The role of imaging in extremity sarcoma surgery.

The surgical management of extremity bone and soft tissue sarcomas has evolved significantly over the last 50 years. The introduction and refinement of high-resolution cross-sectional imaging has allowed accurate assessment of anatomy and tumor extent, and in the current era more than 90% of patients can successfully undergo limb-salvage surgery. Advances in imaging have also revolutionized the clinician's ability to assess treatment response, detect metastatic disease, and perform intraoperative surgical navigation. This review summarizes the broad and essential role radiology plays in caring for sarcoma patients from diagnosis to post-treatment surveillance. Present evidence-based imaging paradigms are highlighted along with key future directions.

Predicting Risk of 30-day Postoperative Morbidity Using the Pathologic Fracture Mortality Index.

INTRODUCTION: The purpose of this study was to evaluate the ability of the Pathologic Fracture Mortality Index (PFMI) to predict the risk of 30-day morbidity after pathologic fracture fixation and compare its efficacy with those of the American Society of Anesthesiologists (ASA) physical status, modified Charlson Comorbidity Index (mCCI), and modified frailty index (mFI-5). METHODS: Cohorts of 1,723 patients in the American College of Surgeons National Surgical Quality Improvement Program database from 2005 to 2020 and 159 patients from a tertiary cancer referral center who underwent fixation for impending or completed pathologic fractures of long bones were retrospectively analyzed. National Surgical Quality Improvement Program morbidity variables were categorized into medical, surgical, utilization, and all-cause. PFMI, ASA, mCCI, and mFI-5 scores were calculated for each patient. Area under the curve (AUC) was used to compare efficacies. RESULTS: AUCs predicting all-cause morbidity were 0.62, 0.54, and 0.56 for the PFMI, ASA, and mFI-5, respectively. The PFMI outperformed the ASA and mFI-5 in predicting all-cause ( P < 0.01), medical ( P = 0.01), and utilization ( P < 0.01) morbidities. In the 2005 to 2012 subset, the PFMI outperformed the ASA, mFI-5, and mCCI in predicting all-cause ( P = 0.01), medical ( P = 0.03), and surgical ( P = 0.05) morbidities but performed similarly to utilization morbidity ( P = 0.19). In our institutional cohort, the AUC for the PFMI in morbidity stratification was 0.68. The PFMI was associated with all-cause (odds ratio [OR], 1.30; 95% confidence interval [CI], 1.12 to 1.51; P < 0.001), medical (OR, 1.19; 95% CI, 1.03 to 1.40; P = 0.046), and utilization (OR, 1.32; 95% CI, 1.14 to 1.52; P < 0.001) morbidities but not significantly associated with surgical morbidity (OR, 1.21; 95% CI, 0.98 to 1.49; P = 0.08) in this cohort. DISCUSSION: The PFMI is an advancement in postoperative morbidity risk stratification of patients with pathologic fracture from metastatic disease. LEVEL OF EVIDENCE: III.

Metastatic sarcomatoid carcinoma to bone.

BACKGROUND AND OBJECTIVES: Distinguishing sarcomatoid carcinoma from primary sarcoma is clinically important. We sought to characterize metastatic sarcomatoid bone disease and its management. METHODS: We analyzed the characteristics of all cases of sarcomatoid carcinoma to bone at a single institution from 2001 to 2021, excluding patients with nonosseous metastases. Survival was evaluated using the Kaplan-Meier method. RESULTS: We identified 15 cases of metastatic sarcomatoid carcinoma to bone. In seven cases the primary cancer was unknown at presentation. Renal cell carcinoma was suspected or confirmed in nine cases. Nine patients presented with pathologic fracture and two with concomitant visceral metastases. All patients underwent image-guided core needle or open biopsy. Ten required surgery for discrete osseous metastases; in four cases definitive surgery was delayed (median delay, 19 days) due to inability to rule out sarcoma with frozen section. No patients required reoperation or had construct failure. Thirteen died of disease; median survival was 17.5 months (interquartile range, 6.2-25.1). CONCLUSIONS: Metastatic sarcomatoid carcinoma is a clinically challenging entity. Multidisciplinary input and communication are key to identifying the primary carcinoma, locating osseous metastases, and defining an operative fixation that will survive the remainder of the patient's life.

Incidence of and Risk Factors for Thromboembolism After Endoprosthetic Reconstruction in Musculoskeletal Oncology Patients.

BACKGROUND: The aim of the present study was to assess the incidence of and risk factors for thromboembolic events-including assessment of the intraoperative use of tranexamic acid and postoperative use of chemical thromboprophylaxis-in patients undergoing operative treatment of primary bone or soft-tissue sarcoma or oligometastatic bone disease. METHODS: This study was performed as a secondary analysis of prospective data collected from the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) randomized controlled trial, which included 604 patients ≥12 years old who underwent surgical resection and endoprosthetic reconstruction for either primary bone or soft-tissue sarcoma or oligometastatic disease of the femur or tibia. We determined the incidence of thromboembolic events in these patients and evaluated potential risk factors, including patient age, sex, antibiotic treatment group, type of tumor (i.e., primary bone or soft-tissue sarcoma or metastatic bone disease), intraoperative tranexamic acid, tourniquet use, operative time, pathologic characteristics (i.e., American Joint Committee on Cancer grade, vascular invasion, and percent necrosis), postoperative chemical thromboprophylaxis regimen, and surgical site infection. Continuous variables were assessed with use of the Student t test. Categorical variables were assessed with use of the Pearson chi-square test, except when the expected cell counts were <5, in which case the Fisher exact test was utilized. Significance was set at 0.05. RESULTS: Postoperative thromboembolic events occurred in 11 (1.8%) of 604 patients. Patients who experienced a thromboembolic event had a significantly higher mean (± standard deviation) age (59.6 ± 17.5 years) than those who did not experience a thromboembolic event (40.9 ± 21.8; p = 0.002). Patients randomized to the long-term antibiotic group had a significantly higher incidence of thromboembolic events (9 of 293; 3.1%) than those randomized to the short-term antibiotic group (2 of 311; 0.64%; p = 0.03). Neither intraoperative tranexamic acid nor postoperative chemical thromboprophylaxis were significantly associated with the occurrence of a thromboembolic event. CONCLUSIONS: Although relatively rare in the PARITY cohort, thromboembolic events were more likely to occur in older patients and those receiving long-term prophylactic antibiotics. Intraoperative tranexamic acid and postoperative chemical thromboprophylaxis were not associated with a greater incidence of thromboembolic events. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Does the Use of Negative Pressure Wound Therapy and Postoperative Drains Impact the Development of Surgical Site Infections?: A PARITY Trial Secondary Analysis.

BACKGROUND: Surgical site infections (SSIs) represent a major complication following oncologic reconstructions. Our objectives were (1) to assess whether the use of postoperative drains and/or negative pressure wound therapy (NPWT) were associated with SSIs following lower-extremity oncologic reconstruction and (2) to identify factors associated with the duration of postoperative drains and with the duration of NPWT. METHODS: This is a secondary analysis of the Prophylactic Antibiotic Regimens in Tumor Surgery (PARITY) trial, a multi-institution randomized controlled trial of lower-extremity oncologic reconstructions. Data were recorded regarding the use of drains alone, NPWT alone, or both NPWT and drains, including the total duration of each postoperatively. We analyzed postoperative drain duration and associations with tourniquet use, intraoperative thromboprophylaxis or antifibrinolytic use, incision length, resection length, and total operative time, through use of a linear regression model. A Cox proportional hazards model was used to evaluate the independent predictors of SSI. RESULTS: Overall, 604 patients were included and the incidence of SSI was 15.9%. Postoperative drains alone were used in 409 patients (67.7%), NPWT alone was used in 15 patients (2.5%), and both postoperative drains and NPWT were used in 68 patients (11.3%). The median (and interquartile range [IQR]) duration of drains and of NPWT was 3 days (IQR, 2 to 5 days) and 6 days (IQR, 4 to 8 days), respectively. The use of postoperative drains alone, NPWT alone, or both drains and NPWT was not associated with SSI (p = 0.14). Increased postoperative drain duration was associated with longer operative times and no intraoperative tourniquet use, as shown on linear regression analysis (p < 0.001 and p = 0.03, respectively). A postoperative drain duration of ≥14 days (hazard ratio [HR], 3.6; 95% confidence interval [CI], 1.3 to 9.6; p = 0.01) and an operative time of ≥8 hours (HR, 4.5; 95% CI, 1.7 to 11.9; p = 0.002) were independent predictors of SSI following lower-extremity oncologic reconstruction. CONCLUSIONS: A postoperative drain duration of ≥14 days and an operative time of ≥8 hours were independent predictors of SSI following lower-extremity oncologic reconstruction. Neither the use of postoperative drains nor the use of NPWT was a predictor of SSI. Future research is required to delineate the association of the combined use of postoperative drains and NPWT with SSI. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

3D Printing Technology in Pediatric Orthopedics: a Primer for the Clinician.

PURPOSE OF REVIEW: This article reviews the basics of 3D printing and provides an overview of current and future applications of this emerging technology in pediatric orthopedic surgery. RECENT FINDINGS: Both preoperative and intraoperative utilization of 3D printing technology have enhanced clinical care. Potential benefits include more accurate surgical planning, shortening of a surgical learning curve, decrease in intraoperative blood loss, less operative time, and fluoroscopic time. Furthermore, patient-specific instrumentation can be used to improve the safety and accuracy of surgical care. Patient-physician communication can also benefit from 3D printing technology. 3D printing is rapidly advancing in the field of pediatric orthopedic surgery. It has the potential to increase the value of several pediatric orthopedic procedures by enhancing safety and accuracy while saving time. Future efforts in cost reduction strategies, making patient-specific implants including biologic substitutes and scaffolds, will further increase the relevance of 3D technology in the field of pediatric orthopedic surgery.

What Proportion of Patients With Musculoskeletal Tumors Demonstrate Thromboelastographic Markers of Hypercoagulability? A Pilot Study.

BACKGROUND: Thromboelastography (TEG) is a point-of-care venipuncture test that measures the elasticity and strength of a clot formed from a patient's blood, providing a more comprehensive analysis of a patient's coagulation status than conventional measures of coagulation. TEG includes four primary markers: R-time, which measures the time to clot initiation and is a proxy for platelet function; K-value, which measures the time for said clot to reach an amplitude of 20 mm and is a proxy for fibrin cross-linking; maximum amplitude (MA), which measures the clot's maximum amplitude and is a proxy for platelet aggregation; and LY30, which measures the percentage of clot lysis 30 minutes after reaching the MA and is a proxy for fibrinolysis. Analysis of TEG-derived coagulation profiles may help surgeons identify patient-related and disease-related factors associated with hypercoagulability. TEG-derived coagulation profiles of patients with musculoskeletal oncology conditions have yet to be characterized. QUESTIONS/PURPOSES: (1) What TEG coagulation profile markers are most frequently aberrant in patients with musculoskeletal oncology conditions presenting for surgery? (2) Among patients with musculoskeletal oncology conditions presenting for surgery, what factors are more common in those with TEG-defined hypercoagulability? (3) Do patients with musculoskeletal oncology conditions with preoperative TEG-defined hypercoagulability have a higher postoperative incidence of clinically symptomatic venous thromboembolism (VTE) than those with a normal TEG profile? METHODS: In this retrospective, pilot study, we analyzed preoperatively drawn TEG assays on 52 patients with either primary bone sarcoma, soft tissue sarcoma, or metastatic disease to bone who were scheduled to undergo either tumor resection or nail stabilization. Between January 2020 and December 2021, our orthopaedic oncology service treated 410 patients in total. Of these, 13% (53 of 410 patients) had preoperatively drawn TEG assays. TEG assays were collected preincision as part of a division initiative to integrate the assay into a clinical care protocol for patients with primary bone or soft tissue sarcoma or metastatic disease to bone. Unfortunately, failures to adequately communicate this to our anesthesia colleagues on a consistent basis resulted in a low overall rate of assay draws from eligible patients. One patient on therapeutic anticoagulation preoperatively for the treatment of active VTE was excluded, leaving 52 patients eligible for analysis. We did not exclude patients taking prophylactic antiplatelet therapy preoperatively. All patients were followed for a minimum of 6 weeks postoperatively. We analyzed factors (age, sex, tumor location, presence of metastases, and soft tissue versus bony disease) in reference to hypercoagulability, defined as a TEG result indicating supranormal clot formation (for example, reduced R-time, reduced K-value, or increased MA). Patients with clinical concern for deep vein thrombosis (DVT) (typically painful swelling of the affected extremity) or pulmonary embolism (typically by dyspnea, tachycardia, and/or chest pain) underwent duplex ultrasonography or chest CT angiography, respectively, to confirm the diagnosis. Categorical variables were analyzed via a Pearson chi-square test and continuous variables were analyzed via t-test, with significance defined at α = 0.05. RESULTS: Overall, 60% (31 of 52) of patients had an abnormal preoperative TEG result. All abnormal TEG assay results demonstrated markers of hypercoagulability. The most frequent aberration was a reduced K-value (40% [21 of 52] of patients), followed by reduced R-time (35% [18 of 52] of patients) and increased MA (17% [9 of 52] of patients). The mean ± SD TEG markers were R-time: 4.3 ± 1.0, K-value: 1.2 ± 0.4, MA: 66.9 ± 7.7, and LY30: 1.0 ± 1.2. There was no association between hypercoagulability and tumor location or metastatic stage. The mean age of patients with TEG-defined hypercoagulability was higher than those with a normal TEG profile (44 ± 23 years versus 59 ± 17 years, mean difference 15 [95% confidence interval (CI) 4 to 26]; p = 0.01). In addition, female patients were more likely than male patients to demonstrate TEG-defined hypercoagulability (75% [18 of 24] of female patients versus 46% [13 of 28] of male patients, OR 3.5 [95% CI 1 to 11]; p = 0.04) as were those with soft tissue disease (as opposed to bony) (77% [20 of 26] of patients with soft tissue versus 42% [11 of 26] of patients with bony disease, OR 4.6 [95% CI 1 to 15]; p = 0.01). Postoperatively, symptomatic DVT developed in 10% (5 of 52; four proximal DVTs, one distal DVT) of patients, and no patients developed symptomatic pulmonary embolism. Patients with preoperative TEG-defined hypercoagulability were more likely to be diagnosed with symptomatic postoperative DVT than patients with normal TEG profiles (16% [5 of 31] of patients with TEG-defined hypercoagulability versus 0% [0 of 21] of patients with normal TEG profiles; p = 0.05). No patients with normal preoperative TEG profiles had clinically symptomatic VTE. CONCLUSION: Patients with musculoskeletal tumors are at high risk of hypercoagulability as determined by TEG. Patients who were older, female, and had soft tissue disease (as opposed to bony) were more likely to demonstrate TEG-defined hypercoagulability in our cohort. The postoperative VTE incidence was higher among patients with preoperative TEG-defined hypercoagulability. The findings in this pilot study warrant further investigation, perhaps through multicenter collaboration that can provide a sufficient cohort to power a robust, multivariable analysis, better characterizing patient and disease risk factors for hypercoagulability. Patients with TEG-defined hypercoagulability may warrant a higher index of suspicion for VTE and careful thought regarding their chemoprophylaxis regimen. Future work may also evaluate the effectiveness of TEG-guided chemoprophylaxis, as results of the assay may inform selection of antiplatelet versus anticoagulant agent. LEVEL OF EVIDENCE: Level III, therapeutic study.

Tenosynovial Giant Cell Tumor Mimicking Acute Septic Arthritis of the Hip: A Case Report.

A 12-year-old boy presented to the pediatric emergency department with a 5-day history of atraumatic, progressively worsening right hip pain and inability to ambulate. He was afebrile and had elevated inflammatory markers (Erythrocyte Sedimentation Rate [ESR]: 42 mm/hr, C-Reactive Protein [CRP]: 6.6 mg/dL) with a normal white blood cell count of 6050 cells/mm3. Given the clinical concern for septic arthritis, joint aspiration of the right hip was done and demonstrated a bloody appearance with a WBC count of 54,999 cells/mm3 and RBC count of 7,000 cells/mm3. MRI of the right hip demonstrated an intra-articular mass suggestive of tenosynovial giant cell tumor/pigmented villonodular synovitis. Subsequent biopsy and excision of the mass confirmed the diagnosis. The acute presentation of tenosynovial giant cell tumor with features mimicking septic arthritis is uncommon. This rare presentation of an already uncommon diagnosis should be considered in a child with an equivocal presentation for severe hip pain because misdiagnosis may lead to unnecessary or inadequately planned surgical treatment of the condition.

Profound Hypercalcemia Associated with Acute Toxic-Metabolic Encephalopathy After Calcium Sulfate Bead Use: A Case Report.

CASE: We present the case of an 81-year-old woman who developed profound hypercalcemia requiring admission to the intensive care unit after calcium sulfate bead use during revision hip arthroplasty. The patient's serum calcium level peaked at 21.0 mg/dL and was associated with acute encephalopathy. After treatment with calcitonin and bisphosphonates, her serum calcium level normalized and her mentation improved. CONCLUSION: The risk of clinically significant hypercalcemia should be considered when using calcium sulfate during orthopaedic surgery.

Are We Working Harder for Less Pay? A Survey of Medicare Reimbursement for Hand and Upper Extremity Surgery.

BACKGROUND: Ongoing concern for declining Medicare payment to surgeons may incentivize surgeons to perform more cases to maintain productivity goals. The authors evaluated trends in physician payment, patient charges, and reimbursement ratios for the most common hand and upper extremity surgical procedures. METHODS: The authors examined Medicare surgeon payment, patient charges, and surgical volume from 2012 to 2017 for 83 common surgical procedures, incorporating the year-to-year Consumer Price Index to adjust for inflation. The reimbursement ratio was calculated by dividing payment by charge. Weighted (by surgery type and volume) averages were calculated. RESULTS: Total Medicare surgeon payment increased 5.6 percent to $272 million for the studied procedures. Patient charges were seven times greater than payment, growing 24 percent to $1.9 billion. Despite growth of total payment, the average overall weighted payment for a single surgery decreased 3.5 percent. The average weighted patient charge increased 8 percent, whereas the reimbursement ratio decreased 13 percent. A hand surgeon would need to perform three more cases per 100 in 2017 to maintain the same reimbursement received in 2012. After categorizing these 83 surgical procedures, distal radius fixation (>3 parts, 21 percent increase; >2-part intra-articular, extra-articular, and percutaneous pinning, 17 percent increase), bony trauma proximal to the distal radius (10 percent increase), and upper extremity flap (5 percent increase) were subject to the greatest increases in payment. Payment for forearm fasciotomy (39 percent decrease), endoscopic carpal tunnel release (30 percent decrease), and mass excisions proximal to the wrist (18 percent decrease) decreased the most. CONCLUSIONS: From 2012 to 2017, despite a disproportionate increase in procedure charges, Medicare surgeon payment has not decreased substantially; however, total reimbursement is multifactorial and involves multiple sources of revenue and cost.

Impact of 2013 ACGME Minimum Case Requirements on Orthopedic Resident Operative Volume.

In 2013, the Accreditation Council for Graduate Medical Education (ACGME) mandated orthopedic surgery residents to perform at least 1000 surgical cases during residency and specified "case minimums" for 15 core procedure categories. We assessed trends in the volume and variability of graduating orthopedic surgery resident caseload since the implementation of these case minimums. We performed a retrospective linear regression analysis of ACGME-published case log data of US orthopedic residents graduating from 2014 to 2019, with trend analysis, comparison of case volume between residents in 10th and 90th percentiles, and comparison of logged cases vs case minimums for core procedures. Median total procedures performed increased from 1464 (range, 592-2842) in 2014 to 1709 (range, 870-3318) in 2019, representing a 17% increase in case volume (P<.001). Residents performing at the 90th percentile logged twice as many cases as residents performing at the 10th percentile. Of the core procedures, carpal tunnel release and total knee arthroplasty most greatly exceeded ACGME requirements (performed at 4.3 to 4.7 times the minimums, respectively). Graduating resident case volume increased significantly from 2014 to 2019. Variability in operative experience remains high and did not change significantly during the study period. [Orthopedics. 2022;45(1):25-30.].

Septic Arthritis Among Users of Injection Drugs: Clinical Course and Microbial Characteristics.

Injection drug use (IDU) is a risk factor for septic arthritis (SA) of native joints. Amid the opioid crisis, IDU rates have increased. This study assessed differences in pre-operative characteristics, microbial characteristics, and postoperative outcomes of 177 cases of SA treated operatively from 2015 to 2019 at 3 US hospitals, by self-reported IDU status. Forty cases (23%) involved patients who reported IDU. Patient characteristics, comorbidities, microbial characteristics, duration of hospital stay, discharge destination, follow-up rates, and rates of persistent/secondary infection were compared by self-reported IDU status. Compared with non-IDU-associated SA (non-IDU-SA), IDU-associated SA (IDU-SA) was associated with female sex (P=.001), younger age (P<.001), lower body mass index (P<.001), tobacco use (P<.001), and psychiatric diagnosis (P=.04) and was more likely to involve methicillin-resistant Staphylococcus aureus (P<.001). The IDU-SA was associated with discharge to a skilled nursing facility or against medical advice (P<.001) and with loss to follow-up (P=.01). The 2 groups did not differ in terms of American Society of Anesthesiologists classification, joint involved, Gram stain positivity, presence of bacteremia, peripherally inserted central catheter placement, return to hospital within 3 months, or persistent/secondary positive results on culture within 3 months. Patients with IDU-SA were younger, were more likely to be female, had lower body mass index, and had fewer medical comorbidities but were more likely to use tobacco and to have a psychiatric diagnosis compared with patients with non-IDU-SA. Methicillin-resistant S aureus was more common in the IDU-SA group, as was discharge to a skilled nursing facility or against medical advice. Patients with IDU-SA were less likely to return for follow-up than patients with non-IDU-SA. [Orthopedics. 2021;44(6):e747-e752.].

Empathy Among Orthopaedic Surgery Trainees.

BACKGROUND: It has been postulated that the process of-and stresses associated with-medical training may cause a loss of empathy among trainees. Because empathy is considered an important value for clinicians and may even be associated with better patient outcomes, we assessed the empathy of orthopaedic surgery trainees and identified factors associated with empathy. METHODS: Between June and September 2020, an anonymous survey was distributed electronically to trainees in 23 Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs via the Collaborative Orthopaedic Educational Research Group. The survey comprised the validated Short-Form 8-Item Empathy Quotient (EQ-8) questionnaire-scored on a scale of 0, least empathetic, to 16, most empathetic-and single-item measure of emotional exhaustion and depersonalization derived from the Maslach Burnout Index-scored using a frequency scale. In total, 438 of 605 (72%) trainees completed the survey. The scores were compared via one-way analysis of variance, with Bonferroni correction and Tukey post-hoc testing, α = 0.05. RESULTS: The mean (±SD) EQ-8 score among respondents was 11.3 ± 3.3. Women scored significantly higher (mean, 12.2 ± 2.8) than men (mean, 11.2 ± 3.3) (p = 0.02). Mean scores were significantly higher for trainees planning on a career in academic medicine (12.0 ± 2.9) than those intending to pursue private practice (10.9 ± 3.3) or those with a military commitment (10.4 ± 3.4) (p = 0.01). An inverse relationship was found between EQ-8 scores and single-item Maslach Burnout Index measures in depersonalization and emotional exhaustion (both, p < 0.01). No significant differences were found in EQ-8 scores across postgraduate year, program location, primary training setting, intended fellowship, relationship status, or whether they reported having children. CONCLUSIONS: We found no association between postgraduate year and EQ-8 score. Women and those intending to pursue a career in academic medicine had significantly higher levels of empathy. A significant inverse relationship was found between burnout and empathy. Respondents with higher levels of emotional exhaustion and depersonalization had lower levels of empathy.

Treatment of Radiation-Associated Fractures: A Critical Analysis Review.

¼: Fractures that result from radiation-induced bone damage are a recognized adverse effect of radiation therapy (RT). ¼: The mechanisms of damage from RT are thought to be related to impaired vascularity, aberrations in osteoclast and osteoblast-mediated bone turnover, and compromise of cortical and trabecular microarchitecture. ¼: Treatment of radiation-associated fractures is challenging, with rates of delayed union and nonunion of >50%. ¼: Fracture management strategies, each with its own profile of risks and benefits, include prophylactic intramedullary nailing of long bones, open reduction and internal fixation with adjunctive iliac crest or vascularized fibular grafting, and endoprosthetic reconstruction.

Intravascular Mesenchymal Chondrosarcoma of the Femoral Vein: A Case Report.

CASE: A 30-year-old man presented with progressive lower right extremity pain and swelling, initially diagnosed as a deep venous thrombosis. He returned 18 months later after 2 episodes of gross hemoptysis, with chest computed tomography angiography findings concerning for tumor thrombus in the left pulmonary artery. Subsequent advanced imaging showed a lesion arising from his right femoral vein, which open biopsy revealed to be a primary intravascular mesenchymal chondrosarcoma. He underwent medical therapy, with improvement of pain and swelling and successful return to work. CONCLUSION: Mesenchymal chondrosarcoma is a rare pathology, and its intravascular origin makes this case extraordinarily uncommon.

Decrease in Resident Arthroscopic Case Volume After 2013 Implementation of Minimum Case Requirements.

PURPOSE: To analyze graduating U.S. orthopaedic resident case logs to determine temporal trends in knee and shoulder arthroscopic case volumes, as well as changes in the variability of caseload volumes since the implementation of Accreditation Council for Graduate Medical Education (ACGME) minimum case requirements ("case minimums") in 2013. METHODS: We abstracted ACGME-published case log data for all U.S. orthopaedic surgery residents who graduated from 2007 to 2013 (before implementation of case minimums) and from 2014 to 2019 (after implementation). Using a case-control study design, we compared mean numbers of arthroscopic knee and shoulder cases reported per resident between the 2 time periods by using unpaired 2-tailed t tests. P values < .05 were considered significant. RESULTS: The mean number of arthroscopy knee cases reported by residents decreased from 164 before implementation of case minimums to 107 after implementation (P < .001). The mean number of shoulder cases decreased similarly from 98 to 66 (P < .001). Among residents with caseload volumes in the 90th percentile ("high-volume caseloads") the decrease was greatest, with 38% fewer knee cases and 41% fewer shoulder cases logged. The ratio of the number of cases in the 90th percentile of caseload to the number in the 10th percentile decreased significantly after implementation of case minimums (P < .001). CONCLUSIONS: After implementation of ACGME case minimums in 2013, the numbers of arthroscopic knee and shoulder cases reported by graduating U.S. orthopaedic surgery residents decreased significantly. The disparity between the number of cases that constitutes a high-volume caseload and the number that constitutes a low-volume caseload narrowed, suggesting greater uniformity in resident exposure to these procedures across training programs. LEVEL OF EVIDENCE: Level III, retrospective comparative study.

How We Do It: Modified Residency Programming and Adoption of Remote Didactic Curriculum During the COVID-19 Pandemic.

OBJECTIVE: To describe the modified operational plan we implemented for residents and faculty in our orthopedic surgery department to allow continuation of resident education and other core activities during the novel coronavirus (COVID-19) pandemic. DESIGN: Description of educational augmentation and programming modifications. SETTING: The Johns Hopkins Hospital and Johns Hopkins Bayview Medical Center, Baltimore, MD. PARTICIPANTS: Residents and faculty, Department of Orthopaedic Surgery. METHODS: In response to the COVID-19 pandemic, we developed and implemented a modified operational schedule and remote curriculum in the orthopedic surgery department of our health system. Our plan was guided by the following principles: protecting the workforce while providing essential clinical care; maintaining continuity of education and research; and promoting social distancing while minimizing the impact on team psychosocial well-being. RESULTS: The operational schedule and remote curriculum have been implemented successfully and allow resident education and other core departmental functions to continue as our health care system responds to the pandemic. CONCLUSIONS: We have been proactive and deliberate in implementing these operational changes, without compromise of our workforce. This experience provides residents exposure to real-life systems-based practice. We hope that our early experience will provide a framework for other surgical residency programs facing this crisis.

Medicare Compensation Rates for Hand and Shoulder/Elbow Surgery by Operative Time: A Comparative Analysis.

BACKGROUND: There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the perception that this exposure will improve their professional "marketability" in a subspecialty they perceive as having higher compensation. METHODS: Using Medicare data, we investigated the most common surgeries from these fields and determined which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement (payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that of hand surgery. RESULTS: Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery has a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), and reimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P<0.01). Non-weighted mean wRVUs/min were similar (0.12±0.03 vs. 0.13±0.03, P = 0.12). When weighted by procedure frequency, hand surgery had greater wRVUs/min (0.15±0.036 vs. 0.13±0.032), payments/min ($14.17±4.50 vs. $6.97±2.26), charges/min ($75.68±30.47 vs. $42.61±7.83), and reimbursement (20±5.0% vs. 17±6.0%) (all, P<0.01). CONCLUSION: According to Medicare compensation, and when weighted by procedure frequency, hand procedures are associated with greater overall mean wRVUs/min, payments/min, charges/min, and reimbursement compared with shoulder and elbow procedures. Hand-surgery fellowship applicants should be aware that subspecialty compensation is complex in nature but should seek shoulder/elbow elective experience to acquire an additional surgical skill-set as opposed to primarily monetary reason.