The AOA: A Comprehensive House with Compassionate Leaders. Presidential Address to the AOA, June 15, 2020: AOA Critical Issues.

ABSTRACT: The American Orthopaedic Association (AOA) is the world's oldest orthopaedic association and it has been responsible for the founding of many prominent organizations as well as The Journal of Bone & Joint Surgery. While the AOA has traditionally focused on academic orthopaedic leadership, the time has come to expand our horizons and look to include all orthopaedic leaders from the wide variety of leadership roles in which they currently serve.Orthopaedic surgeons who demonstrate compassionate leadership will find that they create stronger, more successful teams. Compassionate leadership is a skill that can be learned, and investing the energy to develop this skill will have a profound impact on our success as orthopaedic surgeons and leaders.

Operative Experience During Orthopaedic Residency Compared with Early Practice in the U.S.

BACKGROUND: The goal of surgical education is to prepare the trainee for independent practice; however, the relevance of the current residency experience to practice remains uncertain. The purpose of this study was to identify the surgical procedures most frequently performed in orthopaedic residency and in early surgical practice and to identify surgical procedures performed more often or less often in orthopaedic residency compared with early surgical practice. METHODS: This retrospective cohort study included American Medical Association (AMA) Current Procedural Terminology (CPT) codes (n = 4,329,561 procedures) reported by all U.S. orthopaedic surgery residents completing residency between 2010 and 2012 (n = 1,978) and AMA CPT codes for all procedures (n = 413,370) reported by U.S. orthopaedic surgeons who took the American Board of Orthopaedic Surgery Part II certifying examination between 2013 and 2015 (n = 2,205). Relative rates were determined for AMA CPT codes and AMA CPT code categories for adult and pediatric surgeries that had frequencies of ≥0.1% for both practitioners and residents. RESULTS: The top 25 adult AMA CPT code categories contributed 82.1% of the total case volume for residents and 82.4% for practitioners. Knee and shoulder arthroscopy were the most frequently performed procedures in adults in both residency and early practice. Humerus/elbow fracture and/or dislocation procedures and "other musculoskeletal-introduction or removal" procedures were the most frequently performed procedures in pediatric cases in both residency and early practice. Of the total 78 adult and 82 pediatric code categories included in our analysis that had a frequency of >1% in residency or early practice, there were 4 adult and 6 pediatric code categories demonstrating 44% to 1,164% greater frequency in residency than in early practice, and there were 8 adult and 7 pediatric code categories demonstrating 26% to 73% less frequency in residency than in early practice. CONCLUSIONS: Similarity between residency and early practice experience is generally strong. However, we identified several AMA CPT code categories and individual CPT codes for which the level of exposure during residency varied substantially from early practice experience. These findings can help residencies ensure adequate trainee exposure to procedures performed commonly in early practice.

Malignant and benign bone tumors that you are likely to see.

Although primary malignancies of bone are rare, thousands of benign bone tumors are diagnosed annually. It is important to be able to distinguish benign lesions from malignant lesions and differentiate those lesions that can be watched versus lesions that require further treatment and referral to an orthopaedic oncologist. Learning to distinguish these entities and their appropriate treatment or triage will positively affect the patient and the surgeon's practice.

2011 Mid-America Orthopaedic Association Dallas B. Phemister Physician in Training Award: Can musculoskeletal tumors be diagnosed with ultrasound fusion-guided biopsy?

BACKGROUND: Percutaneous biopsy for musculoskeletal tumors commonly relies on imaging adjuncts including ultrasound (US), CT, or MRI. These modalities however have disadvantages (US) or are cumbersome, not universally available, and costly (CT and MRI). US fusion is a novel technique that fuses previously obtained CT or MRI data with real-time US, which allows biopsies to be performed in an US suite. It has proven useful in various body systems but musculoskeletal applications remain scarce. Our goal is to evaluate the fusion technology and determine its ability to diagnose musculoskeletal tumors. QUESTIONS/PURPOSES: We determined whether biopsies performed via US fusion compared with CT guidance provide equivalent diagnostic yield and accuracy and allow quicker biopsy scheduling and procedure times. METHODS: Forty-seven patients were assigned to undergo either US fusion (with MR, n = 16 or CT, n = 15) or CT-guided biopsies (n = 16). We evaluated adequacy of the histologic specimen (diagnostic yield) and correlation with surgical pathology (diagnostic accuracy). We determined scheduling times and lengths of the biopsy. RESULTS: US fusion and CT-guided biopsy groups had comparable diagnostic yields (CT = 94%; US/MRI = 94%; US/CT = 93%) and accuracy (CT = 83%; US/MRI = 90%; US/CT = 100%). US fusion biopsies were faster to schedule and perform. All procedures were safe with minimal complications. CONCLUSIONS: US fusion provides a high diagnostic yield and accuracy comparable to CT-guided biopsy while performed in the convenience of an US suite. This may have resulted in the observed faster scheduling and biopsy times. LEVEL OF EVIDENCE: Level II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

Imaging interpretation of oncologic musculoskeletal conditions.

There is considerable overlap in the clinical and imaging presentation of general orthopaedic conditions and musculoskeletal neoplasms. At centers that treat orthopaedic oncologic conditions, it is not uncommon to see patients with spine and extremity tumors previously treated for presumed general orthopaedic ailments. It is important for orthopaedic surgeons to understand how to interpret commonly ordered radiographic studies (radiographs, MRIs, and CT scans) as they relate to bone and soft-tissue tumors, to be familiar with the imaging appearance of common musculoskeletal lesions in the extremities and spine, and to understand what imaging findings should trigger a referral to an orthopaedic oncologist.

Tumors for the general orthopedist: how to save your patients and practice.

It is likely that most orthopaedic surgeons will see a patient with a benign or malignant musculoskeletal tumor sometime during their career. However, because of the rarity of these entities, many surgeons may benefit from a review of how to evaluate a patient with a bone lesion or soft-tissue mass. A logical approach is necessary in evaluating imaging studies as well as in the workup of children and adults with a possible tumor. It is important to have a good working relationship with a musculoskeletal radiologist to assist in interpreting the images. If the treatment algorithms lead to a conclusive diagnosis of a benign bone tumor, benign soft-tissue mass, or metastatic bone disease, the orthopaedic surgeon may choose to definitively treat the patient. If the workup indicates an indeterminate lesion, it may be prudent to discuss the situation with an orthopaedic oncologist or transfer the care of the patient to a physician with more specialized knowledge. A careful, logical workup is needed prior to surgery to limit risks to the patient and optimize the chances for a favorable outcome.

Musculoskeletal neoplasia: helping the orthopaedic surgeon establish the diagnosis.

Encountering musculoskeletal neoplasia in the clinical practice of orthopaedic surgery is a rather uncommon event but can be an anxiety-provoking experience when it occurs. Using a systematic approach to imaging these lesions includes evaluation via plain radiographs and other modalities such as bone scintigraphy (BS), computed tomography (CT), magnetic resonance imaging (MRI), and positron emission tomography (PET). By applying specific imaging characteristics obtained from these different modalities, the radiologist and orthopaedic surgeon can jointly create an appropriate differential diagnosis. The radiologist plays a key role as part of the diagnostic team, including providing crucial support for biopsy and staging. This article discusses a systematic approach in the evaluation and staging of musculoskeletal neoplasia from the perspective of supporting the orthopaedic surgeon.

Osseous change adjacent to soft-tissue hemangiomas of the extremities: correlation with lesion size and proximity to bone.

OBJECTIVE: The purpose of this study was to describe the findings of MR imaging and radiographic changes that occur in osseous structures adjacent to soft-tissue hemangiomas of the extremities and to correlate them with patient symptomatology, the size of the hemangiomas, and their proximity to adjacent bone. MATERIALS AND METHODS: We retrospectively reviewed the radiographs and MR images of 35 patients with soft-tissue hemangiomas of the extremities. The pattern and extent of the osseous change were categorized as periosteal, cortical, or medullary. Symptomatology, size, and proximity of the hemangioma to the adjacent bone were compared with the presence or absence of osseous change. Statistical analysis was performed using the Student's t test. RESULTS: Osseous change was noted on radiographs in 13 (37%) of 35 patients and on MR images in 11 (31%) of 35 patients with a total of 14 patients (40%) showing osseous change on at least one study. Periosteal change was present in eight (23%) of 35 patients; cortical change, in 11 (31%) of 35 patients; and medullary change, in 10 (29%) of 35 patients. Direct contact between the soft-tissue hemangioma and the adjacent bone was seen in 13 of 14 patients with osseous change. In those patients without osseous change, the average distance between the soft-tissue hemangioma and bone was 1.06 cm (range, 0-4 cm). No correlation was found between symptoms and the presence of osseous change. CONCLUSION: Soft-tissue hemangiomas of the extremities frequently result in adjacent osseous change that can be categorized as either periosteal, cortical, or medullary. Only medullary changes correspond with hemangioma size, whereas all three categories of change correlate with the proximity of the hemangioma to the adjacent bone. The presence of osseous change does not correlate with patient symptomatology.

Primary periosteal lymphoma: an unusual presentation of non-Hodgkin's lymphoma with radiographic, MR imaging, and pathologic correlation.

This report describes a primary periosteal location of non-Hodgkin's lymphoma, without nodal disease, and without adjacent intramedullary disease at presentation. The clinical and imaging appearance of periosteal lymphoma simulates other neoplastic osseous surface tumors more than that of lymphoma in other locations. Consideration of this rare presentation of non-Hodgkin's lymphoma in the differential diagnosis of periosteal bone lesions can be helpful to ensure proper diagnosis and treatment.