Inside
(p. 1) President’s Message From the Editor (p. 2) OTA Sponsored NEW JOT Supplement (p. 3) 2013 Annual Meeting (p. 4) A Year’s Reflection – Specialty Day Highlights (p. 5) Surgical Technique Videos Needed Curriculum Lectures (p. 6) Tackling Youth Gun Violence (p. 7) Atilla Poka, MD Landstuhl Report Fellows Course (p. 8) Synergy between Foot & Ankle and Trauma Capitol Hill Days (p. 11) Call for Volunteers (p. 12) Fellowship Committee SF Match (p. 13) Fellows Corner Winquist Award Tip of the Month (p. 14) Spring RCFC 2.0 Grant Recipients (p. 15) CFO Report PA & NP Membership EBQVS Report (p. 16) ACS NTDB Bylaws Boston Doctors and Marathon Victims (p. 17) Upcoming Webinars Golf in Phoenix (p. 18) Announcements
The Newsletter of the Orthopaedic Trauma Association Spring 2013
Message from the President Andrew H. Schmidt, MD
Here in the upper Midwest, the temperature has finally hit 50° F, the snow and ice is melting, and both geese and motorcycles are reappearing. That can only mean one thing – summer is coming! Unfortunately, in this part of the country, that also means that the summer trauma season is just around the corner too. As always, spring also ushers in changes within the OTA as we say goodbye to those members whose leadership terms are ending, while at the same time we welcome others who are just beginning. This year, Dave Templeman finishes his term on the OTA Board of Directors. Dave has served the OTA in prior terms as a Board Member and as the Chair of the Program Committee before serving as OTA President. He is currently Chair-elect of the Board of Specialty Societies and is a member of the AAOS Board of Directors, where he will continue to serve all of us. Jim Goulet is also leaving the OTA Board, having finished his term as Chair of the Program Committee. Under Jim’s leadership, the OTA Annual Meeting continued to experience fantastic growth, and the Program Committee added several new items to the Annual Meeting last year, including the NP/PA course and the Orthopedic Bootcamp. I’d like to give a special and heartfelt “Thank You!” to both Dave and Jim for all that they have done for the OTA. An equally strong thanks must be given to all of the OTA members who volunteered and took on a number of new positions in the organization this year. To the many more members who volunteered but did not find themselves appointed to new committees, please don’t give up, there will be things for all of you to contribute to! During the past two years, under the leadership of our prior three Presidents, Bob Probe, Andy Pollak, and Tim Bray, the OTA Board and committee structure was reorganized and a comprehensive strategic planning process completed. During continued on page
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Message From the Editor Hassan R. Mir, MD
Welcome to the Spring 2013 OTA Newsletter! This edition has several announcements, committee reports and columns to peruse in your spare time between polytraumas. Included are messages from the incoming and outgoing OTA Presidents, articles on member outreach into the community and advocacy, an interesting Fellows Corner, and very well-written piece on the synergy between our field and foot & ankle surgery. I wish you all the best of luck with trauma season, and I look forward to seeing you on the other side this fall. The next edition of the newsletter will be coming to you before the Fall 2013 OTA Annual Meeting, so please be sure to send any suggestions, content and photos over the summer to Hassan.Mir@Vanderbilt.edu.
From the President, continued from pg. 1 Andrew Schmidt, MD
this next year, we will begin to see the fruits of that process. We already have a new committee, the Evidence-Based Quality, Value, and Safety committee, chaired by Bill Obremskey. This group is already hard-at-work on a number of projects that you can read about in other sections of this newsletter, and which you will be hearing more about in the future. We are excited about a number of initiatives that the Health Policy committee has planned. The Classification and Outcomes Committee is planning some interesting research on the new OTA Classification of Open Fractures; if you are interested in this be sure to read Craig Roberts’ update in this newsletter. Please read through this newsletter for even more news about what all of the various OTA committees are up to. Last fall, culminating an effort that began several years ago, an OTA-sponsored resolution on resident duty-hour limits was passed by a floor vote of the members of the AAOS Board of Councilors and the Board of Specialty Societies. The purpose of the resolution was to ask the AAOS Leadership to engage the ACGME and other surgical specialty societies with the goal of relaxing resident duty-hour restrictions, which are particularly difficult in surgery and trauma, and have not had the expected benefits in patient care and resident education. The AAOS Board of Directors unanimously recommended the resolution for approval by AAOS membership. The AAOS Resolution Committee unfortunately modified the resolution, and although the final version is not as strongly worded and comprehensive as originally proposed, the OTA Board supports it, and believes there is potential for positive change as a result of its passage. If you have not done so, I strongly encourage you to vote today. In addition, I also hope you will cast your vote for the AAOS Nominating Committee via this link. There are two OTA past presidents nominated this year, Dr. Bruce Browner and Dr. Tim Bray. Both receive my personal recommendation as well qualified candidates with knowledge and expertise to serve both the AAOS and OTA. The deadline to vote is May 24th. Finally, it is with sadness that I mention the passing of Cliff Turen, a long-time OTA member, educator, and a dedicated and
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skilled surgeon, who died in a plane crash this past January. Cliff was a dear friend to many of us, and he will be sorely missed in the years to come. I look forward to my year as OTA President. There are a lot of important, exciting projects being done, with the help of many of you. Please do not hesitate to contact me or anyone at the OTA office if you have any ideas, questions, comments, or concerns We are here to serve all of you, as we all work together to improve the care of our patients. Have a nice spring!
Andy Schmidt
New Offering for our Members... OTA Sponsored JOT Supplement Ross K. Leighton, MD, OTA President-Elect
The Orthopaedic Trauma Association has decided to support a supplement in the Journal of Orthopaedic Trauma each year. The topics would have to be into the Board no later than the first of November and should include some funding outside of OTA support. The OTA will provide a maximum of $20,000 for this monograph. Optimally, the authors of the supplement will have obtained some funding. Is it our hope to have two or three presentations submitted from which the Board will choose the one that is of most interest to the membership. Obviously, a topic that is timely and of high interest at the time will be preferred. For details click here.
29th Annual Meeting
Thomas F. Higgins, MD, Program Chair
Pre-Meeting Courses • • • • • • •
On behalf of the Board of Directors and Annual Meeting Program Committee, please accept our invitation to the 29th Annual Meeting of the Orthopaedic Trauma Association (OTA), October 9 – 12, 2013, at the JW Marriott Desert Ridge, Phoenix, Arizona. The 2013 program will provide the most comprehensive and up-todate program related to treatment of musculoskeletal injury available. A diverse spectrum of topics and the opportunity to attend a wide range of sessions including scientific presentations of original research, didactic lectures, small group discussions, and hands-on labs provide learning opportunities that meet the needs of all musculoskeletal health care professionals. We truly believe that anyone involved in the field will benefit from the 2013 Annual Meeting. The preliminary program and registration will be available in June. Please consider joining us in Phoenix!
Basic Science Focus Forum Grant Writing Workshop International Orthopaedic Trauma Care Forum Masters Level Trauma Coding Course Orthopaedic Trauma Boot Camp Orthopaedic Trauma for NP’s and PA’s Young Practitioners Forum
CHINA OTA 2013 Guest Nation
Comprehensive Fracture Course for Residents
NEW
MODULE
October 9 - 11, 2013
FORMAT
Course Co-Directors: Michael T. Archdeacon, MD Kyle J. Jeray, MD NOTE: Faculty volunteers needed.
In recognition of the importance and benefits of sharing knowledge and experience with international colleagues, the OTA instituted a Guest Nation Program. We are proud to welcome China as the 3rd Annual OTA Guest Nation. Representatives from China: Manyi Wang, OTA International Member, and colleagues will participate in a symposium during the Annual Meeting as well as present at the International Forum. We are pleased to have this opportunity for collaboration with our Chinese colleagues. It will be an honor to recognize their contributions and achievements.
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A Year’s Reflection
Robert A. Probe, MD Each Spring, on the Saturday of the AAOS Annual Meeting, the OTA goes through a leadership transition. Last month, David Templeman rotated off of the Presidential Line after six years of exemplary service. While Dave’s sage organizational insight will be sorely missed, newfound research talents were added as Ted Miclau assumes the role of Second President Elect. As we take the occasion to reflect on the last twelve months, the collective accomplishments of the OTA’s educators, researchers, committees, councils, board and staff did much at advance our mission of improving the care of the trauma patient. Operationally, all of the committees found their legs and ran under the new council structure. Unlike many strategic plans which are created to collect dust, each of the articulated goals of our 2011 plan was embraced by a highly engaged and newly empowered group of Board Members. More than a new organizational chart, expanding the sphere of influence and authority of all Board Members unleashed a talent pool that performed exceptionally. The Education Council continued on its path of rapid cycle improvement in the highly interactive
resident and fellow programs. Innovative initiatives that continue to confirm the premise that adults learn best while participating in higher order thinking. Additionally, an 2012 Annual Report ambitious project of creating a surgical technique video library and making this available to the membership is well under way with Click to view the the expectation of a 2012 Annual Report. significant release in 2013. The Research Council continued its perennial work of funding one of the most cost efficient granting programs within medicine. It also expanded its sphere of influence with the origination of a directed topic research program which has shown substantial interest from a cadre of newly interested potential corporate sponsors. Most significantly, this council birthed the evidenced based, quality, value and safety committee. All that are knowledgeable about the failings of American Healthcare can appreciate The Orthopaedic Trauma Association is the worldwide authoritative source for the optimum treatment and prevention of traumatic musculoskeletal injury.
continued on page
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AOFAS / OTA Combined Specialty Day Session
(L to R) John Anderson, MD, Lew Schon, MD, Donald Bohay, MD, David Thordarson, MD, Robert Probe, MD, Clifford Jones, MD
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Sincere appreciation to AOFAS Emeritus Member, Paul Docktor, MD, for sharing his passion of photography at the 2013 Specialty Day Meeting.
A Year’s Reflection, continued from pg. 4
Robert A. Probe, MD the potential that this committee has in playing a leadership role in influencing change in a system badly in need of reform. The Membership Council, once again demonstrated the perceived value of OTA membership by contributing double digit growth to a membership that now numbers 1,652. A remarkable accomplishment while membership in many organizations is declining. While very pleased with our domestic growth, this Council is embracing the challenge of International expansion with strategically targeted international programs and exposure. Notable achievement also came from the Governance Council. Through perseverance and political savvy, a resolution to thoughtfully examine the effect of work hour restrictions that germinated within the OTA has worked its way through the BOS, AAOS Board and now to the AAOS membership. Because of these efforts, it is likely that an evidence based outcome of the regulatory changes will be pursued and appropriately acted upon. None of these many accomplishments would have been possible without the OTA residing atop a firm financial foundation. Because of a record setting Annual Meeting and a Specialty Day Program that doubled the previous year’s attendance (and a little help from a recovering stock market) the OTA’s Endowed Research and Education crossed the $6,000,000 mark. While I would have like to have credited this multitude of accomplishments to those responsible, the space limitations of this column wouldn’t allow for it. After watching the OTA from virtually every possible vantage point over three decades, it has become clear to me that the consistent and repetitive successes of this organization result from the limitless support of mission that resides in each and every one of our members. Having had the privilege of working alongside such a selfless group of accomplished individuals will be a personal career highlight impossible to replicate. While we have collectively accomplished much in 2012, there remains opportunity to do more. As the presidential gavel passes, I am supremely confident that combined, the leadership abilities of Andy Schmidt and the spirit of the OTA will do just that.
Request for Surgical Technique Videos
Robert F. Ostrum, MD, Chair Video Library Sub-committee The OTA Board of Directors and Education Committee has set on-line education as a high level priority for the coming year. As was reported at the OTA Annual Meeting, I’ve been appointed to lead an effort in developing an on-line surgical techniques video library, in collaboration with the AAOS OrthoPortal. I am writing to ask for your help. We are seeking high quality surgical techniques education videos to populate the library. If you have videos you are willing to share, I encourage you to upload them via this link. Please note, all authors will retain ownership. Note: Prior to uploading your videos, AAOS login on the OrthoPortal is required. After selecting the above link, click “sign in” from the upper right-hand corner.
Trauma & Fracture Care Core Curriculum Lectures Click here to take advantage of this valuable, free resource. The Orthopaedic Trauma & Fracture Care Trauma Association is Residency Core proud to provide this Curriculum Lectures syllabus of lectures, Version III written and edited by the membership, to support comprehensive orthopaedic trauma education. These presentations were created for use by educators and are supplied in a fashion that specifically allows for modification. The OTA respectfully requests that proper credit be given to the original author as well as the OTA when the talks are presented, even in modified form. These talks represent a combination of the literature, as cited, and current practices, as reported by member-authors. These lectures are regularly maintained and updated.
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Tackling Youth Gun Violence:
Orthopaedic Trauma Surgeons take Preventive Measures through Community Action in Schools Manish K. Sethi, MD and A. Alex Jahangir, MD 3. Think it through Manish K. Sethi, MD, and A. Alex Jahangir, MD, 4. Do the right thing are trauma surgeons at Vanderbilt University Medical “Many of our youth today don’t have the tools Center in Nashville, TN. Dr. Sethi, who grew up in to deal with conflict and unfortunately resort to Tennessee, returned as a physician to notice a startling gun violence,” said Dr. Sethi. “AVB is a case-based number of young African-American males who were program designed to give kids the tools to deal with suffering gunshot wounds and being rushed to the difficult situations they may encounter inside and Vanderbilt Emergency Room. outside of school. The kids act out different scenarios In fact, nationally, youth violence is the secondand discuss nonviolent ways to handle the situations.” leading cause of death for young people 15-24. After discussing the prospects of an intervention Furthermore, according to the CDC, each year youth with the Superintendent of Nashville public schools, homicides and assault-related injuries result in an the Center for Health Policy piloted AVB for 100 estimated $16 billion in combined medical and work 6th-Graders over a 3-month stretch in Fall 2012. By loss costs. Looking closer at this problem, Drs. Sethi and “Results of the pre- and post-tests clearly demonstrated Jahangir discovered that between 2004 and 2009, that kids had a better understanding of conflict resolution there was a sharp increase after completing the curriculum. Their perceptions, in youth gun violence in Nashville, especially attitudes, and behaviors toward violence, including for African-Americans aged 18-25. Additionally, gun violence, had also significantly improved.” at Vanderbilt, AfricanAmericans were 3.3 observing weekly classes and administering identical times more likely to show up in the ER with gunshot tests before and after the program, the physicians wounds than their white counterparts. Intervention discovered that this was working. was clearly needed. “Results of the pre- and post-tests clearly Sethi, Jahangir, and colleagues from their demonstrated that kids had a better understanding of Vanderbilt Orthopaedic Institute Center for Health conflict resolution after completing the curriculum,” Policy (VOICHP) have since teamed with the Robert Dr. Sethi said. “Their perceptions, attitudes, and Wood Johnson Foundation to select and customize a behaviors toward violence, including gun violence, gun violence prevention that will work for Nashville. had also significantly improved.” More specifically, these investigators looked for The next step is to improve upon the program middle-school programs, which have been proven utilizing a series of focus groups, and to expand AVB to impact children’s behavior prior to entering the to ten additional schools in Nashville, annually. There vulnerable 18-25 age bracket. are currently 46 total middle schools in Nashville, but After completing a national review of 26 gun the VOICHP have high expectations to move rapidly violence intervention programs and interviewing their towards that number. Drs. Sethi and Jahangir believe leaders, the VOICHP chose the “Aggressors, Victims, that physicians must play a central role in making gun and Bystanders” (AVB) Program—a teenage health violence a permanent fixture in Nashville. teaching module created by educational scientists at “As physicians,” said Dr. Sethi, “It is our role to Children’s Hospital in Boston, MA. The evidencebe leaders in society and to think more broadly about based AVB Program follows a peer-to-peer learning how to effect change in health care. The bottom line is strategy that emphasizes four steps to successfully that we need to get involved in our communities.” resolve conflicts: 1. Keep cool 2. Size up the situation
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Atilla Poka, MD Honored at OTA Specialty Day
Report from Landstuhl
Dr. Atilla Poka was honored on March 23 at Specialty Day for a lifetime of contributions to the Orthopaedic Trauma Association. Eighteen OTA past presidents nominated Dr. Poka for OTA Active Membership due to “exceptional circumstances.” In a letter addressed to the membership chair, Dr. Tejwani, they wrote, “Dr. Poka’s contributions to orthopedic trauma are emblematic of the mission statement of the OTA and his career long commitment to patient care, research, and education are exemplary to all members of the OTA.” Congratulations to Dr. Poka, OTA Active Member.
Thank you for the opportunity to visit the Landstuhl Regional Medical Center from April 14-27th. I had the tremendous pleasure of teaming with Dr. Eric Verwiebe and Dr. Kevin Kuhn, both of whom are currently stationed in Landstuhl. The soldiers evacuated during the time period of my visit were largely single extremity injuries but we were able to perform a number of fracture surgeries and reconstructive procedures. Just prior to my arrival there were a cluster of devastating upper extremity injuries, which provided an opportunity to review the process and allowed me to participate in the review process and multi-specialty conferences, which help to optimize the care provided. The staffing at Landstuhl appears quite robust although I am certain that volume is quite variable and that I may have experienced a temporary lull. I enjoyed participating in the daily morning report and following patients with the trauma team as well as providing lectures on several topics relevant both to fracture and trauma care. The orthopedic surgeons were very efficient and a pleasure to work with and I also enjoyed the General surgery trauma conference and Grand Rounds presented while I was there. This was certainly a worthwhile exchange as we had many opportunities to discuss cases and to exchange ideas regarding the provision of trauma care. I thank the OTA and the military as well as all of the staff and personnel at Landstuhl Regional Medical Center for the chance to rotate there and I found this a very enjoyable as well as fruitful experience.
2013 Fellows Course Faculty The 5th Annual Fellows Course held under the direction of Paul Tornetta, MD on April 18-21 in Boston was a great success and a course to remember. After much consideration of the tragic events only three days prior, President Andy Schmidt stated, “I can think of no better way to honor those who were killed or injured, and to honor the sacrifice of the first responders who placed themselves in harms’ way than by proceeding with this course and doing what we do best, which is to educate and train our future traumatologists.” Thirteen faculty members educated 48 orthopaedic trauma fellows which included cadaveric dissections and lively didactic case presentations.
Carla Smith, MD
2013 Fellows Course 2013 Faculty: (Bottom Row, L to R) J. Tracy Watson, Paul Tornetta III, Timothy J. Bray, Ross K. Leighton, Robert A. Probe; (Top Row, L to R) Andrew H. Schmidt, Roy Sanders, Michael J. Bosse, Kyle J. Jeray, Stephen A. Kottmeier, David C. Teague, David C. Templeman, Thomas A. Russell, J. Spence Reid
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The Synergy Between Foot & Ankle and Trauma Patrick Yoon, MD
A general belief in the orthopaedic trauma community is that in the multiply injured patient, it is the foot and ankle injuries that generally cause the most long-term impairment. Nine years into practice, I’m seeing firsthand what people are talking about. I’ve watched – with more than a little jealousy – my colleagues prn their patients after a femur or pelvic injury because they are doing just great; in the meantime, I’ve got a clinic full of people that I’ve operated on years ago who are suffering from posttraumatic arthritis after a Lisfranc injury or pilon fracture. Over the years I’ve had patients tell me something along the lines of “Why is this taking so long to get better? My buddy had a femur fracture and look at him, he’s fine!”
AAOS Research Capitol Hill Days – Feb. 27-28, 2013 The Orthopaedic Trauma Association was one of seven Specialty Societies represented at Research Capitol Hill Days. Lisa Cannada attended with her patient, Charles Shank, a traumatic amputee. The patients had meetings on (L to R) Charles “Skip” Shank, Julia Latash, Feb. 27th with Legislative Correspondent to Senator Claire the NIH to learn McCaskill (D, MO) and Lisa Cannada, MD. about the efforts and results of research. On February 28th, the patients and their doctors met with the offices of the Senators and Congressman from their state to ask for continued support of NIH/ NIAMS research for the 2014 Fiscal Year Budget with $538 million. We emphasized the facts of musculoskeletal disease being the most common health conditions
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So why would anyone, in their right mind, choose such a career path? Several colleagues of mine from back in residency would quip (only half-jokingly, I imagine) that they were going to start a practice called “Surgery that Actually Works” and do nothing but carpal tunnels, ACLs, primary total joints, and knee scopes, citing the generally positive outcomes from these types of procedures. Conspicuously absent was anything remotely approaching the foot and ankle. I’m sure we all know of people who eschew risky procedures that have a poorer prognosis. continued on page
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in the US including: • Musculoskeletal Disease costs represent $950 billion annually or 7.4% of the GDP. With the Baby Boomer population aging, that amount is expected to rise. • One in two adults reported a chronic musculoskeletal condition in 2008, nearly twice the rate of heart or respiratory problems • More than 30% of Americans require medical care because of a musculoskeletal disease • 17 million adults (7% of the adult population) report difficulty performing ADL’s due to a musculoskeletal condition. More than 1/3 is between 45-64. The meetings were made more effective with the patients telling their story. Mr. Shank was in a motorcycle accident and sustained pelvic fractures and a mangled extremity. He was 58 at the time of his accident. He has returned to a productive life working and was able to walk his son down the aisle at his wedding. This is in part due to the research efforts on wound care and prosthetic advances. We explained trauma can be a random event and affect anyone at anytime and represents a life altering experience. Thank you to the OTA Board of Directors for giving us this opportunity to be one of the seven subspecialty societies represented at RCHD. This is an important event we should continue to support.
Charles “Skip” Shank
ORTHOPAEDIC TRAUMA
On October 1, 2011, Charles “Skip” Shank’s life took an unexpected turn. Skip, a father and avid outdoorsman, was riding his motorcycle when he was suddenly cut off by a car. He tried to avoid a collision; however impact was inevitable. The motorcycle accident crushed Skip’s pelvis and severely fractured his right leg, leaving a gaping open wound. Immediately, he underwent surgery to stabilize his leg. Lisa Cannada, MD, an orthopaedic traumatologist at St. Louis University Hospital, used external fixation, a series of metal rods on the outside of his leg secured to the bone above and below the fracture, to attempt to stabilize the bone and save his leg. Unfortunately, Skip’s injury caused extensive damage to the muscle and soft tissue in his leg. His leg became infected and the soft tissue became necrotic. Just nine days after the accident, Dr. Cannada concluded that Skip’s leg could not be spared. “When the tissue continued to die, it was determined that the best thing to do was amputate,” Skip laments. On October 10, 2011, Skip’s leg was amputated below the knee. In the months after his surgery, Skip developed heterotopic ossification (HO) around his knee joint. HO is the formation of bone in soft tissue. Posttraumatic HO is common and highly problematic. In some patients, HO is asymptomatic; but in others, the abnormal growth causes pain, stiffness, and requires surgical removal. Skip spent five months in a wheelchair, and eventually graduated to crutches. With the help of physical and occupational therapy, Skip was able to return to his job and start to drive again. In the June of 2012, Skip was fitted with a prosthetic leg to allow him to walk without an assistive device. In September, he was able to walk down the aisle at his son’s wedding. With daily exercise, Skip continues to gain strength and is learning to adapt to his prosthesis. “The residual limb is holding up quite well and there seems to be no increase in the HO at this time,” he notes. Each day, Skip encounters obstacles and challenges, but overall is doing quite well. “I have been able to be more a part of everything again,” he says, “from going on the fishing trips to helping my sons with doing different projects on their homes, to being completely selfsufficient.” Skip hopes that continued musculoskeletal research will help future trauma patients have more favorable outcomes. “Additional muscular and vascular research could have a major impact on the ability to save limbs.”
Faces of Orthopaedics 2013 RESEARCH CAPITOL HILL DAYS PATIENT VIGNETTES
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The Synergy Between Foot & Ankle and Trauma, continued from pg. 8 Patrick Yoon, MD
As with a lot of things, the answer is multifactorial. For me it all began with a mentor. Ed Rutledge had done a trauma fellowship with Ken Johnson and subsequently learned foot and ankle from a senior partner here at Hennepin County Medical Center, Leo DeSouza. He was our go-to guy for pilons, calcaneus fractures, lisfranc injuries, and talus fractures. I remember spending eight hours on a Saturday as a resident with him fixing a teenager’s talar neck and body fracture. It was with more than a little irony that he was called “Fast Eddie.” Despite his slow, methodical, meticulous nature – or perhaps because of it – he was one of my favorite attendings from residency. He taught me the value of patience, persistence, and preoperative planning. Sometimes in the middle of surgery he would just sit down and stare and then come back to the table with a new idea of how to tackle a particularly tough reduction. It was one of these moments that gave him the inspiration to try a new idea to remove an incarcerated femoral nail.1 On a slightly tangential note, but one which does illustrate his situational awareness, he told me one day how he was in clinic and needed a SemmesWeinstein 5.07 monofilament but was unable to track one down. While taking a bathroom break he sat there contemplating his situation, looked down, and lo and behold, there, just like manna from heaven, was a Semmes-Weinstein 5.07 monofilament on the floor of the restroom. Certainly, just having a mentor one admires does not necessarily endear a subject matter to an individual. Tim Garvey was another great mentor and operated on my own spine but I wouldn’t be caught dead going into spine. The subject matter has to be intellectually stimulating. For me, the foot is a complex, beautiful thing. There are 28 bones if you include both sesamoids and don’t include the myriad unfused accessory ossification centers that many of us have. Getting them to behave and contribute to a stable, plantigrade structure is challenging. Sure, it can border on being frustrating. Heck, it can drive you outright mad. Sometimes in surgery fixing a complex midfoot fracture-dislocation can be like herding cats. You get one joint to line up perfectly and another one strays off course. You fix that and a third one decides not to line up. You fix that one and the one you were working on to begin with
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now comes undone. Needless to say I’ve learned the value of taking a deep breath. Patience in these matters is probably the second best gift I gleaned from my mentors. I say second best because the first best is preoperative planning. For these complex cases, I cannot overemphasize the importance of preoperative planning. Recent OTA president Dave Templeman is a senior partner of mine and one of my attendings from residency. He always emphasized the importance of preoperative planning and would have your posterior in a sling if you didn’t have a preop plan drawn up when you entered the OR. Even now I will draw out the entire foot preoperatively and sketch in which joints are out, which joints are reduced and stable, and which joints are reduced and unstable. I’ll then list everything I have to do in order it needs to be done and stick it on the wall of the OR. We all have our own methods; this works for me. Although as surgeons we enjoy the technical aspects of performing surgery, for me some of the greatest joys are outside the OR. One is receiving a hug from a patient whose life you’ve changed. Another is sitting down with pencil and paper and mapping out what you’re going to do to piece these 28 bones together. You have to piece them together in a way that keeps them stable, that creates a plantigrade foot, that maintains some semblance – hopefully more – of an arch, that doesn’t kick the first ray up in the air, that preserves the crucial joints if possible, and that is all feasible with the soft tissue envelope you have. Ultimately, the most important thing is patient care. For us in the trauma world, it’s the care of the injured – and often multiple injured – patient. How can we do a better job? Granted, there is much we can improve upon no matter what field within orthopaedic trauma we pursue. With any fracture, we’d like to reduce infection rates, improve range of motion, reduce nonunion and reoperation rates, and make surgery and its recovery less traumatic for the patient. However, returning to our initial point about foot and ankle injuries having the generally worst long-term sequelae, I believe that in most of these areas the traumatized foot, among anatomic regions, has the most work to be done. When that patient with the scapular body fracture, pelvic ring injury, open femur fracture, tibial plateau fracture, and smashed continued on page
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The Synergy Between Foot & Ankle and Trauma, continued from pg. 10
Call for Volunteers
Patrick Yoon, MD
Click here for details on each open position to see which opportunity best suits you.
pilon follows up months later, and I know which one of those injuries he or she is most likely to complain about a year later, I want to devote all my resources to tackling that problem. When I do see that patient a year later, or a decade later, I think there is value in having both a trauma and foot & ankle background. For example, I participated in the early management of a 9-year-old boy who was hit by a car and sustained a deep abrasion through the entire lateral soft tissue envelope of his ankle down into the fibula. After soft tissue reconstruction with plastics doing an ALT flap and myself doing an FHL transfer to reconstruct his peroneals, he did OK for about four years. He recently came back with a worsening supination deformity to his foot. Understanding the importance of maintaining tendon balance in the foot helped me to understand that his posterior tib was going to way outbalance his reconstructed peroneals and help the patient and his family to understand the importance of wearing his AFO and the eventual need for additional work. A foot and ankle background helped me to then also be the one not only to have taken care of him initially, but also follow him over the years and ultimately reconstruct his foot with osteotomies and tendon transfers to restore a plantigrade foot. Helping this kid out has been one of the highlights of my career. There are a lot of benefits to having a subspecialty niche within orthopaedic trauma. For many, having a career to fall back on if trauma burnout becomes severe may be a wise precaution to take. For me, the foot & ankle niche has been intellectually stimulating. I also think it benefits my patients for me to have that extra foot & ankle background to be able to manage not only their acute problems but also their long-term management. While we have a lot to improve upon in terms of long-term outcome for foot and ankle injuries as compared to the rest of the skeleton, it is that gap and that need to improve upon what we have that excites me most about this field. 1. Rutledge EW: A method for removing an incarcerated rod, Orthopaedic Review 22(8):953, 1993 Aug.
Call for Applications
The OTA needs members to become involved with the American College of Surgeons (ACS) Committee on Trauma (COT) orthopaedic specialty section. The COT is responsible for a host of trauma efforts nationally and internationally, from ATLS courses and the National Trauma Data Bank® (NTBD) to verification of trauma centers by the Verification Review Committee (VRC) of the COT. You can read more about this effort in Wade Smith’s article on page 16. • One opening available beginning in 2013 • Two openings available beginning March 2014 For specific details regarding volunteer and COT membership requirements, click on this link. To apply for nomination, please send a letter of interest to ota@aaos.org by May 24th. Committee Member Vacancies The following OTA committees will have openings beginning March 2014: • Annual Program • Fellowship • Bylaws • Health Policy • Education • Military and Research The deadline to apply for a committee position is October 15, 2013. Distinguished Visiting Scholar Program Volunteers are needed to care for wounded service men and women in the ongoing conflict. Education Volunteer Opportunities Individuals are needed for future education volunteer positions: • Resident Course Faculty • Residency Core Curriculum Lecture Authors, Editors & Reviewers • Your Orthopaedic Connection Editors • Reviewers for ICL/Symposia submissions International Education Initiatives Be included on the volunteer list for future international initiatives: • International Course Faculty • International Relations Forum Mentor • SIGN Scholar Host
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Fellowship Committee Mark Lee, MD, Chair
• The OTA 2013 Match took place on March 12th. A match audit was conducted by SF Match, Mark Lee, and an OTA Staff Member prior to release of match result. The results were found to be accurate and in accordance with match requirements. The final match statistics are noted in the table below. (not included in the chart, but of interest, is that 11% of applicants matched their first program choice). • Unmatched positions were posted on the SF Match website on March 12th, and a postscramble match followed for the 9 unfilled positions. • The Fellowship Committee is in the process of reviewing applications for the 2014 match. Programs must meet OTA Fellowship Accreditation requirements to participate in next year’s match. • 2014 Match Calendar • An on-line fellowship log is under development and will be available by summer 2013 for the 2013/2014 Fellowship year.
Orthopaedic Trauma Fellowship Match
April April March March March ‘09 ‘10 ‘11 ‘12 ‘13
Applicant Registrations
110
125
128
140
137
CAS Participants
83
92
112
122
132
# Applicant Rank Lists Submitted
74
84
82
92
94
Matched Total
69
74
64
70
68
Unmatched Total
5
10
18
22
26
% Matching Total
93%
88%
78%
76%
72%
# Applicants Ranked by Programs
71
83
90
94
89
Total # of Withdrawals
4
9
5
4
8
Positions Offered
81
82
81
78
77
Positions Filled
69
74
64
70
68
Unfilled Positions
12
8
17
8
9
Avg. CAS applications per applicant
16
17
14
20
18
Avg. # of offers per applicant
4.33
3.96
4.34
4.14
3.66
Orthopaedic Trauma Fellowships for 2014, cont’d
Current Vacancies in Orthopaedic Trauma Fellowships for 2014 University of Louisville School of Medicine (2949) Louisville, KY Program Director: David Seligson, MD Description: Offering 2 post-match vacancies to begin training in July 2014.
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Wright State University (2969) Dayton, OH Program Director: Michael Prayson, MD Description: Offering 1 post-match vacancy to begin training in July 2014. Temple University Hospital (2970) Philadelphia, PA Program Director: William DeLong, MD Description: Offering 1 post-match vacancy to begin training in July 2014. Complete details on these fellowships available here.
Fellows Corner
CPT Daniel J. Stinner, MD Increase the value you provide as a surgeon by being fiscally responsible. According to CMS data, healthcare costs were $2.9 trillion in 2012 and are estimated to be $3.1 trillion in 2013. Increasing healthcare costs in addition to the recent sequestration have lead administrators to search under every rock they can find to scrounge up a few more pennies. In three months, if not already, we will be the ones making decisions on which implants we want to use and the method in which they are applied. In order to maintain that control, as we get started in our practices, we should make an effort to be fiscally aware of our treatment costs. The more we do it on our own, the less likely we are to have someone trying to do it for us. At our institution, the chief of the service (Dr. William Obremskey) will routinely perform audits of the cost per case for certain CPT codes across the various surgeons in the practice. While there are no repercussions, or incentives for that matter, the survey can be eye opening and helps to the surgeons to be more fiscally aware of their decisions. For example, why use this implant, when an equal quality implant costs 1/3 less? There must be a delicate balance – being fiscally responsible, without lowering the quality of care provided. As such, you increase the value you provide which is quality divided by cost. Who knows, future administrators may not just look at a surgeons case log for credentialing, but also at their costs for certain CPT codes when considering hiring for a new position. Perhaps this will never be the case, but if I were running a business I certainly would be trying to get the best value from my employees. Various methods have been employed by hospitals to keep costs down, such as group purchasing agreements to lower the cost of implants, but perhaps one of the best methods is simply just making the surgeons aware of the costs per case. At our institution a new program was instituted to provide cost per case information available at the end of the case, and aggregate data of cost per case based on CPT codes per surgeon. I feel that this is an excellent feedback system to encourage surgeons to be more cost effective. After all, we all like a challenge. I wish you all well as we finish out our fellowships and look forward to working with you all in the future.
Robert Winquist, MD Award Michael J. Prayson, MD was awarded the cup for the 2012 Fall Residents Comprehensive Fracture Course Casting Lab. He was selected by the 2012 Fall Course Co-Chairs, Michael Archdeacon, MD and Kyle Jeray, MD based on post-course survey feedback received from fellow faculty and the residents who attended the course. Dr. Prayson has led the lab for many years, and was most deserving of this special honor.
Tip of the Month Proximal Humerus Plate for Fixation of Selected Medial Femoral Condyle Fractures William T. Obremskey, MD, MPH (view online for figures) A relatively uncommon but difficult clinical problem is a comminuted medial femoral condyle fracture. I have often struggled with the most appropriate fixation of these fractures. In my experience, these usually occur from either a direct blow or a gunshot wound to the medial femoral condyle. The fractures which have a clean shear fracture are fairly easily treated with a medial parapatellar approach, lag screw fixation and buttress plating with a standard plate. (Figure 1 and 2) I have been challenged when there was a large cavitary defect from impaction injury or gunshot wound blast combined with multiple intra-articular fragments and the need for a broader plate on the medial femoral condyle to either capture and contain bone graft or provide support across multiple fragments. The case here demonstrates the use of a proximal humeral locking plate placed along the medial femoral condyle to act as 1) a buttress plate, 2) screw support of multiple fragments and 3) a broad plate to contain bone graft. (See figures 3-6) It contours well to the medial femoral condyle. (See Figure 7) This off-label plate and screw configuration is 8-10 X more expensive than using a standard Recon or DC plate, but I feel it is warranted in these more complex scenarios when one needs a broader plate and multiple point fixation for multiple fragments. I hope it is helpful.
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2013 OTA Spring RCFC 2.0
WEDNESDAY - SATURDAY
April 10-13, 2013
Matt L. Graves, MD and Gregory J. Della Rocca, MD, PhD, FACS The 2013 OTA Comprehensive Fracture Course for Residents 2.0 took place on April 10-13 in the Westin Lombard Yorktown Center in Lombard, Illinois. In the third year of the new course format, 113 residents attended, thanks to Comprehensive Fracture generous industry support providing scholarships for Course for Residents 2.0 Final Program housing and registration fees. The majority of the participants were from 20 different states within the US, but additional participants Westin Lombard Yorktown Center Lombard, Illinois came from Canada, India, Ireland, New Zealand, the Dominican Republic, and Australia. The new modular design maximized small group interactive sessions and multimodal learning experiences. Improvements were made in standardizing course content, creating clearly defined and easily assessed medical knowledge objectives, and formalizing the pre-course and post-course assessments. Emphasis was given to the application of basic principles learned in the pre-course streaming video modules. This format will be adopted for the Fall course at this year’s annual meeting. April 10 - 13, 2013
Matt L. Graves, MD, Chair Gregory J. Della Rocca, MD, PhD, FACS, Co-Chair
2013 Resident Grant Recipients
June 1, 2013 – May 31, 2014 Grant Cycle Resident Grant Recipients Principal Investigator: Jonathan Scott Harris, MD Co-Investigator: Jeffrey O. Anglen, MD Grant Title: The Safety and Efficacy of Using Romiplostim for Bone Healing Amount: $19,000 Principal Investigator: Motasem I. Refaat, MD Grant Title: Fixation Compliance and BMP Response Amount: $17,700
Co-Investigator: Mark A. Lee, MD
Principal Investigator: Prism S. Schneider, MD, PhD Co-Investigator: Kevin Hildebrand, MD Grant Title: The Dose-response Effect of the Mast Cell Stabilizer, Ketotifen Fumarate, on Post-traumatic Joint Contractures Amount: $19,219 Principal Investigator: Timothy Sean Leroux, MD Co-Investigator: Patrick David George Henry, MD, FRCSC Grant Title: Assessing Knowledge Translation in Orthopaedic Surgery: A Time-series Analysis of Midshaft Clavicle Fracture Fixation in Ontario, Canada Amount: $19,626
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TOTAL AWARDED: $75,545
Report from the CFO
PA and NP Membership in the OTA
The financial assets of the OTA achieved robust growth in 2012 due to the success of our annual meeting and a strong stock market recovery. Our total fund balances on 12/31/12 were $6,605,426 up more than $1,000,000 from year end 2011. The majority of this money, approximately $5.5 million, is held in our Research and Education Fund which support our many research grants and educational activities. The annual return on our Research and Education Fund investments in 2012 was 13.5% net of fees. This return compared favorably with the blended benchmark of 13.1%. For reference, since our account is more conservative and not invested solely in stocks, the Dow Jones Industrial Average had a 10.1% return in 2012 while the S & P 500 index had a 16% return. Our Research and Education Fund is invested 71% in equities (stocks) and 29% in fixed income securities. In terms of our stock investments, roughly 51% are invested in large cap value and growth stocks, 19% in mid and small cap stocks, 11% in international markets, 8% in emerging markets and 11% in real estate. Ongoing challenges in the medical product industry have placed pressure on corporate donations. We have seen a decline in unrestricted research fund donations but continue to receive outstanding support for our many educational programs. Our Fund Development committee continues to work on plans for new sources of funding in order to maintain are current level of both research and education support.
The OTA offered its first NP/PA course at the Annual 2012 Meeting, and is planning another for the Annual 2013 Meeting. The meeting exceeded its original target of 100 attendees and received positive feedback and suggestions for the upcoming 2013 meeting. Membership is available to non-physician health care providers involved in the care of patients with musculoskeletal trauma injuries, with current licensure from licensing board, and one sponsor form or recommendation letter from an OTA Active, Senior or Research member. Membership is maintained by complying with the dues, fees, and assessment requirements established by the Board of Directors of the Orthopaedic Trauma Association. Benefits of membership include discounts for subscription to the Journal of Orthopaedic Trauma and significantly discounted registration for the Annual Meeting and educational opportunities. Members are eligible to apply for OTA funded research grants, receive the OTA newsletter, access the trauma registry database, conduct research surveys of membership, OTA members only webpage access, participate in OTA committees, and serve as faculty at OTA sponsored courses. OTA membership has been a very positive experience for me, with committee and course faculty experiences. I highly encourage PAs and NPs to consider membership and am happy to discuss it with anyone interested. Thank You
David J. Hak, MD, MBA
Daniel Coll, MHS, PA-C
Evidence Based Medicine Quality, Value and Safety Committee Report William T. Obremskey, MD
The Orthopaedic Trauma Association Board of Directors has changed the evidence based medicine ad hoc committee into a formal committee entitled The Evidence Based Medicine Quality, Value and Safety Committee (EBQVS). This will be consistent with an AOS similar committee. Committee members are Bill Obremskey, Paul Tornetta, Steve Olson, Claude Sagi, and Cory Collinge. New members that have been appointed by the Board of Directors include Bruce Browner, Arvind Nana, and Jaimo Ahn. The Board of Directors has charged us to: 1. Maintain a list of “best articles” under specif-
ic topics. Please see these under “services” on the members-only page of the OTA. 2. Guidelines: We have performed practice pattern surveys on 1) treatment of open fractures, 2) Treatment of segmental defects in open fractures, and 3) DVT prophylaxis. These will be completed and reported within the Journal of Orthopaedic Trauma. Members can expect 1 to 2 surveys per year on current practice pattern and with commentary and recommendations by the EBQVS Committee. continued on page
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EBQVS Report, continued from pg. 15 William T. Obremskey, MD
3. Quality metrics. a. The OTA is working with the AAOS on hip fracture protocols development. This is being led by Steve Olson. b. QI projects: A readily available QI database for each practitioner will be available via Red Cap. Members can use the database to enter basic data and outcomes on patients with open tibia fractures and pilon fractures. This will be the beginning of a process to help members develop own QI projects. Members will be able to compare their own data to all data nationally, which will allow members to assess areas and needs for QI.
ACS National Trauma Data Bank速 Wade R. Smith, MD
The ACS/COT Ortho subspecialty group and OTA leadership are working with the COT leadership to increase OTA involvement in the National Trauma Data Base (NTDB). This is a nation wide data registry including more than 7 million trauma patient records. Every ACS verified trauma center is required to download their trauma registry database to the NTDB. The NTDB is managed by the COT and is increasingly being used for large scale research. In the near future, federal policy and funding decisions may rely in part on NTDB data. Currently, orthopaedic trauma data is sparsely reported and there has not been a systematic approach. The OTA and COT leadership have agreed to evolve the musculoskeletal sections as a joint effort. An OTA task force was appointed to evaluate the current data fields and provide recommendations. The goal will be to play an ongoing role in musculoskeletal data collection and analysis. Task force members include: Bruce Browner, MD (Advisor), Wade Smith, MD (Chair), Craig Roberts, MD, Ellen MacKenzie, MD, Bruce Ziran, MD, Saam Morshed, MD, Doug Lundy, MD, Jeff Anglen, MD, and Spence Reid, MD. Please address comments or questions to Wade Smith, chair.
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Bylaws
James P. Stannard, MD, Chair Two bylaws amendments passed at the OTA March 23, 2013 business meeting on Specialty Day. (1)
Proposal 1 was a change to Article V: Members, Section III: Election Procedures for Active Membership, allowing one of the two required sponsors to be an OTA International Active Member.
Section III. Election Procedures for Active Membership a. Applications for active membership shall be made online. b. The applicant must be sponsored by two active, senior, or research members, one of whom must be from a community and institution other than the applicant. One of the two sponsors may be an OTA International Active Member - Associate and Clinical members applying for active membership are not required to supply sponsors. (2)
Proposal 2 called for the addition of the following new membership approval in exceptional circumstances.
Section IV: Approval of Membership based on Exceptional Circumstances In recognition of occasional exceptional circumstances, OTA membership may be granted to an individual with an affirmative vote of 2/3 of surviving OTA Past Presidents and unanimous cons of the OTA Board of Directors.
Lessons From Military Surgeries Informed Treatment of Boston Victims Link to online article. Courtesy of The New York Times Andrew Schmidt is quoted in USA Today regarding Boston Marathon Attack and another article regarding amputees.
Upcoming Webinars May 14th
Tibial Shaft Fractures: Moderator: Michael T. Archdeacon, MD The State of the Starting Point, Nailing Extreme Proximal and Distal Fractures, and Basics of Open Fracture Management Invited Presenters: Robert F. Ostrum, MD and Robert V. O’Toole, MD
July (day TBD)
Surviving a Night on Call: Moderator: Samir Mehta, MD The Current State of Orthopaedic Urgencies and Emergencies Faculty: Lisa K. Cannada, MD, Robert P. Dunbar, MD, and Wade R. Smith, MD
September 24th
Periprosthetic Femoral Shaft and Supracondylar Moderator: Brett D. Crist, MD, FACS Fractures Femur Fractures - General Principles and Role for Locked Plates and Revision Arthroplasty? Invited Presenters: Frank A. Liporace, MD and Michael Suk, MD JD, MPH
November 19th
Common Upper Extremity Fractures: Moderator: Heather Vallier, MD The When and How of Surgical Management Invited Presenters: Kevin J. Malone and Lisa A. Taitsman, MD
2013 Annual Meeting Golf Tournament October 9-12, 2013 The 2013 OTA Annual Meeting will take place at the JW Marriott Desert Ridge and has a spectacular course in its backyard. We are considering organizing a scramble Tuesday, October 8 or Sunday, October 13, 2013, one day following the Annual Meeting. If we have enough interested parties we will provide additional information this spring so that proper flight and hotel accommodations can be arranged. If you are unable to participate Sunday, October 13, and wish to play during the week, please select the link (right) to be placed on a golf contact list. Course Description: Palmer Course The Palmer Signature Course at Wildfire Golf Club delivers a target golf
experience, while the expansive fairways allow golfers to remain in play even on an errant shot. The bunkering on the 7,170-yard, par 72 Arnold Palmer design is superb with four to six tee boxes on every hole, generously sized bent grass greens and sweeping fairways, which create an experience unlike any other. The golf course winds through the rugged Sonoran desert, offering stunning views of the McDowell Mountains, Camelback Mountain and Squaw Peak, making it the perfect setting for golfers of all skill levels.
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Click this link to express interest!
Announcements • COMPLIMENTARY Webinar: MAY 14, 2013
Tibial Shaft Fractures – The State of the Starting Point, Nailing Extreme Proximal and Distal Fractures, and Basics of Open Fracture Management Moderator: Michael T. Archdeacon, MD Invited Presenters: Robert F. Ostrum, MD Robert V. O’Toole, MD
• Resident Grant Application
Deadline – June 19, 2013
•
Annual Meeting Housing: Member priority housing opens in June.
• Membership Deadline:
November 1, 2013 Last chance to apply for membership in 2013! Application and requirements available here.
• JOT Supplement Funding Application
Deadline – November 1, 2013
• Disaster Response Course
Dec 13 - 14, 2013 – Vail, Colorado
The ORS and OTA presented a New Horizon Workshop at the ORS 2013 Annual Meeting in San Antonio. This workshop was recorded and is available on the ORS website as a complimentary webcast. New Horizon Workshop: Current Management, Clinical Controversies, and Basic Scientific Understanding of Polytraumatized Patients with Major Skeletal Trauma (Presented by the ORS and the Orthopaedic Trauma Association/OTA) Organizer: Todd McKinley, MD, Indiana University Health Methodist Hospital This purpose of this workshop is to discuss current clinical and basic scientific knowledge bases pertaining to orthopaedic injuries in polytraumatized patients. Management of multiple injured patients frequently involves addressing major axial and appendicular skeletal trauma. Timing, magnitude, and technical choices of orthopaedic interventions can affect the outcomes of these patients. This workshop is designed to generate interaction between orthopaedic clinicians who manage multiply injured patients and basic and clinical scientists interested in major orthopaedic injuries, systemic response to trauma, and bone healing. There are many research topics within Orthopaedic Surgery including bone healing, systemic inflammation, tissue energetics, rehabilitation, and bone and cartilage injury that are profoundly affected by polysystem trauma. This workshop is significant because it will address how polytrauma affects a wide variety of orthopaedic-related issues.
• Job Posting – Members – Post your job for free!
The Patient and The Injury: Decision Making Adam J. Starr, MD, University of Texas Southwestern
• Washington Update
Damage Control Vs. Early Total Care Robert V. O’Toole, MD, Shock Trauma Center
Take advantage of this member benefit.
Timing and Magnitude of Orthopaedic Intervention: Basic Evidence that Guides Clinical Practice H. Christopher Pape, MD, University of Aachen
• Donate Here!
Please consider supporting OTA Research.
Thank you to all 2012 donors to date! List of 2012 Donors
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Polytrauma and Fractures Moving Toward the Future Todd O. McKinley, MD, Indiana University Health Methodist Hospital
Orthopaedic Trauma Association 6300 N. River Road, Suite 727, Rosemont, IL 60018-4226 Phone: (847)698-1631 Fax: (847)823-0536 e-mail: ota@aaos.org Home Page: http://www.ota.org