The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 92, Issue Supplement 2

Scientific Articles | December 01, 2010

Immersion Education for Orthopaedic Pathology: A Review of the Orthopaedic In-Training Examination and American Board of Orthopaedic Surgery Certification

Derek F. Papp, MD¹; James C. Johnston, MD¹; John A. Carrino, MD, MPH¹; Edward F. McCarthy, MD¹; Frank J. Frassica, MD¹

¹ c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director, Editorial Services, Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A665, Baltimore, MD 21224-2780. E-mail address for E.P. Henze: ehenze1@jhmi.edu

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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

J Bone Joint Surg Am, 2010 Dec 01;92(Supplement 2):152-160. doi: 10.2106/JBJS.J.00828

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Residency programs have the task of training future orthopaedic surgeons and providing them with a solid knowledge base. This knowledge base, which ultimately guides the surgeon in decision-making and patient care, also figures prominently in how the resident performs on the Orthopaedic In-Training Examination and the American Board of Orthopaedic Surgery certification examination. The purposes of the Orthopaedic In-Training Examination, which was first administered in 1963, are to measure resident knowledge against a national standard, determine minimal standards for trainees, and measure the quality of teaching at the different residency programs¹. Studies have correlated performance on the Orthopaedic In-Training Examination with performance on Part I of the American Board of Orthopaedic Surgery examination²,³. Residents with average scores in the 27th percentile or lower on the Orthopaedic In-Training Examination during postgraduate years two through five have a 57% chance of failing Part I of the American Board of Orthopaedic Surgery examination².

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Introduction

Introduction | Immersion Education | Bone Lesions | Overview | References

Residency programs have the task of training future orthopaedic surgeons and providing them with a solid knowledge base. This knowledge base, which ultimately guides the surgeon in decision-making and patient care, also figures prominently in how the resident performs on the Orthopaedic In-Training Examination and the American Board of Orthopaedic Surgery certification examination. The purposes of the Orthopaedic In-Training Examination, which was first administered in 1963, are to measure resident knowledge against a national standard, determine minimal standards for trainees, and measure the quality of teaching at the different residency programs¹. Studies have correlated performance on the Orthopaedic In-Training Examination with performance on Part I of the American Board of Orthopaedic Surgery examination^2,3. Residents with average scores in the 27th percentile or lower on the Orthopaedic In-Training Examination during postgraduate years two through five have a 57% chance of failing Part I of the American Board of Orthopaedic Surgery examination².

Investigators have analyzed the Orthopaedic In-Training Examination with regard to the various subspecialties and orthopaedic topics, including orthopaedic pathology⁴, hand⁵, sports medicine⁶, foot and ankle⁷, and osteonecrosis⁸. The purpose of these analyses was to determine the topics most likely to be included on the test and thereby facilitate the design of lesson plans and study aids for more focused preparation for the examination. The analysis by Frassica et al.⁴ of the content, question types, and types of images appearing on the orthopaedic pathology section of the test can be used to develop a curriculum for educating residents. As an example, the most common malignant bone tumors addressed by questions on the Orthopaedic In-Training Examination were metastatic bone lesions, osteosarcomas, and Ewing tumors. Other common benign bone lesions included osteomyelitis, giant cell tumor, fibrous dysplasia, and Paget disease.

Source of Funding

There was no external source of funding for this study.

Immersion Education

Introduction | Immersion Education | Bone Lesions | Overview | References

Immersion education has been used successfully, particularly in teaching foreign languages to resident physicians^9,10 and Peace Corps volunteers. By using "drill" sessions, students work toward learning a language in an interactive setting; the focus is on prompting the student to learn through a greater number of responses per student and maintaining a rapid pace⁹. Similarly, a curriculum might be developed that immerses the student in a multitude of cases and questions that are pertinent to the most common bone lesions.

The utility of Internet-based adjuncts to residency education has been previously described as promising^11,12, and resident use of computer-based web sites that provide tests for educational purposes has grown¹¹. For example, the Council of Emergency Medicine Residency Directors question bank (www.cordem.org) provides more than 1900 questions for emergency medicine residents to use in practice for examinations and allows online testing, the results of which can be sent to the resident program director. When surveyed regarding their experience with the program, 80% of residency programs responded that they found the online testing "very useful" or "extremely useful."¹¹

Our purposes were to describe and provide examples of the clinical presentation, radiographic appearance, and treatment of commonly tested bone lesions. With the Orthopaedic In-Training Examination and the American Board of Orthopaedic Surgery certification examination moving to a computer format, familiarity with computer-based testing systems will help test-takers.

Bone Lesions

Introduction | Immersion Education | Bone Lesions | Overview | References

Osteosarcoma

The most common primary bone neoplasm, osteosarcoma, typically presents in a patient's second or third decade of life^13,14. Patients typically have constant pain that continues to bother them into the night and/or wakes them up. Radiographically, the neoplasm appears as an aggressive, destructive lytic lesion that involves the metaphysis with associated new bone formation, periosteal reaction, and a visible soft-tissue mass¹³ (Fig. 1). Treatment includes neoadjuvant chemotherapy and wide resection of the lesion¹³. There is no difference in survival between patients treated with limb salvage procedures and those treated with amputation¹⁴.

Fig. 1

Fig. 1 This anteroposterior radiograph of the knee shows an osteosarcoma of the proximal part of the tibia. Note the osseous destruction and new bone formation in the soft tissues.

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Parosteal Osteosarcoma

Parosteal osteosarcoma originates on the surface of the bone, most commonly on the distal part of the femur¹³. The heavily mineralized lesion has a characteristic lobulated appearance with a broad attachment to the bone (Fig. 2). It is a low-grade tumor with a <5% chance of metastasis¹³. Most patients present with less pain compared with that associated with a classic osteosarcoma and instead complain of mild pain, a mass, and/or joint dysfunction¹³. Treatment includes wide resection.

Fig. 2

Fig. 2 This anteroposterior radiograph of the distal part of the femur shows a parosteal osteosarcoma. The characteristic broad-based attachment to the bone is seen, as is the heavily mineralized, lobular formation of the lesion.

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Periosteal Osteosarcoma

According to Revell et al.¹⁵, this malignant primary bone tumor was first described as a distinct entity by Lichtenstein in 1955¹⁶. Unlike parosteal osteosarcoma, which is a solid bone-forming lesion, periosteal osteosarcoma is composed primarily of cartilage^4,15. It is a medium-grade surface lesion that is typically metaphyseal or diaphyseal¹³. Unlike parosteal osteosarcoma, the lesion has spicules of mineralization radiating from the cortex, providing a "sunburst" appearance¹³ (Fig. 3). It is much less mineralized than parosteal osteosarcoma. The treatment of periosteal osteosarcoma includes wide resection.

Fig. 3

Fig. 3 This anteroposterior radiograph of the tibia shows a sunburst pattern of bone emanating from the tibial shaft, which is characteristic of a periosteal osteosarcoma.

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Chondrosarcoma

Derived from chondrocytes, chondrosarcoma is the second most common primary malignant bone tumor. Radiographs show lytic lesions that often erode the cortex with or without cortical thickening (Fig. 4). The aggressiveness of this lesion is linked to the histologic grade. Grade-1 tumors almost never metastasize and are difficult to differentiate from benign enchondromas. Often the best way to differentiate a chondrosarcoma from an enchondroma is with serial radiographs at monthly intervals to determine whether the tumor is growing; enchondromas never grow. Grade-2 chondrosarcomas have increased cellularity but rarely have mitotic figures and are more locally aggressive, with a 15% to 20% rate of metastasis¹⁷. Grade-3 chondrosarcomas (dedifferentiated and mesenchymal types) have distinct findings of a malignant lesion with a high histologic grade and mitotic figures with increased cellularity, leading to a 70% rate of metastasis^13,18. Because chondrosarcomas are resistant to chemotherapy and radiation, surgery is the treatment of choice. Local staging at the time of surgical resection and the histologic grade are predictors of the prognosis¹⁸.

Fig. 4

Fig. 4 This anteroposterior radiograph of a chondrosarcoma in the femur shows the rings, arcs, and stipples present in any cartilage lesion. The tumor also has destroyed much of the bone's cortex.

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Nonossifying Fibroma

These benign metaphyseal lesions, commonly found in adolescents, slowly migrate into the diaphysis over time because of longitudinal growth. They are most commonly seen about the knee. A sclerotic rim with scalloped margins is observed on radiographs. These lesions are eccentric, metaphyseal lesions with a sclerotic rim¹³ (Fig. 5). They do not require any treatment, and radiographs are usually sufficient imaging studies to make this diagnosis.

Fig. 5

Fig. 5 This anteroposterior radiograph of the distal part of the tibia shows a nonossifying fibroma. Note the eccentric, metaphyseal location of the lesion and the scalloped rim.

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Bone Island/Enostosis/Osteopoikilosis

Bone islands are a locus of dense cortical bone in the medullary canal. These asymptomatic developmental abnormalities are often found incidentally on radiographs. One of the senior authors (E.F.M.) describes them to patients as "birthmarks in bone." The lesions are usually small (<1 cm), with well-circumscribed edges on radiographs, and additional imaging is not required to make the diagnosis. Although they can be large (3 to 5 cm) and occasionally demonstrate increased radioisotope uptake on a bone scan, they are benign, and reassurance is the best treatment (Fig. 6). Osteopoikilosis, also known as "spotted bone disease," is a genetic disorder causing multiple enostoses throughout the skeleton. This disease can be differentiated from metastases because the enostoses are distributed in clusters in the epiphysis and metaphysis throughout the skeleton¹³.

Fig. 6

Fig. 6 This lateral radiograph of the distal part of the femur shows an isolated, well-circumscribed osseous lesion—i.e., a bone island.

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Enchondroma/Enchondromatosis

Enchondromas are benign hyaline cartilage lesions in the medullary canal. They are common in the femur and the most common bone tumor in the hand. They likely result from a portion of the cartilaginous physis becoming entrapped in the metaphysis during growth. For this reason, they grow until skeletal maturity but never afterward. The diagnosis of enchondroma is made with radiographs, which show a well-defined central lytic cartilage lesion with rings, arcs, and stipples (Fig. 7). Histologically, they are identical to mature hyaline cartilage. Although enchondromas are benign, they have an appearance similar to that of low-grade chondrosarcomas and should be followed with serial radiographs to monitor for growth¹³.

Fig. 7

Fig. 7 This lateral radiograph of the knee shows an enchondroma in the distal part of the femoral shaft and the femoral metaphysis. It shows rings, arcs, and stipples of cartilaginous lesions.

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Enchondromatosis, or "Ollier disease," is a syndrome of multiple enchondromas (Fig. 8). The lesions cause angular deformity and limb-length discrepancy. Up to 50% of these patients develop a low-grade chondrosarcoma¹⁷.

Fig. 8

This anteroposterior radiograph of the pelvis in a patient with Ollier disease shows multiple enchondroma lesions involving multiple bones.

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Osteochondroma/Multiple Hereditary Exostoses

Osteochondromas are common cartilage-capped osseous metaphyseal lesions (Fig. 9). Most lesions are 1 to 3 cm long, and they can be pedunculated or sessile. If the lesion is pedunculated, the stalk is in continuity with the medullary canal. Many osteochondromas are asymptomatic, but if they do cause symptoms, surgical removal is common. There is a <1% chance of a solitary osteochondroma transforming into a chondrosarcoma¹³.

Fig. 9

This anteroposterior radiograph of the distal part of the femur shows an isolated osteochondroma that shares the medullary cavity.

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Multiple hereditary exostoses are skeletal dysplasias with multiple sessile osteochondromas throughout the skeleton, causing limb-length and angular deformities (Figs. 10 and 11). They are inherited in an autosomal dominant pattern with mutations in the tumor suppressor genes EXT1, EXT2, and EXT3. The radiographic findings include widened metaphyses, and the lesions are most common in the forearm, knee, and ankle. Up to 10% of patients develop chondrosarcomas, most commonly in the pelvis¹⁹.

Fig. 10

This anteroposterior radiograph of the pelvis shows multiple hereditary exostoses in the pelvis with multiple bones affected. Note how the proximal femoral metaphyses are broadened, which is characteristic of this lesion.

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Fig. 11

Fig. 11 This anteroposterior radiograph of the knee shows multiple hereditary exostoses with the distal part of the femur and proximal part of the tibia more broad than normal and multiple sessile and pedunculated osteochondromas.

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Eosinophilic Granuloma

Eosinophilic granuloma is a benign tumor of Langerhans-type histiocytes. They are usually painful lesions, with 90% occurring in children between five and fifteen years old²⁰. Radiographs show well-circumscribed, punched-out lytic lesions in the skull, ribs, clavicle, scapula, vertebrae, long bones, and pelvis (Fig. 12). In the spine, the common vertebral collapse is called "vertebra plana" (Fig. 13). Histologic analysis shows Langerhans cells with eosinophils and inflammatory cells. Treatment consists of intralesional injection of methylprednisolone acetate. In the spine, most solitary lesions can be treated with bracing and, rarely, radiation therapy for spinal cord compromise¹⁹.

Fig. 12

Fig. 12 This anteroposterior radiograph of lesion in the scapula shows a "hole within a hole," characteristic of eosinophilic granuloma, or Langerhans-cell histiocytosis.

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Fig. 13

Fig. 13 This lateral radiograph of the spine shows vertebra plana (a collapsed vertebral body), which is characteristic of eosinophilic granuloma or Langerhans-cell histiocytosis.

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Giant Cell Tumor

Giant cell tumor is an aggressive benign neoplasm that causes severe osseous destruction and can metastasize to the lungs²¹. The most common tumor sites include the distal part of the femur, proximal part of the tibia, and distal part of the radius, although giant cell tumor can appear just about anywhere in the skeleton²¹. Radiographically, a giant cell tumor is seen to be a purely lytic metaphyseal-epiphyseal lesion that can extend to the subchondral bone¹³ (Fig. 14). In the spine, this tumor primarily involves the vertebral bodies²². Biopsy specimens show a uniform distribution of giant cells along with mononuclear ovoid and spindle-shaped cells^13,21. Most lesions are treated with intralesional curettage^13,21.

Fig. 14

Fig. 14 This lateral radiograph of the ankle shows a well-defined lytic lesion that involves the metaphysis and epiphysis (typical of a giant cell tumor).

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Paget Disease

Paget disease is a disorder that causes osseous remodeling by a number of enlarged osteoclasts, with the deposition of new bone and subsequent deformity as the bone remodels²³. The cause is likely a slow virus, although there appears to be a genetic or geographic component to the disease: patients from Northern Europe and England appear to be more at risk for the disease¹³. Radiographically, patients with Paget disease show coarsened trabeculae, cortical thickening, and bone expansion with loss of the medullary cavity¹³ (Fig. 15). Over time, the long bones can bow. Treatment includes bisphosphonate therapy^13,23.

Fig. 15

Fig. 15 Paget disease has radiographic features that can be seen on this anteroposterior radiograph of the left hip. The thickened iliopectineal line, or "brim sign," is present, along with the thickened trabeculae, particularly about the acetabulum.

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Osteoid Osteoma

Osteoid osteoma presents as a painful lesion that is commonly found in the cortex of long bones, although it can also be found in the spine and pelvis. The pain associated with this lesion typically decreases with administration of nonsteroidal anti-inflammatory medications^13,24-26. The lesion itself is a 5 to 15-mm nidus that appears radiolucent on radiographs¹³ (Fig. 16). Advanced imaging studies, such as computed tomography or magnetic resonance imaging, have a higher sensitivity in diagnosing the lesion²⁴. Treatment most commonly involves radiofrequency ablation, although, in areas where this treatment may endanger critical adjacent neurovascular structures (e.g., the spine²⁵ and hand²⁶), the surgeon may perform resection and curettage.

Fig. 16

Fig. 16 This anteroposterior radiograph of the index finger shows an osteoid osteoma of the distal portion of the middle phalanx. The nidus is clearly visualized as a small area of bone within an area of radiolucency.

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Chondroblastoma

Chondroblastoma is a relatively rare entity, accounting for approximately 1% of all primary bone tumors²⁷. Although found just about anywhere in the skeleton, it most commonly occurs about the hip, shoulder, and knee joints²⁷. The lesion itself appears on radiographs as a lytic lesion confined to the epiphysis of a long bone (Fig. 17). Biopsy specimens show scattered giant cells in a field of mononuclear cells with what has been described as "chicken-wire" calcification¹³. Treatment includes curettage and grafting.

Fig. 17

Fig. 17 As seen on this anteroposterior radiograph of the proximal part of the tibia, a chondroblastoma is an epiphyseal lesion with surrounding sclerosis and no evidence of bone destruction.

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Unicameral Bone Cyst

Unicameral bone cysts commonly occur in children and heal with skeletal maturity. The most common sites include the proximal part of the humerus and proximal part of the femur²⁸. The bone cyst appears on radiographs as a lucent lesion with symmetric expansion of the bone (Fig. 18). The presence of a "fallen-leaf" sign (a piece of cortical bone that has fallen into the cyst and rests at the bottom) may be noted on radiographs¹³. Biopsy specimens show a thin membrane with no nuclear atypia and scattered inflammatory cells with spindle cells¹³.

Fig. 18

Fig. 18 This anteroposterior radiograph of the shoulder shows a unicameral bone cyst. The lesion is sclerotic with thinning of the metaphyseal cortex and a healing fracture.

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Overview

Introduction | Immersion Education | Bone Lesions | Overview | References

The bone lesions noted above, although clinically rare, often appear on the Orthopaedic In-Training Examination. The diagnosis, management, associated pathological findings, and genetic abnormalities of each entity are testable topics on the Orthopaedic In-Training Examination and Part I of the American Board of Orthopaedic Surgery examination. The education of surgical residents in an efficient, effective manner should be a priority for each orthopaedic program. Resident education through immersion is a teaching modality that might be useful in the education process, as this approach has proven to be effective in our institution.

References

Introduction | Immersion Education | Bone Lesions | Overview | References

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Dougherty PJ; Walter N; Schilling P; Najibi S; Herkowitz H. Do scores of the USMLE Step 1 and OITE correlate with the ABOS Part I certifying examination?: a multicenter study. Clin Orthop Relat Res. 2010 Mar 30 [Epub ahead of print].

Herndon JH; Allan BJ; Dyer G; Jawa A; Zurakowski D. Predictors of success on the American Board of Orthopaedic Surgery examination. Clin Orthop Relat Res. 2009;467:2436-45.[PubMed][CrossRef]

Frassica FJ; Papp D; McCarthy E; Weber K. Analysis of the pathology section of the OITE will aid in trainee preparation. Clin Orthop Relat Res. 2008;466:1323-8.[PubMed][CrossRef]

Marker DR; Mont MA; McGrath MS; Frassica FJ; LaPorte DM. Current hand surgery literature as an educational tool for the orthopaedic in-training examination. J Bone Joint Surg Am. 2009;91:236-40.[PubMed][CrossRef]

Srinivasan RC; Seybold JD; Salata MJ; Miller BS. An analysis of the orthopaedic in-training examination sports section: the importance of reviewing the current orthopaedic subspecialty literature. J Bone Joint Surg Am. 2010;92:778-82.[PubMed][CrossRef]

Srinivasan RC; Seybold JD; Kadakia AR. Analysis of the foot and ankle section of the Orthopaedic In-Training Examination (OITE). Foot Ankle Int. 2009;30:1060-4.[PubMed][CrossRef]

Marker DR; Mont MA; Seyler TM; LaPorte DM; Frassica FJ. Current literature: an educational tool to study osteonecrosis for the Orthopaedic In-Training Examination?Orthop Clin North Am. 2009;40:299-304.[PubMed][CrossRef]

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Burnette K; Ramundo M; Stevenson M; Beeson MS. Evaluation of a web-based asynchronous pediatric emergency medicine learning tool for residents and medical students. Acad Emerg Med. 2009;16 Suppl 2:S46-50.[PubMed][CrossRef]

Frassica FJ; Frassica DA; McCarthy EF. Orthopaedic pathology. In: Miller MD, editor. Review of orthopaedics. 5th ed. Philadelphia: Saunders; 2008. p 498-550.

Marulanda GA; Henderson ER; Johnson DA; Letson GD; Cheong D. Orthopedic surgery options for the treatment of primary osteosarcoma. Cancer Control. 2008;15:13-20.[PubMed]

Revell MP; Deshmukh N; Grimer RJ; Carter SR; Tillman RM. Periosteal osteosarcoma: a review of 17 cases with mean follow-up of 52 months. Sarcoma. 2002;6:123-30.[PubMed][CrossRef]

Lichtenstein L. Tumors of periosteal origin. Cancer. 1955;8:1060-9.[PubMed][CrossRef]

McCarthy EF; Frassica FJ. Pathology of bone and joint disorders: with clinical and radiographic correlation. Philadelphia: WB Saunders; 1998. Primary bone tumors; p 195-275.

Giuffrida AY; Burgueno JE; Koniaris LG; Gutierrez JC; Duncan R; Scully SP. Chondrosarcoma in the United States (1973 to 2003): an analysis of 2890 cases from the SEER database. J Bone Joint Surg Am. 2009;91:1063-72.[PubMed][CrossRef]

Weber K. Benign bone tumors and reactive lesions. In: Lieberman JR, editor. AAOS comprehensive orthopaedic review. Rosemont: American Academy of Orthopaedic Surgeons; 2009. p 391-415.

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Suneja R; Grimer RJ; Belthur M; Jeys L; Carter SR; Tillman RM; Davies AM. Chondroblastoma of bone: long-term results and functional outcome after intralesional curettage. J Bone Joint Surg Br. 2005;87:974-8.[PubMed]

Saraph V; Zwick EB; Maizen C; Schneider F; Linhart WE. Treatment of unicameral calcaneal bone cysts in children: review of literature and results using a cannulated screw for continuous decompression of the cyst. J Pediatr Orthop. 2004;24:568-73.[PubMed] [CrossRef]

Topics

osteosarcoma ; osteitis deformans ; chondrosarcoma ; bone cysts ; certification ; chondroblastoma ; chondroma ; enchondromatosis ; eosinophilic granuloma ; hereditary multiple exostoses

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Derek F. Papp, James C. Johnston, John A. Carrino, Edward F. McCarthy, Frank J. Frassica; Immersion Education for Orthopaedic Pathology: A Review of the Orthopaedic In-Training Examination and American Board of Orthopaedic Surgery Certification. The Journal of Bone & Joint Surgery. 2010 Dec;92(Supplement_2):152-160.

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