Dr. Tornetta to contact Dr. Gregory Zych about this project and discuss coordination with the OKU-Trauma.

American College of Emergency Physicians contacted the AAOS regarding a draft clinical policy on penetrating extremity injuries. Dr. Kellam appointed Buckley, Kramer, Dirschl and Marsh to an evidence based guidelines committee of the OTA to help evaluate this and similiar issues.

Mike Bosse, the OTA representative to the "Bone and Joint Decade" meeting in Lund, Sweden, reported to the board about the meeting and the goals of this project, which is to improve the health related quality of life for people with musculoskeletal conditions worldwide, by increasing awareness, empowering patients, promoting cost-effective treatment and prevention, and advancing understanding. Bosse recommended that the OTA endorse the program, write an editorial about it for JOT, and earmark funds to support the meeting.

The board discussed relations with American College of Surgeons. The consensus was that we need to be more active in that organization to influence policy, the board encouraged all OTA members (particularly officers and committee chairs) to become fellows in the ACS and participate in local state trauma committees. They also decided to seek additional orthopaedic input on the national ACS committee on Trauma. Dovetailing that issue was a discussion of orthopaedic trauma care quality assurance, and how the OTA can help orthopaedists set up and organize trauma care in different hospital settings. Thsi is an issue of great interest to the membership (see last newsletter editorial). A committee of Bray, Burgess and Kellam was set up to look at this issue.

In response to a inquiry from the Argentinian OTA regarding a possible joint meeting, the board discussed the concept of joint meetings with other societies. It was suggested that we invite foreign society presidents to our meeting as guests in order to encourage communication.

Dr. Helfet discussed the OTA multicenter research project on DVT prophylaxis and the plans for Specialty Day 1999. Board meeting was announced for February 4, 1999 in Anaheim. Joe Lane and Ken Koval were announced as appointees to the AAOS committee on geriatrics, and Andy Burgess as the representative of the OTA to Coalition for American Trauma Care.

Committee Reports

Health Policy and Planning, Peter Trafton, Chair:
The OTA strategy should be attempting to obtain and maintain a seat at the relevant policy-making tables. This should be pursued by: continuing and increasing our involvement in the Coalition for American Trauma Care (CATC) and increase our annual support of that organization from $5,000 to $10,000; encouraging OTA members to become Fellows of the ACS and participate in local ACS Trauma Committee activities; encourage OTA members to seek leadership roles in the AAOS.

Program, Tom Varecka, chair:
Out of 315 abstracts submitted to this program, 77 were selected. The quality was the best in many years. One author backed out of presentation 1 week before the meeting with inadequate excuse; the Board decided to forbid acceptance of any paper from that author for 5 years. The committee will develop an "associate chair" position designed to provide training for the next chairman. Jack Wilber will be the next chairman, and Paul Tornetta will be associate chairman. The board commended the committee for it's excellent work.

Fellowship, and Career Planning, Chris Born, chair:
The Committee on Fellowship and Career Choices of the OTA has completed the following documents: a curriculum for orthopaedic trauma training at the resident level, guidelines for orthopaedic trauma fellowships, and two bibliographies. Committee members who have worked on these include Fred Barrick, Kathryn Cramer, Mike Miller, Stephen Sims, David Stephen, Paul Tornetta, Ray White and Paige Whittle.

The residency curriculum includes 75 topics designed to be covered over a two-year cycle. A residency program can appropriately modify the curriculum to avoid crossover and redundancy with the didactic programs of other sub-specialties. A sub-committee is currently working on the development of a slide/lecture program based on this curriculum as well as a handbook which could be carried by house officers for quick reference. There is one bibliography for textbook readings keyed to a resident's level, and one which covers the literature thoroughly. Both will be periodically updated by the committee. Publication of these documents is planned by the Journal of Orthopaedic Trauma for 1999. They will be made available on the OTA's website following publication.

Future plans include updating of the fellowship handbook as well as the development of a course on the financial aspects of orthopaedic trauma (coding, billing, etc.). A review of the fellowship application process is also to be considered. There still remains a serious problem whereby applicants feel coerced into making an immediate decision about a program and are not given a fair opportunity to interview elsewhere for fear of losing a position. A number of years ago an attempt was made to go through the "Match", but this failed miserably as a number of programs elected to continue to circumvent the rules. Mechanisms whereby a program might be sanctioned are currently being considered but no final decision has been made.

Research, Mike Bosse, chair:
The committee received 32 pre-proposals, 22 full proposals were requested and 18 received. The committee recommends funding for 8 projects with a total price tag of $194,000. There were 4 requests to extend grants, of which 3 were approved. The following OTA members received funding for their proposed projects: Philip Wolinsky, Neil Sharkey, J. Lawrence Marsh, David Diduch, Ellen MacKenzie, Theodore Miclau, Mark Reilly and Emil Schemitsch. The committee is planning to develop a database of the papers and presentations which have resulted from OTA funded projects in order to track the productiveness of these grants. Since 1990, we have awarded $728,139 which has resulted in 19 published papers and 55 presentations.

The OTA sponsored multi center research projects have started with two studies: a prospective, randomized study regarding closure strategy for open wounds (chaired by William DeLong), and a longitudinal, observational study regarding DVT/PE prophylaxis (chaired by David Helfet). Details about these projects should be available by Specialty Day at the AAOS meeting.

Membership, Paul Tornetta, chair:
Lists of new members were presented to the Board for approval. The committee requested that the Board give them some guidance regarding what type of membership the organization wants in terms of exclusivity, and criteria for membership. Discussion concerning the role of associate members resulted in a recommendation that associate members can be on committees, but not on the Board, cannot vote, cannot be committee chair, and cannot sponsor new members. These will be sent to the bylaws committee as recommendations. A proposed time limit of 5 years for associate membership was discussed, and the requirements for active members to attend minimum number of meetings.

The membership committee would like to identify senior members who might be interested in some type of formal mentoring of younger, less experienced members with the goal of helping them meet the publication requirements of active membership. Interested members should contact Paul Tornetta. Also, all members should encourage their younger colleagues and fellows to join the OTA.

Membership and Bylaws Committees are currently reviewing two issues that may impact membership. The first is the question of active membership for D.O. physicians, who are restricted because of the requirement to be a fellow of the AAOS. The second is the status of international members, specifically the granting of voting privileges and other rights with the exception of sitting on the Board. Comments or questions should be directed to Paul Tornetta, MD, Boston Medical Center, 818 Harrison Avenue, Dowling 2 North, Boston MA 02118.

Journal of Orthopaedic Trauma, Roy Sanders, editor:
Overall subscription rate is up to about 2600, with increasing institutional and international subscriptions. The Canadian Orthopaedic Trauma Association and the American Fracture Association have committed to participate. New features include a "Technical Tricks" section, and abstract exchange with Umfallchirurgie, the German trauma journal. The JOT will publish the best papers from the annual meeting in a "fast track" manner, and is hoping all OTA members will make the JOT their journal of first choice for publication of their work.

Archives, Jeff Anglen, chair:
The committee has generated a list of what materials should be kept. It recommends to the Board that the materials presently in the Archives should be catalogued and indexed and that should be updated annually. The History of the organization should be updated annually by the Archives committee.

Newsletter/web, Jeff Anglen, chair:
On time and under budget. There was great response to the information printed in the last newsletter regarding organization of orthopaedic trauma services. This seems to be an issue of concern to the membership, particularly those working in private hospitals without residents. Craig Roberts is now helping with the newsletter, additional members are needed. There was discussion of professional management of the website, benefits and costs.

Annual Meeting Program in Vancouver
A tremendously successful educational meeting was put on in Vancouver, attended by over 900 participants. All the abstracts from papers and posters are now available through our web site at: http://www.ota.org. The program committee has selected the highlight papers and Bovill award winner, as well as the best poster. These will be presented as part of the Specialty Society Day at the AAOS meeting in Anaheim. The highlight papers are:

1. The Success of Exchanged Reamed Intramedullary Nailing for Femoral Shaft Non Unions
   David J. Hak, et al
2. A Prospective Randomized Clinical Trial Comparing Reamed vs Unreamed Intramedullary Nailing...
   Russell DeGroote, et al
3. A Prospective Comparison of Antegrade and Retrograde Femoral Intramedullary Nailing
   Robert F. Ostrum, et al
4. Conversion of External Fixation to Intramedullary Nailing for Femoral Shaft Fractures in Polytrauma Patients
   Peter J. Nowotarski, et al
5. Ender Rod Fixation for Pediatric Femur Fractures
   Kathryn E. Cramer, et al
6. Effect of Interposed Periosteum in an Animal Physeal Fracture Model
   Laura Senunas Phieffer, et al
7. Competence of the Deltoid Ligament in Bimalleolar Ankle Fractures After Medical Malleolar Fixation In-Vivo
   Paul Tornetta
8. A Randomized Prospective Trial of Humeral Shaft Fracture Fixation: Compression Plate vs Intramedullary Nail
   R.G. McCormack, et al
9. Low Profile Fixation of Tibial Plateau Fractures
   George Herriott, et al
10. Fix and Flap, the Radical Treatment of Severe Open Fractures of the Tibia
    Siva Gopal, et al
11. The Effect of Unreamed, Limited-Reamed and Standard-Reamed Intramedullary Nailing on Cortical Bone Porosity and New Bone Formation
    Thomas M. Hupel, et al
12. Anatomic and Biomechanical Considerations Using a Lateral Starting Approach for Intramedullary Nailing of Proximal Third Tibia Fractures
    Ronald Wobig, et al
13. The Safe Zone for Tibial Nailing
    Paul Tornetta, et al

The Bovil Award is going to Bob Ostrum for his paper on Antegrade vs Retrograde Nailing of the Femur. The outstanding poster of the meeting was: Proximal humeral fracture fixation: A biomechanical analysis of plate osteosynthesis systems by James P. Lever, et.al

OTA Specialty Day Program will be held in the Pacific C Ballroom of the Anaheim Hilton and Towers. In addition to presentation of the highlight papers and a member-only business meeting, there will be pro- and -con type discussions of some controversies in orthopaedic trauma, such as: reduction and stabilization of isolated femoral shaft fractures in the 6 to 12 age group, anatomical reduction and plate fixation of displaced distal radius fractures, antegrade IM locked nailing for humeral shaft fractures, retrograde locked nailing for intra-articular distal femur fractures, femoral neck fracture in the55-75 age group, ORIF vs. Ex fix of Pilon fractures and others. There will be an OTA members dinner as usual.

The OTA Regional Trauma Update course in 1999 will be held 7/16-18 at the Four Seasons Hotel in Seattle. Program chairs Chip Routt and Bob Winquist have developed an innovative format including small group discussion of difficult cases. Please spread the word about the course, and encourage your colleagues to attend. Courses for 2000 will be held in Calgary and Kansas City.

Abstract forms for the 1999 meeting in Charlotte have been mailed and the deadline for submission is March 9, 1999. Please contact HQ if you have not received yours.

Remember that you can designate half of your annual OREF donation ( if $1,000 or above) to support the OTA's research endowment. Last year, the following members exercised that option to donate to the OTA: Anglen, Behrens, Binski, Browner, Carlson, Chapman, Dalzell, Duwelius, Edwards, Fahey, Geel, Goulet, Hartzler, Harvey, Hurwitz, Johnson, Koval, Lang, Lange, Lhowe, Maletz, McGanity, Ott, Patzakis, Putnam, Respet, Rosen, Swiontkowski, Thorne, Trafton, Varecka, Vasileff, Versteeg, Winquist, Yang. Thanks to these members for their generosity and commitment to trauma research.

It is hard to believe that another year and my tenure as President of OTA is almost over. Fortunately, with the excellent OTA staff, Board and Committee members this has been a relatively productive year and yes, we are making progress. To mention just a few:

Mike Bosse and the Research Committee have completed their grant reviews and the coordination of the two multi-center studies (DVT/PE in Trauma: 1§ vs. Delayed Closure of Wounds in II/IIIA Open Tibia Fractures). Those involved will meet at the AAOS in Anaheim to discuss and initiate these two mammoth projects.

Christopher Born and Paul Tornetta and their Committees have finalized the Orthopaedic Residency Curriculum for Trauma, and the Orthopaedic Trauma Fellowship guidelines a very ambitious, labor intensive and successful endeavour.

Brad Henley and Jeff Anglen continue their efforts on CPT Coding/ Relative Values for Orthopaedic Trauma, i.e. trying to make the "powers" aware of those diagnoses and procedures that are more labor intensive and difficult and deserve more specific coding and proportionate reimbursement definitely needed and of benefit to all, but a tiresome and thankless task.

Ray White and Paul Tornetta and their Committees were re-addressing the status of international members and the relative by-laws to see how it would be possible to have fully fledged "card carrying" foreign ACTIVE members of OTA.

A hot topic, and one needing and getting attention, is our involvement as OTA members, and as an organization, locally and nationally in other organizations having an impact on trauma care, especially the American College of Surgeons. Peter Trafton, Bruce Browner and our President Elect, Andrew Burgess, are addressing this issue directly with the Committee of Trauma of the ACS and with the AOA/AAOS and we await their findings and recommendations.

Tom Varecka, and his Program Committee and the Vancouver local host, Peter O'Brien, put on the best OTA meeting yet and the best of the best will be part of the OTA Specialty Day, February 7th in Anaheim next year.

In fact, we have arranged a very innovative day besides the above highlighted papers from Vancouver and our OTA Business Meeting the remainder of the day will be devoted to 11, we hope, contentious, passionate and spirited debates of controversial topics. The debates will only be successful if we have active involvement and discussion by the audience, especially our membership, so please attend!

Finally, on behalf of the OTA Board of Directors and Officers and, of course, office staff, all the very best for the Holiday Season and for a most Happy and Healthy New Year.

See you in Anaheim!

The responses to the introductory column were terrific. Responses came from as far away as El Paso; Albuquerque; Hanover, Germany; Oklahoma City; Ashland, Kentucky; and Seattle. I have tabulated these below and have tried to add comments that were included. There were many excellent pearls. Because of space limitations, I cannot include them all and apologize for this in advance. Intramedullary Nailing of Distal Third Tibia Fracture Results: Outline of Issues for Discussion

• Are preoperative radiographs of the contralateral leg necessary for determining nail length?
  No (87.5%); Yes (12.5%)
• Is a fracture table necessary?
  No (87.5%); Yes (12.5%) Comments: [Instead of a fracture table setup]"We use a simple frame made from 4 tubular fixator tubes, connected by tube-to-tube clamps."
• Are larger diameter nails better than small diameter nails?
  Larger (62.5%); Smaller (37.5%) Comments: Larger ones are better biomechanically and smaller ones are better physiologically.
• Which end of the nail ought to be locked first?
  Proximal (50%); Distal (37.5%); Proximal (12.5%) if reduction is anatomic and there is no distraction, distal if there is any distraction at the site (to allow backslapping). Comments: "During insertion, unreamed nails frequently push the distal fragment distally resulting in fracture diastasis . . ."
• Should the distal screws be inserted from medial-to-lateral or lateral-to-medial?
  Medial-to-lateral (87.5%); lateral-to-medial (12.5%)
• Is multiplanar fixation necessary in the configuration of distal interlocking screws?
  No (62.5%); Yes (25%); No opinion (12.5%)
• Does the fibula need to be plated in addition to nailing of the tibia?
  Yes (12.5%); Rarely (37.5%); only when truly involves the lateral malleolus (37.5%); no opinion (12.5%)
• If so, which procedure ought to be performed first?
  Plating of the fibula (62.5%); No opinion (37.5%) Comments: "For mid-diaphyseal fibula fractures we routinely try to employ intramedullary fixation of the fibula first, prior to nailing of the tibia."
• Are neurovascular injuries a real concern either preoperatively or postoperatively?
  Yes (62.5%); No (25%); No comment (12.5%)
• Is there a role for retrograde nailing of these injuries?
  No (37.5%); rarely (12.5%); no experience with this (12.5%); no answer (12.5%); not unless the ankle is involved (12.5%); "if the subtalar and ankle joints are already destroyed" (12.5%)
• When are blocking screws (screws beside the nail) useful?
  "No experience with this" (12.5%); "occasionally" (12.5%); for distal one third metaphyseal injuries (12.5%); to correct nail malposition with unreamed nails (12.5%); do not use (12.5%); either for very proximal or very distal fractures (12.5%); only in relation to the stabilizing intra-articular fracture line extensions (12.5%); "These screws, . . . can be used as: 1) alignment tools, 2) stabilization tools; and 3) as a tool for manipulation." (12.5%)

The next topic that has been selected for discussion is:

The Evaluation and Management of Open Tibia Fracture Wounds: Outline of Issues for Discussion

• Do you classify open fracture wounds using the Gustilo classification before or after you surgically debride them?
• Do you photograph open fracture wounds at the time of the first operative procedure?
• Should plastic surgeons be involved with the evaluation of an open fracture wound at the time of the initial surgical procedure?
• Do you do delayed primary closures and skin grafts on calf fasciotomy wounds?
• Do you have any special techniques for performing delayed primary closures of calf fasciotomy wounds?
• Do you do your own rotational flaps?
• Have you ever "fixed and flapped" open fractures without any assistance from other surgical services?

We need your comments. All comments will be held in the strictest confidence. Please send all letters to:

Craig S. Roberts, M.D.
Department of Orthopaedic Surgery
University of Louisville School of Medicine
H.C./ACT RD Floor Bridge
Louisville, KY 40292

The OTA does not endorse these technical points and formally disclaims any responsibility for their use. We look forward to hearing your comments and presenting them in the future issues of Fractoids.