A few random thoughts and rants: While looking through the comments from the participants at the Vancouver meeting, I noticed several who asked for less individual papers and more general didactic type sessions. This points out that our annual meeting is an attempt to meet the needs and interests of several different groups. The general orthopaedist comes for a different purpose than the OTA member or full time traumatologist. Perhaps we could have some sessions for members only, as Jim Kellam has suggested many times, where we can argue out the controversial, cutting edge stuff while other sessions present consensus knowledge about fracture care - the "Boards Answer" stuff. Many of the Specialty Societies have closed meetings, and believe that it fosters a level of discussion that is different, because of the shared context in which the information is presented. Most of the members know the recent history of these issues in a more intimate way - have been to the same meetings, seen the same presentations, read the same articles. Some of the things we want to talk about (acetabular fractures, spine fractures, multiply injured patients) are probably of little interest to the general orthopaedist who just doesn't do it. At the same time we can provide educational programs for the general orthopaedist, and for the orthopaedic resident in the fracture course. This would be like running an update course at the same time as a closed society meeting, and would be a big change - perhaps something to ease into by starting with a few limited closed sessions targeted at the full time traumatologist.

At the MidAmerica Orthopaedic Association meeting recently, we heard from the treasurer of the AAOS about a new multi-year, multi-million $ public relations campaign which the Academy is initiating. Apparently, a survey of the fellows and their patients found some discrepancies in image. For example, while 80% off AAOS fellows surveyed thought that their patients considered them to be "caring and compassionate", only 17% of the patients actually felt that way about their surgeon. The response is to plan a huge advertising campaign to "correct" the public's impression.

Now, I don't want to get off on a rant here, but doesn't this solution seem like the same hubris that got us into this problem? Is it so clear that our image of ourselves is more accurate than the patients'? Orthopaedic surgeons have some wonderful qualities - they are intelligent, hardworking, responsible, industrious, conscientious, honest, and self-sacrificing. But although I believe most are basically good-hearted, "caring and compassionate" are probably not among our strongest positive attributes. The AAOS can spend as many millions as it likes, but to the extent that it is trying to fight reality, it will ultimately fail and lose credibility in the process. If you really want the public image of orthopaedists to change, you have to change the orthopaedists - and that means change how you recruit and train them. Start by recruiting more women and less football jocks; and by ranking the student who got honors in Peds higher than the one who did 5 ortho electives.

Another part of the program involves convincing the public that an orthopaedic doctor is the best place to go for any musculoskeletal complaint. But we better be sure that is true before we start asking people to believe it. There is remarkably little data comparing the care of different types of practitioners for most musculoskeletal complaints, the majority of which are either self-limited or lifestyle related. Take back pain, for instance. Which medical professional treats garden variety backaches quickest, cheapest, safest and with the greatest patient satisfaction? Some pretty good evidence suggests chiropractors do a better job than surgeons for this type of complaint. The Academy may not want to hear that, but a head-in-the-sand approach doesn't change the facts, and neither will an expensive PR campaign.

Of course, that's just my opinion - I could be wrong. I'd love to hear your responses, so mail me or Email me and I'll print the replies that are pertinent, informative or amusing.

Jeff Anglen
anglenj@health.missouri.edu

The OTA's Board met on 2/14/99 in Anaheim and received a number of reports and presentations. Among them:

Ken Johnson and Bill Burman reported that 28 of the 70 presentations from the Resident=s Fracture Course in Vancouver have been captured in multimedia form and are available on the web at tr.bsd.uchicago.edu/hwb/bfc/index.htm. They plan to capture all to the lectures from the 1999 course and have it on the web by 2000. The OTA education committee was charged by the Board to decide how this effort fits into our educational mission, the relation to development of slide sets for the core curriculum in orthopaedic trauma.

Andy Burgess and Jim Kellam gave a report from COMSS. Among other things they noted developments in the AAOS public relations program, which will include an insert on total joint arthroplasty in the USA Today. The Board discussed a similar program of public awareness about trauma issues that might be a project for OTA or for the Academy through the Committee on Trauma. This might be coordinated with the ACS in some way.

Roy Sanders reported on status of the Journal of Orthopaedic Trauma. Total circulation is up to over 2500, and the Journal is becoming involved with more societies - including the Canadian OTA. JOT will publish abstracts and highlights from the International Society of Fracture Repair. Average time to publication is now 7 months from submission. There were 233 manuscripts submitted last year. A case controversies feature will be added, edited by Paul Tornetta. All OTA members should send their best manuscripts to JOT first, in order to support our journal.

Andy Pollack reported on a spine injury conference held by the National Athletic Trainers Association which he attended as the OTA representative. There will be a poster on the issue at Charlotte, and possibly a position paper resulting from the meeting. Tools for facemask removal need to be available on the sidelines and guidelines for care of the spine-injured athlete need to be developed and distributed. The Board noted the importance of OTA's participation in the process.

Barry Riemer reported on the AAOS committee on trauma, and discussed joint sponsorship of trauma/fracture courses, which would help eliminate conflicts and may have some financial advantages.

Jeff Anglen reported on the early activity regarding the 5 year update of the Relative Value Unit scale by HCFA. An appeal in the last newsletter netted very few responses regarding codes that need to be upgraded because of changes in work, or in codes that remain undervalued from previous negotiations. The Board feels this is an important issue, but one that few of the membership understand well enough to care about. Methods were discussed for increasing involvement.

Officer Reports:

CFO Brad Henley went over the balance sheets and investment strategies. Overall, we are quite solvent, and keep approximately 1 year's operating expense on balance. Management fees will go up substantially in 1999, leading to a potential budgetary shortfall, but this is based on very conservative estimates of program revenue. The Research Fund balance at the end of 1998 was approximately 1.2 M$, of which about 1/3 was in the stock market. The Research Fund had a net profit of about 156K$ in 1998, and is projected to do even better in 1999.

President Dave Helfet announced appointment of Andy Burgess to the ACS Advisory Council and nomination of Jeff Anglen to the ACS committee on trauma. He discussed the program for the Academy meeting in 2000, at which Jim Kellam is program committee chair, and at which the OTA would like to jointly sponsor trauma and fracture topic symposia. Ideas for any such programs should be submitted to Jim Kellam or Barry Riemer. He also reported that the OTA has signed on as a supporter of declaring the decade of 2000-2010 as the Bone and Joint Decade.

Old Business/Announcements:

Pre-registration for our Specialty Day program was 400. In 2000, Specialty Day will switch to Saturday at the Academy meeting.

Nancy Franzon will now be full time for the OTA, and Julie VanSelow has been added to the staff at headquarters.

Report of the nominating committee: The slate presented was President-elect - Brad Henley, CFO - Andy Pollack, Board member at large - Paul Tornetta, Membership committee - Ed Rutledge. The Board spent some time discussing the process of nominating committee selection and suggested the use of mailed ballots, proposal of 10 names with four being selected, with the past president as chair. They also discussed adding the editor of the JOT to the Board as ex officio member

Committee Reports

Program committee, Jack Wilber: The Board was given a packet which reviewed the results from the Vancouver meeting. There were over 600 paid registrants, leading to over 212K$ of revenue. The evaluations from the meeting were generally good, although only 90 evaluation forms were turned in. There may be some interest in re-introducing paper discussion in some form. There will be a reception at the Speedway Club at the Charlotte Motor Speedway where everyone will be given ballcaps which say AOTA/Valvoline@ and a cup to spit in.

Education committee, Jim Kellam: Trauma Update courses are scheduled for Seattle in 1999, and for Calgary and Kansas City in 2000. Evaluation forms from the Vancouver Resident=s Course were discussed. The plan at present is to capture the slides and talks from the Resident=s Course for development of a CD-ROM program, that could be sold or given away free on the Internet. Much discussion about the relative merits of these options ensued.

Fellowship and Career Choices, Chris Born: The guidelines for orthopaedic trauma fellowships and the resident curriculum in orthopaedic trauma will be published this year in the Journal of Orthopaedic Trauma and made available on the OTA website. An extensive bibliography on orthopaedic trauma, organized by anatomic segments, will be made available on the website. The committee will be revising the listing of North American fellowships over the next few months. Fellowship directors will be receiving requests to update information on their programs. If there are new fellowships since the last revision (see the listing on the OTA website), please let the committee know about them. Plans are underway to develop a course about billing and coding for fracture care to include in the fall program. There are also plans to develop a slide set program to go along with the resident curriculum syllabus, this may be coordinated with the lectures in the Resident Fracture Course.

Membership, Paul Tornetta: The issue about admitting physicians with a DO degree rather than an MD degree has been discussed by the membership and bylaws committees. The recommendation of the membership committee what that DOs be admitted to active membership if: 1) They are board certified by the DO Board, 2) They complete a 1 year fellowship with an MD OTA member, and 3) They complete the same requirements for practice, publication and recommendation as MD applicants. The Board of Directors agreed with these recommendations and has referred the issue to bylaws committee to draft legislation. The issue concerning rights and roles of international members will be evaluated by surveying the present membership.

Website/Newsletter, Jeff Anglen: The time has come to get professional help in designing and organizing the website in order to keep it useful and to expand its usefulness and a means to distribute content and to educate. The Board agreed to this and directed the committee (Anglen) to look into finding someone.

Research, Mike Bosse: The grant process has been revised to follow the OREF format in order to ease transition of grant submissions to other agencies. Four grantees requested extensions of their funding period, and three were approved. Thirty-two pre-proposals were submitted, 20 were requested to submit full proposals, of which 18 did. Eight were fully funded at a total level of $194K. The two OTA multi center prospective studies have issued a call for participating centers. Dr. DeLong is organizing the study on "Immediate versus Delayed Closure in Open Tibia Fractures" and Dr. Helfet is organizing "PE and symptomatic DVT in Orthopaedic Trauma Patients". Proposed start date is July 1, 1999.

The committee is discussing ways to improve recognition of donors and contributors, especially from industry, as with some sort of award. A review of the research compendium reveals a number of grants that have resulted in no publication or presentation. Those investigators will be contacted to clarify use of the funding.

Health Policy and Planning, Peter Trafton: A task force of specialty societies assembled by the American College of Rheumatology has constructed a musculoskeletal physical exam template in order to make it possible for higher lever E&M code criteria to be met by documentation of a thorough subspecialty examination. In this exam template, each significant element (stability, ROM, strength, vascularity, reflexes, sensation, inspection, palpation) of a standard exam and each Aspecial test@ is included as a countable item or point. Most elements are unilateral, so bilateral assessment results in 2 points. It seems that 12 points will qualify for the highest ("comprehensive") level. The template seems to be flexible enough that any musculoskeletal specialist would readily be able to gain enough points to qualify for the higher levels by adhering to our usual standards of exam and documentation. When accepted by each of the specialty societies in the task force, this will be submitted to the AMA's CPT Editorial Panel, and to HCFA.

Research Grants Awarded

The following members had grant awards recommended by the Research Committee and approved by the Board of Directors.

• David R. Diduch $30,772
• Ellen J. MacKenzie $27,263
• J. Lawrence Marsh $15,000
• Theodore Miclau $20,000
• Mark Reilly $12,000
• Emil H. Schemitsh $59,848
• Neil A. Sharkey $19,995
• Phillip Wolinsky $9,000

Last call for trauma registry conversion from 4.2 to new Windows based data base. DOS customer support of the Trauma Registry will end with the new Windows based conversion. This is the last call for determining which systems need conversion and for whom. If you have any doubt that you were not included in the response of the December request for conversion from either DOS or Trauma 95, please notify the office IMMEDIATELY.

If you have an old 4.2 version and have not notified the OTA office, respond with your request and include your phone number and contact person so that the conversion team may contact you.

Nancy Franzon
OTA Executive Director
6300 North River Road, Suite 727
Rosemont IL 60018
Phone 847-698-1631
Fax 847-823-0536
E-mail franzon@aaos.org

If you are planning to attend the annual meeting in Charlotte this October, please consider helping the education committee by serving as a lab instructor for the Resident's Basic Fracture Course. To volunteer, contact Nancy Franzon at the headquarters by email: franzon@aaos.org or by phone: 847-698-1631

We need OTA members to help spread the word about our courses and programs. Brochures and direct mailings can only do so much. A better and more effective way to encourage people to come to our courses is for each OTA member to help sell the program - make a few calls or send a note to your partners, departments, friends, residents, referring docs. Whenever you are speaking or attending an orthopaedic meeting, encourage people to consider the following OTA programs:

• Seattle Trauma Update Course July 16-18, 1999
• Annual Meeting in Charlotte, North Carolina, October 22-24, 1999
• Resident's Basic Fracture Course, Charlotte, North Carolina, October 21-24, 1999
• Trauma 2000 Update Course, Kansas City, Missouri, April 13-16, 2000
• Calgary Trauma Update Course, Calgary, July 13-15, 2000

The Fractoids staff and the Archives committee are looking for one or more OTA members with a camera and an interest in photography to help document our meetings and events. If you've always had an interest in Photojournalism, this is the place to start. Or if you have an expensive new camera or even a disposable camera, or are willing to buy one and can push a button, let us know. This could be the start of a whole new career! Interviews will be set up for the first 100 applicants. Seriously, though, we need some pics.

Dr. Marc Swiontkowski reports that the MFA (musculoskeletal functional assessment) forms, both long and short, are available on the web at http://www.med.umn.edu/ortho/clinout_res.htm

From nearly 400 submitted abstracts, the Program committee has selected 73 papers, 115 posters, 4 symposia, 4 labs and 4 case presentations for the Charlotte meeting. The meeting begins on Friday, October 22 and runs through noon on Sunday, October 24. Thanks for the hard work is due the committee: Wilber, Tornetta, Varecka, Olson, Buckley, Duwelius, Sims, Gruen, and Schmeling.

The hotel for OTA members is the Charlotte Hilton and Towers Hotel (704-377-1500). Residents and exhibitors are being directed to the Marriott (704-333-9000)

This column continues to generate discussion and exchange of ideas. There were many excellent pearls. Here are the results of the questionnaire from the January issue of Fractoids.

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?

Before (43.7% ) After ( 50% ) Never (6.3%)

Do you photograph open fracture wounds at the time of the first operative procedure?

Yes (20%) No (60%) Sometimes (20%)

Should plastic surgeons be involved with the evaluation of an open fracture wound at the time of the initial surgical procedure?

Yes (6.7%) No (86.6% ) Sometimes (6.7%) Comments: "If the coverage plan would be aided."; "If they are needed. We don't involve them often (very rarely)."

Do you do delayed primary closures and skin grafts of calf fasciotomy wounds?

Yes (93.3%) No (6.7%) Comments: "Both dependent on wound status."

Do you have any special techniques for performing delayed primary closures of calf fasciotomy wounds?

Yes (66.7%) No (33.3%) Comments: - Sure closure (2), Pie Crusting, Rubber Band

Technique (3), Elastics (vessel loops), and Fascio-cutaneous flaps.

Do you do your own rotational flaps?

Yes (35.7% ) No (64.3%)

Have you ever "fixed and flapped" open fractures without any assistance from other surgical services?

Yes (46.7%) No (53.3%)

The next topic that has been selected is:

Treatment of the Floating Shoulder Injury

1. How many times in your career have you seen a floating shoulder injury(combined middle third clavicle fracture and glenoid neck fracture)?

Never 1-5 6-10 10-15 >15 (Please Circle)

2. Do you believe that a combined middle third clavicle fracture and glenoid fracture automatically represents an unstable injury to the superior, suspensory mechanism of the shoulder? Yes No

3. Do you use a CAT scan to evaluate the displacement of a floating shoulder injury?

Yes No

4. If both the clavicle and the glenoid neck fractures are nondisplaced, do you treat these injuries operatively? Yes No

5. Do you think that stabilizing the clavicle fracture, stabilizes the glenoid fracture?

Yes No

6. If both the clavicle and the glenoid neck fractures are displaced, which fracture(s) do you operate on?

Clavicle Glenoid Both Neither

We need your help. All comments will be held in the strictest confidence. Please send all filled out questionnaires and comments by mail or e-mail to:

Craig S. Roberts, M.D.
Department of Orthopaedic Surgery
University of Louisville School of Medicine
3rd Floor ACB Bridge
Louisville, KY 40292
E-mail: CSROBE01@homer.louisville.edu

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 futures issues of Fractoids.