Diagnostic Familiarity with Osteochondroma Among Primary Physicians: A Retrospective Analysis of 195 Referred Cases

Diagnostic Familiarity with Osteochondroma Among Primary Physicians: A Retrospective Analysis of 195 Referred Cases | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Diagnostic Familiarity with Osteochondroma Among Primary Physicians: A Retrospective Analysis of 195 Referred Cases Manabu Hoshi, Masanari Aono, Yoshitaka Ban This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7770891/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 06 Mar, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted 14 You are reading this latest preprint version Abstract Introduction Osteochondroma is the most common benign bone tumor and is typically diagnosed based on its characteristic radiographic features. While it is generally familiar to orthopaedic surgeons, the level of diagnostic familiarity among primary physicians remains unclear. Materials and Methods This retrospective study reviewed 195 patients diagnosed with osteochondroma who were referred to a tertiary orthopaedic oncology center. Inclusion criteria included radiological confirmation of osteochondroma and the availability of referral documents from primary physicians. We evaluated the diagnostic accuracy of primary physicians by classifying their initial impressions as either “osteochondroma/exostosis” or “other diagnoses.” Primary physicians were classified by institutional affiliation (hospital or clinic) and medical specialty (orthopaedic or non-orthopaedic). Results Of the 195 cases, 118 (60.5%) were accurately described as osteochondroma or exostosis by primary physicians. Diagnostic familiarity varied by anatomical location, with higher familiarity in long bones (e.g., femur, tibia, radius/ulna) and lower familiarity in less typical locations such as the toes, fingers, and ribs. Physicians affiliated with hospitals demonstrated significantly higher diagnostic accuracy than those in clinics (p < 0.05), and orthopaedic surgeons outperformed non-orthopaedic physicians (p < 0.01). Conclusions The diagnostic familiarity with osteochondroma among primary physicians was moderate, with accurate identification in over half of the cases. However, familiarity varied depending on anatomical location and physician background. Improved education regarding atypical presentations of osteochondroma may further enhance diagnostic accuracy and patient care. Osteochondroma Exostosis Familiarity Referral document primary physician Figures Figure 1 Figure 2 Figure 3 Figure 4 Introduction Osteochondroma is the most common benign bone tumor, typically arising during childhood or adolescence [ 1 ]. It predominantly affects the metaphyseal regions of long bones, with the distal femur, proximal tibia, and proximal humerus being the most frequent sites [ 2 ]. Radiographically, it appears as a well-demarcated bony outgrowth that maintains corticomedullary continuity with the host bone (Fig. 1 )—a hallmark finding recognized by the WHO classification [ 3 ]. Epidemiologically, osteochondromas account for approximately 20% to 50% of all benign bone lesions [ 4 ]. Although often asymptomatic and discovered incidentally, they may become symptomatic due to mechanical irritation, cosmetic deformity, or compression of adjacent neurovascular structures, particularly when located near joints [ 5 ]. In most cases, plain radiography is sufficient for diagnosis due to their characteristic appearances. Osteochondroma is therefore a familiar entity in general orthopaedic practice, and diagnostic uncertainty is rare. These patients are occasionally referred to tertiary centers specializing in orthopaedic oncology, often due to limited diagnostic familiarity and to difficulty in follow-up from primary physicians. To date, few studies have systematically assessed the level of diagnostic familiarity regarding osteochondroma among non-specialist physicians. The present study aims to address this familiarity by retrospectively reviewing referral documents accompanying osteochondroma cases referred to our institution. Patients and Methods A total of 230 patients diagnosed with osteochondroma between September 2005 and December 2024 were retrospectively identified from our institutional database. Inclusion criteria were as follows: (1) availability of medical records and radiographic images at the time of initial presentation; (2) radiological diagnosis of osteochondroma, confirmed by three orthopaedic oncologists certified by the Japanese Orthopaedic Association; and (3) accessible referral documents submitted by primary physicians. A total of 195 patients diagnosed with osteochondroma between September 2005 and December 2024 were identified from an institutional database for comparative analysis. Demographic and clinical data were extracted from the medical records, including age, sex, presenting symptoms, anatomical location of the lesion, number of lesions, presence of multiple hereditary exostoses (MHE), laterality, referring institution type (clinic or hospital), and medical specialty of the primary physician. In this study, familiarity was defined as the primary physician's ability to recognize osteochondroma based on clinical presentation and plain radiographs prior to specialist referral. To evaluate the familiarity of primary physicians with osteochondroma, we retrospectively reviewed medical records of patients who were referred to our institution with a correctly suspected diagnosis of osteochondroma or exostosis. The initial primary physicians were classified according to their affiliated institution (hospital or clinic) and their specialty (orthopaedic surgeon or non-orthopaedic surgeon). The initial diagnostic impression made by these physicians was recorded and categorized as either “osteochondroma/exostosis” or “non-osteochondroma/exostosis.” In this study, a clinic was defined as a community-based medical facility primarily offering outpatient care, typically staffed by a limited number of healthcare professionals and equipped with fewer than 20 beds. A hospital was defined as a larger medical institution with multiple clinical departments and a minimum capacity of 20 inpatient beds. This study was performed in accordance with relevant guidelines and regulations and approved by the Institutional Review Board of the Osaka City General Hospital. This study was a retrospective chart review; thus, consent for participation was waived, and approval of this waiver was obtained by the institutional review board of Osaka City General Hospital. Statistical analyses Fisher’s exact probability test was performed to statistically assess the relationship between physician characteristics and diagnostic accuracy. Statistical significance was set at p < 0.05, and analyses were performed using Excel Statistics for Windows (version 2025; SSRI Co., Ltd., Tokyo, Japan). Results A total of 195 patients (124 males and 71 females) were retrospectively included in this study. The median age at diagnosis was 13 years (range, 1–68 years). Demographic characteristics are summarized in Table 1. The most common presenting symptom was pain, reported in 91 cases (46.7%), followed by palpable mass in 45 cases (23.1%), deformity in 30 cases (15.4%), and incidental detection in 22 cases (11.3%). The anatomical distribution of lesions included the femur (57 cases), tibia/fibula (57), rib (18), humerus (12), radius/ulna (12), fingers (12), and toes (11). Multiple lesions were identified in 64 patients (32.8%), and multiple hereditary exostoses were diagnosed in 20 patients (10.3%). Primary physicians were affiliated with hospitals in 73 cases (37.4%) and clinics in 122 cases (62.6%). The majority of referrals were made by orthopaedic surgeons (161 cases, 82.6%), followed by pediatricians (11 cases, 5.6%). The suspected diagnoses documented by primary physicians in the accompanying referral letters are summarized in Fig. 2 . Among these, "exostosis" and "osteochondroma" were the most frequently medical terms, noted in 73 and 45 cases, respectively, meaning diagnostic accuracy was 60.5% (73 + 45/195 cases). A total of 42 cases were simply described as bone tumors without a specific qualitative diagnosis. Osteosarcoma was suspected in 2 cases (Fig. 3 a,b). In addition, 8 cases were described simply as “bony protrusions,” while 3 cases were classified as “deformities,” and another 3 as “osseous or chondromatous formations.” The remaining cases were diagnosed as follows: osteoid osteoma (n = 2), arthropathy (n = 2), skin/subcutaneous tumor (n = 2), osteosarcoma (n = 2), accessory bone (n = 1), giant cell tumor of bone (n = 1), enchondroma (n = 1), hernia (n = 1), bone spur (n = 1), extension limitation (n = 1), chondroid lesion (n = 1), calcification (n = 1), myositis ossificans (n = 1), malformation (n = 1), abnormal finding (n = 1), proliferative bone change (n = 1), and lump (n = 1). The familiarity with osteochondroma varied significantly depending on the anatomical location (Fig. 4 ). The radius/ulna had the highest familiarity rate at 72.7%, followed closely by the tibia/fibula (69.0%) and the femur (68.4%). These long bones were generally associated with higher levels of familiarity among primary physicians. Moderate familiarity was observed for the humerus (58.3%), whereas the rib and finger regions showed substantially lower familiarity rates, both at 33.3%. The toe had the lowest familiarity rate at 27.3%. These results suggest that osteochondromas occurring in major long bones are more familiar to primary physicians, while those in smaller or less typical sites such as the toes, fingers, and ribs tend to be less well known. Table 2 presents the association between the initial suspected diagnosis of osteochondroma/exostosis and the characteristics of the primary physicians, including their institutional affiliation and specialty. The primary physicians affiliated with hospitals demonstrated a higher likelihood of correctly diagnosing osteochondroma compared to those practicing in clinics (p < 0.05). Moreover, diagnostic accuracy was significantly greater among orthopaedic surgeons than among non- orthopaedic physicians (p < 0.01). These findings suggest that both the institutional setting and the physician’s specialty play a critical role in the accurate clinical suspicion of osteochondroma/exostosis. Discussion This study investigated the diagnostic familiarity with osteochondroma by retrospectively analyzing referral documents from a large cohort of patients. Overall, diagnostic familiarity was moderately high, with over half of the cases accurately identified as osteochondroma or exostosis by primary physicians. However, familiarity varied substantially depending on anatomical site and institutional setting, indicating room for improvement in recognition among non-specialist physicians. The diagnostic familiarity rate was 60.5%, indicating that nearly 40% of referral documents lacked a specific or correct diagnostic impression of osteochondroma. While osteochondroma is a commonly encountered and radiographically distinct benign bone tumor in orthopedic practice, our findings suggest that familiarity among primary physicians, particularly those outside orthopaedic specialties, tends to be limited, which may be understandable given their relatively infrequent exposure to bone lesions in daily practice. [ 6 , 7 ]. Although only two cases were referred with a suspicion of malignancy, such as osteosarcoma, limited familiarity can still lead to unnecessary anxiety [ 8 ]. Osteochondroma typically presents as a pedunculated or sessile bony outgrowth with corticomedullary continuity, features that are generally diagnostic on plain radiographs[ 6 , 9 ]. However, correct interpretation requires an understanding of both imaging findings and clinical context. While orthopaedic surgeons are more likely to recognize these patterns due to routine exposure, general practitioners and pediatricians may use broader or vague descriptors such as “bone tumor” or “bony protrusion,” reflecting limited exposure to musculoskeletal tumors during training[ 10 ]. One of the most striking findings of this study was the significant variation in familiarity depending on lesion location. Osteochondromas arising in long bones—especially the femur, tibia/fibula, and radius/ulna—were more frequently recognized, with diagnostic familiarity exceeding 68%. In contrast, familiarity rates dropped markedly for lesions in the toes, fingers, and ribs, with the toe showing the lowest recognition rate at 27.3%. This discrepancy likely reflects the more common involvement of long bones in osteochondroma and the greater visibility of such cases in educational materials and clinical practice [ 11 , 12 ]. Conversely, osteochondromas in atypical locations may present with non-specific or misleading symptoms—such as digital deformity or rib discomfort—that are more likely to be misattributed to trauma, arthropathy, or soft tissue masses[ 11 , 13 ]. Additionally, radiographs of the hands and feet often pose interpretation challenges due to overlapping anatomy or smaller lesion size[ 10 ]. The institutional setting of the primary physician was also significantly associated with diagnostic accuracy. Physicians affiliated with hospitals demonstrated a higher rate of correct diagnosis than those in clinics. Several factors may account for this difference, including greater access to diagnostic imaging, consultation with orthopaedic or radiology specialists, and a higher volume of musculoskeletal cases in hospital settings[ 14 ]. In contrast, clinic-based physicians—especially those in community practices—often operate with limited imaging modalities and may face broader, non-specialized case loads, reducing their familiarity with rare orthopaedic conditions[ 14 , 15 ]. Another noted observation in this study was the dual usage of the terms “exostosis” and “osteochondroma.” In our cohort, both terms were frequently used by primary physicians, with “exostosis” appearing slightly more often. Although both refer to the same pathological entity, their usage may reflect differing levels of diagnostic familiarity or educational background. “Osteochondroma” is the preferred term in academic and orthopedic literature and is used in WHO classifications and radiologic reports. The World Health Organization specifically recommends the use of “osteochondroma” rather than “exostosis” as the appropriate terminology. In contrast, “exostosis” is a more generic and less specific term that is often used in clinical practice or in older medical educational contexts. Its usage may indicate a less precise diagnostic impression or unfamiliarity with formal medical nomenclature. However, it should be noted that the use of terms such as “subungual exostosis” is well established in clinical practice and refers to a distinct pathological entity; therefore, such terminology is appropriate and not subject to the same standardization concerns. This study has several limitations. First, it was retrospective in design and limited to a single institution, which may affect generalizability. Second, the diagnostic terminology used in referral letters may not fully reflect the referring physician’s level of understanding, particularly if terms were simplified for communication purposes. Third, the study did not evaluate the long-term outcomes of patients based on initial diagnostic accuracy. Despite these limitations, our findings provide valuable insight into diagnostic patterns and highlight potential areas for educational improvement. In conclusion, while familiarity with osteochondroma among primary physicians was moderately high, it varied significantly based on lesion location and physician background. Osteochondromas in typical long bone sites were more readily identified, whereas lesions in atypical locations were often under-recognized. Hospital-based physicians and orthopaedic surgeons demonstrated greater diagnostic accuracy. These findings highlight the need for enhanced musculoskeletal education among primary care providers to improve early recognition, reduce unnecessary testing, and streamline referrals for benign bone tumors. Declarations Author Contribution M.H. wrote the main manuscript text and B.Y. and M.A.prepared figures and tables. All authors reviewed the manuscript. Acknowledgement None Data Availability The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request. References Kitsoulis P, Galani V, Stefanaki K, Paraskevas G, Karatzias G, Agnantis NJ, Bai M (2008) Osteochondromas: Review of the clinical, radiological and pathological features. Vivo 22(5):633–646 Unni KK, Inwards CY (2010) Dahlin's Bone Tumors: General Aspects and Data on 10,165 Cases, 6th edn. Lippincott Williams & Wilkins, Philadelphia WHO Classification of Tumours Editorial Board (2020) Soft Tissue and Bone Tumours. WHO Classification of Tumours, 5th Edition, Volume 3. Lyon: IARC Press Noordin S, Allana S, Uddin N, Hilal K, Nadeem N, Lakdawala R, Osteochondroma (2010) A multicenter study of clinical, radiological and pathological features of 382 cases. 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Clin Orthop Relat Res 478(5):1054–1060 Jeong JY, Lee EH, Lee SH, Kang YK (2021) Diagnostic accuracy and radiologic characteristics of osteochondroma in unusual locations. Skeletal Radiol 50(3):563–570 D’Ambrosio L, Albano D, Messina C et al (2019) Imaging of osteochondroma: beyond the basics. Clin Imaging 57:83–92 Puri A, Agarwal MG, Reddy K et al (2021) Diagnostic dilemmas in skeletal lesions with atypical presentations. Indian J Orthop 55(1):49–55 Zhao C, Fan H, Jiang S et al (2020) Differences in diagnostic performance for bone tumors between community and academic settings. J Orthop Surg Res 15:111 Ahmed SK, Garton HJ, Mahajan A (2019) Diagnostic challenges in rural settings: musculoskeletal lesions. Rural Remote Health 19(3):5175 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 06 Mar, 2026 Read the published version in Archives of Orthopaedic and Trauma Surgery → Version 1 posted Editorial decision: Revision requested 16 Nov, 2025 Reviews received at journal 15 Nov, 2025 Reviewers agreed at journal 03 Nov, 2025 Reviewers agreed at journal 02 Nov, 2025 Reviews received at journal 26 Oct, 2025 Reviewers agreed at journal 19 Oct, 2025 Reviews received at journal 17 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 16 Oct, 2025 Reviewers agreed at journal 10 Oct, 2025 Reviewers invited by journal 10 Oct, 2025 Editor assigned by journal 07 Oct, 2025 Submission checks completed at journal 07 Oct, 2025 First submitted to journal 03 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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13:56:23","extension":"png","order_by":22,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":7863,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/cde1bb9bb902d71470959daa.png"},{"id":94398425,"identity":"33fb4feb-99d5-4dba-af39-db11f47a20a9","added_by":"auto","created_at":"2025-10-27 13:57:05","extension":"png","order_by":23,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":26981,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/381ded09d9691aaaa5016499.png"},{"id":94489217,"identity":"a30177b5-9e96-4942-b959-bc1f99b8ade1","added_by":"auto","created_at":"2025-10-27 17:03:49","extension":"xml","order_by":24,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":41505,"visible":true,"origin":"","legend":"","description":"","filename":"be6c4f4e602a48e8939157606e518fbb1structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/e7983046aa068d8025ec619a.xml"},{"id":94397257,"identity":"2e29d4e3-8704-4ee3-9380-08e1d67ba83e","added_by":"auto","created_at":"2025-10-27 13:56:34","extension":"html","order_by":25,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":48817,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/edc536a0f7f52f43eb8875cb.html"},{"id":94397351,"identity":"624e9c57-86b1-45a0-802a-99c8d2ebed04","added_by":"auto","created_at":"2025-10-27 13:56:39","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":134240,"visible":true,"origin":"","legend":"\u003cp\u003eA 16-year-old male with an osteochondroma of the distal femur. (a) Anteroposterior radiograph of the right knee shows a pedunculated bony protrusion from the distal metaphysis of the femur.\u003c/p\u003e","description":"","filename":"Figure.2.png","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/8f4110585bf6e401fe56d031.png"},{"id":94397285,"identity":"117ba05c-29d4-4c73-af7d-b1f0b421f965","added_by":"auto","created_at":"2025-10-27 13:56:36","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":98501,"visible":true,"origin":"","legend":"\u003cp\u003eSuspected diagnosis in patient referral document\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/5a3c88e434516d9343a4ded1.png"},{"id":94397551,"identity":"3d031498-f580-40ca-ba06-35588b23290c","added_by":"auto","created_at":"2025-10-27 13:56:43","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":2095223,"visible":true,"origin":"","legend":"\u003cp\u003eA 15-year-old male with a costal osteochondroma misdiagnosed as osteosarcoma by the referring physician. (a) Chest radiograph shows a well-defined, calcified mass arising from the left posterior rib. (b) Axial CT image clearly demonstrates a sessile bony outgrowth with cortical and medullary continuity from the rib, consistent with osteochondroma.\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/3faa4c394d3992e0f1eb65ee.png"},{"id":94397294,"identity":"b4e7fd40-c312-4a16-afb9-01d7f6c47a71","added_by":"auto","created_at":"2025-10-27 13:56:36","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":55261,"visible":true,"origin":"","legend":"\u003cp\u003eFamiliarity with osteochondroma by anatomical location.\u003cbr\u003e\nStacked bar graph illustrating the percentage of primary physicians who reported familiarity with osteochondroma according to the anatomical site of the lesion. The highest levels of familiarity were observed for lesions in the radius/ulna (72.7%), tibia/fibula (69.0%), and femur (68.4%), whereas the lowest levels were noted for lesions in the toe (27.3%), rib (33.3%), and finger (33.3%).\u003c/p\u003e","description":"","filename":"Figure4.png","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/e85da494ba3b45026b68268d.png"},{"id":104251667,"identity":"7bcff373-1e05-4a0e-812a-3baffe49e2b3","added_by":"auto","created_at":"2026-03-09 16:14:50","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2707376,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7770891/v1/f939386b-22a0-4210-95b1-f454da5bc6b5.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Diagnostic Familiarity with Osteochondroma Among Primary Physicians: A Retrospective Analysis of 195 Referred Cases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eOsteochondroma is the most common benign bone tumor, typically arising during childhood or adolescence [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. It predominantly affects the metaphyseal regions of long bones, with the distal femur, proximal tibia, and proximal humerus being the most frequent sites [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Radiographically, it appears as a well-demarcated bony outgrowth that maintains corticomedullary continuity with the host bone (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e)\u0026mdash;a hallmark finding recognized by the WHO classification [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eEpidemiologically, osteochondromas account for approximately 20% to 50% of all benign bone lesions [\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Although often asymptomatic and discovered incidentally, they may become symptomatic due to mechanical irritation, cosmetic deformity, or compression of adjacent neurovascular structures, particularly when located near joints [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn most cases, plain radiography is sufficient for diagnosis due to their characteristic appearances. Osteochondroma is therefore a familiar entity in general orthopaedic practice, and diagnostic uncertainty is rare. These patients are occasionally referred to tertiary centers specializing in orthopaedic oncology, often due to limited diagnostic familiarity and to difficulty in follow-up from primary physicians.\u003c/p\u003e\u003cp\u003eTo date, few studies have systematically assessed the level of diagnostic familiarity regarding osteochondroma among non-specialist physicians. The present study aims to address this familiarity by retrospectively reviewing referral documents accompanying osteochondroma cases referred to our institution.\u003c/p\u003e"},{"header":"Patients and Methods","content":"\u003cp\u003eA total of 230 patients diagnosed with osteochondroma between September 2005 and December 2024 were retrospectively identified from our institutional database. Inclusion criteria were as follows: (1) availability of medical records and radiographic images at the time of initial presentation; (2) radiological diagnosis of osteochondroma, confirmed by three orthopaedic oncologists certified by the Japanese Orthopaedic Association; and (3) accessible referral documents submitted by primary physicians.\u003c/p\u003e\u003cp\u003eA total of 195 patients diagnosed with osteochondroma between September 2005 and December 2024 were identified from an institutional database for comparative analysis.\u003c/p\u003e\u003cp\u003eDemographic and clinical data were extracted from the medical records, including age, sex, presenting symptoms, anatomical location of the lesion, number of lesions, presence of multiple hereditary exostoses (MHE), laterality, referring institution type (clinic or hospital), and medical specialty of the primary physician.\u003c/p\u003e\u003cp\u003eIn this study, familiarity was defined as the primary physician's ability to recognize osteochondroma based on clinical presentation and plain radiographs prior to specialist referral. To evaluate the familiarity of primary physicians with osteochondroma, we retrospectively reviewed medical records of patients who were referred to our institution with a correctly suspected diagnosis of osteochondroma or exostosis. The initial primary physicians were classified according to their affiliated institution (hospital or clinic) and their specialty (orthopaedic surgeon or non-orthopaedic surgeon). The initial diagnostic impression made by these physicians was recorded and categorized as either \u0026ldquo;osteochondroma/exostosis\u0026rdquo; or \u0026ldquo;non-osteochondroma/exostosis.\u0026rdquo;\u003c/p\u003e\u003cp\u003eIn this study, a clinic was defined as a community-based medical facility primarily offering outpatient care, typically staffed by a limited number of healthcare professionals and equipped with fewer than 20 beds. A hospital was defined as a larger medical institution with multiple clinical departments and a minimum capacity of 20 inpatient beds.\u003c/p\u003e\u003cp\u003e This study was performed in accordance with relevant guidelines and regulations and approved by the Institutional Review Board of the Osaka City General Hospital. This study was a retrospective chart review; thus, consent for participation was waived, and approval of this waiver was obtained by the institutional review board of Osaka City General Hospital.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical analyses\u003c/h2\u003e\u003cp\u003eFisher\u0026rsquo;s exact probability test was performed to statistically assess the relationship between physician characteristics and diagnostic accuracy. Statistical significance was set at p\u0026thinsp;\u0026lt;\u0026thinsp;0.05, and analyses were performed using Excel Statistics for Windows (version 2025; SSRI Co., Ltd., Tokyo, Japan).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eA total of 195 patients (124 males and 71 females) were retrospectively included in this study. The median age at diagnosis was 13 years (range, 1\u0026ndash;68 years). Demographic characteristics are summarized in Table\u0026nbsp;1.\u003c/p\u003e\u003cp\u003eThe most common presenting symptom was pain, reported in 91 cases (46.7%), followed by palpable mass in 45 cases (23.1%), deformity in 30 cases (15.4%), and incidental detection in 22 cases (11.3%).\u003c/p\u003e\u003cp\u003eThe anatomical distribution of lesions included the femur (57 cases), tibia/fibula (57), rib (18), humerus (12), radius/ulna (12), fingers (12), and toes (11). Multiple lesions were identified in 64 patients (32.8%), and multiple hereditary exostoses were diagnosed in 20 patients (10.3%).\u003c/p\u003e\u003cp\u003ePrimary physicians were affiliated with hospitals in 73 cases (37.4%) and clinics in 122 cases (62.6%). The majority of referrals were made by orthopaedic surgeons (161 cases, 82.6%), followed by pediatricians (11 cases, 5.6%).\u003c/p\u003e\u003cp\u003eThe suspected diagnoses documented by primary physicians in the accompanying referral letters are summarized in Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Among these, \"exostosis\" and \"osteochondroma\" were the most frequently medical terms, noted in 73 and 45 cases, respectively, meaning diagnostic accuracy was 60.5% (73\u0026thinsp;+\u0026thinsp;45/195 cases). A total of 42 cases were simply described as bone tumors without a specific qualitative diagnosis. Osteosarcoma was suspected in 2 cases (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003ea,b). In addition, 8 cases were described simply as \u0026ldquo;bony protrusions,\u0026rdquo; while 3 cases were classified as \u0026ldquo;deformities,\u0026rdquo; and another 3 as \u0026ldquo;osseous or chondromatous formations.\u0026rdquo; The remaining cases were diagnosed as follows: osteoid osteoma (n\u0026thinsp;=\u0026thinsp;2), arthropathy (n\u0026thinsp;=\u0026thinsp;2), skin/subcutaneous tumor (n\u0026thinsp;=\u0026thinsp;2), osteosarcoma (n\u0026thinsp;=\u0026thinsp;2), accessory bone (n\u0026thinsp;=\u0026thinsp;1), giant cell tumor of bone (n\u0026thinsp;=\u0026thinsp;1), enchondroma (n\u0026thinsp;=\u0026thinsp;1), hernia (n\u0026thinsp;=\u0026thinsp;1), bone spur (n\u0026thinsp;=\u0026thinsp;1), extension limitation (n\u0026thinsp;=\u0026thinsp;1), chondroid lesion (n\u0026thinsp;=\u0026thinsp;1), calcification (n\u0026thinsp;=\u0026thinsp;1), myositis ossificans (n\u0026thinsp;=\u0026thinsp;1), malformation (n\u0026thinsp;=\u0026thinsp;1), abnormal finding (n\u0026thinsp;=\u0026thinsp;1), proliferative bone change (n\u0026thinsp;=\u0026thinsp;1), and lump (n\u0026thinsp;=\u0026thinsp;1).\u003c/p\u003e\u003cp\u003eThe familiarity with osteochondroma varied significantly depending on the anatomical location (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). The radius/ulna had the highest familiarity rate at 72.7%, followed closely by the tibia/fibula (69.0%) and the femur (68.4%). These long bones were generally associated with higher levels of familiarity among primary physicians. Moderate familiarity was observed for the humerus (58.3%), whereas the rib and finger regions showed substantially lower familiarity rates, both at 33.3%. The toe had the lowest familiarity rate at 27.3%. These results suggest that osteochondromas occurring in major long bones are more familiar to primary physicians, while those in smaller or less typical sites such as the toes, fingers, and ribs tend to be less well known.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;2 presents the association between the initial suspected diagnosis of osteochondroma/exostosis and the characteristics of the primary physicians, including their institutional affiliation and specialty.\u003c/p\u003e\u003cp\u003eThe primary physicians affiliated with hospitals demonstrated a higher likelihood of correctly diagnosing osteochondroma compared to those practicing in clinics (p\u0026thinsp;\u0026lt;\u0026thinsp;0.05). Moreover, diagnostic accuracy was significantly greater among orthopaedic surgeons than among non- orthopaedic physicians (p\u0026thinsp;\u0026lt;\u0026thinsp;0.01). These findings suggest that both the institutional setting and the physician\u0026rsquo;s specialty play a critical role in the accurate clinical suspicion of osteochondroma/exostosis.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study investigated the diagnostic familiarity with osteochondroma by retrospectively analyzing referral documents from a large cohort of patients. Overall, diagnostic familiarity was moderately high, with over half of the cases accurately identified as osteochondroma or exostosis by primary physicians. However, familiarity varied substantially depending on anatomical site and institutional setting, indicating room for improvement in recognition among non-specialist physicians.\u003c/p\u003e\u003cp\u003eThe diagnostic familiarity rate was 60.5%, indicating that nearly 40% of referral documents lacked a specific or correct diagnostic impression of osteochondroma. While osteochondroma is a commonly encountered and radiographically distinct benign bone tumor in orthopedic practice, our findings suggest that familiarity among primary physicians, particularly those outside orthopaedic specialties, tends to be limited, which may be understandable given their relatively infrequent exposure to bone lesions in daily practice. [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Although only two cases were referred with a suspicion of malignancy, such as osteosarcoma, limited familiarity can still lead to unnecessary anxiety [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOsteochondroma typically presents as a pedunculated or sessile bony outgrowth with corticomedullary continuity, features that are generally diagnostic on plain radiographs[\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. However, correct interpretation requires an understanding of both imaging findings and clinical context. While orthopaedic surgeons are more likely to recognize these patterns due to routine exposure, general practitioners and pediatricians may use broader or vague descriptors such as \u0026ldquo;bone tumor\u0026rdquo; or \u0026ldquo;bony protrusion,\u0026rdquo; reflecting limited exposure to musculoskeletal tumors during training[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eOne of the most striking findings of this study was the significant variation in familiarity depending on lesion location. Osteochondromas arising in long bones\u0026mdash;especially the femur, tibia/fibula, and radius/ulna\u0026mdash;were more frequently recognized, with diagnostic familiarity exceeding 68%. In contrast, familiarity rates dropped markedly for lesions in the toes, fingers, and ribs, with the toe showing the lowest recognition rate at 27.3%. This discrepancy likely reflects the more common involvement of long bones in osteochondroma and the greater visibility of such cases in educational materials and clinical practice [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Conversely, osteochondromas in atypical locations may present with non-specific or misleading symptoms\u0026mdash;such as digital deformity or rib discomfort\u0026mdash;that are more likely to be misattributed to trauma, arthropathy, or soft tissue masses[\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Additionally, radiographs of the hands and feet often pose interpretation challenges due to overlapping anatomy or smaller lesion size[\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe institutional setting of the primary physician was also significantly associated with diagnostic accuracy. Physicians affiliated with hospitals demonstrated a higher rate of correct diagnosis than those in clinics. Several factors may account for this difference, including greater access to diagnostic imaging, consultation with orthopaedic or radiology specialists, and a higher volume of musculoskeletal cases in hospital settings[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In contrast, clinic-based physicians\u0026mdash;especially those in community practices\u0026mdash;often operate with limited imaging modalities and may face broader, non-specialized case loads, reducing their familiarity with rare orthopaedic conditions[\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAnother noted observation in this study was the dual usage of the terms \u0026ldquo;exostosis\u0026rdquo; and \u0026ldquo;osteochondroma.\u0026rdquo; In our cohort, both terms were frequently used by primary physicians, with \u0026ldquo;exostosis\u0026rdquo; appearing slightly more often. Although both refer to the same pathological entity, their usage may reflect differing levels of diagnostic familiarity or educational background. \u0026ldquo;Osteochondroma\u0026rdquo; is the preferred term in academic and orthopedic literature and is used in WHO classifications and radiologic reports. The World Health Organization specifically recommends the use of \u0026ldquo;osteochondroma\u0026rdquo; rather than \u0026ldquo;exostosis\u0026rdquo; as the appropriate terminology. In contrast, \u0026ldquo;exostosis\u0026rdquo; is a more generic and less specific term that is often used in clinical practice or in older medical educational contexts. Its usage may indicate a less precise diagnostic impression or unfamiliarity with formal medical nomenclature. However, it should be noted that the use of terms such as \u0026ldquo;subungual exostosis\u0026rdquo; is well established in clinical practice and refers to a distinct pathological entity; therefore, such terminology is appropriate and not subject to the same standardization concerns.\u003c/p\u003e\u003cp\u003eThis study has several limitations. First, it was retrospective in design and limited to a single institution, which may affect generalizability. Second, the diagnostic terminology used in referral letters may not fully reflect the referring physician\u0026rsquo;s level of understanding, particularly if terms were simplified for communication purposes. Third, the study did not evaluate the long-term outcomes of patients based on initial diagnostic accuracy. Despite these limitations, our findings provide valuable insight into diagnostic patterns and highlight potential areas for educational improvement.\u003c/p\u003e\u003cp\u003eIn conclusion, while familiarity with osteochondroma among primary physicians was moderately high, it varied significantly based on lesion location and physician background. Osteochondromas in typical long bone sites were more readily identified, whereas lesions in atypical locations were often under-recognized. Hospital-based physicians and orthopaedic surgeons demonstrated greater diagnostic accuracy. These findings highlight the need for enhanced musculoskeletal education among primary care providers to improve early recognition, reduce unnecessary testing, and streamline referrals for benign bone tumors.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eM.H. wrote the main manuscript text and B.Y. and M.A.prepared figures and tables. All authors reviewed the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eNone\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKitsoulis P, Galani V, Stefanaki K, Paraskevas G, Karatzias G, Agnantis NJ, Bai M (2008) Osteochondromas: Review of the clinical, radiological and pathological features. Vivo 22(5):633\u0026ndash;646\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eUnni KK, Inwards CY (2010) Dahlin's Bone Tumors: General Aspects and Data on 10,165 Cases, 6th edn. Lippincott Williams \u0026amp; Wilkins, Philadelphia\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWHO Classification of Tumours Editorial Board (2020) Soft Tissue and Bone Tumours. WHO Classification of Tumours, 5th Edition, Volume 3. Lyon: IARC Press\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNoordin S, Allana S, Uddin N, Hilal K, Nadeem N, Lakdawala R, Osteochondroma (2010) A multicenter study of clinical, radiological and pathological features of 382 cases. J Pak Med Assoc 60(10):802\u0026ndash;805\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMurphey MD, Choi JJ, Kransdorf MJ, Flemming DJ, Gannon FH (2000) Imaging of osteochondroma: variants and complications with radiologic-pathologic correlation. Radiographics 20(5):1407\u0026ndash;1434\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eOsteochondromas An Updated Review of Epidemiology, Pathogenesis, Clinical Presentation, Radiological Features and Treatment Options. In Vivo 2021 Mar-Apr ;35(2):681\u0026ndash;691\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaminiau AH (2019) Osteochondroma: a common benign tumor with a rare malignant transformation. J Pediatr Orthop B 28(3):217\u0026ndash;221\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHameetman L, Szuhai K, Yavas A et al (2020) The role of EXT1 in osteochondroma development and progression to peripheral chondrosarcoma. J Pathol 250(4):408\u0026ndash;417\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGeiger J, Farzan M, Aboulafia AJ (2018) Solitary osteochondromas of the long bones. J Am Acad Orthop Surg 26(5):160\u0026ndash;165\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDowney RJ, Mirsky DM, Sarmiento KD et al (2020) Recognition of benign bone tumors by primary care physicians: a clinical challenge. Clin Orthop Relat Res 478(5):1054\u0026ndash;1060\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eJeong JY, Lee EH, Lee SH, Kang YK (2021) Diagnostic accuracy and radiologic characteristics of osteochondroma in unusual locations. Skeletal Radiol 50(3):563\u0026ndash;570\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eD\u0026rsquo;Ambrosio L, Albano D, Messina C et al (2019) Imaging of osteochondroma: beyond the basics. Clin Imaging 57:83\u0026ndash;92\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePuri A, Agarwal MG, Reddy K et al (2021) Diagnostic dilemmas in skeletal lesions with atypical presentations. Indian J Orthop 55(1):49\u0026ndash;55\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eZhao C, Fan H, Jiang S et al (2020) Differences in diagnostic performance for bone tumors between community and academic settings. J Orthop Surg Res 15:111\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eAhmed SK, Garton HJ, Mahajan A (2019) Diagnostic challenges in rural settings: musculoskeletal lesions. Rural Remote Health 19(3):5175\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Osteochondroma, Exostosis, Familiarity, Referral document, primary physician","lastPublishedDoi":"10.21203/rs.3.rs-7770891/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7770891/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOsteochondroma is the most common benign bone tumor and is typically diagnosed based on its characteristic radiographic features. While it is generally familiar to orthopaedic surgeons, the level of diagnostic familiarity among primary physicians remains unclear.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMaterials and Methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis retrospective study reviewed 195 patients diagnosed with osteochondroma who were referred to a tertiary orthopaedic oncology center. Inclusion criteria included radiological confirmation of osteochondroma and the availability of referral documents from primary physicians. We evaluated the diagnostic accuracy of primary physicians by classifying their initial impressions as either “osteochondroma/exostosis” or “other diagnoses.” Primary physicians were classified by institutional affiliation (hospital or clinic) and medical specialty (orthopaedic or non-orthopaedic).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOf the 195 cases, 118 (60.5%) were accurately described as osteochondroma or exostosis by primary physicians. Diagnostic familiarity varied by anatomical location, with higher familiarity in long bones (e.g., femur, tibia, radius/ulna) and lower familiarity in less typical locations such as the toes, fingers, and ribs. Physicians affiliated with hospitals demonstrated significantly higher diagnostic accuracy than those in clinics (p \u0026lt; 0.05), and orthopaedic surgeons outperformed non-orthopaedic physicians (p \u0026lt; 0.01).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe diagnostic familiarity with osteochondroma among primary physicians was moderate, with accurate identification in over half of the cases. However, familiarity varied depending on anatomical location and physician background. Improved education regarding atypical presentations of osteochondroma may further enhance diagnostic accuracy and patient care.\u003c/p\u003e","manuscriptTitle":"Diagnostic Familiarity with Osteochondroma Among Primary Physicians: A Retrospective Analysis of 195 Referred Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-26 00:34:03","doi":"10.21203/rs.3.rs-7770891/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-16T05:08:59+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-16T03:42:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"193843402953281291404970575446973753522","date":"2025-11-03T15:08:17+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320668388255439630385039067251331107738","date":"2025-11-02T07:32:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-26T11:25:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"330220641565282786745515589674490203744","date":"2025-10-19T10:00:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-10-17T14:03:07+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"149092518465952500465898392374122666817","date":"2025-10-17T03:04:41+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"136175158172245694518607685158287053264","date":"2025-10-16T16:03:45+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"17301567905339790794361212267025268976","date":"2025-10-10T18:49:46+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-10-10T10:47:17+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-07T13:04:40+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-07T13:03:25+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2025-10-03T06:43:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"0241cb24-cedf-4905-a616-c7df21a5b32e","owner":[],"postedDate":"October 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-09T16:10:38+00:00","versionOfRecord":{"articleIdentity":"rs-7770891","link":"https://doi.org/10.1007/s00402-026-06222-6","journal":{"identity":"archives-of-orthopaedic-and-trauma-surgery","isVorOnly":false,"title":"Archives of Orthopaedic and Trauma Surgery"},"publishedOn":"2026-03-06 15:59:12","publishedOnDateReadable":"March 6th, 2026"},"versionCreatedAt":"2025-10-26 00:34:03","video":"","vorDoi":"10.1007/s00402-026-06222-6","vorDoiUrl":"https://doi.org/10.1007/s00402-026-06222-6","workflowStages":[]},"version":"v1","identity":"rs-7770891","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7770891","identity":"rs-7770891","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}