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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
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
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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
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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 [email protected].
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 [email protected].
Writing for JOPA: Information for Authors