Open Fracture of the tibia is treated. To this point you could bill A065, K961(SV travel fee), K992(SV fee), E082(Admission fee (30%add to consult), F079, E555, E556, E409.

To discharge you could charge further visit fee (C062) times 2 and discharge fee C124 plus E083 (+30%) if you are MRP.

If this were another case and the patient arrived in an emergency clinic you might be able to charge a travel fee to go to the clinic U963 (let’s say it was a weekend) and for each patient seen you could charge U998 or U999 for each patient up to 20 patients for the period from 0700 to 2400.

For 20 patients plus a travel fee the total pay for a Saturday day period might be (20 x 56.25+36.40) $1061.40 for special visit fees alone for the 0700 to 2400 time period. After 2400 hours until 0700 there is no limit to travel or visit fees.

The E082 fee is an interesting fee as it appears to apply to every MRP who admits his own patient and adds a 30% add-on to the admission fees (C122) Similarly the E083 adds to the subsequent visit fee but for a MRP surgeon it is suggested that you add it to the C124 discharge fee (an applicable fee).

If you do not treat a patient surgically but you are the MRP you can add the E082 or E083 to any of the C122/123/124/142/143 codes adding 30% to each. Since writing this article I have discovered that Special visit fees do not apparently apply to a surgical visit that is going to the OR.

When they first were published I asked the OMA if you could charge Special Visit Premium for Surgical call, going to the OR and I was told yes.

Unfortunately we have tried to bill that fee and have been rejected; in fact our program will not even accept it.

I will attempt to clarify this in our favour this year.

In the meantime, the CMPA continues to offer advice and support to our seroconverted members. They have assembled their own information gathering BBP expert panel, who will hopefully educate all stakeholders, including the CPSO.

The COA National Standards Committee has hired a research assistant, who is presently reviewing all pertinent literature, and will report back to the committee in one month. It is hoped that we will be able to create a policy paper for orthopedic surgeons across Canada with recommendations for MD testing (or not), patient testing, and equipment provisions. I will continue to fight for our rights!

Arthroscopic Bankart Repair: Tips & Tricks

1 .Open vs Arthroscopic:

2 .Anatomy

• Ball-and-socket joint with poor bony stability
• Glenoid labrum, surrounding capsular ligaments important for static stability
• Rotator cuff muscles important for dynamic stability
• Inferior Glenohumeral capsulolabral complex is the major ligamentous restraint for both anterior and posterior stability:

3. Clinical

4. Techniques (Tips & Tricks)
1. Patient positioning

• Beach Chair
  Vs.
• Lateral
• After trying both, I prefer lateral for labral repairs
• Both require tractioning/positioning device
• Spider
• STAR Sleeve

2. Portals
Use 1 viewing and at least 2 working portals:
Posterior
Antero-Medial
Antero-Superior
I use 7 mm cannulas for working portals

3. Diagnostic Arthroscopy

• Look for additional pathology: HAGL, SLAP, GARD, etc
• Measure glenoid bone loss
• ? Engaging Hill-Sacks by AB/ER of shoulder (out of traction)

4. Prepare Glenoid

• Release adhesions:
• Free labrum and capsule totally
• “float” labrum to glenoid
• Debride glenoid (rim and medial neck): “if it doesn’t bleed… it won’t heal”

5. Pass Shuttle Suture

• I pass a suture shuttle 1st as this is the most technically difficult part of the procedure: Spectrum with #1 Prolene
• Start @ 6 o’clock position inferiorly
• Grasp more capsule/labrum if significant capsular redundancy
• Can use single pass instruments if suture anchor placed 1st

6. Drill and Place anchor

• Use MRI lucent anchor (PEEK or Bio) with #2 High strength suture material
• Place on glenoid rim (in area decorticated) for anatomic repair and maximal biologic healing
• Try to get 1st anchor as low as possible (consider percutaneous 5 o’clock portal)
• Affect a distal-to-proximal capsular shift by placing anchor superior to shuttle suture

7. Recreate the Labral Bumper

• Consider a mattress suture configuration for deficient labrum in chronic repairs
  arthroscopic knot
• For simple suture configuration: the “post” suture is the limb passing through the tissue
• Use sliding locking knot: Weston, SMC, Duncan, etc
• Back-up knot with 3 x ½ hitches on alternating posts
• If suture not sliding… construct Revo non-sliding knot

8. Center Humeral Head on Glenoid

• The essential end-point is to see the humeral head centered on the glenoid bare spot (from anterosuperior portal)
• Consider capsular plication sutures (anterior or posterior) to correct for humeral head shift

9. Understand Limitations

• Acute bony Bankart > 25% = ARIF/ORIF
• Chronic Glenoid bone loss >25% = open Latarjet
• Engaging large Hill Sacks Lesion = Remplissage vs. Bone Grafting vs Latarjet
• Combined moderate Glenoid bone loss + Hill Sacks Lesion = Remplissage vs Latarjet
• HAGL Lesion = open humeral capsular shift

This year the WSIB agreement is being renegotiated by the OMA. However the OOA is not at the table for negotiation, nor are plastics and anesthesia. To quote our current OMA president, “If you are not at the table, then you are part of the menu.”

Realizing this, the OOA has contacted Mr. Steven Mahoney, chair of the WSIB board. We have pointed out to him the current problems with our system and the subsequent problems with their patients. The vast majority of these problems are related to delays in being seen in consultation and delays in treatment. We have proposed a system similar to Alberta and B.C. where patients are given “expedited care” and the Orthopaedic surgeons are rewarded financially to provide this care. We have received a positive response from Mr. Mahoney, referring us to Donna Bain, Vice President, Health Services, in early December. We have not receive any response from her as yet. This letter was forwarded to her December 9, 2009

We, your board at the OOA, see this as a win-win situation at this time. The WSIB patients will receive faster care with better outcomes, the WSIB will save a significant amount of money and the Orthopaedic surgeons of Ontario will be compensated appropriately for the care they provide.

At the AGM a vote was taken regarding this situation. It was overwhelmingly passed to pursue this agenda and if WSIB is not responsive to consider some type of job action. Hopefully they will see the benefits in this agreement and proceed with an agreement with us. We will keep the members updated about this situation.

Historically, the foundation of human resources in Ottawa has always been in the form of medical housestaff be they students, postgraduate residents and sub-specialty clinical and research fellows. Most medical students have a mandatory two week rotation in their third year. As they are adjusting to the clinical, ward, and patient issues they require additional energy and time from the orthopaedic surgeon. They are a part of the house staff. Their assistance is during the first pass at a patient, be it on the ward or in emergency department or clinic.
Residents are funded by the province to provide clinical service as they gain an orthopaedic education. Thus they can become certified and practice in the Canadian system and elsewhere. They learn with hands-on training and patient management. There is a recent increase in resident numbers but the Royal College requirement avoids an inappropriate “service to education ratio”, forcing us to find additional help, particularly with the increase in hip and knee arthroplastic procedures. Clinical fellows are available sporadically, frequently with subspecialty
services. Fellows provide a significant role, but often without any ward duties. They assist the orthopaedic surgeon in the training and mentoring of residents and medical students and further the academic research mission, vital and valuable to an academic orthopaedic division such as ours.

Several of the local Family Physicians assist in the O.R. Some of these Physicians have a Sport Medicine sub-specialty and interest. A small core of these physicians assesses patients in an Intake Clinic for hip and knee arthritis. This model is beyond some of the more commonly used models using Advanced Practice Physiotherapists and Nurses in this role. Sport Medicine Physicians with extensive training and experience are able to review the gamut of conservative treatment options prior to surgical intervention.

A program has begun for the training and collegial work with Advanced Practice Physiotherapists in assessing Intake Clinic patients and managing post operative patients. Recent initiatives for APP’s are Same Day Discharge for unicompartment knee replacement and accelerated discharge for anterior approach hip arthroplasty and subvastus total knee replacement. This model we hope will expand.

The Physician Assistant Pilot was made available to us last year. Unfortunately our hospital elected to accept the requests only for Internal Medicine. PA’s may be able to provide a very significant role by filling the “service” gaps that can not be met by resident/ fellow housestaff. We await a chance to assess this alternative.