Dear Dr. Wenger:

We thank you for your constructive comments on the American Orthopaedic Association (AOA) Position Statement “Leadership in Orthopedics – Taking a Stand to Own the Bone.”

It is clear you agree with our basic thesis that, despite extraordinary advances in health care, patients with musculoskeletal disorders, and particularly those with fragility fractures, are not always receiving the highest standard of care as defined by evidence-based guidelines. Orthopaedic surgeons, as the first responders to fragility fractures, are in a unique position to facilitate and improve the healing process.

The sticking point appears to be the word “own.” You appear to define it as “possess” but we intended to imply “responsibility” and, more important, “obligation”. We believe that orthopaedic surgeons, the physicians whose focus is musculoskeletal health, are obligated to be the champion of improved bone health in America. The “Own the Bone” campaign is about owning up to that obligation.

When introducing the Surgeon General’s Report “Osteoporosis and Bone Health,” Dr. Richard Carmona pointed out that he knew very little about bone health prior to commissioning the report. When he attended medical school, osteoporosis and fragility fractures were considered a natural part of aging. Our own orthopaedic colleagues demonstrate that his education represents the rule, not the exception. Papers by Bernstein, DiCaprio, Freedman, and others report that musculoskeletal topics are taught by just over 40% of medical schools during the preclinical years and that a clinical rotation in musculoskeletal care is required in only 20%. Other medical disciplines will not take the lead here – nor should they. Endocrinologists and other sub-specialists may know more than orthopaedists about the nuances of rare metabolic bone disorders, but no other profession is as focused as we are on the broad aspects of bone health including biomechanics, nutrition, and repair. Equally important, we, more than any other specialty, understand the impact of bone health gone awry.

“Own the Bone” calls on orthopaedists to bring greater visibility to improved bone health by acting as its champions, not as mere technicians. We can serve as champions and leaders – uniting our fellow health professionals around a common goal of improving fragility fracture outcomes and post-fracture care. Our role as leaders also includes increasing public awareness of the prevention and treatment of bone disease. It includes outreach to academic medicine to expand musculoskeletal health training in medical school curricula.

Improving musculoskeletal health is far too big a challenge to be assumed by one specialty alone, but meeting such a challenge will require coordinated effort and leadership. It is this need that the AOA “Own the Bone” campaign seeks to fill.

Laura L. Tosi, MD, Stuart A. Hirsch, MD, Kenneth J. Koval, MD, Staphanie E. Mercado, Louis U. Bigliani, MD,

Corresponding author: Laura L. Tosi, MD Division of Orthopaedic Surgery Children’s National Medical Center 111 Michigan Ave. NW Washington, DC 20010

To The Editor:

I am writing to comment on the position statement noted above which recently appeared in the journal.

The overall encouragement for orthopedists to take an interest in bone fragility seems sound, since all would agree that we should feel a responsibility for understanding the systems which we are trained to diagnose and treat. Whether or not a busy operating orthopedic surgeon can provide the best medical management for osteoporosis (particularly in elderly patients who often are taking multiple drugs with associated risks for drug interactions) remains to be determined. I would note that we are also in the midst of an “avoid medical mistakes” campaign with poor knowledge of drug interactions a common source for medical errors.

My main reason for writing is to object to the second phrase in the title regarding taking a stand to “Own the Bone”. This catchy phrase may have some rhythmic value, but I find it inappropriate. To my ear, the term “own the bone” sounds aggressive, making us sound like someone who might be difficult to work with. A colleague has noted that only a possessive dog would have a strong need to “own his bone”.

Proper treatment of fractures of all types, particularly those possibly related to metabolic bone disease, requires sophisticated interchange and cross-consultation among specialties, including internal medicine, radiology, endocrinology, pediatrics, etc. Much of what I learned about metabolic bone disease, osteopenia, and/or osteoporosis has come from internists, pediatricians, endocrinologists and pediatric endocrinologists. For example, work by 20th century physician scientists such as Fuller Albright (Harvard; 1900-1969) allowed us to fully understand renal physiology, hyperparathyroidism, and its relationship to bone disease. I am certain that the late Professor Albright would be shocked to find that orthopedic surgeons now claim to “own the bone”.

Making a bold statement that orthopedists should “own the bone” seems counterproductive, with the potential to re-introduce outdated prejudices regarding the intellect of the average orthopedist (“strong as an ox and twice as smart”).

Perhaps you can forward these comments to the authors of the position paper for their comments. I compliment them on their good intentions and would be interested in hearing their opinion as to whether moderation or revision of their title might improve the chances for their campaign to succeed.

Dennis R. Wenger, M.D.

Director, Orthopedic Training Program Children’s Hospital-San Diego

Clinical Professor of Orthopedic Surgery University of California-San Diego