Pub Date : 2019-10-01DOI: 10.1097/CORR.0000000000000958
Steven A. Long, G. Thomas, M. Karam, D. Anderson
BACKGROUND Skills training and simulation play an increasingly important role in orthopaedic surgical education. The intent of simulation is to improve performance in the operating room (OR), a trait known as transfer validity. No prior studies have explored how simulator-based wire navigation training can transfer to higher-level tasks. Additionally, there is a lack of knowledge on the format in which wire navigation training should be deployed. QUESTIONS/PURPOSES (1) Which training methods (didactic content, deliberate practice, or proficiency-based practice) lead to the greatest improvement in performing a wire navigation task? (2) Does a resident's performance using a wire navigation simulator correlate with his or her performance on a higher-level simulation task in a mock OR involving a C-arm, a radiopaque femur model, and a large soft tissue surrogate surrounding the femur? METHODS Fifty-five residents from four different medical centers participated in this study over the course of 2 years. The residents were divided into three groups: traditional training (included first-year residents from the University of Iowa, University of Minnesota, and the Mayo Clinic), deliberate practice (included first-year residents from the University of Nebraska and the University of Minnesota), and proficiency training (included first-year residents from the University of Minnesota and the Mayo Clinic). Residents in each group received a didactic introduction covering the task of placing a wire to treat an intertrochanteric fracture, and this was considered traditional training. Deliberate practice involved training on a radiation-free simulator that provided specific feedback throughout the practice sessions. Proficiency training used the same simulator to train on specific components of wire navigation, like finding the correct starting point, to proficiency before moving to assessment. The wire navigation simulator uses a camera system to track the wire and provide computer-generated fluoroscopy. After training, task performance was assessed in a mock OR. Residents from each group were assessed in the mock OR based on their use of fluoroscopy, total time, and tip-apex distance. Correlation analysis was performed to examine the relationship between resident performance on the simulator and in the mock OR. RESULTS Residents in the two simulation-based training groups had a lower tip-apex distance than those in the traditional training group (didactic training tip-apex distance: 24 ± 7 mm, 95% CI, 20-27; deliberate practice tip-apex distance: 16 ± 5 mm, 95% CI, 13-19, p = 0.001; proficiency training tip-apex distance: 15 ± 4 mm, 95% CI, 13-18, p < 0.001). Residents in the proficiency training group used more images than those in the other groups (didactic training: 22 ± 12 images, p = 0.041; deliberate practice: 19 ± 8 images; p = 0.012, proficiency training: 31 ± 14 images). In the two simulation-based training groups, resident performance on the simulator
背景技能训练与模拟在骨科外科教学中发挥着越来越重要的作用。模拟的目的是提高手术室(OR)的表现，这是一种被称为转移效度的特征。之前没有研究探索如何将基于模拟器的有线导航训练转移到更高级别的任务中。此外，还缺乏关于有线导航培训应采用何种形式的知识。(1)哪种训练方法(教学内容、刻意练习还是基于熟练程度的练习)能最大程度地提高导线导航任务的执行能力?(2)住院医生使用导线导航模拟器的表现是否与他或她在涉及c型臂、不透射线的股骨模型和股骨周围大软组织替代物的模拟手术室中更高级别模拟任务的表现相关?方法来自四个不同医疗中心的55名住院医师参与了为期2年的研究。住院医生被分为三组:传统训练组(包括来自爱荷华大学、明尼苏达大学和梅奥诊所的一年级住院医生)、刻意练习组(包括来自内布拉斯加州大学和明尼苏达大学的一年级住院医生)和熟练训练组(包括来自明尼苏达大学和梅奥诊所的一年级住院医生)。每个组的住院医生都接受了一个说教性的介绍，包括放置金属丝治疗转子间骨折的任务，这被认为是传统的训练。刻意练习包括在无辐射模拟器上进行训练，在整个练习过程中提供具体的反馈。熟练度培训使用相同的模拟器来训练电线导航的特定组件，比如找到正确的起点，在进入评估之前熟练度。导线导航模拟器使用一个摄像系统来跟踪导线，并提供计算机生成的透视。训练结束后，在模拟手术室中评估任务表现。每个组的住院医生在模拟手术室中根据他们使用透视、总时间和尖端-尖端距离进行评估。进行相关分析以检查在模拟器和模拟手术室中的住院表现之间的关系。结果两个模拟训练组的住院医生的尖尖距离低于传统训练组(教学训练的尖尖距离:24±7 mm, 95% CI, 20-27;刻意练习尖端距离:16±5 mm, 95% CI, 13-19, p = 0.001;熟练训练尖端距离:15±4 mm, 95% CI, 13-18, p < 0.001)。熟练训练组住院医师使用图像数量多于其他组(教学训练组:22±12张图像，p = 0.041;刻意练习:19±8个图像;P = 0.012，熟练训练:31±14张图像)。在两个基于模拟的训练组中，模拟器上的常驻表现，即尖端距离、图像使用和总时间，与模拟OR中的表现相关(r-square分别= 0.15 [p = 0.030]、0.61 [p < 0.001]和0.43 [p < 0.001])。当住院医师项目设计他们的课程来训练导线导航技能时，重点应该放在提供一个允许刻意练习的环境上，并对他们的表现进行即时反馈。本研究中的模拟器为住院医生学习这一关键技能提供了一个安全的环境。证据等级:II级，治疗性研究。
{"title":"Erratum to: Do Skills Acquired from Training with a Wire Navigation Simulator Transfer to a Mock Operating Room Environment?","authors":"Steven A. Long, G. Thomas, M. Karam, D. Anderson","doi":"10.1097/CORR.0000000000000958","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000958","url":null,"abstract":"BACKGROUND Skills training and simulation play an increasingly important role in orthopaedic surgical education. The intent of simulation is to improve performance in the operating room (OR), a trait known as transfer validity. No prior studies have explored how simulator-based wire navigation training can transfer to higher-level tasks. Additionally, there is a lack of knowledge on the format in which wire navigation training should be deployed. QUESTIONS/PURPOSES (1) Which training methods (didactic content, deliberate practice, or proficiency-based practice) lead to the greatest improvement in performing a wire navigation task? (2) Does a resident's performance using a wire navigation simulator correlate with his or her performance on a higher-level simulation task in a mock OR involving a C-arm, a radiopaque femur model, and a large soft tissue surrogate surrounding the femur? METHODS Fifty-five residents from four different medical centers participated in this study over the course of 2 years. The residents were divided into three groups: traditional training (included first-year residents from the University of Iowa, University of Minnesota, and the Mayo Clinic), deliberate practice (included first-year residents from the University of Nebraska and the University of Minnesota), and proficiency training (included first-year residents from the University of Minnesota and the Mayo Clinic). Residents in each group received a didactic introduction covering the task of placing a wire to treat an intertrochanteric fracture, and this was considered traditional training. Deliberate practice involved training on a radiation-free simulator that provided specific feedback throughout the practice sessions. Proficiency training used the same simulator to train on specific components of wire navigation, like finding the correct starting point, to proficiency before moving to assessment. The wire navigation simulator uses a camera system to track the wire and provide computer-generated fluoroscopy. After training, task performance was assessed in a mock OR. Residents from each group were assessed in the mock OR based on their use of fluoroscopy, total time, and tip-apex distance. Correlation analysis was performed to examine the relationship between resident performance on the simulator and in the mock OR. RESULTS Residents in the two simulation-based training groups had a lower tip-apex distance than those in the traditional training group (didactic training tip-apex distance: 24 ± 7 mm, 95% CI, 20-27; deliberate practice tip-apex distance: 16 ± 5 mm, 95% CI, 13-19, p = 0.001; proficiency training tip-apex distance: 15 ± 4 mm, 95% CI, 13-18, p < 0.001). Residents in the proficiency training group used more images than those in the other groups (didactic training: 22 ± 12 images, p = 0.041; deliberate practice: 19 ± 8 images; p = 0.012, proficiency training: 31 ± 14 images). In the two simulation-based training groups, resident performance on the simulator","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"52 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"72722540","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-10-01DOI: 10.1097/CORR.0000000000000941
B. S. Bal, W. Teo, Lawrence H. Brenner
Surgeons know that staying current on surgical techniques is important; they may not realize that medicolegal principles evolve just as quickly. In 2018, it was reasonable to believe that one might be sued for malpractice by a patient; in 2019, a Minnesota Supreme Court decision found that a physician-patient relationship is not a necessary element in a medical malpractice claim [8]. In the ruling, the Court ruled that during the time that a physician acts in a professional capacity, if it is reasonably foreseeable that a third-party will rely on the physician’s medical decisionmaking that may ultimately harm the patient, then a physician duty of care toward that patient arises, even absent a physician-patient relationship [8]. Modern medical practice is increasingly democratized by team-based approaches to medical care, information disclosure and dissemination, and shared decision-making. But the Minnesota court ruling is a reminder that courts still hold a traditional view that the physician is ultimately responsible for the patient, even for medical advice and decisionmaking done without establishing a physician-patient relationship.
{"title":"Medicolegal Sidebar: Getting Sued By Someone Else's Patient-When Does a Curbside Consultation Carry Medicolegal Jeopardy?","authors":"B. S. Bal, W. Teo, Lawrence H. Brenner","doi":"10.1097/CORR.0000000000000941","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000941","url":null,"abstract":"Surgeons know that staying current on surgical techniques is important; they may not realize that medicolegal principles evolve just as quickly. In 2018, it was reasonable to believe that one might be sued for malpractice by a patient; in 2019, a Minnesota Supreme Court decision found that a physician-patient relationship is not a necessary element in a medical malpractice claim [8]. In the ruling, the Court ruled that during the time that a physician acts in a professional capacity, if it is reasonably foreseeable that a third-party will rely on the physician’s medical decisionmaking that may ultimately harm the patient, then a physician duty of care toward that patient arises, even absent a physician-patient relationship [8]. Modern medical practice is increasingly democratized by team-based approaches to medical care, information disclosure and dissemination, and shared decision-making. But the Minnesota court ruling is a reminder that courts still hold a traditional view that the physician is ultimately responsible for the patient, even for medical advice and decisionmaking done without establishing a physician-patient relationship.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"39 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"79859134","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-26DOI: 10.1097/CORR.0000000000000979
S. Leopold
Most orthopaedic surgeons I know pride themselves on engaging with their patients as individuals. Many bridle at the idea that trendy, shared decision-making models are somehow something new, as they feel they’ve been sharing decisions with their patients all along; I believe many of them are right about this. And yet some of those same surgeons adopt heavy-handed approaches that seem to misunderstand how surgical risk really works when they insist on binary cutoffs for parameters like BMI, hemoglobin A1C, and cigarette smoking as a condition to offer elective surgery to their patients. When a surgeon unilaterally defines and applies such cutoffs in practice, by definition shared decision-making cannot take place. When the risk factors only seem modifiable, but in fact are not (or when they are only minimally modifiable), the use of rigid thresholds may become coercive. For these and other reasons, orthopaedic surgeons should stop using hard cutoffs for parameters like BMI, hemoglobin A1C, and smoking in the context of deciding whether to offer a patient elective surgery. The idea of using surgery as a “carrot” to nudge patients towards healthier behaviors—with the endpoint of offering an elective procedure the patient seeks as the inducement for efforts made—is entirely reasonable. When done with care and sensitivity, it can be one portion of a healthcare partnership in which both parties take some responsibility for achieving a result that both will be pleased with. But surgeons don’t have to operate on anyone we don’t want to treat, and increasingly we’re being held to financial account for the complications that result from our elective procedures. I believe this combination can result in surgeons setting unrealistic or impossible health goals for patients who seek particular interventions, and withholding those interventions from patients when they inevitably (or nearly inevitably) fall short [9]. This strikes me as potentially coercive. It’s also not well-supported by the available evidence.
{"title":"Editorial: The Shortcomings and Harms of Using Hard Cutoffs for BMI, Hemoglobin A1C, and Smoking Cessation as Conditions for Elective Orthopaedic Surgery.","authors":"S. Leopold","doi":"10.1097/CORR.0000000000000979","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000979","url":null,"abstract":"Most orthopaedic surgeons I know pride themselves on engaging with their patients as individuals. Many bridle at the idea that trendy, shared decision-making models are somehow something new, as they feel they’ve been sharing decisions with their patients all along; I believe many of them are right about this. And yet some of those same surgeons adopt heavy-handed approaches that seem to misunderstand how surgical risk really works when they insist on binary cutoffs for parameters like BMI, hemoglobin A1C, and cigarette smoking as a condition to offer elective surgery to their patients. When a surgeon unilaterally defines and applies such cutoffs in practice, by definition shared decision-making cannot take place. When the risk factors only seem modifiable, but in fact are not (or when they are only minimally modifiable), the use of rigid thresholds may become coercive. For these and other reasons, orthopaedic surgeons should stop using hard cutoffs for parameters like BMI, hemoglobin A1C, and smoking in the context of deciding whether to offer a patient elective surgery. The idea of using surgery as a “carrot” to nudge patients towards healthier behaviors—with the endpoint of offering an elective procedure the patient seeks as the inducement for efforts made—is entirely reasonable. When done with care and sensitivity, it can be one portion of a healthcare partnership in which both parties take some responsibility for achieving a result that both will be pleased with. But surgeons don’t have to operate on anyone we don’t want to treat, and increasingly we’re being held to financial account for the complications that result from our elective procedures. I believe this combination can result in surgeons setting unrealistic or impossible health goals for patients who seek particular interventions, and withholding those interventions from patients when they inevitably (or nearly inevitably) fall short [9]. This strikes me as potentially coercive. It’s also not well-supported by the available evidence.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"14 12 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-26","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"78388917","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CORR.0000000000000895
R. J. Mistovich
While preferences and knowledge have changed over time, the role of uniforms and even clothing colors remains important for all vocations [7]. Indeed, one’s personal presentation is a modifiable component of a first impression [3]. From the military, to the clergy, to the physician wearing scrubs on daytime television, society still has expectations regarding the appearance of professionals. However, unlike many other vocations, doctors have historically adopted a uniform that was not only culturally appropriate, but also functional. The traditional role of the physician uniform has been to promote the eradication of disease and minimize its spread through the best current evidence. From the plague doctor’s protective suit and beak filled with herbs and straw, to advancements like sterile gloves, scrubs, and masks; form has followed function in terms of the physician uniform. Physician attire must facilitate (or at least not impair) best medical practices, allow for the physical demands of our field, and mitigate (or at least not worsen) disease propagation. Physician attire must also meet patients’ social expectations, which may be culture-bound, and may change over time. And although we cannot control patients’ biases with respect to physician age, ethnicity, or gender, we should promote a uniform that conveys professionalism. The ideal physician uniform should seek to offset any biases patients may have, and help identify the individual as a physician, and not a nurse, medical student, or hospital administrator. Research conducted in an urban outpatient orthopaedic setting [4] suggests that patients have expectations regarding how doctors should present themselves; specifically, it appears that in that setting, patients prefer orthopaedic surgeons to wear either a white coat or scrubs. The current study by Jennings and colleagues [5] extends what we know on this topic; it found that in the inpatient setting, patients preferred both male and female orthopaedic surgeons to wear a white coat with scrubs or white coat with business attire most frequently, then, respectively, ranked scrubs alone, business attire, and least preferred casual attire. Prior work by Jennings and colleagues [4] studied patient preferences for orthopaedic surgeons in the outpatient setting. At that time, they did note some variations in patient preference based on the sex of the surgeon, with male physicians preferred to be in a white coat over business attire. However, there was no difference in confidence ranking of male surgeons in scrubs alone versus a white coat over business attire, and no differences in any category between scrubs alone and business attire. For women surgeons, there was an equal preference for a white coat over business attire or scrubs alone, and scrubs alone evoked a greater rating of confidence than business attire. Regardless of gender, patients still disliked surgeons in casual attire. This CORR Insights is a commentary on the article “Orthopa
{"title":"CORR Insights®: Orthopaedic Physician Attire Influences Patient Perceptions in an Urban Inpatient Setting.","authors":"R. J. Mistovich","doi":"10.1097/CORR.0000000000000895","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000895","url":null,"abstract":"While preferences and knowledge have changed over time, the role of uniforms and even clothing colors remains important for all vocations [7]. Indeed, one’s personal presentation is a modifiable component of a first impression [3]. From the military, to the clergy, to the physician wearing scrubs on daytime television, society still has expectations regarding the appearance of professionals. However, unlike many other vocations, doctors have historically adopted a uniform that was not only culturally appropriate, but also functional. The traditional role of the physician uniform has been to promote the eradication of disease and minimize its spread through the best current evidence. From the plague doctor’s protective suit and beak filled with herbs and straw, to advancements like sterile gloves, scrubs, and masks; form has followed function in terms of the physician uniform. Physician attire must facilitate (or at least not impair) best medical practices, allow for the physical demands of our field, and mitigate (or at least not worsen) disease propagation. Physician attire must also meet patients’ social expectations, which may be culture-bound, and may change over time. And although we cannot control patients’ biases with respect to physician age, ethnicity, or gender, we should promote a uniform that conveys professionalism. The ideal physician uniform should seek to offset any biases patients may have, and help identify the individual as a physician, and not a nurse, medical student, or hospital administrator. Research conducted in an urban outpatient orthopaedic setting [4] suggests that patients have expectations regarding how doctors should present themselves; specifically, it appears that in that setting, patients prefer orthopaedic surgeons to wear either a white coat or scrubs. The current study by Jennings and colleagues [5] extends what we know on this topic; it found that in the inpatient setting, patients preferred both male and female orthopaedic surgeons to wear a white coat with scrubs or white coat with business attire most frequently, then, respectively, ranked scrubs alone, business attire, and least preferred casual attire. Prior work by Jennings and colleagues [4] studied patient preferences for orthopaedic surgeons in the outpatient setting. At that time, they did note some variations in patient preference based on the sex of the surgeon, with male physicians preferred to be in a white coat over business attire. However, there was no difference in confidence ranking of male surgeons in scrubs alone versus a white coat over business attire, and no differences in any category between scrubs alone and business attire. For women surgeons, there was an equal preference for a white coat over business attire or scrubs alone, and scrubs alone evoked a greater rating of confidence than business attire. Regardless of gender, patients still disliked surgeons in casual attire. This CORR Insights is a commentary on the article “Orthopa","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"19 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"75781124","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CORR.0000000000000867
Santiago A. Lozano Calderón, C. Garbutt, Jason Kim, Christopher E Lietz, Yen-Lin E Chen, K. Bernstein, I. Chebib, G. Nielsen, V. Deshpande, Renee Rubio, Yaoyu E. Wang, John Quackenbush, T. Delaney, K. Raskin, J. Schwab, G. Cote, D. Spentzos
BACKGROUND MicroRNAs are small, noncoding RNAs that regulate the expression of posttranslational genes. The presence of some specific microRNAs has been associated with increased risk of both local recurrence and metastasis and worse survival in patients with osteosarcoma. Pathologic fractures in osteosarcoma are considered to be more the manifestation of a neoplasm with a more aggressive biological behavior than the cause itself of worse prognosis. However, this has not been proved at the biological or molecular level. Currently, there has not been a microRNA profiling study of patients who have osteosarcoma with and without pathologic fractures that has described differences in terms of microRNA profiling between these two groups and their correlation with biologic behavior. QUESTIONS/PURPOSES (1) In patients with osteosarcoma of the extremities, how do the microRNA profiles of those with and without pathologic fractures compare? (2) What relationship do microRNAs have with local recurrence, risk of metastasis, disease-specific survival, and overall survival in osteosarcoma patients with pathologic fractures? METHODS Between 1994 and 2013, 217 patients were diagnosed and treated at our institution for osteosarcoma of the extremities. Patients were excluded if (1) they underwent oncologic resection of the osteosarcoma at an outside institution (two patients) or (2) they were diagnosed with an extraskeletal osteosarcoma (29 patients) or (3) they had less than 1 year of clinical follow-up and no oncologic outcome (local recurrence, metastasis, or death) (four patients). A total of 182 patients were eligible. Of those, 143 were high-grade osteosarcomas. After evaluation of tumor samples before chemotherapy treatment, a total of 80 consecutive samples were selected for sequencing. Demographic and clinical comparison between the sequenced and non-sequenced patients did not demonstrate any differences, confirming that both groups were comparable. Diagnostic samples from the extremities of 80 patients with high-grade extremity osteosarcomas who had not yet received chemotherapy underwent microRNA sequencing for an ongoing large-scale osteosarcoma genome profiling project at our institution. Six samples were removed after a second look by a musculoskeletal pathologist who verified cellularity and quality of samples to be sequenced, leaving a total of 74 patients. Of these, two samples were removed as they were confirmed to be pelvic tumors in a second check after sequencing. The final study sample was 72 patients (11 patients with pathologic fractures and 61 without). Sequencing data were correlated with fractures and local recurrence, risk of metastasis, disease-specific survival, and overall survival through Kaplan-Meier analyses. RESULTS Several microRNAs were expressed differently between the two groups. Among the markers with the highest differential expression (edgeR and DESeq algorithms), Hsa-mIR 656-3p, hsa-miR 493-5p, and hsa-miR 381-3p w
{"title":"Clinical and Molecular Analysis of Pathologic Fracture-associated Osteosarcoma: MicroRNA profile Is Different and Correlates with Prognosis.","authors":"Santiago A. Lozano Calderón, C. Garbutt, Jason Kim, Christopher E Lietz, Yen-Lin E Chen, K. Bernstein, I. Chebib, G. Nielsen, V. Deshpande, Renee Rubio, Yaoyu E. Wang, John Quackenbush, T. Delaney, K. Raskin, J. Schwab, G. Cote, D. Spentzos","doi":"10.1097/CORR.0000000000000867","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000867","url":null,"abstract":"BACKGROUND\u0000MicroRNAs are small, noncoding RNAs that regulate the expression of posttranslational genes. The presence of some specific microRNAs has been associated with increased risk of both local recurrence and metastasis and worse survival in patients with osteosarcoma. Pathologic fractures in osteosarcoma are considered to be more the manifestation of a neoplasm with a more aggressive biological behavior than the cause itself of worse prognosis. However, this has not been proved at the biological or molecular level. Currently, there has not been a microRNA profiling study of patients who have osteosarcoma with and without pathologic fractures that has described differences in terms of microRNA profiling between these two groups and their correlation with biologic behavior.\u0000\u0000\u0000QUESTIONS/PURPOSES\u0000(1) In patients with osteosarcoma of the extremities, how do the microRNA profiles of those with and without pathologic fractures compare? (2) What relationship do microRNAs have with local recurrence, risk of metastasis, disease-specific survival, and overall survival in osteosarcoma patients with pathologic fractures?\u0000\u0000\u0000METHODS\u0000Between 1994 and 2013, 217 patients were diagnosed and treated at our institution for osteosarcoma of the extremities. Patients were excluded if (1) they underwent oncologic resection of the osteosarcoma at an outside institution (two patients) or (2) they were diagnosed with an extraskeletal osteosarcoma (29 patients) or (3) they had less than 1 year of clinical follow-up and no oncologic outcome (local recurrence, metastasis, or death) (four patients). A total of 182 patients were eligible. Of those, 143 were high-grade osteosarcomas. After evaluation of tumor samples before chemotherapy treatment, a total of 80 consecutive samples were selected for sequencing. Demographic and clinical comparison between the sequenced and non-sequenced patients did not demonstrate any differences, confirming that both groups were comparable. Diagnostic samples from the extremities of 80 patients with high-grade extremity osteosarcomas who had not yet received chemotherapy underwent microRNA sequencing for an ongoing large-scale osteosarcoma genome profiling project at our institution. Six samples were removed after a second look by a musculoskeletal pathologist who verified cellularity and quality of samples to be sequenced, leaving a total of 74 patients. Of these, two samples were removed as they were confirmed to be pelvic tumors in a second check after sequencing. The final study sample was 72 patients (11 patients with pathologic fractures and 61 without). Sequencing data were correlated with fractures and local recurrence, risk of metastasis, disease-specific survival, and overall survival through Kaplan-Meier analyses.\u0000\u0000\u0000RESULTS\u0000Several microRNAs were expressed differently between the two groups. Among the markers with the highest differential expression (edgeR and DESeq algorithms), Hsa-mIR 656-3p, hsa-miR 493-5p, and hsa-miR 381-3p w","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"4 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91370756","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CORR.0000000000000917
K. Ashmore, S. Cialdella, A. Giuffrida, E. Kon, M. Marcacci, B. Di Matteo
From the column editor, The Renaissance-era German mercenary Gottfried “Götz” von Berlichingen defied the odds by surviving both a significant battle wound to his right arm and an upper extremity amputation at a time when few survived either. Ambroise Paré’s discovery that surgical patients were more likely to survive their operation without cauterization would not occur for another 30 years. The invention of the tourniquet did not occur for another century. However, von Berlichingen did survive, only to be confronted with a problem that is still relevant 500 years later. Indeed, despite 21st century silicone chip microprocessors, miniature electric motors, sensors, and myoelectric controls, developing an upper extremity prosthesis with suitable functionality remains a remarkably difficult problem to solve. But in the guest ArtiFacts column that follows, Berardo Di Matteo and his research group from Milan, Italy use their established expertise in the field of orthopaedic history [3, 4] to detail how, with the help of a local blacksmith, von Berlichingen managed to successfully wear and operate a functional iron prosthesis capable of wielding a sword in multiple battles, earning him the nickname “Götz of the Iron Hand.” — Alan J. Hawk BA The Renaissance contributed more than just art and architecture, and more even than the science of Kepler and Galileo. Then [1] as now [6], war and bloodshed advance the art and science of medicine, and wars were a part of life during the Renaissance. An innovation arising from one of those wars—a genuine representation both of the artistic and medical ingenuity of the time—is the extraordinary case of the “iron hand” of the 16 century German knight and mercenary Gottfried “Götz” von Berlichingen. Born into a wealthy German family in 1480, von Berlichingen was drawn to the battlefield at an early age. Before his 17th birthday, he enlisted into the Brandenburg-Ansbach army, where he served the Holy Roman Empire, before leaving to form his own mercenary squad at the age of 20 [7]. A skilled and fierce mercenary and commander, von Berlichingen’s impressive 47-year military career [7] spanned numerous German civil wars, including the German peasants’ war (1524 to 1525), as well as bloody European battles against the French and the Ottomans [1, 10]. While invading the city of Landshut as a mercenary in 1504 [11], enemy cannon fire jolted von Berlichingen’s blade against himself, maiming his right arm at the elbow. German doctors A note from the Editor-in-Chief: We are pleased to present the next installment of ArtiFacts. In this month’s guest column, Berardo Di Matteo and his research group explore the life of Renaissance-era German mercenary Gottfried “Götz” von Berlichingen, who had his right arm amputated from the elbow following a battle in 1504. Rather than transition into civilian life, the brutal mercenary and commander commissioned a local blacksmith to create an iron right arm prosthesis that he could wear in
文艺复兴时期的德国雇佣兵戈特弗里德·“Götz”·冯·伯利辛根(Gottfried“Götz”von Berlichingen)在右臂严重受伤和上肢截肢的战斗中幸存下来，这在当时几乎没有人幸存下来。Ambroise par发现手术患者在没有烧灼的情况下更有可能在手术中存活，这一发现在30年后才出现。止血带的发明又过了一个世纪才出现。然而，冯·伯利辛根确实活了下来，只是面对了一个500年后仍然相关的问题。事实上，尽管有21世纪的硅片微处理器、微型电动机、传感器和肌电控制，开发具有适当功能的上肢假体仍然是一个非常困难的问题。但在接下来的客座文物专栏中，来自意大利米兰的Berardo Di Matteo和他的研究小组利用他们在骨科历史领域的专业知识[3,4]详细介绍了von Berlichingen是如何在当地铁匠的帮助下成功佩戴和操作功能性铁假体的，该假体能够在多次战斗中挥舞剑，为他赢得了“Götz铁手”的绰号。文艺复兴的贡献不仅仅是艺术和建筑，甚至超过了开普勒和伽利略的科学。当时[1]和现在[6]一样，战争和流血推动了医学艺术和科学的发展，战争是文艺复兴时期生活的一部分。其中一场战争产生了一项创新，这是当时艺术和医学创造力的真实代表，这就是16世纪德国骑士和雇佣兵戈特弗里德·“Götz”·冯·伯利辛根的“铁腕”非凡案例。1480年，冯·伯利辛根出生在一个富裕的德国家庭，很小的时候就被吸引到战场上。在他17岁生日之前，他应征加入了勃兰登堡-安斯巴赫军队，在那里他为神圣罗马帝国服务，然后在20岁时离开组建自己的雇佣兵小队[7]。作为一名技术娴熟、勇猛的雇佣兵和指挥官，冯·伯利辛根在47年的军事生涯中令人印象深刻[7]，经历了多次德国内战，包括德国农民战争(1524年至1525年)，以及与法国和奥斯曼人的血腥欧洲战争[1,10]。1504年，当他以雇佣兵身份入侵兰茨胡特城时[11]，敌人的炮火把冯·伯利辛根的刀刃撞到了自己身上，使他的右臂肘部受伤。主编留言:我们很高兴为大家呈现下一期的《人工制品》。在本月的客座专栏中，Berardo Di Matteo和他的研究小组探讨了文艺复兴时期德国雇佣兵Gottfried“Götz”von Berlichingen的生活，他在1504年的一场战斗中右臂从肘部被截肢。这位残暴的雇佣兵兼指挥官并没有转变为平民生活，而是委托当地的一位铁匠为他制作了一个可以在战斗中佩戴的铁制右臂假体。在截肢后，冯·伯利辛根确实在许多对抗中戴上了假肢，最终幸存下来。作者证明其本人及其直系亲属均无任何商业关联，如咨询公司、股票所有权、股权、专利/许可安排等可能与所提交的文章存在利益冲突。本文仅代表作者个人观点，不代表CORR或骨关节外科医师协会的观点或政策。B. DiMatteoMD(续)，Humanitas临床与研究所，Via A. Manzoni 113, 20089，意大利米兰，Rozzano, Email: berardo。dimatteo@gmail.com
{"title":"ArtiFacts: Gottfried \"Götz\" von Berlichingen-The \"Iron Hand\" of the Renaissance.","authors":"K. Ashmore, S. Cialdella, A. Giuffrida, E. Kon, M. Marcacci, B. Di Matteo","doi":"10.1097/CORR.0000000000000917","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000917","url":null,"abstract":"From the column editor, The Renaissance-era German mercenary Gottfried “Götz” von Berlichingen defied the odds by surviving both a significant battle wound to his right arm and an upper extremity amputation at a time when few survived either. Ambroise Paré’s discovery that surgical patients were more likely to survive their operation without cauterization would not occur for another 30 years. The invention of the tourniquet did not occur for another century. However, von Berlichingen did survive, only to be confronted with a problem that is still relevant 500 years later. Indeed, despite 21st century silicone chip microprocessors, miniature electric motors, sensors, and myoelectric controls, developing an upper extremity prosthesis with suitable functionality remains a remarkably difficult problem to solve. But in the guest ArtiFacts column that follows, Berardo Di Matteo and his research group from Milan, Italy use their established expertise in the field of orthopaedic history [3, 4] to detail how, with the help of a local blacksmith, von Berlichingen managed to successfully wear and operate a functional iron prosthesis capable of wielding a sword in multiple battles, earning him the nickname “Götz of the Iron Hand.” — Alan J. Hawk BA The Renaissance contributed more than just art and architecture, and more even than the science of Kepler and Galileo. Then [1] as now [6], war and bloodshed advance the art and science of medicine, and wars were a part of life during the Renaissance. An innovation arising from one of those wars—a genuine representation both of the artistic and medical ingenuity of the time—is the extraordinary case of the “iron hand” of the 16 century German knight and mercenary Gottfried “Götz” von Berlichingen. Born into a wealthy German family in 1480, von Berlichingen was drawn to the battlefield at an early age. Before his 17th birthday, he enlisted into the Brandenburg-Ansbach army, where he served the Holy Roman Empire, before leaving to form his own mercenary squad at the age of 20 [7]. A skilled and fierce mercenary and commander, von Berlichingen’s impressive 47-year military career [7] spanned numerous German civil wars, including the German peasants’ war (1524 to 1525), as well as bloody European battles against the French and the Ottomans [1, 10]. While invading the city of Landshut as a mercenary in 1504 [11], enemy cannon fire jolted von Berlichingen’s blade against himself, maiming his right arm at the elbow. German doctors A note from the Editor-in-Chief: We are pleased to present the next installment of ArtiFacts. In this month’s guest column, Berardo Di Matteo and his research group explore the life of Renaissance-era German mercenary Gottfried “Götz” von Berlichingen, who had his right arm amputated from the elbow following a battle in 1504. Rather than transition into civilian life, the brutal mercenary and commander commissioned a local blacksmith to create an iron right arm prosthesis that he could wear in ","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"95 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85292067","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CORR.0000000000000816
D. Davidson
Outcomes following treatment can be determined with the use of disease-specific outcomes tools like theWOMAC for hip and knee osteoarthritis or, if one seeks a moreholistic view of the patient’s overall well-being, then the use of broader functional outcomes and/or healthrelated quality of life measures may be more appropriate. While subspecialists may tend to focus ondisease or even jointspecific scales, the understanding of a patient’s overall outcome is likely to be incomplete if function and health-related quality of life are not measured [1]. Most oncology studies now include function and health-related quality of life measures, and perhaps because of this, some have delivered important findings [3, 5, 7]. For example, one study found that anxiety and depression was the domain with the greatest change between the time of diagnosis of adult soft-tissue sarcoma and 1-year following completion of treatment [3]. Another study found that body image issues and mobility concerns are common among survivors of sarcoma and these individuals may be reluctant to share these concerns with their providers [7]. Finally, a study on Ewing’s sarcoma survivors reported mild-to-moderate disability and impairments in 32% of patients, with older patients, females, and those with a pelvic site of disease to be at greatest risk of long-term issues [5]. These studies exemplify the importance of a more comprehensive outcome measurement compared to disease-specific or functional outcomes alone. Standardization of health-related quality of life tools and interpretation among children, adolescents, and young adult populations has been recommended on the basis of results from a systematic review [6], in order to improve the information provided by these measures. Before including either functional or health-related quality of life outcome measures in a study, the measurement tool must be validated in the specific population in which it is intended to be used. Absent this information, it is not possible to know whether the outcome tool measures what it intends to measure or does so accurately or in a valid way. In the current study, Piscione and colleagues [4] accomplished this critical task for the pediatric population with benign and malignant bone tumors. By developing and subsequently validating a measure of physical function specific to this patient population, they have contributed a means by which to determine patient reported physical function amongst children and adolescents.
{"title":"CORR Insights®: The Pediatric Toronto Extremity Salvage Score (pTESS): Validation of a Self-reported Functional Outcomes Tool for Children with Extremity Tumors.","authors":"D. Davidson","doi":"10.1097/CORR.0000000000000816","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000816","url":null,"abstract":"Outcomes following treatment can be determined with the use of disease-specific outcomes tools like theWOMAC for hip and knee osteoarthritis or, if one seeks a moreholistic view of the patient’s overall well-being, then the use of broader functional outcomes and/or healthrelated quality of life measures may be more appropriate. While subspecialists may tend to focus ondisease or even jointspecific scales, the understanding of a patient’s overall outcome is likely to be incomplete if function and health-related quality of life are not measured [1]. Most oncology studies now include function and health-related quality of life measures, and perhaps because of this, some have delivered important findings [3, 5, 7]. For example, one study found that anxiety and depression was the domain with the greatest change between the time of diagnosis of adult soft-tissue sarcoma and 1-year following completion of treatment [3]. Another study found that body image issues and mobility concerns are common among survivors of sarcoma and these individuals may be reluctant to share these concerns with their providers [7]. Finally, a study on Ewing’s sarcoma survivors reported mild-to-moderate disability and impairments in 32% of patients, with older patients, females, and those with a pelvic site of disease to be at greatest risk of long-term issues [5]. These studies exemplify the importance of a more comprehensive outcome measurement compared to disease-specific or functional outcomes alone. Standardization of health-related quality of life tools and interpretation among children, adolescents, and young adult populations has been recommended on the basis of results from a systematic review [6], in order to improve the information provided by these measures. Before including either functional or health-related quality of life outcome measures in a study, the measurement tool must be validated in the specific population in which it is intended to be used. Absent this information, it is not possible to know whether the outcome tool measures what it intends to measure or does so accurately or in a valid way. In the current study, Piscione and colleagues [4] accomplished this critical task for the pediatric population with benign and malignant bone tumors. By developing and subsequently validating a measure of physical function specific to this patient population, they have contributed a means by which to determine patient reported physical function amongst children and adolescents.","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"88631044","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CORR.0000000000000904
D. Lebrun
{"title":"Residency Diary: Intern Year Part 2 (April-June)-Teams in Residency.","authors":"D. Lebrun","doi":"10.1097/CORR.0000000000000904","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000904","url":null,"abstract":"","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"3 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"91320877","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CORR.0000000000000906
J. Kelly
{"title":"Your Best Life: When Mindfulness is Not the Answer-Alternative Approaches to Managing Anger and Conflict.","authors":"J. Kelly","doi":"10.1097/CORR.0000000000000906","DOIUrl":"https://doi.org/10.1097/CORR.0000000000000906","url":null,"abstract":"","PeriodicalId":10465,"journal":{"name":"Clinical Orthopaedics & Related Research","volume":"438 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"85537698","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Pub Date : 2019-09-01DOI: 10.1097/CORR.0000000000000910
S. Leopold
Many surgeons dislike or distrust methods-intensive research approaches like meta-analyses [14], and even experienced readers—including seasoned peer reviewers—head for the hills when it takes heavy computing power to grind data into answers [15], as is the case for studies using machine learning. So, let’s take a break this month from all that math, and luxuriate in the glow of some great qualitative research in this month’s Spotlight. Nary a decimal point or p value in sight. Did I hear someone say, “What’s qualitative research?” I’m not surprised. As far as I can recall, we’ve published only two papers [10, 12] in Clinical Orthopaedics and Related Research using qualitative or interview-based methods in the 7 years since I joined the team, and I’ve seen similarly sporadic deployment of these approaches in other leading generalinterest journals of our specialty [6, 8]. That’s too bad. The kinds of quantitative approaches that clinicians (and readers of clinical research) are most familiar with—case series, historically controlled studies, and even randomized trials—can tell us the what and the when, but they fall short on the why and the how. Specifically, they provide little or no insight into why our patients make the decisions they make, and how those patients perceive (and sometimes misunderstand) important facts about their own bodies. Facts that, in principle, their doctors have tried to explain. For these reasons, I’m excited to share a wonderful example of the genre in this month’s CORR from Dr. Jo-Anne Manski-Nankervis’s study group in Melbourne, Australia, which offers a number of penetrating insights into common misperceptions patients have about knee arthritis [2]. The authors, including first author, Samantha Bunzli PhD, performed indepth interviews with more than two dozen patients who were on a surgical waiting list to ascertain patients’ beliefs about what osteoarthritis is, what causes it, what may happen to it if left untreated, and how the condition can best be controlled or managed. The sample size—a question, no doubt, on every reader’s mind who is accustomed to seeing a larger number there—was determined by an a priori analytic approach that resulted in recruitment until no new themes emerged during these conversations. Some of the misunderstandings were staggering. Many patients’ (mis)understandings about the causes of their arthritis, their anticipation of worsening pain with time, and their beliefs about potential harms associated with choosing a non-surgical course, in particular, cannot be substantiated by any interpretation of the evidence on the topic of which I am aware. More importantly, those serious misapprehensions seem A note from the Editor-In-Chief: In “Editor’s Spotlight,” one of our editors provides brief commentary on a paper we believe is especially important and worthy of general interest. Following the explanation of our choice, we present “Take 5,” in which the editor goes behind the discovery with a
许多外科医生不喜欢或不信任像荟萃分析这样的密集研究方法，甚至有经验的读者——包括经验丰富的同行评议人——在需要大量计算能力才能将数据分解成答案时也会望而却步，就像使用机器学习的研究一样。所以，这个月让我们从所有的数学中休息一下，尽情享受本月重点报道节目中一些伟大的定性研究的光芒。看不到小数点或p值。我是否听到有人说，“什么是定性研究?”我并不感到惊讶。据我所知，在我加入团队的7年里，我们只在《临床骨科与相关研究》上发表了两篇论文[10,12]，使用了定性或基于访谈的方法，我也看到这些方法在我们专业的其他领先的通用期刊上也有类似的零星应用[6,8]。那太糟糕了。临床医生(和临床研究的读者)最熟悉的定量方法——病例系列，历史对照研究，甚至随机试验——可以告诉我们是什么和什么时候，但它们缺乏为什么和如何。具体来说，它们很少或根本没有深入了解我们的病人为什么做出他们所做的决定，以及这些病人是如何看待(有时是误解)关于他们自己身体的重要事实的。原则上，他们的医生试图解释这些事实。由于这些原因，我很高兴在本月的CORR中分享一个来自澳大利亚墨尔本的乔-安妮·曼斯基-南克维斯博士的研究小组的精彩例子，它为患者对膝关节关节炎的常见误解提供了一些深刻的见解。包括第一作者Samantha Bunzli博士在内的作者对20多名正在等待手术的患者进行了深入的采访，以确定患者对骨关节炎是什么、是什么引起的、如果不治疗可能会发生什么、以及如何最好地控制或管理这种疾病的看法。样本大小——毫无疑问，这是每个习惯于看到更大数字的读者心中的一个问题——是由一种先验分析方法决定的，这种方法导致了招募，直到在这些对话中没有出现新的主题。有些误解是令人震惊的。许多患者对关节炎原因的(错误)理解，他们对疼痛随时间加重的预期，以及他们对选择非手术治疗相关的潜在危害的信念，特别是，不能通过任何对我所知道的主题的证据的解释来证实。更重要的是，这些严重的误解似乎是主编的注释:在“编辑聚焦”中，我们的一位编辑对一篇我们认为特别重要且值得普遍关注的论文提供了简短的评论。在解释了我们的选择之后，我们将呈现“第5条”，在这条视频中，编辑将通过对“编辑聚焦”中这篇文章的一位作者的一对一采访，深入了解这一发现的背后。提交人证明，他本人及其直系亲属均无任何可能与所提交文章产生利益冲突的商业协会(如咨询公司、股票所有权、股权、专利/许可安排等)。所表达的观点是作者的观点，不反映CORR或骨关节外科医生协会的观点或政策。此评论引用的文章可在:DOI: 10.1097/CORR.0000000000000784。S. S. Leopold MD(;)，临床骨科及相关研究，1600 Spruce Street, Philadelphia, PA 19013 USA, Email: sleopold@clinorthop.org
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