Clinical Orthopaedics and Related Research®

, Volume 471, Issue 3, pp 905–914

Using the CUSUM Test to Control the Proportion of Inadequate Open Biopsies of Musculoskeletal Tumors

  • David J. Biau
  • Kurt R. Weiss
  • Rej S. Bhumbra
  • Darin Davidson
  • Chris Brown
  • Jay S. Wunder
  • Peter C. Ferguson
Symposium: Highlights from the First Combined 2011 Meeting of the Musculoskeletal Tumor Society and Connective Tissue Oncology Society



Biopsies of musculoskeletal tumors lead to alterations in treatment in almost 20% of cases. Control charts are useful to ensure that a process is operating at a predetermined level of performance, although their use has not been demonstrated in assessing the adequacy of musculoskeletal biopsies.


We therefore (1) assessed the incidence of and the reasons for inadequate musculoskeletal biopsies when following guidelines for performing the procedure; and (2) implemented a process control chart, the CUSUM test, to monitor the proportion of inadequate biopsies.


We prospectively studied 116 incisional biopsies. The biopsy was performed according to 10 rules to (1) minimize contamination in the tissues surrounding the tumor; and (2) improve accuracy. A frozen section was systematically performed to confirm that a representative specimen was obtained. Procedures were considered inadequate if: (1) another biopsy was necessary; (2) the biopsy tract was not appropriately placed; and (3) the treatment provided based on the diagnosis from the biopsy was not appropriate.


Five (4.3%) of the 116 incisional biopsy procedures were considered failures. Three patients required a second repeat open biopsy and two were considered to receive inappropriate treatment. No alarm was raised by the control chart and the performance was deemed adequate over the monitoring period.


The proportion of inadequate musculoskeletal open biopsies performed at a referral center was low. Using a statistical process control method to monitor the failures provided a continuous measure of the performance.


  1. 1.
    Ashford RU, McCarthy SW, Scolyer RA, Bonar SF, Karim RZ, Stalley PD. Surgical biopsy with intra-operative frozen section. An accurate and cost-effective method for diagnosis of musculoskeletal sarcomas. J Bone Joint Surg Br. 2006;88:1207–1211.PubMedCrossRefGoogle Scholar
  2. 2.
    Biau DJ, Meziane M, Bhumbra RS, Dumaine V, Babinet A, Anract P. Monitoring the quality of total hip replacement in a tertiary care department using a cumulative summation statistical method (CUSUM). J Bone Joint Surg Br. 2011;93:1183–1188.PubMedCrossRefGoogle Scholar
  3. 3.
    Biau DJ, Resche-Rigon M, Godiris-Petit G, Nizard R, Porcher R. Quality control of surgical and interventional procedures: a review of the CUSUM. Qual Saf Health Care. 2007;16:203–207.PubMedCrossRefGoogle Scholar
  4. 4.
    Bickels J, Jelinek JS, Shmookler BM, Neff RS, Malawer MM. Biopsy of musculoskeletal tumors. Current concepts. Clin Orthop Relat Res. 1999;368:212–219.PubMedCrossRefGoogle Scholar
  5. 5.
    Collins GS, Jibawi A, McCulloch P. Control chart methods for monitoring surgical performance: a case study from gastro-oesophageal surgery. Eur J Surg Oncol. 2011;37:473–480.PubMedCrossRefGoogle Scholar
  6. 6.
    de Leval MR, Francois K, Bull C, Brawn W, Spiegelhalter D. Analysis of a cluster of surgical failures. Application to a series of neonatal arterial switch operations. J Thorac Cardiovasc Surg. 1994;107:914–923.PubMedGoogle Scholar
  7. 7.
    Dupuy DE, Rosenberg AE, Punyaratabandhu T, Tan MH, Mankin HJ. Accuracy of CT-guided needle biopsy of musculoskeletal neoplasms. AJR Am J Roentgenol. 1998;171:759–762.PubMedGoogle Scholar
  8. 8.
    Ehrlich PF, Friedman DL, Schwartz CL. Monitoring diagnostic accuracy and complications. A report from the Children’s Oncology Group Hodgkin lymphoma study. J Pediatr Surg. 2007;42:788–791.PubMedCrossRefGoogle Scholar
  9. 9.
    Institute of Medicine. To Err Is Human: Building a Safer Health System. Washington, DC, USA: National Academy Press; 2000.Google Scholar
  10. 10.
    Institute of Medicine. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC, USA: National Academy Press; 2001.Google Scholar
  11. 11.
    Macpherson GJ, Brenkel IJ, Smith R, Howie CR. Outlier analysis in orthopaedics: use of CUSUM: the Scottish Arthroplasty Project: shouldering the burden of improvement. J Bone Joint Surg Am. 2011;93:81–88.PubMedCrossRefGoogle Scholar
  12. 12.
    Mankin HJ, Lange TA, Spanier SS. The hazards of biopsy in patients with malignant primary bone and soft-tissue tumors. J Bone Joint Surg Am. 1982;64:1121–1127.PubMedGoogle Scholar
  13. 13.
    Mankin HJ, Mankin CJ, Simon MA. The hazards of the biopsy, revisited. Members of the Musculoskeletal Tumor Society. J Bone Joint Surg Am. 1996;78:656–663.PubMedGoogle Scholar
  14. 14.
    Montgomery DC. Introduction to Statistical Quality Control. 5th ed. New York, NY, USA: John Wiley and Sons; 2005.Google Scholar
  15. 15.
    Morton AP, Whitby M, McLaws ML, Dobson A, McElwain S, Looke D, Stackelroth J, Sartor A. The application of statistical process control charts to the detection and monitoring of hospital-acquired infections. Qual Clin Pract. 2001;21:112–117.CrossRefGoogle Scholar
  16. 16.
    National Cancer Institute. A snapshot of sarcoma. Available at: Accessed December 22, 2011.
  17. 17.
    Page ES. Continuous inspection schemes. Biometrika. 1954;41:100–115.Google Scholar
  18. 18.
    Papanna R, Biau DJ, Mann LK, Johnson A, Moise KJ. Use of the Learning Curve-Cumulative Summation test for quantitative and individualized assessment of competency of a surgical procedure in obstetrics and gynecology: fetoscopic laser ablation as a model. Am J Obstet Gynecol. 2011;204:1–9.CrossRefGoogle Scholar
  19. 19.
    Pollock RC, Stalley PD. Biopsy of musculoskeletal tumours—beware. ANZ J Surg. 2004;74:516–519.PubMedCrossRefGoogle Scholar
  20. 20.
    Rimondi E, Rossi G, Bartalena T, Ciminari R, Alberghini M, Ruggieri P, Errani C, Angelini A, Calabro T, Abati CN, Balladelli A, Tranfaglia C, Mavrogenis AF, Vanel D, Mercuri F. Percutaneous CT-guided biopsy of the musculoskeletal system: results of 2027 cases. Eur J Radiol. 2011;77:34–42.PubMedCrossRefGoogle Scholar
  21. 21.
    Rougraff BT, Aboulafia A, Biermann JS, Healey J. Biopsy of soft tissue masses: evidence-based medicine for the Musculoskeletal Tumor Society. Clin Orthop Relat Res. 2009;467:2783–2791.PubMedCrossRefGoogle Scholar
  22. 22.
    Skrzynski MC, Biermann JS, Montag A, Simon MA. Diagnostic accuracy and charge-savings of outpatient core needle biopsy compared with open biopsy of musculoskeletal tumors. J Bone Joint Surg Am. 1996;78:644–649.PubMedGoogle Scholar
  23. 23.
    Spiegelhalter D, Grigg O, Kinsman R, Treasure T. Risk-adjusted sequential probability ratio tests: applications to Bristol, Shipman and adult cardiac surgery. Int J Qual Health Care. 2003;15:7–13.PubMedCrossRefGoogle Scholar
  24. 24.
    The inquiry into the management of care of children receiving complex heart surgery at the Bristol Royal Infirmary. The Report of the Public Inquiry into children’s heart surgery at the Bristol Royal Infirmary 1984-1995. 2001. Available at:; Accessed May 21, 2012.

Copyright information

© The Association of Bone and Joint Surgeons® 2012

Authors and Affiliations

  • David J. Biau
    • 1
  • Kurt R. Weiss
    • 2
  • Rej S. Bhumbra
    • 3
  • Darin Davidson
    • 4
  • Chris Brown
    • 5
    • 6
  • Jay S. Wunder
    • 5
    • 6
  • Peter C. Ferguson
    • 5
    • 6
  1. 1.Department of Orthopaedic SurgeryHospital CochinParisFrance
  2. 2.Division of Musculoskeletal Oncology, Department of Orthopaedic SurgeryShadyside Medical CenterPittsburghUSA
  3. 3.London Sarcoma ServiceRoyal National Orthopaedic HospitalStanmoreUK
  4. 4.Department of Orthopaedics and Sports MedicineUniversity of WashingtonSeattleUSA
  5. 5.University Musculoskeletal Oncology UnitMount Sinai HospitalTorontoCanada
  6. 6.Sarcoma Site Group, Department of Surgical OncologyPrincess Margaret HospitalTorontoCanada

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