Matthew R. DiCaprio

Fibrous Dysplasia. Pathophysiology, Evaluation, and Treatment

Fibrous dysplasia is a common benign skeletal lesion that may involve one bone (monostotic) or multiple bones (polyostotic) and occurs throughout the skeleton with a predilection for the long bones, ribs, and craniofacial bones. The etiology of fibrous dysplasia has been linked to an activating mutation in the gene that encodes the alpha subunit of stimulatory G protein (G(s)alpha) located at 20q13.2-13.3. Most lesions are monostotic, asymptomatic, and identified incidentally and can be treated with clinical observation and patient education. Bisphosphonate therapy may help to improve function, decrease pain, and lower fracture risk in appropriately selected patients with fibrous dysplasia. Surgery is indicated for confirmatory biopsy, correction of deformity, prevention of pathologic fracture, and/or eradication of symptomatic lesions. The use of cortical grafts is preferred over cancellous grafts or bone-graft substitutes because of the superior physical qualities of remodeled cortical bone.

Curricular requirements for musculoskeletal medicine in American medical schools.

A fundamental knowledge of the musculoskeletal system and its disorders is necessary for most practicing physicians, regardless of their specialty. Disorders of the musculoskeletal system are the primary reason that individuals seek medical attention in the United States 1,2. Nonetheless, there is evidence that medical students are not well prepared in this area. Freedman and Bernstein 3 administered a basic-competency examination comprising twenty-five questions on musculoskeletal medicine to a group of eighty-five recent medical school graduates. The examination was validated by 124 chairmen of orthopaedic departments, and a passing grade of 73.1% was set. With use of this criterion, 82% were found to have failed the examination. The examination was further validated by the directors of medical residency programs, and a comparable passing score was set 4. Moreover, Clawson et al. 5 surveyed 5487 second-year residents in United States allopathic and osteopathic residency programs and found that many considered themselves ill-prepared in the area of musculoskeletal medicine. On the basis of these reports, it is reasonable to believe that medical students in the United States are not receiving the instruction in musculoskeletal medicine that they need. We hypothesized that if preparation in musculoskeletal medicine is indeed inadequate, a lack of required curricular time devoted to these subjects may be the cause. Therefore, we assessed the extent to which American medical schools require either a preclinical course in musculoskeletal medicine or a clinical clerkship in a related field, namely, orthopaedic surgery, rheumatology, or physiatry (physical medicine and rehabilitation). Curriculum data were obtained from the 122 medical schools in the continental United States and Hawaii. The American Association of Medical Colleges web site, www.aamc.org, provided links to the web sites of all medical schools in the United States. Data were obtained directly from curriculum information published on the …

Malignant Bone Tumors: Limb Sparing Versus Amputation

&NA; Amputation, once the mainstay of treatment of malignant bone tumors, now is used selectively and infrequently. Most patients are candidates for limbsparing procedures because of effective chemotherapeutic agents and regimens, improved imaging modalities, and advances in reconstructive surgery. Patient age as well as tumor location and extent of disease help define the most appropriate surgical alternatives. Options for skeletal reconstruction include modular endoprostheses, osteoarticular or bulk allografts, allograft‐prosthetic composites, vascularized bone grafts, arthrodesis, expandable prostheses, rotationplasty, and limb‐lengthening techniques. Two key factors must be considered: survival rates should be no worse than those associated with amputation, and the reconstructed limb must provide satisfactory function. Functional outcome studies comparing limb‐sparing procedures and amputation have inherent limitations, including the inability to randomize treatment and the subjective nature of important outcome measures.

The Relationship Between Required Medical School Instruction in Musculoskeletal Medicine and Application Rates to Orthopaedic Surgery Residency Programs

BACKGROUND Orthopaedic residency programs lack gender and race diversity. This study examines the hypothesis that exposure to a required course in musculoskeletal medicine in medical school is associated with a higher rate of application to orthopaedic surgery residency programs by underrepresented groups. METHODS All 122 medical schools in the United States were surveyed in 2001 to determine whether they required dedicated course work in musculoskeletal medicine, defined as a preclinical module or clinical clerkship in orthopaedic surgery, rheumatology, or physiatry. Data from the Electronic Residency Application Service were obtained for the class of 2002. From these two sources, the rate of applications from students to orthopaedic surgery residency programs was calculated as a function of exposure to a required course in musculoskeletal medicine. Subgroup analysis was further carried out for women and for African Americans, Latinos, and Native Americans. RESULTS In 2002, there were 16,294 graduates of American medical schools, of whom approximately 55% had mandatory instruction in musculoskeletal medicine. The rate of application to orthopaedic surgery residency programs was 5.7% among the students with required instruction compared with a rate of 5.1% for students without such required instruction. The rate of application for female students was 2.0% for those who had required courses and 1.1% for the female students who had not had the required courses. The rate of application for minority students in schools with required courses was 8.2% compared with a rate of 6.1% for those students without such exposure. CONCLUSIONS Required instruction in musculoskeletal medicine was associated with a 12% higher rate of application to orthopaedic surgery residency programs among all students (5.7% of those who received required instruction compared with 5.1% of those who did not). The relative difference was more pronounced among women (a 75% difference in the rate of application) and minorities (a 35% difference in the rate of application). This study suggests that required instruction in musculoskeletal medicine can help to promote diversity in orthopaedic surgery residency programs.

Diagnosis and Management of Langerhans Cell Histiocytosis

Langerhans cell histiocytosis is a rare group of disorders without a well-understood etiology. Known formerly as histiocytosis X, the disease has a wide spectrum of clinical presentations, including eosinophilic granuloma (solitary bone lesion), diabetes insipidus, and exophthalmos. It is also known by several eponyms, including Hand-Schüller-Christian disease when it manifests as a triad of cranial bone lesions and Letterer-Siwe disease when it is found in infantile patients with severely disseminated disease. Children aged 5 to 15 years are most commonly affected. Many of these patients initially present to orthopaedic surgeons, and misdiagnosis is frequent. To accurately diagnosis and treat these patients, the orthopaedic surgeon must be familiar with the clinical manifestations and pathophysiology of the disease as well as the treatment guidelines and outcomes for Langerhans cell histiocytosis.