Clinical Orthopaedics and Related Research®

, Volume 473, Issue 3, pp 868–874 | Cite as

What Is the Use of Imaging Before Referral to an Orthopaedic Oncologist? A Prospective, Multicenter Investigation

  • Benjamin J. Miller
  • Raffi S. Avedian
  • Rajiv Rajani
  • Lee Leddy
  • Jeremy R. White
  • Judd Cummings
  • Tessa Balach
  • Kevin MacDonald
  • on behalf of the Musculoskeletal Oncology Research Initiative
Symposium: 2013 Meetings of the Musculoskeletal Tumor Society and the International Society of Limb Salvage



Patients often receive advanced imaging before referral to an orthopaedic oncologist. The few studies that have evaluated the value of these tests have been single-center studies, and there were large discrepancies in the estimated frequencies of unnecessary use of diagnostic tests.


(1) Is there regional variation in the use of advanced imaging before referral to an orthopaedic oncologist? (2) Are these prereferral studies helpful to the treating orthopaedic oncologist in making a diagnosis or treatment plan? (3) Are orthopaedic surgeons less likely to order unhelpful studies than other specialties? (4) Are there any tumor or patient characteristics that are associated with the ordering of an unhelpful study?


We performed an eight-center prospective analysis of patients referred for evaluation by a fellowship-trained orthopaedic oncologist. We recorded patient factors, referral details, advanced imaging performed, and presumptive diagnosis. The treating orthopaedic oncologist determined whether each study was helpful in the diagnosis or treatment of the patient based on objective and subjective criteria used in prior investigations. We analyzed the data using bivariate methods and logistic regression to determine regional variation and risk factors predictive of unhelpful advanced imaging. Of the 371 participants available for analysis, 301 (81%) were referred with an MRI, CT scan, bone scan, ultrasound, or positron emission tomography scan.


There were no regional differences in the use of advanced imaging (range of patients presenting with advanced imaging 66%–88% across centers, p = 0.164). One hundred thirteen patients (30%) had at least one unhelpful study; non-MRI advanced imaging was more likely to be unhelpful than MRIs (88 of 129 [68%] non-MRI imaging versus 46 of 263 [17%] MRIs [p < 0.001]). Orthopaedic surgeons were no less likely than nonorthopaedic surgeons to order unhelpful studies before referral to an orthopaedic oncologist (56 of 179 [31%] of patients referred by orthopaedic surgeons versus 35 of 119 [29%] referred by primary care providers and 22 of 73 [30%] referred by nonorthopaedic specialists, p = 0.940). After controlling for potential confounding variables, benign bone lesions had an increased odds of referral with an unhelpful study (59 of 145 [41%] of benign bone tumors versus 54 of 226 [24%] of soft tissue tumors and malignant bone tumors; odds ratio, 2.80; 95% confidence interval, 1.68–4.69, p < 0.001).


We found no evidence that the proportion of patients referred with advanced imaging varied dramatically by region. Studies other than MRI were likely to be considered unhelpful and should not be routinely ordered by referring physicians. Diligent education of orthopaedic surgeons and primary care physicians in the judicious use of advanced imaging in benign bone tumors may help mitigate unnecessary imaging.

Level of Evidence

Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.


Positron Emission Tomography Orthopaedic Surgeon Soft Tissue Tumor Positron Emission Tomography Scan Bone Scan 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



We thank Yubo Gao PhD, for his assistance with the statistical analysis.


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Copyright information

© The Association of Bone and Joint Surgeons® 2014

Authors and Affiliations

  • Benjamin J. Miller
    • 1
  • Raffi S. Avedian
    • 2
  • Rajiv Rajani
    • 3
  • Lee Leddy
    • 4
  • Jeremy R. White
    • 5
  • Judd Cummings
    • 6
  • Tessa Balach
    • 7
  • Kevin MacDonald
    • 8
  • on behalf of the Musculoskeletal Oncology Research Initiative
  1. 1.Department of Orthopaedics and RehabilitationUniversity of IowaIowa CityUSA
  2. 2.Department of OrthopaedicsStanford University Medical CenterRedwood CityUSA
  3. 3.Department of OrthopaedicsUniversity of Texas Health Science CenterSan AntonioUSA
  4. 4.Department of OrthopaedicsMedical University of South CarolinaCharlestonUSA
  5. 5.Department of Orthopaedics and RehabilitationUniversity of OklahomaOklahoma CityUSA
  6. 6.Department of OrthopaedicsUniversity of ArizonaScottsdaleUSA
  7. 7.Department of Orthopaedic SurgeryUniversity of Connecticut Health CenterFarmingtonUSA
  8. 8.Department of Orthopaedic SurgeryVirginia Mason Medical CenterSeattleUSA

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