Curettage as first surgery for bone giant cell tumor : adequate surgery is more important than oncology training or surgical management by high volume specialized teams

We reviewed the files of 203 patients with extremities GCTB treated with curettage as first surgery from 1990 to 2013. Median follow-up was 84.2 months. We evaluated whether the years of practice and training in orthopaedic oncology are associated with local recurrences, function and complications after curettage as first surgery for giant cell tumour of bone (GCTB). Local recurrences were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Function was not significantly different between orthopaedic oncology trained and non-trained surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. The only important univariate and multivariate predictor for local recurrence was PMMA adjuvant. Complications were not significantly different between orthopaedic oncology trained and non-trained orthopaedic surgeons and between orthopaedic surgeons with < 10 years and ≥ 10 years of practice. Curettage may be effectively performed as first surgery for GCTB by early-career (< 10 years of practice) non-trained orthopaedic oncology orthopaedic surgeons. PMMA adjuvant is recommended after appropriate curettage.

     

FDA public workshop: Orthopaedic sensing,measuring, and advanced reporting technology (SMART) devices

Traditional orthopaedic devices do not communicate with physicians or patients post‐operatively. After implantation, follow‐up of traditional orthopaedic devices is generally limited to episodic monitoring. However, the orthopaedic community may be shifting towards incorporation of smart technology. Smart technology in orthopaedics is a term that encompasses a wide range of potential applications. Smart orthopaedic implants offer the possibility of gathering data and exchanging it with an external reader. They incorporate technology that enables automated sensing, measuring, processing, and reporting of patient or device parameters at or near the implant. While including advanced technology in orthopaedic devices has the potential to benefit patients, physicians, and the scientific community, it may also increase the patient risks associated with the implants. Understanding the benefit‐risk profile of new smart orthopaedic devices is critical to ensuring their safety and effectiveness. The 2018 FDA public workshop on orthopaedic sensing, measuring, and advanced reporting technology (SMART) devices was held on April 30, 2018, at the FDA White Oak Campus in Silver Spring, MD with the goal of fostering a collaborative dialogue amongst the orthopaedic community. Workshop attendees discussed four key areas related to smart orthopaedic devices: engineering and technology considerations, clinical and patient perspectives, cybersecurity, and regulatory considerations. The workshop presentations and associated discussions highlighted the need for the orthopaedic community to collectively craft a responsible path for incorporating smart technology in musculoskeletal disease care.     

The incidence of fractures and dislocations referred for orthopaedic services in a capitated population

BACKGROUND: The purpose of this study was to determine the annual incidence rates of non-work-related traumatic fractures and dislocations (excluding head and facial injuries) referred for orthopaedic services in a large population enrolled under a capitated insurance contract. METHODS: The number of fractures and dislocations that were referred for orthopaedic services were recorded prospectively from among an average of 135,333 persons per year who were enrolled under a capitated insurance contract during the three-year study period. These data were used to determine the gender-specific and age-specific incidence rates of fractures and dislocations referred for orthopaedic services. RESULTS: A total of 3440 fractures and 422 dislocations were referred for orthopaedic services during the three-year study period. The incidence rate of fractures referred for orthopaedic services was 8.47 per 1000 member-years, with a significantly (p < 0.0001) higher rate among males. Members between the ages of ten and fourteen years had the highest rate of fractures referred for orthopaedic services (21.52 per 1000 member-years). The lifetime risk of a traumatic fracture referred for orthopaedic services to the age of sixty-five years was one in two for both males and females. The incidence rate of dislocations referred for orthopaedic services was 1.04 per 1000 member-years, which did not differ significantly (p = 0.75) between genders. Members between the ages of fifteen and nineteen years had the highest rate of dislocations referred for orthopaedic services (2.75 per 1000 member-years). The lifetime risk of a traumatic dislocation referred for orthopaedic services to the age of sixty-five years was one in sixteen for both male and female members. CONCLUSIONS: Young males had the highest rate of traumatic fractures referred for orthopaedic services. Adolescents of both genders had high rates of traumatic dislocations referred for orthopaedic services. The lifetime risk of a non-work-related fracture referred for orthopaedic services to the age of sixty-five years is approximately equal to that of coronary artery disease.     

Orthopaedic operations in the United States, 1979 through 1983

Data from the National Center for Health Statistics were used to analyze the number of orthopaedic operations that were performed in the United States in 1979, 1981, and 1983. During the study period there was an increase of 24 per cent in the total number of orthopaedic procedures. During the same five-year period, the number of orthopaedic surgeons increased 28 per cent. Orthopaedic surgeons performed 3,549,000 operations in 1983, the most common orthopaedic procedure being open reduction and internal fixation of a fracture (331,000). This was also the eleventh most common operation performed in this country in 1983. The number of arthroscopic procedures (260,000) increased 100 per cent during the period of study, and this procedure was the sixteenth most common operation performed in the United States. In 1983, orthopaedic operations comprised 19 per cent of the surgery performed in this country. These figures illustrate the dynamics of the operative practice of orthopaedic surgeons in the United States. The figures show that the number of orthopaedic operations has markedly increased over the five-year period, but this increase is not as great as the increase in the number of orthopaedic surgeons. Future individual operative workloads of orthopaedists will decrease if these trends continue.     

Involvement of orthopaedic surgeons for cancer patients in orthopaedic training facilities certified by the Japanese Orthopaedic Association - A nationwide survey

BackgroundIn order to improve cancer care in Japan further, it is now required for orthopaedic surgeons to get actively involved in managing locomotive organs such as bones, muscles and nerves in cancer patients. In 2018, the Japanese Orthopaedic Association (JOA) conducted a questionnaire survey to investigate the current status of cancer treatment at the orthopaedic training facilities certified by the JOA. We analyzed the results of that questionnaire survey, focusing on the data from the core hospitals for cancer care (designated cancer hospitals), to clarify the involvement of orthopaedic surgeons in cancer treatment.Materials and methodsA nationwide survey was conducted in the orthopaedic training facilities certified by the JOA using an online questionnaire from March 15th to 31st, 2018. To clarify the involvement of orthopaedic surgeons in cancer treatment, we analyzed the results of that questionnaire survey, focusing on the data from the designated cancer hospitals in Japan.ResultsFrom the questionnaire survey, it became clear that 24% of the orthopaedic training facilities certified by the JOA are designated cancer hospitals. There were significant differences concerning cancer treatment and the prospect of orthopaedic surgeons' involvement in the treatment for bone metastases between institutions classified according to number of both certified orthopaedic surgeons by the JOA and specialists for bone and soft tissue tumors. In addition, in 45% of the designated cancer hospitals, orthopaedic surgeons treated bone metastases that occur in cancer patients, but in the rest of the institutions, orthopaedic surgeons did not yet adequately respond.ConclusionIn order to further improve the locomotive function and quality of life (QOL) in cancer patients, it was seemed to be necessary that all medical professionals engaged in cancer treatment, including orthopaedic surgeons, recognize the importance of locomotive management for cancer patients. In addition, the results of this study suggested that the presence of more than six certified orthopaedic surgeons by the JOA, including one or more specialists for bone and soft tissue tumors, may be able to create an environment conducive to the involvement of orthopaedic surgeons in cancer treatment at the facility.     

Women and minorities in orthopaedic residency programs

Women and underrepresented minorities make up smaller proportions of orthopaedic residency programs than their numbers in medical school would predict, according to our evaluation of self-reported orthopaedic residency data from 1998 and 2001, as well as information on medical students published in 2002. Based on race, ethnicity, and sex, comparisons were made between students entering and graduating from medical school and those in orthopaedic residency programs. With few exceptions, the percentages of women and underrepresented minorities were statistically significantly lower among those training in orthopaedic residency programs compared with those same groups entering and graduating from medical school. The percentage of women and minorities in orthopaedic residency programs remained constant between 1998 and 2001. Further study is necessary to determine whether fewer students of color and women apply to orthopaedic residency programs because of lack of interest, lack of appropriate mentoring and role models, or other factors.     

新型冠状病毒肺炎疫情下骨科疾病的诊疗原则

由冠状病毒(2019 novel coronavirus,2019-nCoV)引发的新型冠状病毒肺炎(coronavirus disease 2019,COVID-19)疫情仍在持续,由此造成的医护人员感染并不少见。如何才能做到既满足临床骨科疾病的诊疗需求,又防止疫情的大肆蔓延是骨科医生面临的巨大挑战。依据骨科患者的暴露史和病情进行分级防控极为重要,为减少医护人员和患者的暴露,保证医疗安全和降低防疫物资的消耗,将骨科患者分为三级(1、2、3级)六类(1A、1B、2A、2B、3A、3B)进行处理,为各级医院骨科开展临床诊治提供有效参考。     

Expanding roles of the orthopaedic surgeon

Many sources predict an oversupply of orthopaedic surgeons in the United States continuing into the next 30 years. The most attractive solution to this problem is to expand the scope of orthopaedic practice by regaining direct patient access to orthopaedic specialty care, by developing and bringing new technologies and treatments to the marketplace quickly, and by developing alternatives to the typical orthopaedic practice such as expanding nonoperative care, improving the quality of the office practice, and exploring volunteer opportunities.     

Occupational hazards to the pregnant orthopaedic surgeon

The number of female orthopaedic residents and orthopaedic surgeons has increased substantially. Concerns have been raised regarding the effect of the work environment on the health of the female orthopaedic surgeon and her fetus or neonate. Occupational risks, and specifically risks to the pregnant orthopaedic surgeon, are becoming an important issue in medicine. Such risks include exposure to methylmethacrylate (MMA), anesthetic gases, blood-borne pathogens, radiation, emotional stress, and physical stress. Awareness of and knowledge about such exposures are needed for the pregnant orthopaedic surgeon to make informed decisions about her occupational exposures and to be proactive about her own and her child's health.     

MD-PhD graduates remain underrepresented in orthopaedic surgery: National MD-PhD Program Outcome Survey update

With the dramatic expansion of the biomedical knowledge base and increasing demands for evidence-based medicine, the role of the clinician-scientist is becoming increasingly important. In orthopaedic surgery, clinician-scientists are at the forefront of translational efforts to address the growing burden of musculoskeletal disease, yet MD-PhD trained investigators have historically been underrepresented in this field. Here, we examine the trend, over time, of MD-PhD graduates pursuing orthopaedic surgery, compared with other specialties. Survey data from the 2018 Association of American Medical Colleges National MD-PhD Program Outcomes Study, including data on 4,647 individuals who had completed residency training and 2,124 who were still in training, were reanalyzed. Numbers, proportions, workplace choice, and percent research effort of MD-PhD graduates completing orthopaedic surgery were compared with other surgical and nonsurgical specialties. Trends over time were analyzed by linear regression. While a decreasing proportion of MD-PhD graduates completed internal medicine training, just 1.1% of MD-PhD graduates completed orthopaedic surgery training, lower than that of all other surgical specialties. The proportion of MD-PhD graduates completing orthopaedic surgery has not increased over time and was mirrored in MD-PhD residents still in training. Though MD-PhDs are increasingly choosing to pursue “nontraditional” specialties, they remain underrepresented in orthopaedic surgery, compared with other clinical disciplines. Thus, there exists an opportunity to encourage MD-PhD graduates to pursue careers in orthopaedic surgery, to supplement the existing intellectual capital in the orthopaedic science workforce. This, along with other strategies to support all orthopaedic surgeon-scientists, will ultimately advance the care of musculoskeletal diseases.     

THE ORTHOPAEDIC WORKFORCE IN QUEENSLAND NOW AND INTO THE TWENTY-FIRST CENTURY

The objectives of this study were to determine the number and distribution of orthopaedic surgeons in Queensland at present and to assess the adequacy of trainee intake for the future. Characteristics of the orthopaedic workforce in Queensland in 1990 were analysed with regard to the total number of orthopaedic surgeons, their regional distribution, their ratio to the population and their age distribution. Similar statistics were derived for the years 1981 and 1986 and trends were examined. By projecting these trends, the number of surgeons likely to be practising in 2001 was estimated. Using projected population figures, the number of orthopaedic surgeons required in 2001 was calculated, assuming an optimum ratio of surgeons to population of one per 25 000. It was found that in 1990 sufficient orthopaedic surgeons were practising in Queensland but that there was some rnaldistribution. With the increased intake of five new training registrars per year, the number of orthopaedic surgeons in Queensland in 2001 should be appropriate, as long as current trends continue.     

Orthopaedic training in China: experiences from the promotion of orthopaedic specialist training in China

There is no unified national training system for orthopaedic surgeons in China. With such rapid progress in many aspects of life in China, there is an imminent need for improvement in the training of orthopaedic specialists. Since 2003 the orthopaedic community in Hong Kong has been working in collaboration with their colleagues in mainland China to develop a training system for orthopaedic surgery. We adopted the system from the Royal College of Surgeons of Edinburgh (RCSEd), setting up a trial centre in the Beijing Jishuitan hospital in 2006, with trainers and trainees attaining the standards set by RCSEd and the Hong Kong College of Orthopaedic Surgeons (HKCOS). This trial is ongoing, with the success of two trainees who passed the exit examination in 2010 and became the first Chinese orthopaedic surgeons with a joint fellowship of both the RCSEd and the HKCOS. Following this inaugural success, we are confident that China will develop a training system for orthopaedic surgeons to a consistently high international standard.     

Critical shortage of orthopaedic services in Ontario,Canada

BACKGROUND: Questions regarding the adequacy of the current orthopaedic workforce in Canada to meet the present and future demands for orthopaedic services raise the need for accurate estimates of the supply and demand for orthopaedic services. The present study provides estimates of current supply of orthopaedic services in Ontario, the largest province of Canada, in order to allow for direct comparisons with data on workforce requirements. METHODS: All identified orthopaedic surgeons in Ontario were sent a self-administered questionnaire in 2000, which was similar to a previous survey in 1997. The age and gender of eligible respondents were obtained from the College of Physicians and Surgeons of Ontario. One full-time-equivalent orthopaedist was assumed to have 2200 annual hours of direct patient contact and to provide forty-four weeks of clinical work per year. RESULTS: The response rate was 94%. The mean age of the 337 active orthopaedic surgeons was forty-nine years, an increase of four years since 1997. Six percent of the respondents were women in both survey years. Approximately twenty-three half days of office and surgery time per 100,000 population were reported, which represents approximately two full-time equivalent orthopaedic surgeons per 100,000 population. On the average, eight half days of combined office and surgery time were reported per surgeon per week. CONCLUSIONS: The estimated supply of orthopaedic surgeons in Ontario (two full-time equivalents per 100,000 population) falls short of the recently calculated requirement in the United States (5.6 full-time equivalents per 100,000 population). These data suggest that there is currently a shortage of orthopaedic services in Ontario, which will be exacerbated by the aging of a profession already working near full capacity.     

Outcomes of patients with orthopaedic trauma admitted to level 1 trauma centres

BACKGROUND: Although orthopaedic trauma results in significant disability and substantial financial cost, there is a paucity of large cohort studies that collectively describe the functional outcomes of a variety of these injuries. The current study aimed to investigate the outcomes of patients admitted with a range of orthopaedic injuries to adult Level 1 trauma centres. METHODS: Patients were recruited from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR), which included all patients with orthopaedic trauma admitted to the two adult Level 1 trauma centres in Victoria (Australia). Patients were categorised into three groups; isolated orthopaedic injuries, multiple orthopaedic injuries and orthopaedic and other injuries. Demographic and injury data were collected from the medical record and hospital/trauma databases, and functional outcome instruments were given at 6 months post-injury. RESULTS: Of the 1303 patients recruited for VOTOR over a 12-month period, 1181 patients were eligible for the study and a response rate of 75.6% was obtained at 6 months post-injury. Patients reported ongoing pain (moderate-severe: 37.2%), disability (79.5%) and inability to return to work (35.2%). Poorer outcomes were evident in patients with orthopaedic and other injuries than those with single or multiple orthopaedic injuries alone. CONCLUSION: A large percentage of patients have ongoing pain and disability and a reduced capacity to return to work 6 months after orthopaedic trauma. Further research into the long-term outcomes of patients with orthopaedic injuries is required to identify patient subgroups and specific injuries and procedures that result in high morbidity.     

Orthopaedic abnormalities in primary myopathies

Orthopaedic abnormalities are frequently recognised in patients with myopathy but are hardly systematically reviewed with regard to type of myopathy, type of orthopaedic problem, and orthopaedic management. This review aims to summarize recent findings and current knowledge about orthopaedic abnormalities in these patients, their frequency, and possible therapeutic interventions. A MEDLINE search for the combination of specific terms was carried out and appropriate articles were reviewed for the type of myopathy, types of orthopaedic abnormalities, frequency of orthopaedic abnormalities, and possible therapeutic interventions. Orthopaedic abnormalities in myopathies can be most simply classified according to the anatomical location into those of: the spine, including dropped head, camptocormia, scoliosis, hyperlordosis, hyperkyphosis, or rigid spine; the thorax, including pectus excavatum (cobbler's chest), anterior/posterior flattening, or pectus carinatum (pigeon's chest); the limb girdles, including scapular winging and pelvic deformities; and the extremities, including contractures, hyperlaxity of joints, and hand or foot deformities. These orthopaedic abnormalities can be most frequently found in arthrogryposis, muscular dystrophies, congenital myopathies, myofibrillar myopathies, and myotonic dystrophies. Occasionally, they also occur in metabolic myopathies or other types of myopathy. Most of the orthopaedic abnormalities are sufficiently accessible to conservative or surgical orthopaedic treatment. Orthopaedic abnormalities have major implications in the management and outcome of myopathy patients; they should be closely monitored and treated on time.     

Cartilage hair hypoplasia: characteristics and orthopaedic manifestations

PurposeCartilage hair hypoplasia (CHH) is a rare metaphyseal chondrodysplasia characterized by short stature and short limbs, found primarily in Amish and Finnish populations. Cartilage hair hypoplasia is caused by mutations in the RMRP gene located on chromosome 9p13.3. The disorder has several characteristic orthopaedic manifestations, including joint laxity, limited elbow extension, ankle varus, and genu varum. Immunodeficiency is of concern in most cases. Although patients exhibit orthopaedic problems, the orthopaedic literature on CHH patients is scant at best. The objective of this study was to characterize the orthopaedic manifestations of CHH based on the authors’ unique access to the largest collection of CHH patients ever reported.MethodsThe authors examined charts and/or radiographs in 135 cases of CHH. We analyzed the orthopaedic manifestations to better characterize and further understand the orthopaedic surgeon’s role in this disorder. In addition to describing the clinical characteristics, we report on our surgical experience in caring for CHH patients.ResultsGenu varum, with or without knee pain, is the most common reason a patient with CHH will seek orthopaedic consultation. Of the cases reviewed, 32 patients had undergone surgery, most commonly to correct genu varum.ConclusionThis paper characterizes the orthopaedic manifestations of CHH. Characterizing this condition in the orthopaedic literature will likely assist orthopaedic surgeons in establishing a correct diagnosis and appreciating the orthopaedic manifestations. It is important that the accompanying medical conditions are appreciated and evaluated.

Electronic supplementary material

The online version of this article (doi:10.1007/s11832-015-0646-z) contains supplementary material, which is available to authorized users.     

The orthopaedic surgeon and manufacturing industry relationship. Ethical guidelines

Orthopaedic surgery has progressed over the years because of innovative work of pioneering orthopaedic surgeons; new developments in internal fixation techniques and implants codeveloped with the orthopaedic manufacturing industry have improved treatment greatly. This article analyzes and reviews the relationship of orthopaedic surgeons to the orthopaedic implant industry, analyzing three broad categories of the relationship: (1) physicians receiving gifts from industry; (2) the orthopaedic industry's financial support of educational and research endeavors of academic trauma and other centers; and (3) the relationship of the industry with innovators in the field of orthopaedic surgery by retainer fees, royalties, and stock options from industry. The ethical relationship requires: (1) putting the patient's concerns first above vested interests; (2) an awareness of a potential for abuse; and (3) a level of awareness of the relationship and the ability to explain and inculcate this relationship in the teaching program of young residents to maintain the high standards that have been set.     

Surgical simulation in orthopaedic skills training

Mastering rapidly evolving orthopaedic surgical techniques requires a lengthy period of training. Current work-hour restrictions and cost pressures force trainees to face the challenge of acquiring more complex surgical skills in a shorter amount of time. As a result, alternative methods to improve the surgical skills of orthopaedic trainees outside the operating room have been developed. These methods include hands-on training in a laboratory setting using synthetic bones or cadaver models as well as software tools and computerized simulators that enable trainees to plan and simulate orthopaedic operations in a three-dimensional virtual environment. Laboratory-based training offers potential benefits in the development of basic surgical skills, such as using surgical tools and implants appropriately, achieving competency in procedures that have a steep learning curve, and assessing already acquired skills while minimizing concerns for patient safety, operating room time, and financial constraints. Current evidence supporting the educational advantages of surgical simulation in orthopaedic skills training is limited. Despite this, positive effects on the overall education of orthopaedic residents, and on maintaining the proficiency of practicing orthopaedic surgeons, are anticipated.     

Patient expectations and satisfaction in orthopaedic surgery: A review of the literature

Patient expectations have been shown to be an independent predictor of outcomes in clinical medicine. In the orthopaedic literature, the majority of studies have focused on the relationship between pre-operative expectations and post-operative outcomes in patients undergoing total hip arthroplasty, total knee arthroplasty, shoulder surgery, and spine surgery. Various methodologies have been used to assess patient expectations in orthopaedic surgery, including direct questioning, short questionnaires, and validated surveys. Multiple patient factors have been associated with greater expectations prior to elective orthopaedic surgery, and greater pre-operative expectations have been shown to be associated with better subjective and objective outcomes after total hip and knee arthroplasty, shoulder surgery, and spine surgery. While there are very few validated measures of patient satisfaction after orthopaedic surgery, increased post-operative patient satisfaction is consistently associated with meeting pre-operative patient expectations. Given the relationship between pre-operative patient expectations and post-operative outcomes and patient satisfaction, understanding and defining expectations prior to elective orthopaedic surgery may optimize outcomes. In this review, we aim to summarize the current literature on patient expectations in orthopaedic surgery.     

Factors Influencing Geriatric Orthopaedic Trauma Mortality

IntroductionThis study aimed to: (1) evaluate the independent risk factors related to survival and mortality and (2) predict survival in geriatric orthopaedic trauma patients admitted to our institution's ICU as a Level 1 or 2 trauma activation.MethodsA retrospective review was performed on patients age >60, over a 10 year period, who were involved in a multi-trauma with orthopaedic injuries. Variables evaluated include: sex, age, Injury Severity Score (ISS), mechanism of injury, number and type of orthopaedic injury, anticoagulant use, comorbidities, length of stay in intensive care unit (ICU), type of ICU, ventilator use, vasopressors use, incidence of multiple organ dysfunction syndrome (MODS), number of surgeries, and 1-month and 6-month mortality. A Kaplan-Meier estimator and Cox proportional hazards analysis were used to predict and assess survival probability.Results174 patients were included, with an average mortality of 47.7%. Deceased patients had a significantly greater age, ISS, vasopressor usage, ICU stay, incidence of MODF, incidence of genitourinary disease, anticoagulant usage, ventilator usage, number of orthopaedic surgeries, and orthopaedic injuries. The relative risk for mortality within the first month was significantly associated with increased age, ISS, high-energy trauma, length of ICU stay, MODS, psychiatric disease, and anticoagulant use. Patients with an ISS ≤30 were significantly more likely to survive than patients with an ISS of >30. Greater age, ISS, length of ICU stay, incidence of MODS, anticoagulant, and ventilator use were significantly predictive of lower survival rates. Mechanism of injury, number of orthopaedic surgeries and orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival.ConclusionsAn ISS >30 at admission is strongly predictive of a lower probability of survival. Genitourinary disease was associated with increased mortality. Low age, ISS, length of stay in ICU, incidence of MODS, anticoagulant use, and ventilator use, are significantly predictive of survival. Number of orthopaedic surgeries, orthopaedic injuries, and type of orthopaedic injury were not found to be predictive of survival. These indications help us to better understand factors predictive of death among geriatric orthopaedic trauma patients, and improve the way we can diagnose and care for them.