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Aims COVID-19-related patient care delays have resulted in an unprecedented patient care backlog in the field of orthopaedics. The objective of this study is to examine orthopaedic provider preferences regarding the patient care backlog and financial recovery initiatives in response to the COVID-19 pandemic. Methods An orthopaedic research consortium at a multi-hospital tertiary care academic medical system developed a three-part survey examining provider perspectives on strategies to expand orthopaedic patient care and financial recovery. Section 1 asked for preferences regarding extending clinic hours, section 2 assessed surgeon opinions on expanding surgical opportunities, and section 3 questioned preferred strategies for departmental financial recovery. The survey was sent to the institution’s surgical and nonoperative orthopaedic providers. Results In all, 73 of 75 operative (n = 55) and nonoperative (n = 18) providers responded to the survey. A total of 92% of orthopaedic providers (n = 67) were willing to extend clinic hours. Most providers preferred extending clinic schedule until 6pm on weekdays. When asked about extending surgical block hours, 96% of the surgeons (n = 53) were willing to extend operating room (OR) block times. Most surgeons preferred block times to be extended until 7pm (63.6%, n = 35). A majority of surgeons (53%, n = 29) believe that over 50% of their surgical cases could be performed at an ambulatory surgery centre (ASC). Of the strategies to address departmental financial deficits, 85% of providers (n = 72) were willing to work extra hours without a pay cut. Conclusion Most orthopaedic providers are willing to help with patient care backlogs and revenue recovery by working extended hours instead of having their pay reduced. These findings provide insights that can be incorporated into COVID-19 recovery strategies. Level of Evidence: III Cite this article: Bone Jt Open 2021;2(7):562–568.

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.

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.

There has been increasing use of social media in recent years by hospitals and health-care providers. Social media can provide an extension of the physician to an online presence and have potential practice-building implications.» Online social networks such as Facebook, Twitter, Instagram, and Snap

Case: Atypical presentations of Ewing sarcoma (ES) can lead to misdiagnosis and delays in treatment. We present a rare case of ES in the hand of an adult woman who underwent multiple interventions prior to referral to our institution. At 22 months after definitive treatment, the patient remained pleased with the result and had no evidence of recurrence. Conclusion: To our knowledge, ES of the hand in an adult woman has not yet been reported in the literature, and a lack of recognition of this condition might be secondary to the absence of features traditionally associated with malignant bone neoplasms. A broader differential diagnosis after intervention failures offers the opportunity for diagnosis and appropriate treatment.

Establishing a definitive diagnosis between benign enchondroma versus low-grade chondrosarcoma presents a potential challenge to both clinicians and pathologists. microRNAs (small non-coding RNAs) have proven to be effective biomarkers for the identification of tumors and tumor progression. We present analysis, both array and quantitative PCR, that shows consistently and substantially increased expression of two microRNAs, miRs-181a and -138, in low-grade chondrosarcomas compared with enchondromas. The data suggest these microRNAs would provide an analytical distinction between the chondrosarcoma and benign neoplasms that can be performed in formalin-fixed paraffin-embedded specimens. Together with recent publications, these data indicate that miRs-181a and -138 also play a role in tumor development and homeostasis and may provide new targets for the development of much needed therapeutic intervention.

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.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.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.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.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 II, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

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.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.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.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.

The association between tears of the acetabular labrum and paralabral cysts has been well documented, and magnetic resonance imaging (MRI) has been shown to be the most accurate noninvasive method of depicting not only the normal anatomic structures of the hip, but also the common pathologic processes such as labral tears and paralabral cysts. We present the case of an acetabular paralabral cyst that resulted in clinically symptomatic compression of the sciatic nerve.

Purpose: We compared the expression of microRNAs (miRNAs) in rat chondrosarcoma relative to normal rat cartilage with miRNA expression in human chondrosarcoma relative to normal human cartilage. We did this in order to answer the question: Are the miRNA profiles of chondrosarcoma in humans and rats similar enough to allow for the rat model to be valid for study of chondrosarcoma in humans? Methods: Twenty rats were sacrificed, cartilage was collected, RNA extracted and 233 miRNAs analyzed. The expression of these miRNAs was then compared to their expression in normal human tissue and chondrosarcoma. Integrative correlation coefficients were applied to the data in whole to measure the similarity between the rat and human miRNA. Results: For normal human versus normal rat cartilage the integrative correlation coefficient was 0.84 (95% CI: 0.82–0.87). The integrative correlation coefficient for chondrosarcoma in human versus rat tissue was 0.70 (95% CI: 0.65–0.74). Conclusions: Our findings suggest that human and rat normal cartilage, as well as chondrosarcoma genetics, are sufficiently similar for use of rat models to study chondrosarcoma (integrative correlation coefficient [Formula: see text]). We also revealed similarities between specific miRNA, especially those with the most similar fold-change (miR26b, 126, 145, 195, and 320).

This report describes a technique in which temporary extra-anatomic revascularization of an amputated part was used to preserve a free flap while tumor resection and chest wall reconstruction were performed.A patient with multiple local recurrences of basosquamous carcinoma of the shoulder underwent forequarter amputation with en bloc resection of the upper chest wall. During the resection, an elbow disarticulation of the amputated limb was performed. The vascular pedicle of the amputated forearm was joined to the dorsalis pedis vessels of the foot. Following completion of tumor resection and chest wall reconstruction, the forearm was disconnected from the foot and re-anastomosed to thoracic vessels, and a circumferential fasciocutaneous free flap was then harvested and inset.No ischemic flap complications occurred, and the patient recovered well. Ample time was afforded for complete tumor resection with negative margins and prosthetic reconstruction of the chest wall.The technique of temporary, simultaneous extra-anatomic revascularization of an amputated part for later free flap harvest may be helpful in avoiding potentially long flap ischemia times in selected complex oncologic resections.

Purpose. This pictorial essay reviews our experience with MR scans with gadolinium in patients with musculoskeletal tumors and tumor mimickers. Design. Review of 242 MR scans obtained in the initial evaluation of a possible primary musculoskeletal neoplasm. All scans included a T1-weighted, fat-suppressed sequence following intravenous administration of gadolinium. Results. MR scans with gadolinium did not contribute to differential diagnosis or patient management in 89% of the patients in this series. However, intravenous gadolinium did assist in guiding the biopsy of bulky lesions and evaluating treated tumor beds for possible recurrence. MR scans with gadolinium were sometimes helpful when the differential diagnosis included synovitis, Morton’s neuroma or intramuscular myxoma, and when it was important to differentiate cystic from solid lesions. Conclusions. Routine use of gadolinium in every initial MR examination of a possible musculoskeletal mass is not warranted. However, there are appropriate selected indications for gadolinium administration as outlined above.

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.

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.

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.

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.

Imaging is an integral part of the diagnosis, staging and evaluation of outcomes for bone and soft-tissue neoplasms. Each of the available imaging tools has a different role.The authors reviewed the efficacy of the current imaging modalities in the diagnosis, staging, and follow-up of patients with musculoskeletal neoplasia.Plain-film radiography remains the gold standard in the differential diagnosis of bone lesions. Bone scintigraphy is an excellent screening modality, and computed tomography is especially useful in evaluating lesions of the axial skeleton. The superior soft-tissue resolution and multiplanar capabilities achieved with magnetic resonance imaging, however, has replaced the need for CT scans in many cases.The technological advances seen in recent years in all areas of imaging have improved the capabilities of these modalities to assist in the diagnosis, definition of tumor extent, and accurate staging of musculoskeletal tumors.

A case of pathologically proven extraskeletal osteochondroma is presented with magnetic resonance imaging (MRI), computed tomography (CT), bone scan and radiographic findings. The diagnosis of extraskeletal osteochondroma should be considered when a discrete, ossified mass is localized in the soft tissues of the distal extremities. Nomenclature surrounding this entity is controversial and is discussed.

Periosteal ganglions are rare. While a characteristic radiographic appearance has been described in previous reports1,4-6, the use of modern imaging techniques has expanded the diagnostic evaluation of such lesions. A right-hand-dominant, forty-seven-year-old male truck driver was examined for minor trauma to the left wrist and was noted to have a soft-tissue mass on the dorsal aspect of the distal part of the forearm. The patient had not noted the mass and could not recall a history of previous trauma to the area. He reported occasional nocturnal pain in the distal part of the forearm, but he was otherwise asymptomatic and had no functional limitations. Physical examination revealed that the soft-tissue mass was between the distal five centimeters of the radius and that of the ulna. The overlying skin was uninvolved, and the mass was only slightly tender on palpation. There was no limitation of motion of the upper extremity and only mild pain with resisted extension of the wrist. The findings of the remainder of the physical examination were unremarkable. Standard radiographs showed an oval juxtacortical mass along the ulnar aspect of the distal part of the radius (Fig. 1). A thin layer of peripheral calcification and multiple thin septations were visible. A shallow erosion was present in the cortex of the radius. Oblique radiograph showing a six to seven-centimeter-long juxtacortical mass with peripheral calcification, thin calcified septations, and cortical erosion. A technetium-99 methylene diphosphonate bone scan showed only modestly increased uptake in the ulnar aspect of the distal part of the radius. Magnetic resonance imaging was performed to characterize further the soft-tissue component of the mass. A gradient-echo image was made in the coronal plane (repetition time, thirty-three milliseconds; echo time, ten milliseconds; flip …

Hideaki E. Takahashi, Tetsuro Morita, Tetsuo Hotta, and Akira Ogose, editors. Tokyo: Springer-Verlag; 2003. 216 pages. $119.00. This concise textbook on the operative treatment of pelvic tumors represents the thirty-year experience of the senior editor and author, Dr. H.E. Takahashi, at the Niigata University Medical Hospital in Japan. Dr. Takahashi (who has some forty years of experience in the operative treatment of musculoskeletal tumors) and his contributors have done a very nice job of organizing a concise, readable, and generally well-illustrated surgical text. This single-volume textbook is tastefully constructed …

Operation Just Cause was until recently the largest American combat operation since Vietnam, and remains the largest nighttime parachute operation since World War II. All 252 casualties were airlifted to San Antonio, Texas, for medical treatment. Greater than 80% sustained orthopedic injuries. Sixteen patients were admitted for injuries to the back or neck. Three of the four patients with significant fractures or fracture-dislocations were paraplegic. Two of the three patients with gunshot wounds to the back required extensive reconstruction for wound management. In addition to the 252 casualties, there were 23 fatalities, among whom 7 suffered major injuries to the spine. Spine injuries represented the most significant source of long-term morbidity among those soldiers wounded in combat in Panama, and were common among the fatalities. Noteworthy in these cases was the high percentage of severe neurologic injuries in patients with significant fractures (75%), particularly fractures associated with gunshot wounds. Also of interest were the cases of major soft tissue injury associated with high-velocity gunshot wounds (66%) and the extensive soft tissue surgery needed to treat these injuries. Language: en