2 JOPA

Journal Mission The Journal of Orthopedics for Physician Assistants (JOPA) is an academic resource created to

deliver ongoing orthopedic education for physician

assistants. The journal is a unique forum to share

our knowledge and experiences with colleagues in

the profession. JOPA strives to publish timely and

practical articles covering all subspecialties. Each

article is peer reviewed to ensure accuracy, clinical

relevance, and readability.

Dagan Cloutier, PA-C, Editor in Chief

Ryan Ouellette, Webmaster, thejopa.org

Charles D. Frost, DHSc, PA-C Content Editor

Spectrum Marketing, Journal Design

Orthopedic Publishing Resources, LLC, Publisher

Journal of

Orthopedics for Physician Assistants

Contents 4 Paget’s Disease

9 Changing the Future of the Physician Assistant: How One Entrepreneurial PA Gained Autonomy, Freedom, and Ownership

12 Recognizing Common Bone Tumors on Plain Radiographs for the Practicing Physician Assistant

Monthly Image Quiz Follow-up 17 Posterior Shoulder Dislocation

19 Chondrosarcoma

21 Extensor Tendon Injury

23 PI CME: Improving the Recognition and Management of Osteoporosis Post-Fracture

28 Writing for JOPA Information for Authors

Disclaimer: Statements and opinions expressed in articles

are those of the authors and do not necessarily re! ect those

of the publisher. The publisher disclaims any responsibility

or liability for any material published herein. Acceptance of

advertising does not imply the publisher guarantees,

warrants, or endorses any product or service.

Physician AssistantReview Board

Marlon AlexanderRosharon, TX

Corey AndersonHarrisburg, SD

Brian BarryPortsmouth, NH

David BeckPittsburgh, PA

Heidi BolgrenEdina, MN

Ryan BrainardSavannah, GA

Afton Branton Geneva, NY

Molly BuerkAurora, CO

Mark CarboAlexandria, LA

Ray CarlsonSan Diego, CA

Jeff ChambersAthens, Georgia

Larry CollinsTampa, FL

Michael CreminsHartford, CT

Greg DeConciliisBoston, MA

Charles DowellVancouver, WA

Caitlin EagenBoston, MA

Sophie EllisVancouver, WA

Marcie FitzgeraldErie, PA

Erich FoggYork, ME

Charles D. FrostNorfolk, VA

Bruce GallioReno, NV

Angela GrochowskiHorsham, PA

Michael Hollopeter

Houston, TX

Jennifer HartmanPeoria, AZ

Michael HarveyFishers, IN

Sean HazzardBoston, MA

Matt HenryRapid City, SD

Tim HolmstromPullman, WA

Mike HouleHartford, CT

Alan Johnston Nashua, NH

Stuart JonesBrentwood, TN

Jason KatzPhiladelphia, PA

Jill KnightSeattle, WA

Stanley KotaraLubbock, TX

Kathleen Martinelli Durham, NC

Sean MetzBuffalo, VA

Ronald McCallSpring" eld, MO

Patrick McCarthyManchester, NH

Randall PapeUSAF Academy, CO

Keith PaulGreensboro, NC

Jason RandBoston, MA

Robert RoganPoughkeepsie, NY

Scott WaltonCaribou, ME

Todd RudyWellsboro, PA

Bradford SalzmannRoyalton, VT

Jeffrey SommersMarietta, OH

Steve Steiner Manchester, NH

Wendi Martin StewartHouston, TX

Lori TappenDallas, TX

Timothy ThompsonNaples, FL

Mary VacalaSavannah, GA

Courtney Van ArsdaleBoston, MA

Marcos VargasFlushing, MI

JOPA is proud to partner with the Clinical Advisor and the America Association of Surgical Physician

Assistants (AASPA) to provide an orthopedic

focused educational resource for all Physician

Assistants and Nurse Practitioners.

Help grow JOPA! Share this issue with your colleagues.

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4 JOPA

Paget’s Disease

Jenny Cates, OT-C

Nashua, NH

The rare bone disorder, Paget’s disease,

is named for the 19th century surgeon Sir James

Paget, a self proclaimed medical pioneer of 19th

century. He began his medical apprenticeship

at the young age of 16; he then attended St

Bartholomew’s Hospital of medical studies in

London at the age of 20. Prior to graduation

Paget was known for his " rst discovery of

the parasitic disease Trichina spiralis, also

known as Trichinosis. Many more of Paget’s

accomplishments included the " rst to describe

osteochondritis dessicans, median nerve

compression of the wrist, and maxillary vein

thrombosis. Though he was credited with many

achievements, he is most known for osteoitis

deformans, Paget’s disease of the bone.

Description:

Normal bone in an adult skeleton

undergoes constant remodeling. Bone remodeling

happens when osteoclast cells breakdown and

remove bone tissue, while osteoblast cells are

the building blocks to new bone tissue. The bone

remodeling process, in Paget’s disease, happens

at an accelerated rate, in both the removal and

building of the bone tissue. Osteoclasts found

in Paget’s are much larger than that of a normal

cell and contains more than one nuclei. These

Paget cells contain a micro" lament with the same

structured RNA of the childhood measles virus.

It has been said that the measles virus may play

a role in Paget’s disease, but there has been no

scienti" c proof to back up this statement.

Pagetic osteoclasts are accelerated in the

breakdown of bone tissue. The osteoblasts are

forming new bone at such a quick rate, the layout

of the new bone is disorganized and the patterns

yield a weaker bone more prone to fracture.

Monostotic disease involves a single bone and

begins at one end of the bone and progresses to

the other end. Monostotic disease of Paget’s is

more common and is seen in the axial skeleton.

Polystotic disease involves several bones and is

more commonly found in the lower extremities.

The most commonly affected bone is the pelvis,

then the lumbar spine, and the third most

common is the femur.

There are three phases of this disease:

1. Lytic Stage: This is the early stage of the

disease when the ostetoclastic activity dominates

in a localized area of the bone.

2. Intermediate Stage: There is a rapid increase

of osteoblastic activity and the new bone is

laid down at such a quick rate that the new

pattern has a woven appearance rather than a

lamellar " nish. This woven appearance is not

characteristic to Paget’s disease but rather to the

high turnover rate of new bone. The cortex of

the new bone is very thick and is the site of the

accelerated bone turnover.

3. Final Stage: This stage shows less evidence

of bone formation; the new woven bone is now

converted into sclerotic bone that is mosaic in

appearance. The irregular woven bone with its

weak sections of lamellar bone is disorganized

in a weak pattern, causing the bone to be

susceptible to fractures.

Figure 1. Paget’s of the Pelvis. Source

Learningradiology.com

Paget’s Disease

Jenny Cates, OT-C

Nashua, NH

JOPA 5

Many patients actually have a normal

functioning life and might never know they have

Paget’s. The disease is known in the UK, Western

Europe, Australia, New Zealand, and the United

States. The disease affects individuals over the

age of 40, though juvenile Paget’s disease does

exist. It has been proven that patient’s that

have been diagnosed with the disease have had

a known relative with Paget’s, though there is

no proof that the gene is passed down to each

generation.

Symptoms and Complications:

Patients with Paget’s disease are often

asymptomatic, at least in the beginning stage

of the disease. As the disease progresses, the

bone may become enlarged, bone pain may

become more of a dull throb, and the patient may

experience a decrease in joint range of motion.

Unlike osteoarthritis, the patient may experience

pain during rest and at night. There may be

redness and swelling of the skin over the affected

area of the bone. This happens because of the

increase of blood ! ow to the site. Joint pain is

another symptom, especially if the femur or tibia

is involved; the joints become compromised

when the affected bone takes on a new shape.

This bowing shape happens because of the

rapid remodeling of the weight bearing bone,

thus resulting in a weak bone. Most fractures of

the bowed limb happen on the concave surface

of the bone. As the disease progresses and the

bones become weak, a fracture may occur. X-ray

may reveal the deformity of the bone. In fact,

about 80% of individuals are diagnosed with

Paget’s disease following an x-ray performed

for an unrelated reason. Overactive osteoclasts

can release a high level of calcium which may

leave the patient with fatigue, weakness, loss of

appetite, abdominal pain, kidney stones and/or

constipation.

Complications of the disease can be quite

severe. Heart failure is a complication because

with the high turnover rate of bone the demands

increase vascular demand to bone. Fractures

may also occur in malignant degenerative sites,

but these are rare complications of Paget’s

disease. Spinal stenosis is common in the lumbar

vertebrae, as well as headaches and hearing

loss if the disease affects the skull. Swelling of

the skull, especially the frontal bone, will cause

nerve damage and pressure inside the skull.

Paget’s disease may also involve the facial bones,

causing dental problems and may compromise the

airways.

Diagnosis:

Paget’s disease is quite often discovered

when a patient is seen for other unrelated tests

such as blood work, routine physical exam, or

x-ray. Unless the patient has a physical deformity

or acute pain, the disease may go undetected

Figure 2. Paget’s of the Femur. Source

Learningradiology.com

6 JOPA

for quite some time. It is dif" cult to pin point

Paget’s disease of the bone when it shares many

common characteristics of other diseases such

as: Sclerosis, osteoarthritis, myelo" brosis, renal

osteodystrophy, and " brogenisis imperfecta.

X-ray will show certain characteristics of the

disease, such as the “blade of grass” lesion. This

lesion can affect long bones, beginning at one

end and advancing to the other end. The lesion

is caused by the expansion of the cortex and will

suggest malignancy of the bone. If the disease

has advanced prior to diagnosis some x-rays

may show thickened and coarse trabecular bone.

Areas that may show thickening are the pelvic

brim, and parts of the skull. In the sceleric phase

the bones may show uniform increase of density,

while in the skull, osteoblastic formations may

cross suture lines. Ultimately the diagnosis of

Paget’s disease includes x-ray " ndings, positive

bone scan results, and elevation in serum alkaline

phosphatase (SAP).

Treatment:

Treatment of this disease depends on

the patient and his/her symptoms. A patient

with asymptomatic Paget’s disease often does

not require treatment. Bisphosphonates and

Calcitonin are drugs used to control the the

activity of osteoclasts, and also help with bone

pain. Bisphosphonates predominantly control

the bone turnover, and are prescribed orally to

patients. Bisphosphonates have been shown

to normalize SAP levels over time. Calcitonin is

a polypeptide hormone and is injected into the

patient; it is successful in slowing bone turnover

rate. Unfortunately the patient can form a

resistance to the drug after some use.

It can be dif" cult at time to treat the pain

when clinicians are unsure if the pain is from

osteoarthritis caused by the disease. If this is the

case then analgesic will be prescribed and may

help with swelling and pain. If there is pain in the

pelvis or hip a cane may be used to aid in weight

bearing in these areas. Also orthotics may be

used as a form of treatment.

Sometimes surgery is needed for a

signi" cant bone deformity, such as an osteotomy,

where a wedge of bone is removed to help align

the bone. Some patients may experience a low

rate of healing in fractures which is caused by the

abnormal bone turnover.

Conclusion:

Paget’s disease is a hidden disease.

Although not a common problem it does affect

about 3-4% of the entire population. Paget’s

disease, though potentially debilitating, is

treatable. The point of clinicians when treating

the disease is to slow or help control the function

of osteoclasts and osteoblasts, and to make the

bone a more effective structure.

Reference

Moon BS, Luna JT, Raymond KA, Maldewell JE.

Paget’s Disease of Bone. Orthopedic Knowledge

Online Journal 2010. 8(1). Accessed on January 1,

2010.

Reduce the need for opioids while providing long-lasting pain control...all from a single dose

• Indicated for single-dose administration into the surgical site to produce postsurgical analgesia

• DepoFoam® uniquely delivers bupivacaine over time1

• Eliminates the need for catheters and pumps that may hinder recovery2-5

• Demonstrated safety and tolerability profile similar to placebo

• Dose based on the administration site and the volume required to cover the area

In the management of postsurgical pain

A SMOOTH START TO RECOVERY BEGINS WITH EXPAREL

©2015 Pacira Pharmaceuticals, Inc., Parsippany, NJ 07054 PP-EX-US-0778 05/15

The clinical benefit of the decrease in opioid consumption has not been demonstrated.

Important Safety Information

EXPAREL is contraindicated in obstetrical paracervical block anesthesia. EXPAREL has not been studied for use in patients younger than 18 years of age. Non-bupivacaine-based local anesthetics, including lidocaine, may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more. Other formulations of bupivacaine should not be administered within 96 hours following administration of EXPAREL. Monitoring of cardiovascular and neurological status, as well as vital signs should be performed during and after injection of EXPAREL as with other local anesthetic products. Because amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, EXPAREL should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations. In clinical trials, the most common adverse reactions (incidence ≥10%)following EXPAREL administration were nausea, constipation, and vomiting. Studies demonstrating the safety and efficacy of EXPAREL were conducted in hemorrhoidectomy and bunionectomy; EXPAREL has not been demonstrated to be safe and effective in other procedures.

Please see brief summary of Prescribing Information on reverse side.

For more information, please visit www.EXPAREL.com or call 1-855-RX-EXPAREL (793-9727).

References: 1. How DepoFoam® works. Pacira Pharmaceuticals, Inc. website. http://www.exparel.com/how-to-use/about-depofoam.shtml. Accessed February 25, 2015. 2. Process for handling elastomeric pain relief balls (ON-Q PainBuster and others) requires safety improvements. Institute for Safe Medication Practices website. https://www.ismp.org/newsletters/acutecare/articles/20090716.asp. Accessed June 19, 2014. 3. I-Flow ON-Q pump with ONDEMAND bolus button. US Food and Drug Administration website. http://www.fda.gov/MedicalDevices/Safety/ListofRecalls/ucm317826.htm. Accessed January 5, 2015. 4. Continuous peripheral nerve blocks in outpatients. NYSORA–The New York School of Regional Anesthesia website. http://www.nysora.com/regional-anesthesia/foundations-of-ra/3055-continuous-peripheral-nerve-blocks-in-outpatients.html. Accessed January 5, 2015. 5. Frost & Sullivan. New opportunities for hospitals to improve economic efficiency and patient outcomes: the case of EXPAREL™, a long-acting, non-opioid local analgesic. http://www.frost.com/prod/servlet/cpo/252218999. Accessed January 5, 2015. 6. Data on file. Parsippany, NJ: Pacira Pharmaceuticals, Inc.; February 2015.

Used in more than

1 million patients since 20126

Brief Summary (For full prescribing information refer to package insert)

INDICATIONS AND USAGEEXPAREL is a liposome injection of bupivacaine, an amide-type local anesthetic, indicated for administration into the surgical site to produce postsurgical analgesia.

EXPAREL has not been studied for use in patients younger than 18 years of age.

CONTRAINDICATIONSEXPAREL is contraindicated in obstetrical paracervical block anesthesia. While EXPAREL has not been tested with this technique, the use of bupivacaine HCl with this technique has resulted in fetal bradycardia and death.

WARNINGS AND PRECAUTIONS

Warnings and Precautions Specific for EXPARELAs there is a potential risk of severe life-threatening adverse effects associated with the administration of bupivacaine, EXPAREL should be administered in a setting where trained personnel and equipment are available to promptly treat patients who show evidence of neurological or cardiac toxicity.

Caution should be taken to avoid accidental intravascular injection of EXPAREL. Convulsions and cardiac arrest have occurred following accidental intravascular injection of bupivacaine and other amide-containing products.

Using EXPAREL followed by other bupivacaine formulations has not been studied in clinical trials. Other formulations of bupivacaine should not be administered within 96 hours following administration of EXPAREL.

EXPAREL has not been evaluated for the following uses and, therefore, is not recommended for these types of analgesia or routes of administration.

• epidural

• intrathecal

• regional nerve blocks

• intravascular or intra-articular use

EXPAREL has not been evaluated for use in the following patient population and, therefore, it is not recommended for administration to these groups.

• patients younger than 18 years old

• pregnant patients

• nursing patients

The ability of EXPAREL to achieve effective anesthesia has not been studied. Therefore, EXPAREL is not indicated for pre-incisional or pre-procedural loco-regional anesthetic techniques that require deep and complete sensory block in the area of administration.

ADVERSE REACTIONSAdverse Reactions Reported in All Wound Infiltration Clinical StudiesThe safety of EXPAREL was evaluated in 10 randomized, double-blind, local administration into the surgical site clinical studies involving 823 patients undergoing various surgical procedures. Patients were administered a dose ranging from 66 to 532 mg of EXPAREL. In these studies, the most common adverse reactions (incidence greater than or equal to 10%) following EXPAREL administration were nausea, constipation, and vomiting.

The common adverse reactions (incidence greater than or equal to 2% to less than 10%) following EXPAREL administration were pyrexia, dizziness, edema peripheral, anemia, hypotension, pruritus, tachycardia, headache, insomnia, anemia postoperative, muscle spasms, hemorrhagic anemia, back pain, somnolence, and procedural pain.

DRUG INTERACTIONSEXPAREL can be administered undiluted or diluted up to 0.89 mg/mL (i.e., 1:14 dilution by volume) with normal (0.9%) sterile saline for injection or lactated Ringer’s solution. EXPAREL must not be diluted with water or other hypotonic agents as it will result in disruption of the liposomal particles.

EXPAREL should not be admixed with other local anesthetics.

EXPAREL may be locally administered after at least 20 minutes following local administration of lidocaine.

Bupivacaine HCl, when injected immediately before EXPAREL, may impact the pharmacokinetic and/or physicochemical properties of the drugs if the milligram dose of bupivacaine HCl solution exceeds 50% of the EXPAREL dose. The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to toxicity.

EXPAREL should not be admixed with other drugs prior to administration.

USE IN SPECIFIC POPULATIONSPregnancy Category CRisk SummaryThere are no adequate and well-controlled studies of EXPAREL in pregnant women. Animal reproduction studies have been conducted to evaluate bupivacaine. In these studies, subcutaneous administration of bupivacaine to rats and rabbits during organogenesis was associated with embryo-fetal deaths in rabbits at a dose equivalent to the maximum recommended human dose (MRHD). Subcutaneous administration of bupivacaine to rats from

implantation through weaning, also at an MRHD-equivalent dose, produced decreased pup survival. EXPAREL should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.

Clinical ConsiderationsLabor or DeliveryBupivacaine is contraindicated for obstetrical paracervical block anesthesia. While EXPAREL has not been studied with this technique, the use of bupivacaine for obstetrical paracervical block anesthesia has resulted in fetal bradycardia and death.

Bupivacaine can rapidly cross the placenta, and when used for epidural, caudal, or pudendal block anesthesia, can cause varying degrees of maternal, fetal, and neonatal toxicity. The incidence and degree of toxicity depend upon the procedure performed, the type, and amount of drug used, and the technique of drug administration. Adverse reactions in the parturient, fetus, and neonate involve alterations of the central nervous system, peripheral vascular tone, and cardiac function.

DataAnimal DataBupivacaine hydrochloride was administered subcutaneously to rats at doses of 4.4, 13.3, and 40 mg/kg/day and to rabbits at doses of 1.3, 5.8, and 22.2 mg/kg/day during the period of organogenesis (implantation to closure of the hard palate). No embryo-fetal effects were observed in rats at the doses tested with the high dose causing increased maternal lethality. An increase in embryo-fetal deaths was observed in rabbits at the high dose in the absence of maternal toxicity. This dose is clinically relevant as is comparable to the MRHD based on Body Surface Area (BSA) comparisons.

In a rat pre- and post-natal development study conducted at subcutaneous doses of 4.4, 13.3, and 40 mg/kg/day with dosing from implantation through weaning (during pregnancy and lactation), decreased pup survival was observed at the high dose, a clinically relevant dose as it is comparable to the MRHD based on BSA comparisons.

Nursing MothersPublished literature reports that bupivacaine is present in human milk at low levels; however, the drug is poorly absorbed orally. Exercise caution when administering EXPAREL to a nursing woman.

Pediatric UseSafety and effectiveness in pediatric patients below the age of 18 have not been established.

Geriatric UseOf the total number of patients in the EXPAREL wound infiltration clinical studies (N=823), 171 patients were greater than or equal to 65 years of age and 47 patients were greater than or equal to 75 years of age. No overall differences in safety or effectiveness were observed between these patients and younger patients. Clinical experience with EXPAREL has not identified differences in efficacy or safety between elderly and younger patients, but greater sensitivity of some older individuals cannot be ruled out.

Hepatic ImpairmentBecause amide-type local anesthetics, such as bupivacaine, are metabolized by the liver, these drugs should be used cautiously in patients with hepatic disease. Patients with severe hepatic disease, because of their inability to metabolize local anesthetics normally, are at a greater risk of developing toxic plasma concentrations.

Renal ImpairmentBupivacaine is known to be substantially excreted by the kidney, and the risk of toxic reactions to this drug may be greater in patients with impaired renal function. Care should be taken in dose selection of EXPAREL.

OVERDOSAGEIn the clinical study program, maximum plasma concentration (Cmax) values of approximately 34,000 ng/mL were reported and likely reflected inadvertent intravascular administration of EXPAREL or systemic absorption of EXPAREL at the surgical site. The plasma bupivacaine measurements did not discern between free and liposomal-bound bupivacaine making the clinical relevance of the reported values uncertain; however, no discernable adverse events or clinical sequelae were observed in these patients.

DOSAGE AND ADMINISTRATIONEXPAREL is intended for single-dose administration only. The recommended dose of EXPAREL is based on the surgical site and the volume required to cover the area.

Surgery Dose of EXPAREL Volume of EXPARELBunionectomy1

106 mg 8 mL

Hemorrhoidectomy2 266 mg 20 mL1Infiltrate 7 mL of EXPAREL into the tissues surrounding the osteotomy and 1 mL into the subcutaneous tissue.2Dilute 20 mL of EXPAREL with 10 mL of saline, for a total of 30 mL, and divide the mixture into six 5 mL aliquots. Perform the anal block by visualizing the anal sphincter as a clock face and slowly infiltrating one aliquot to each of the even numbers.

Administration Precautions

Admixing EXPAREL with other drugs prior to administration is not recommended.

• Non-bupivacaine based local anesthetics, including lidocaine,may cause an immediate release of bupivacaine from EXPAREL if administered together locally. The administration of EXPAREL may follow the administration of lidocaine after a delay of 20 minutes or more.

• Bupivacaine HCl, when injected immediately before EXPAREL, may impact the pharmacokinetic and/or physicochemical properties of the drugs if the milligram dose of bupivacaine

HCl solution exceeds 50% of the EXPAREL dose. The toxic effects of these drugs are additive and their administration should be used with caution including monitoring for neurologic and cardiovascular effects related to toxicity.

• When a topical antiseptic such as povidone iodine (e.g., Betadine®) is applied, the site should be allowed to dry before EXPAREL is administered into the surgical site. EXPAREL should not be allowed to come into contact with antiseptics such as povidone iodine in solution.

Studies conducted with EXPAREL demonstrated that the most common implantable materials (polypropylene, PTFE, silicone, stainless steel, and titanium) are not affected by the presence of EXPAREL any more than they are by saline. None of the materials studied had an adverse effect on EXPAREL.

Non-Interchangeability with Other Formulations of BupivacaineDifferent formulations of bupivacaine are not bioequivalent even if the milligram dosage is the same. Therefore, it is not possible to convert dosing from any other formulations of bupivacaine to EXPAREL and vice versa.

Dosing in Special PopulationsEXPAREL has not been studied in patients younger than 18 years of age, pregnant patients or patients who are nursing.

CLINICAL PHARMACOLOGY

PharmacokineticsLocal infiltration of EXPAREL results in significant systemic plasma levels of bupivacaine which can persist for 96 hours. Systemic plasma levels of bupivacaine following administration of EXPAREL are not correlated with local efficacy.

CLINICAL STUDIESThe efficacy of EXPAREL was compared to placebo in two multicenter, randomized, double-blinded clinical trials. One trial evaluated the treatments in patients undergoing bunionectomy; the other trial evaluated the treatments in patients undergoing hemorrhoidectomy. EXPAREL has not been demonstrated to be safe and effective in other procedures.

BunionectomyA multicenter, randomized, double-blind, placebo-controlled, parallel-group study evaluated the safety and efficacy of 106 mg EXPAREL in193 patients undergoing bunionectomy. The mean age was 43 years (range 18 to 72). Study medication was administered directly into the wound at the conclusion of the surgery, prior to wound closure. Pain intensity was rated by the patients on a 0 to 10 numeric rating scale (NRS) out to 72 hours. Postoperatively, patients were allowed rescue medication (5 mg oxycodone/325 mg acetaminophen orally every 4 to 6 hours as needed) or, if that was insufficient within the first 24 hours, ketorolac (15 to 30 mg IV). The primary outcome measure was the area under the curve (AUC) of the NRS pain intensity scores(cumulative pain scores) collected over the first 24 hour period. There was a significant treatment effect for EXPAREL compared to placebo.

In this clinical study, EXPAREL demonstrated a significant reduction in pain intensity compared to placebo for up to 24 hours. The difference in mean pain intensity between treatment groups occurred only during the first 24 hours following study drug administration. Between 24 and 72 hours after study drug administration, there was minimal to no difference between EXPAREL and placebo treatments on mean pain intensity.

HemorrhoidectomyA multicenter, randomized, double-blind, placebo-controlled, parallel-group study evaluated the safety and efficacy of 266 mg EXPAREL in 189 patients undergoing hemorrhoidectomy. The mean age was 48 years (range 18 to 86). Study medication was administered directly into the wound (greater than or equal to 3 cm) at the conclusion of the surgery. Pain intensity was rated by the patients on a 0 to 10 NRS at multiple time points up to 72 hours. Postoperatively, patients were allowed rescue medication (morphine sulfate 10 mg intramuscular every 4 hours as needed). The primary outcome measure was the AUC of the NRS pain intensity scores (cumulative pain scores) collected over the first 72 hour period. There was a significant treatment effect for EXPAREL compared to placebo.

In this clinical study, EXPAREL demonstrated a significant reduction in pain intensity compared to placebo for up to 24 hours. The difference in mean pain intensity between treatment groups occurred only during the first 24 hours following study drug administration. Between 24 and 72 hours after study drug administration, there was minimal to no difference between EXPAREL and placebo treatments on mean pain intensity; however, there was an attendant decrease in opioid consumption, the clinical benefit of which was not demonstrated.

Pacira Pharmaceuticals, Inc.San Diego, CA 92121 USA

Patent Numbers:6,132,766 5,891,4675,766,627 8,182,835

Trademark of Pacira Pharmaceuticals, Inc.

For additional information call 1-855-RX-EXPAREL (1-855-793-9727)

Rx only May 2015

JOPA 9

Changing the Future of the Physician Assistant How One Entrepreneurial PA Gained Autonomy, Freedom, and Ownership

Having joined the Army as an orthopedic

technician right out of high school, I knew this

would be the perfect segue to ful" lling my dream

of becoming a Physician Assistant one day. To see

this goal through, I spent nearly every minute of

my free-time ful" lling the PA prerequisites outside

of my daily Army responsibilities.

When my military career concluded in

1997, I worked as a civilian orthopedic tech in a

clinic until I was accepted into PA school in 1998

at the University of Alabama at Birmingham.

University of Alabama Birmingham is one of only a

couple surgical PA programs. My training included

ER, Internal Med, OB/GYN, and Pediatric rotations

and then the rest were surgical subspecialties.

My diploma from UAB speci" cally states Bachelor

of Science, Surgical PA Program. I spent the

two years in the surgical PA program, and upon

graduation, landed my " rst job in orthopedics

with an orthopedic spine surgeon.

From there, I moved to Idaho where I’ve

worked for at least 15 doctors over the years.

These were not individual practitioners, but

rather groups of orthopedic physicians with

anywhere from four to six surgeons per group.

I quickly discovered that being a younger

PA just out of school can make it challenging

sometimes in these types of group practices. As

one would expect, it was almost impossible to

command any sort of respect because of the lack

experience. And, unfortunately, this naturally can

have an effect on overall con" dence.

Moreover, the group practice settings

in which I worked was further complicated by

the surgeon/PA ratio-- which was always greater

than 1:1. This scenario leaves the PA to chase

around two, three or even four surgeons at a

time. Feeling understaffed, running back and forth

between of" ces, covering surgeries in neighboring

towns, and working amongst multiple clinics

was exhausting, bordering upon the absurd and

inef" cient to say the least.

If you’ve labored in this sort of PA

existence, you are painfully aware that your

time is spread very thinly – and time-off is

near extinction. Even when time-off had been

scheduled, a surgeon would inadvertently

schedule something last minute. There were times

I would cover call, or cover somebody else’s

call, only to have cases added-on. While those

scenarios can be quite typical in orthopedics, it

seemed to happen more frequently when there

were fewer PA’s covering more surgeons.

With the days getting longer and the

workload larger, the entire situation was

becoming increasingly frustrating – with less time

for myself, vacation, or quality time home with

Jeff Smith, PA-C

Direct Orthopedic Care

Boise, ID

10 JOPA

my family. That was my wake-up call. Something

needed to change. I needed my life back and more

control over my work life balance. Working for

“the man” was no longer appealing. I wanted more

autonomy, freedom and control over my career.

To accomplish this, it was clear I needed to

harness more of an entrepreneurial spirit to have

more control over my destiny - even if it meant

taking on more of the risk/reward model.

Fortunately, when I was beginning to

question everything, I was approached by

a local Boise orthopedic surgeon who was

looking for help in the OR. He encouraged me

to start a surgical assist practice. The practice,

Direct Surgical Assist, was my " rst taste of

entrepreneurism in the PA world. Essentially, the

business model was to hire and train PA’s to assist

in orthopedic procedures. Our PA staff became

that ‘extra set of hands’ for orthopedic practices

when more than one surgeon was needed in a

procedure, but insurance reimbursement made

a second attending surgeon less cost effective.

However, this was a perfect scenario for a surgical

PA.

Initially, the thought of being ‘my own

boss’ for the " rst time in my professional life

was wildly appealing. If there was no surgery

scheduled I could actually go the bank or get my

hair cut during normal business hours—not on

my day off.

However, I did discover that with

entrepreneurism came a necessity for a crash

course education in " nance, taxes, insurance

rules, law and whole host of other factors needed

to ‘be the boss’. Admittedly, I found out rather

soon that ‘ownership’ is not something for the

faint of heart.

None-the-less, the ! exibility of being in

control of my own schedule for the " rst time in

my professional life was incredibly liberating and

refreshing. Unfortunately, I was still doing a lot

of chasing of surgeons and at the mercy of some

pretty crazy hours.

With the success of Direct Surgical Assist,

a new joint venture idea was formulated with one

of the local orthopedic practices in town for an

orthopedic walk-in clinic. Direct Orthopedic Care

(DOC). DOC is an orthopedic, walk-in style clinic

created for patients with various orthopedic

conditions to skip the emergency room and

walk-in to our clinic to be immediately seen and

evaluated by an experienced orthopedic PA. We

are open 365 days a year and have our orthopedic

physicians always available. One of our surgeons

is either in the of" ce or on-call to provide back-up

coverage and guidance. The surgeons are present

in the clinic about 50% of the time. They run their

own clinics during normal business hours.

Like before with Direct Surgical Assist,

DOC offered an opportunity for ownership.

However, this time the attraction was to become

an actual part-owner of the orthopedic practice.

As a PA, this is relatively unheard of. Imagine; to

be involved in the decision making process as

well as the management of the daily operations—

not to mention the ability to share in the practice

pro" t!

JOPA 11

For years, as a PA, I was at the mercy of

someone else. I followed and chased somebody

else around. I was the one sitting in the of" ce at

8 p.m. at night while everyone else was home

with their families. When the doctors of Direct

Orthopedic Care (DOC) approached me about

this opportunity, I jumped on board and never

looked back.

One of the unique aspects of the new

DOC model, besides PA co-ownership, is that

we are the primary eyes, ears and hands of the

practice every day. The out-patient, walk-in

model dictates rapid assessment and treatment.

With that, the orthopedic physicians need a

‘partnership’ support system in place that allows

them to focus on surgeries (off-site) that evolve

from the patients. In that sense, the physicians

we work with respect the PA’s immensely. They

understand and rely upon the PA staff’s ability

to effectively work-up each patient and provide

a thorough evaluation. They are con" dent in our

ability to provide a diagnosis and a treatment

plan and they recognize the value we offer in

delivering to them a patient who may have an

immediate need for surgery.

Here, our doctors work with us while still

allowing us our autonomy and independence. We

actually run our own clinics. However, I can say

with con" dence we have a strong relationship

with the surgeons because they know we are

a highly skilled and effective group. All the

necessary tests are ordered, the treatment plans

are appropriate and the patient is handed off

when needed.

The DOC staf" ng model is simple. We work

on a rotating schedule through a period of seven

days where our PAs work three or four days in

a row. We are not on-call and typically work a

set and speci" c shift. When the shift is over, we

are done – we walk out and leave. The schedule

affords us the time to get out and travel and enjoy

our lifestyles. There are no more unnecessary

nights at the clinic, no graveyard rounds, and my

children and I see more of each other.

This model is working so well for our PA’s,

surgeons and patients that we are growing in

leaps and bounds. We are currently in the process

of opening three more locations in the greater

Boise area alone, have a location in East Texas,

and have other locations opening up in cities

throughout the United States.

From the perspective of a PA, the

opportunities afforded by this joint venture model

are highly sought after. With a starting salary

that falls within the 95th percentile of industry

standards and ample time off, combined with the

ability to have ownership in the business and

dividends, this type of model would probably

be appealing to most any aspiring PA with an

entrepreneurial spirit.

Taking this step has been incredible.

I’m active, I get outside, and I see the sun every

day. I spend time with my family. The quality of

my life has changed signi" cantly. The ! exible

schedule at DOC has allowed me to pursue other

interests. Mountain biking, my current passion, is

an activity I now enjoy weekly. I have biked more

times in the last four months than I have in the

last four years. You cannot put a price on that.

In looking back, as PA’s, I think we have to

ask ourselves what is important? Are we valued

by those we work with? Is our quality of life living

up to our expectations? Do we want to spend

countless days chasing others, or do we want

to be a meaningful part of a team with a stake in

ownership? These questions are critical to our

future. In our careers, we spend the better part of

our life trying to have a meaningful impact on our

patients’ lives. It is time that we start doing the

same for ourselves.

Jeff Smith, PAC

Direct Orthopedic Care

208.321.4000

jeffsmith@boisedoc.com

12 JOPA

Recognizing Common Bone Tumors on Plain Radiographs

for the Practicing Physician Assistant

Charles Frost, DHSc, MPAS, PA-C, DFAAPAEVMS MPA Program

Abstract

Bone lesions on plain radiographs are

a frequent puzzle for the practicing clinician.

The clinician must decide, with some degree

of con" dence, whether the lesion needs urgent

evaluation, can be worked up locally, or can be

observed. This article proposes some guidelines

that will help in that decision making process.

Based solely on plain radiographs, a consensus

of clinical advice from experience and numerous

references will be presented to suggest the

most likely diagnostic choices. Commonly

occurring benign lesions, such as non-ossifying

" broma and unicameral bone cyst as well as

common malignant tumors, chondrosarcoma,

osteosarcoma etc. will be reviewed. This is not an

all-inclusive or de" nitive text; it is basic advice on

common lesions.

Recognizing Common Bone Tumors on Plain Radiographs for the Practicing Physician Assistant

The best course to follow in identifying

bone lesions is one that is methodical and easily

reproducible. Parsons et Al has described a

method of evaluating plain radiographs that is

consistent with that seen in most orthopedic

practices and orthopedic oncology. This method,

relying on plain radiographs, is cost-ef" cient and

relatively easy to assimilate. Plain " lms remain

the gold standard for establishing a differential

diagnosis for bone lesions (Sanders & Parsons,

2001, p. 222). It can give the student, as well as the

practicing clinician, information that can guide

further imaging or referral in a timely manner1.

This method relies on asking four basic

questions and deriving information on tumor

matrix. Those questions are: (1) Where is the

location of the lesion? (2) What is the extent of the

lesion? (3) What is the lesion doing to the bone?

(4) What is the bone doing to the lesion? The

information on tumor matrix can be derived from

hints visible in the radiograph or not visible in the

case of a lucent lesion1.

The location of a lesion, combined with

the age of a patient, can be one of the most

Recognizing Common Bone Tumors on Plain Radiographs

for the Practicing Physician Assistant

Charles Frost, DHSc, MPAS, PA-C, DFAAPAEVMS MPA Program

Figure 1. UW Medicine, 2011 Figure 2. UW Sabatt, 2011

JOPA 13

important guides in classifying a primary bone

lesion. A number of authors, following Madewell,

et.al. 1981, have produced a line drawing to aid

in identity by location. One is available in the

Tarascon Pocket Orthopedica 2nd edition from

Tarascon Publishing p.197. Several other versions

derived from the original are available in the

internet. Two versions are presented here with

citations for their authors (Figures 1 and 2).

Where is the location of the lesion?

Clinicians are used to looking at x-rays

in two views at right angles to each other. This

adds to the location identi" cation of common

lesions. In the lateral or longitudinal plane we look

at tumors based on epiphyseal, metaphyseal or

diaphysial location.

Commonly seen epiphyseal tumors include

chondrosarcoma, chondroblastoma, giant cell

tumor, and aneurysmal bone cysts as well as

infection. Metaphyseal tumors include, non-

ossifying " broma (NOF) near the growth plate,

and bone cysts (solitary, aneurysmal, and giant

cell). Osteochondroma and chondrosarcoma,

osteogenic sarcoma and the juvenile Brodie

abscess canal form in this area. In the diaphysis

of bone, ostoeblastoma, Ewing sarcoma, NOF, and

osteoid osteoma should be suspected1.

In the transverse or AP plane, we can

look at location based on the midline of the

bone being viewed. Lesions arising in the

center, enchondroma for example, lesions that

are eccentric, giant cell tumor, osteosarcoma,

or lesions that are cortical, osteoid osteoma

and NOF1. Some lesions may seem to sit on the

bone cortex or periosteum (parosteal), such as

osteochondroma or parosteal osteosarcoma. A

number of lesions show a predilection for speci" c

sites (Table1).

What is the lesion doing to the bone?

The second question is what is the lesion doing

to the bone? Bone destruction can be lytic or

sclerotic. Lesions can be geographic, with well-

de" ned margin, often irregular, with a short

zone of transition between the lesion and the

surrounding bone. A permeative lesion, merges

with the uninvolved bone and has a long zone of

transition. Finally, moth-eaten lesions have areas

of destruction with ragged margins, less de" ned

lesion margin and a long zone of transition. The

radiographic appearance of the margin “tends

to correspond well with the aggressiveness of

the tumor” 1,2. Margins between the lesion and

the bone can indicate the aggressiveness of the

lesion. Slow progressing lesions are “walled-off”

by native bone, producing well de" ned, distinct

margins. Lesions that progress rapidly destroy

bone producing indistinct margins1.

What is the bone doing to the lesion?

Bone has a limited number of reactions

that it can exhibit in response to a tumor. It

can be destroyed (lysis) leaving a lytic lesion.

Bone can react to the advancing tumor causing

sclerosis. Lastly bone can remodel in the face

of the tumor, known as periosteal reaction.

This reaction is predicated by the rate of tumor

growth, rapid growth shows destruction or lysis,

slow growth shows predominance of sclerosis1.

Periosteal reaction has to mineralize

before it shows on plain " lms. This process

can take 10 to 21 days and is dependent on the

aggressiveness and duration of the tumor. Thick

uninterrupted periosteal reaction suggests a

long standing process such as stress fracture

or chronic infection. Spiculated or lamellated

periosteal reaction is suggestive of an aggressive

process and most likely a tumor. This process

can be seen in what is known as a Codman

Triangle. This process shows periosteal

Bone Tumor Most Common Sites(In order of precedence)

Simple bone cyst Proximal humerus, Proximal

femur

Aneurysmal bone cyst, giant

cell, osteosarcoma

Distal femur, proximal tibia

Enchondroma Metaphysis of small bone of

hands and feet

Osteochondroma Distal femur, proximal tibia,

proximal humerus

Chondroblastoma Proximal humerus, proximal

femur

Ewing’s Femur, " bula, tibia

Fibrous dysplasia Ribs, proximal femur, tibia,

distal femur

Osteoid osteoma Femur, tibia

Chondroblastoma Pelvis, femur

Osteoblastoma Posterior spine

Myeloma Vertebra

Table 1

14 JOPA

reaction and elevation, with the advancing tumor

destroying this as its margin advances (Image 6).

Hint on tumor matrix

The matrix is more than a series of Keanu

Reeves " lms, it is the internal tissue of a tumor.

While most often it is soft tissue in nature,

Sclerotic margins are seen

in unicameral bone cysts (UBC),

enchondroma, " brous dysplasia

(FD), chondroblastoma and giant cell

tumors (GCT) (Image 1).

Well de" ned but non-sclerotic

margins are seen in GCT,

enchondroma, chondroblastoma,

FD and chondrosarcoma (Image 2).

Lytic lesions with ill-de" ned margins

are found in chondrosarcoma,

osteosarcoma, lymphoma, metastasis,

GCT and infections (Image 3.)

Moth-eaten lesions are seen in

myeloma, infection, osteosarcoma,

chondrosarcoma and lymphoma

(Image 4). Permeative (poorly

demarcated) lesions are found

in Ewing’s, myeloma metastasis,

lymphoma, and osteosarcoma (Image

5)1.

occasionally it offers clues on tumor types. When

not radiolucent, it can show stippling, a series

of calci" ed rings, dots or arcs, in enchondroma,

chondroblastoma, and chondrosarcoma. The

tumor may also present with an ossi" c matrix as

in osteosarcoma1.

In using the aforementioned criteria to

JOPA 15

identify tumors by presentation; " brous dysplasia,

metastatic carcinoma, chondroid tumor, infection,

and eosinophilic granuloma, form " ve diagnoses

that are so variable in presentation that they must

be considered in the differntial diagnosis of any

unknown bone lesion2.

Summary

Using this four question technique will

enable the practicing clinician to have some

con" dence in a differential diagnosis for any bone

lesion seen on plain " lms. Location and extent,

margins and bone reaction will help identify

lesions that need referrral to a specialist, but

more importantly, allow adequate descriptions for

complete communication. This does not resolve

the provider from the duty to obtain other studies

that are prudent. Many oncologists will be more

than happy to discuss cases and recommend

which specialised exams such as bone scan,

MRI (with or without contrast), or CT scans that

will most helpful to aid in staging or diagnosis

pending their consult.

References

1. Sabat, MD, D. (2010). Radiology of bone tumors

[PowerPoint slides]. Retrieved from Google

Scholar/Slideshare: http://www.slideshare.net/

2. Sanders, T. G., & Parsons, T. W. (2001).

Radiographic imaging of musculoskeletal

neoplasia. Cancer Control, 8, 221-230.

Retrieved from http://www.medscape.com/

viewarticle/409049

3. Hameed, M., & Dorfman, H. (2011). Primary

malignant bone tumors-recent developments.

Seminars in Diagnostic Pathology, 28, 86-101.

http://dx.doi.org/10.1053j.semdp.2011.02.002

Lucent lesions of bone. (2011). Retrieved from

http://www.rad.washington.edu/academics/

academic-sections/msk/teaching-materials/online-

musculoskeletal-radiology-book/lucent-lesions-of-

bone

Image 6. Codman triangle

SEIZE THE INITIATIVE

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Demonstrate to your practice and patients your advanced level of knowledge in this specialty.

You are building your reputation as a clinician, and

you want to set yourself apart. You’ve honed your skills.

You’ve gained knowledge and expertise. You’ve done

everything to be an accomplished orthopaedic surgery PA.

The Certificate of Added Qualifications is your chance to

prove it. The CAQ is offered by NCCPA to help you document

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a practice exam or register for the CAQ program.

“ I have been promoted

and given higher pay

and more responsibility

since earning a CAQ.” - Mark Wright,

2011 CAQ in Orthopaedic Surgery

JOPA 17

September Image Quiz: Posterior Shoulder Dislocation

Figure 1 Figure 2

A 53-year old male presents to your of" ce

with right shoulder pain for 8 weeks. The pain

started after he experienced a witnessed seizure

at home. He was seen in the ED after the seizure

but did not have any x-rays done prior to being

discharge home. He was seen by his primary

care provider two weeks after the seizure with

complaints of persistent right shoulder pain and

was prescribed muscle relaxants and narcotic pain

medication. After two more weeks of shoulder

pain his PCP ordered an MRI and referred him

to orthopedics. MRI of the shoulder shows a

posteriorly dislocated humeral head with a large

impacted fracture involving >25% of the articular

surface. Early osteonecrosis of the humeral head

is evident but there is no rotator cuff tear. AP,

scapular outlet, and axillary view x-rays taken

in the of" ce 8 weeks after the injury are shown

above.

What is the next best step in treatment?

A. Open reduction with subscapularis

transposition

B. Reverse total shoulder arthroplasty

C. Closed Reduction and immobilization for 4-6

weeks

D. Hemiarthroplasty

The patient has a chronic posterior

shoulder dislocation that is 2 months old. An

engaging Hill-Sachs lesion is noted on the axillary

view and involves >25% of the articular surface.

Early osteonecrosis is also present. The patient

underwent a right shoulder hemiarthroplasty.

Posterior shoulder dislocations are

rarely seen and account for an estimated 3% of

all shoulder dislocations. Posterior shoulder

dislocations are commonly associated with a

seizure that causes a sudden internal rotation,

adduction, and axial loading of the humeral head.

Bilateral shoulders are involved in an estimated

11% of posterior dislocations after a seizure.

Because the humeral head internal rotators are

twice as strong as the external rotators a sudden

forceful contraction can cause a dislocation.

X-rays are often read as normal and up to 50%

of these injuries that present in the emergency

department aren’t identi" ed.

Physical exam " ndings may include a

prominent posterior shoulder and coracoid.

The humeral head may be engaged on the

posterior glenoid causing an external rotation

block. The arm is held in adduction and internal

rotation for comfort and attempts to abduct and

externally rotate the arm will cause pain. Standard

radiographs in the ED usually include an AP and

a scapula outlet view. An axillary view is often not

performed as shoulder abduction is too painful

for the patient to tolerate. However, obtaining an

18 JOPA

September Image Quiz: Posterior Shoulder Dislocation

axillary view is critical to diagnosing shoulder

dislocations. A Velpeau axillary or modi" ed

axillary can be performed in patients in a sling

who cannot abduct their arm. During a Velpeau

axillary the patient leans back 30 degrees against

a table with a cassette on top. The x-ray tube is

directed down vertically through the shoulder

and onto the cassette. CT scan can diagnose a

posterior dislocation and also helps determine

the extent of the cortication on the anterior

medial portion of the humeral head from the

impacted posterior glenoid. This compression

fracture that occurs after a posterior dislocation

is called a reverse Hill-Sachs lesion. MRI is useful

to evaluate the rotator cuff and other soft tissues.

Posterior dislocations occasionally reduce

spontaneously but most require closed reduction.

Open reduction may be necessary if the posterior

dislocation is chronic or over 6 weeks old or

if the reverse Hill-Sachs lesion cannot not be

disengaged. Closed reduction using traction and

external rotation should not be performed if the

reverse Hill-Sachs lesion is still engaged as this

may cause a fracture of the remaining humeral

surface. After reduction, functional range of

motion should be assessed. If the shoulder is

stable through range of motion and the reverse

Hill-Sachs lesion involves less than 25% of the

humeral surface then the patient can be treated

nonoperatively. Nonoperative treatment involves

sling immobilization in a neutral or externally

rotated position for 4-6 weeks. Shoulder stability

is reassessed and physical therapy is initiated

if the joint is stable. Patients who sustain a

dislocation as a result of a seizure and who

present with a large reverse Hill-Sachs lesion have

a higher risk of developing recurrent instability.

If the shoulder remains unstable after

closed reduction then a stabilization procedure is

recommended. Techniques involve transposition

of the subscapularis tendon into the humeral

defect with or without an osteomized lesser

tuberosity as well as disimpaction and bone

grafting for lesions less than 25% of the humeral

surface. Lesions up to 40 to 50% of humeral head

involvement may require a structural allograft

to " ll the defect. Injury to the posterior capsule

and fracture of the glenoid may cause residual

instability after these stabilization procedures

and both should be addressed surgically as well.

Posterior dislocations with a large humeral defect

greater than 50% of the articular surface are

most commonly treated with hemiarthroplasty.

Hemiarthroplasty is also indicated for chronic

dislocations, avascular necrosis, humeral head

collapse, and humeral head arthritis.

References.

1. Robinson CM, Aderinto J. Current Concepts

Review: Posterior Shoulder Dislocations and

Fracture-Dislocations. JBJS 2005. (87)3; 639-650

2. Posterior Shoulder Dislocations. www.

orthobullets.com. Accessed 8/15/15.

Figure 3 Figure 4

JOPA 19

October Image Quiz: Chondrosarcoma

Figure 1

A 42-year old male presents with a 2-month history of right sided groin pain. He denies injury or any known precipitating event. The pain is constant at rest and seems to be worse at night. He denies any history of known cancer. An AP pelvis x-ray, coronal MRI image, and an axial CT image are shown above. Results from a needle biopsy are consistent with a low grade chondrosarcoma.

What is the next best step in treatment?

A. Wide surgical excisionB. Radiation and chemotherapyC. Intralesional curettageD. Serial x-rays

Chondrosarcoma is the third most common malignant bone tumor behind myeloma and osteosarcoma. Although rare in presentation, an estimated 600 patients are diagnosed each year in the United States. Chondrosarcomas typically occur in ! at bones including the shoulder and pelvic girdles, but may also occur in the extremities. Common presentation includes males between the ages of 40-60 years of age with deep pain that is persistent at rest. Chondrosarcomas can appear radiographically as a low grade intracompartmental lesion much like an enchondroma. However, serial radiographs done each month will show continued growth with chondrosarcomas. Chondrosarcomas come in two forms: primary and secondary.

Figure 2

Primary chondrosarcomas arise de novo from the intramedullary space of bone. Secondary chondrosarcomas arises from preexisting benign lesions such as osteochondromas, multiple hereditary exostosis, enchondromas, Ollier’s disease, and Mafucci’s syndrome. Typically, 85% of chondrosarcomas are grade 1 or 2.

On plain x-rays it can be dif" cult to differentiate between benign lesions and chondrosarcomas. X-rays will likely show a lytic, lobular lesion with a pattern of calci" cation within a cartilaginous matrix. Low grade lesions may show cortical thickening and endosteal

Figure 3

20 JOPA

October Image Quiz: Chondrosarcoma

erosion where high-grade lesions show cortical destruction and soft tissue invasion. CT scan is sensitive in determining the extent of cortical destruction and the presence of new lucencies which suggest malignant transformation. CT scan of the chest may be done as high grade tumors are prone to pulmonary metasteses. MRI may be used to determine the extent of soft tissue involvement.

Generally chondrosarcoma is a slow growing malignancy but tumor aggressiveness can vary. Radiographic appearance and histiologic " ndings are not great predictors of tumor aggression. Factors that suggest a high grade malignancy include increasing size of the tumor, the presence of pain that persists at rest, and age over 40. Lesions located in the pelvis and proximal extremities are more likely to be malignant than tumors in the distal extremities. The diagnosis is often in! uenced by clinical history and physical exam " ndings as radiographic and histiologic " ndings are unreliable in con" rming the diagnosis. Pain, in! ammation, and increasing tumor signs suggest malignancy. Serial radiographs to monitor changes of tumor size over time may be the most accurate method in determining malignant potential. A de" nitive diagnosis is established by correlating clinical and radiographic " ndings, gross pathological " ndings, and histopathological " ndings. A biopsy may be performed prior to the de" nitive surgical procedure. However, biopsies poorly differentiate low grade vs. high grade lesions and therefore are not usually helpful in preoperative planning. Special care is taken during the biopsy to avoid spreading tumors cells along the needle tract.

Treatment is often dictated by the tumor grade which is based on histiologic " ndings, anatomic location, and the presence or absence of metastasis. Radiation and chemotherapy treatments are ineffective due to the slow growing nature and poor vascularity of chondrosarcomas. Surgical intervention including intralesional curettage or wide surgical excision is the treatment of choice for all chondrosarcomas. Intralesional curettage is primarily used in low grade lesions in the extremities but is not recommended for chondrosarcomas of the pelvis due to the higher recurrence rates. Wide surgical excision involves resection of the involved bone and surrounding tissue with the goal of removing

all malignant cells. During a wide surgical excision procedure, intraoperative tissue is sent for frozen section until all margins are free of malignant cells. If tumor cells are noted on the marginal excision tissue then the margins are widened during the same operative setting until all margins are negative.

References1. Scharschmidt T, Mayerson J. Chondrosarcoma. Orthopedic Knowledge Online Journal 2010. 8(10)

2. Patel SR, Benjamin RS. Soft Tissue and Bone Sarcomas and Bone Metastases. In: Kasper D, Fauci A, Hauser S, Longo D, Jameson J, Loscalzo J. eds. Harrison’s Principles of Internal Medicine, 19e. New York, NY: McGraw-Hill; 2015.

JOPA 21

November Image Quiz: Extensor Tendon Injury

Figure 1

A 22-year old male presents with a stab

wound to the forearm that occurred during an

altercation 5 days ago. The knife entered the

dorsal and distal one-third forearm on the ulnar-

side. He is unable to extend his ring, middle,

and index " ngers and thumb since the injury. He

can actively extend the small " nger and wrist.

Sensation over the dorsum of the wrist and hand

is intact. Flexion of all the " ngers and wrist is

intact. The entrance wound and extension lag

deformities are shown above.

Which tendon is most likely injured?

A. Extensor carpi radialis longus

B. Extensor digitorum communis

C. Extensor digiti minimi

D. Abductor pollicis longus

The patient was taken to the operating

room for wound exploration one week after the

injury. The extensor digitorum communis to

the index, middle, and ring " ngers was found to

be lacerated. The extensor pollicis longus and

extensor indicis proprius tendons were also

lacerated. The posterior interosseous nerve was

found to be intact. The lacerated tendons were

repaired with 3-0 prolene suture. The patient

was placed in a short arm cast with the wrist

and MCP joints in extension for three weeks

postoperatively. Passive ROM with occupational

therapy was initiated at 3 weeks.

Figure 2

The forearm has super" cial and deep

layers of muscle. The super" cial layer going

radial to ulnar includes the extensor carpi radialis

longus (ECRL), extensor carpi radialis brevis

(ECRB), extensor digitorum communis (EDC),

extensor digiti minimi (EDM), and extensor carpi

ulnaris (ECU). The deep layer going radial to

ulnar includes the abductor pollicis longus (APL),

extensor pollicis brevis (EPB), extensor pollicis

longus (APL), and extensor indicis proprius (EIP).

Extensor tendon lacerations are classi" ed

by zone of injury. Zone 1 injuries involve the

terminal extensor tendon as it attaches to the

DIP of the " ngers or the IP of the thumb. An

example of a zone 1 injury is a mallet " nger. Zone

2 injuries occur at the level of the middle phalanx

of the " ngers or proximal phalanx of the thumb.

Zone 3 injuries occur over the PIP joints of the

" ngers or the MCP joint of the thumb. A zone 3

injury may result in a boutonnierre deformity. A

zone 4 injury occurs over the proximal phalanx

of the " ngers or metacarpal of the thumb. A zone

5 injury occurs over the " nger MCP joints or the

metacarpal of thumb. Lacerations over the thumb

in zones 3 through 5 may cause disruption of the

extensor pollicis longus and extensor pollicis

brevis tendons. Zone 6 injuries occur over the

metacarpals, zone 7 over the wrist, zone 8 over

the distal forearm, and zone 9 over the extensor

muscle bellies proximally.

The patient’s injury involved the extensor

November Image Quiz: Extensor Tendon Injury

digitorum muscle in zone 8 of the forearm. The

extensor digitorum muscle or extensor digitorum

communis (EDC) originates from the lateral

epicondyle and divides into four extensor tendons

of the hand. The four tendon insertions are to

the 2nd through the 5th digits. The EDC tendons

divide over the proximal phalanx into a central

and two lateral bands. The central band inserts

into the base of the middle phalanx while the two

lateral bands reunite over the middle phalanx

and insert into the base of the distal phalanx.

The EDC extends the MCP joints and the IP joints

of the 2nd through 5th digits, and aids in wrist

extension. The patient is able to extend the small

" nger which indicates the extensor digiti minimi

(EDM) is intact. He is also able to extend the

wrist which indicates the extensor carpi radialis

is likely intact. The patient’s inability to extend

the index " nger indicates that the EDC and EIP are

lacerated as both extend the index " nger.

Proximal forearm lacerations that cause

dysfunction of the EDC, EDM, ECU, APL, EPL,

EPB, and EIP may be from an isolated posterior

interosseous nerve injury (PIN). The PIN

innervates the muscles of the " nger extensors at

the proximal forearm so proximal injury causes

distal motor de" cits. The PIN doesn’t have

cutaneous innervation so light touch sensation

will be intact distally despite the motor de" cits.

As the PIN tracks distally the nerve becomes

sensory and innervates the dorsal capsule of the

wrist. PIN neurectomy at the wrist level may be

performed for pain relief in patients with chronic

wrist pain that would rather avoid major surgery

such as wrist arthrodesis.

References

Tang, P. Fischer CR. Lacerations to Zones VIII

and IX. It is not just a tendon injury. Advances in

Orthopedics. Volume 2011 (2011).

Extensor tendon injuries. www.othobullets.com.

Accessed 10/12/2015.

JOPA 23

PI CME: Improving the Recognition and Management of

Osteoporosis Post-Fracture

The New Hampshire Society of Physician Assistants has partnered with the Journal of

Orthopedics for Physician Assistants (JOPA) to create performance improvement (PI) CME for physician

assistants who practice in orthopedic surgery. The program is hosted by the website

www.CME4PAC.com and can be completed by becoming a CME4PAC member. The PI-CME program is

titled “Improving the Recognition and Management of Osteoporosis Post-Fracture”. Osteoporosis is a

major health problem that is often overlooked in an orthopedic setting. Orthopedic physician assistants

frequently treat patients who sustain fragility fractures and therefore have a valuable opportunity to

play a larger role in recognizing and treating osteoporosis. Orthopedic providers should go beyond

treating the existing fragility fracture by ensuring the underlying cause of the fracture is identified and

treated as well. Improving the recognition and treatment of osteoporosis will help us prevent future

fractures in our patients.

The PI CME program is broken into three stages. The program first starts with a chart review to

assess how you are performing on certain measures (stage 1), next an action plan is created to

implement improvements (stage 2), and finally a second chart review is done to asses performance

improvement (stage 3). Each stage is described in more detail below. The performance measures for this

PI CME program are based on the Physician Quality Reporting System (PQRS) which encourages eligible

providers to report information on quality of care to Medicare. The three PQRS measures chosen for

this PI CME program include 1. (PQRS Measure # 024) All patients aged over 50 years old who sustained

a distal radius, vertebral, or hip fracture should have documentation in the medical record that the

patient was or should be tested or treated for osteoporosis, 2. (PQRS Measure # 041) All patients aged

50 years and older with a diagnosis of osteoporosis should have documentation that pharmacologic

therapy has been prescribed within 12 months, and 3. (PQRS Measure # 155) All patients aged 65 years

and older with a history of falls should have a plan of care for falls documented within 12 months.

Ready to begin!

Stage 1: Approved for 5 PI CME Credits

The PI CME program begins with stage 1. Randomly select 10 patient charts that meet the following

criteria: patient aged over 65 years old who sustained a vertebral or hip fracture from a fall. Selecting

the last ten patients you saw that meet this criteria is the easiest way to randomly select your charts.

This may require assistance from your IT department to find patients efficiently within your practice’s

EMR. It may be helpful to search patients by ICD 9 or ICD 10 diagnosis codes. ICD 9 codes to search for

may include: femoral neck fracture (820) and vertebral fracture (805). ICD 10 codes include: femoral

neck fracture (S72.0) and vertebral fracture (S32). For each patient, determine if the required

documentation was found in the patient’s chart for each of the following three measures below (A, B,

C).

PI CME: Improving the Recognition and Management of

Osteoporosis Post-Fracture

The New Hampshire Society of Physician Assistants has partnered with the Journal of

Orth edic fo Ph icia Assist ts (JOPA) to at rf im t (PI) CME f hysici

24 JOPA

Three PQRS performance improvement measures and documentation required to satisfy each:

Measure A. All patients aged over 50 years old who sustained a distal radius, vertebral, or hip fracture

should have documentation in the medical record that the patient was or should be tested or treated

for osteoporosis. This may include ordering bone density testing or documenting that a referral to the

primary care provider recommending doing so was done. Documentation must indicate that

communication to the patient’s primary care physician occurred within three months of treatment for

the fracture.

Measure B. All patients aged 50 years and older with a diagnosis of osteoporosis should have

documentation that pharmacologic therapy has been prescribed within 12 months. If the patient has

been diagnosed with osteoporosis and is not on medication you should document the reason why the

med is not prescribed. This may include a medical reason, patient refusal, or recent diagnosis after a

fracture. According to the National Osteoporosis Foundation, a history of a hip or vertebral fragility

fracture meets the diagnostic criteria for osteoporosis. Pharmacologic therapy should be considered in

all postmenopausal women and men age 50 and older who present with a hip or vertebral fracture.

Patients over 65 years of age who present with a hip or vertebral fragility fracture without a prior

diagnosis of osteoporosis should have documentation that osteoporosis was discussed and that a

medication was recommended. U.S. Food and Drug Administration approved pharmacologic options for

osteoporosis prevention and/or treatment of postmenopausal osteoporosis include, in alphabetical

order: bisphosphonates (alendronate, ibandronate, and risedronate), calcitonin, estrogens (estrogens

and/or hormone therapy), parathyroid hormone (PTH (1-34), teriparatide), and selective estrogen

receptor modules or SERMs (raloxifene).

Measure C. All patients aged 65 years and older with a history of falls should have a plan of care for falls

documented within 12 months. The medical record must include documentation that balance, strength,

and gait training/instructions were provided OR referral to an exercise program, which includes at least

one of the three components: balance, strength or gait OR referral to physical therapy. A referral should

be documented within 12 months from the fall.

Make sure you have reviewed the documentation required in order to satisfy each performance

measure. Please refer to the pre evaluation forms on page 26 to record your performance results for

Stage 1. Each of your 10 selected patients should be assigned a chart number for the pre evaluation

form. If the measure was satisfied, or the required documentation was found in the patient’s chart,

place a Y (for yes) in the table correlating with the patients chart number. If the required documentation

was not found place an N (for no). Repeat this step for each of the three measures. This data will be

documented as your baseline performance results. Please keep the pre evaluation form until the

conclusion of this PI CME program. You will need this data to fill out the final evaluation form and

receive CME credits.

JOPA 25

Stage 2: Approved for 5 PI CME Credits

Stage 2: Evaluate your practice gaps and create an action plan to implement improvements. Each

practice is different so you will need to decide what specific methods you will take to improve measure

performance. Developing patient handouts or creating alerts in your EMR may help you remember to

document adequately in the appropriate patients. Adequate documentation should be noted in at least

50% your selected patient’s charts. A few questions you should consider when creating a plan to

implement improvements include:

· What are your specific goals for improvement? Are your goals 100% compliance? 50%

compliance? Do you plan on developing protocols that will help flag all patients aged over 65

years old who sustain a distal radius, vertebral, or hip fracture from a fall?

· What changes do you plan to implement? EMR changes? Patient handouts?

· How long do you expect your implementation efforts to take? You should determine how long it

will take you to implement improvements and set a date to evaluate the impact of your

improvement effort (Stage 3).

· Whose cooperation will you need to help you implement these changes, or whose approval will

you need if this effort is to be successful?

If your pre-assessment showed that you are deficient in your required documentation for the measures

we ask that you review the free resources below to help improve your performance. These educational

resources will also help you better inform your patients.

National Osteoporosis Foundation Clinician’s Guide to Prevention and Treatment of Osteoporosis:

http://nof.org/files/nof/public/content/file/2791/upload/919.pdf

Free Patient Handouts from the National Osteoporosis Foundation Website: http://nof.org/resources

Stage 3: Approved for 5 PI CME Credits

Stage 3: Beginning at least 30 days after implementing your improvement methods, randomly select 10

patient charts for those patients aged over 65 years old who sustained a vertebral or hip fracture from a

fall. These charts Should Not be the same charts that were used in the pre evaluation portion of the

program. For each patient’s chart, answer the questions with a Y (for yes) or N (for no) in the post

evaluation form. The results should be recorded on the post evaluation forms on page 27. Compare the

results of your performance improvement effort to your baseline results. Results can be compared by

creating a fraction of the 10 patients (numerator 10) and the number of Yes answers (denominator) in

the pre evaluation. For example, if you had 3 charts that met the performance measures documentation

requirements then the pre evaluation score would be (10 divided by 3) = 30% compliance. Now do the

same to determine the percent compliance for the second set of patients in the post evaluation.

Completion: Bonus 5 PI CME credits for a total of 20 PI CME Credits. In order to receive all 20

performance improvement credits you will need to complete and submit the pre and post evaluation

forms electronically on the programs hosting website www.CME4PAC.com. All CME4PAC members will

have access to the final e-form which can be found on the “My Account” page once logged in.

26 JOPA

PI CME: Improving the Recognition and Management of Osteoporosis Post-Fracture: Pre Evaluation Form

Pre Evaluation Measure A Chart

1

Chart

2

Chart

3

Chart

3

Chart

4

Chart

5

Chart

6

Chart

7

Chart

8

Chart

9

Chart

10

All patients aged over 50 years old who sustained a distal radius,

vertebral, or hip fracture should have documentation in the

medical record that the patient was or should be tested or treated

for osteoporosis. This may include ordering bone density testing or

documenting that a referral to the primary care provider

recommending doing so was done. Documentation must indicate

that communication to the clinician managing the on-going care of

the patient occurred within three months of treatment for the

fracture.

Pre Evaluation Measure B Chart

1

Chart

2

Chart

3

Chart

3

Chart

4

Chart

5

Chart

6

Chart

7

Chart

8

Chart

9

Chart

10

All patients aged 50 years and older with a diagnosis of

osteoporosis should have documentation that pharmacologic

therapy has been prescribed within 12 months. If the patient has

been diagnosed with osteoporosis and is not on medication you

should document the reason why the med is not prescribed. This

may include a medical reason, patient refusal, or recent diagnosis

after a fracture. According to the National Osteoporosis

Foundation, a history of a hip or vertebral fragility fracture meets

the diagnostic criteria for osteoporosis. Pharmacologic therapy

should be considered in all postmenopausal women and men age

50 and older who present with a hip or vertebral fracture. Patients

over 65 years of age who present with a hip or vertebral fragility

fracture without a prior diagnosis of osteoporosis should have

documentation that osteoporosis was discussed and that a

medication was recommended. U.S. Food and Drug Administration

approved pharmacologic options for osteoporosis prevention

and/or treatment of postmenopausal osteoporosis include, in

alphabetical order: bisphosphonates (alendronate, ibandronate,

and risedronate), calcitonin, estrogens (estrogens and/or hormone

therapy), parathyroid hormone (PTH (1-34), teriparatide), and

selective estrogen receptor modules or SERMs (raloxifene).

Pre Evaluation Measure C Chart

1

Chart

2

Chart

3

Chart

3

Chart

4

Chart

5

Chart

6

Chart

7

Chart

8

Chart

9

Chart

10

All patients aged 65 years and older with a history of falls should

have a plan of care for falls documented within 12 months. The

medical record must include documentation that balance,

strength, and gait training/instructions were provided OR referral

to an exercise program, which includes at least one of the three

components: balance, strength or gait OR referral to physical

therapy. A referral should be documented within 12 months from

the fall.

Determine your pre evaluation performance by creating a fraction of the 10 patients (numerator 10) and the number of Yes answers

(denominator) in the pre evaluation. For example, if you had 3 charts which had adequate documentation in the pre evaluation the score would

be (10 divided by 3) = 30% compliance.

Pre Evaluation Score: _________%_

JOPA 27

Post Evaluation Form

Post Evaluation Measure A Chart

1

Chart

2

Chart

3

Chart

3

Chart

4

Chart

5

Chart

6

Chart

7

Chart

8

Chart

9

Chart

10

All patients aged over 50 years old who sustained a distal radius,

vertebral, or hip fracture should have documentation in the

medical record that the patient was or should be tested or treated

for osteoporosis. This may include ordering bone density testing or

documenting that a referral to the primary care provider

recommending doing so was done. Documentation must indicate

that communication to the clinician managing the on-going care of

the patient occurred within three months of treatment for the

fracture.

Post Evaluation Measure B Chart

1

Chart

2

Chart

3

Chart

3

Chart

4

Chart

5

Chart

6

Chart

7

Chart

8

Chart

9

Chart

10

All patients aged 50 years and older with a diagnosis of osteoporosis

should have documentation that pharmacologic therapy has been

prescribed within 12 months. If the patient has been diagnosed with

osteoporosis and is not on medication you should document the

reason why the med is not prescribed. This may include a medical

reason, patient refusal, or recent diagnosis after a fracture. According

to the National Osteoporosis Foundation, a history of a hip or

vertebral fragility fracture meets the diagnostic criteria for

osteoporosis. Pharmacologic therapy should be considered in all

postmenopausal women and men age 50 and older who present with

a hip or vertebral fracture. Patients over 65 years of age who present

with a hip or vertebral fragility fracture without a prior diagnosis of

osteoporosis should have documentation that osteoporosis was

discussed and that a medication was recommended. U.S. Food and

Drug Administration approved pharmacologic options for osteoporosis

prevention and/or treatment of postmenopausal osteoporosis include,

in alphabetical order: bisphosphonates (alendronate, ibandronate,

and risedronate), calcitonin, estrogens (estrogens and/or hormone

therapy), parathyroid hormone (PTH (1-34), teriparatide), and

selective estrogen receptor modules or SERMs (raloxifene).

Post Evaluation Measure C Chart

1

Chart

2

Chart

3

Chart

3

Chart

4

Chart

5

Chart

6

Chart

7

Chart

8

Chart

9

Chart

10

All patients aged 65 years and older with a history of falls should

have a plan of care for falls documented within 12 months. The

medical record must include documentation that balance,

strength, and gait training/instructions were provided OR referral

to an exercise program, which includes at least one of the three

components: balance, strength or gait OR referral to physical

therapy. A referral should be documented within 12 months from

the fall.

Post Evaluation Score: _________%_

28 JOPA

The Journal of Orthopedics for Physician Assistants (JOPA) is a

peer-reviewed publication that delivers a broad range of orthopedic

content across all subspecialties. Authors can contribute any original

article that promotes an orthopedic education for physician assistants

(several examples are listed below). JOPA avoids publishing original

research articles, as well as articles previously published or being

considered for publication in other journals. Articles are peer reviewed

by a panel of orthopedic physicians and PAs to ensure accuracy, clinical

relevance, and readability.

References should be cited using the AMA Manual of Style, 10th edition. References should be recent and

predominately drawn from peer reviewed journals. Textbook and website references should be avoided if possible.

Article content, including the manuscript body and any tables, should be submitted in Microsoft Word format to

facilitate editing. Please use a standard font, such as Times New Roman, and a 12-point font size. Use appropriate

headings and subheadings in feature articles to organize paragraphs. JOPA reserves the right to edit content for space

and/or grammar issues. Any images that accompany an article must be sent as separate downloadable " les from the

manuscript text for publishing.

Featured Review Articles

Featured review articles should contain a comprehensive

review of literature on an orthopedic topic of choice.

These academic literature reviews should be heavily

referenced and may be co-authored. Subspecialists

should consider writing on topics in their " elds of

expertise. Featured review length should be 4-8 pages.

When considering the appropriate length, keep in mind

the clinical signi" cance and readability of content.

Review Articles

Review articles should be 3-4 pages on an orthopedic

topic of choice. Review articles should be selective and

include few references. Authors may review a clinical

condition, surgical procedure, or any other topic related

to orthopedics. Preceptors may consider co-authoring a

review article with a PA student interested in pursuing a

career in orthopedics.

Case Studies

Case studies choose a case and provide a complete

history of the clinical presentation, treatment, and

outcome. Radiographs and other imaging should

be included to follow the course of a diagnosis and

treatment. Several learning points should be included at

the end of the case study, with appropriate references.

Please remove all patient identi" cation information prior

to submission.

Case Reviews and Image Quizzes

Case reviews present a unique case with several images

and a brief description of the presentation, diagnosis,

and treatment. Image quizzes include an image for

readers to interpret. Answers should be provided, with

a brief explanation of the patient and correct diagnosis.

Do not include literature review or references for case

reviews or image quizzes.

Be Creative!

Consider submitting a description of how your practice

uses PAs or the relationship you have with your

supervising physicians. Consider writing on a patient’s

experience and how it could be of value to PA colleagues.

Write a detailed narrative of a typical day in your life as

a PA. Personal experiences can be some of the most

interesting and helpful articles for other PAs to read. If

you have any other submission ideas, please contact the

editor at dcloutier@thejopa.org.

Supervising Physicians and

Allied Health Professionals

Supervising physicians may submit articles on topics in

their subspecialty or issues related to the PA profession.

Physicians may also choose to write on a procedure or

service unique to their practice. Co-authoring an article

with a supervising physician is a great way to promote

the physician-PA relationship. Nurse Practitioners

practicing in orthopedics are encouraged to contribute,

and may receive a free copy of JOPA by contacting

the editor or subscribing online. Contributions from

other allied health professionals, such as physical

therapists and athletic trainers, give PAs an opportunity

to learn from those with whom we share patient care

responsibilities. Allied health professionals who wish

to contribute to JOPA can contact the editor, Dagan

Cloutier, at dcloutier@thejopa.org.

Writing for JOPA: Information for Authors