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Objective By aggregating the literature, we evaluated the association between use of specific antihypertensive drugs and the risk of hip fractures compared with nonuse. Study design and setting We systematically searched the Pubmed, Embase, and Cochrane databases from inception of each database until July 30, 2020 to identify articles including patients 18 years of age or older reporting on the association between antihypertensive drugs and the risk of hip fracture. Antihypertensive drugs were restricted to thiazides; beta-blockers; calcium-channel blockers; angiotensin-converting enzyme (ACE) inhibitors; and angiotensin receptor blockers. Nonusers encompass all patients that are not using the specific antihypertensive drug that has been reported. Unadjusted odds ratios with 95% confidence intervals (CIs) of the association between antihypertensive drug use and hip fractures were reported. Meta-analysis was performed when a minimum of five studies were identified for each antihypertensive drug class. Quality assessment was done using ROBINS-I tool. The GRADE approach was used to evaluate the certainty of the evidence. Results Of 962 citations, 22 observational studies were included; 9 studies had a cohort design and 13 studies were case-control studies. No randomized controlled trials were identified. We found very low certainty of evidence that both thiazides (pooled odds ratio: 0.85, 95% CI 0.73 to 0.99, p = 0.04) as well as beta-blockers (pooled odds ratio: 0.88, 95% CI 0.79 to 0.98, p = 0.02) were associated with a reduced hip fracture risk as compared to specific nonuse. One study, reporting on angiotensin receptor blockers, also suggested a protective effect for hip fractures, whereas we found conflicting findings in four studies for calcium-channel blockers and in two studies for ACE inhibitors. Conclusion Among 22 observational studies, we found very low certainty of evidence that, compared to specific nonuse of antihypertensive drugs, use of thiazides, beta-blockers, and angiotensin receptor blockers were associated with a reduced protective hip fracture risk, while conflicting findings for calcium-channel blockers and ACE inhibitors were found. Given the low quality of included studies, further research –randomized controlled trials– are needed to definitively assess the causal relationship between specific antihypertensive drug classes and (relatively infrequent) hip fractures.

Background: In chronic radial head dislocation cases, the radial head may enlarge and become dome-shaped. To date, there is no validated tool to quantify radial head deformation and predict its influence on surgical outcomes. This study assesses the potential value of volume and surface calculations obtained by quantitative three-dimensional computed tomography scanning (Q3DCT) in the workup for a corrective surgery in pediatric patients with missed Monteggia lesions. Material and methods: Ten consecutive pediatric patients with a missed Monteggia lesion were included (2012-2020). The volume and articular surface size of the radial head were calculated using Q3DCT, and a three-dimensional reconstruction of the articular surface relief was depicted in a heat map. The head-neck ratio was calculated and compared to Q3DCT data of missed Monteggia patients and their age-/sex-matched controls. Results: The radial head volume and radial articular surface size did not differ significantly between patients with missed Monteggia lesions and age-/sex-matched controls (volume 1487 mm3 vs. 1163 mm3, P = .32; articular surface size 282 mm3 vs. 236 mm3, P = .33). Optically, heat maps of the articular surface of missed Monteggia patients did not differ notably from control heat maps. A higher head-neck ratio correlated to a larger radial head volume (Pearson r = 0.73; P = .2). Discussion and conclusion: Q3DCT may be an interesting tool in the preoperative workup of pediatric missed Monteggia lesions. Prospective research with larger cohort sizes and data that compares the affected side to the contralateral elbow is needed to assess its true clinical potential.

Background We assessed whether there was a difference in attenuation measurements (in Hounsfield units – HU) and geometric distribution of HU between femora with metastatic lesions that fracture, and metastatic lesions that did not fracture nor underwent prophylactic fixation. Methods Nine patients with femoral metastases who underwent CT and developed a pathological fracture were matched to controls. All femora were delineated in axial CT slices using a region of interest (ROI) tool; the HU within these ROIs were used to calculate: (1) the cumulative HU of the affected over the nonaffected side per slice and presented as a percentage, and (2) the cumulative HU accounting for geometric distribution (polar moment of HU). We repeated the analyses including cortical bone only (HU of 600 and above). Results CT-based calculations did not differ between patients with a lesion that fractured and those that did not fracture nor underwent prophylactic fixation when analyzing all tissue. However, when including cortical bone only, the pathological fracture group had a lower cumulative HU value compared to the no fracture and no fixation group for the weakest cross-sectional CT image (pathological fracture group, mean: 71, SD: 23 and no fracture and no prophylactic fixation group, mean: 85, SD: 18, p = 0.042) and the complete lesion analysis (pathological fracture group, mean: 78, SD: 21 and no fracture and no prophylactic fixation group, mean: 92, SD: 15, p = 0.032). Conclusion The demonstrated CT-based algorithms can be useful for predicting pathological fractures in metastatic lesions.

Spinal epidural lipomatosis (SEL) refers to an excessive accumulation of fat within the epidural space. It can be idiopathic or secondary, resulting in significant morbidity. The prevalence of SEL, including idiopathic and secondary SEL, and its respective risk factors are poorly defined.We sought to: (1) assess the prevalence of SEL among patients who underwent a dedicated magnetic resonance imaging (MRI) scan of the spine-including incidental SEL (ie, SEL without any spine-related symptoms), SEL with spine-related symptoms, and symptomatic SEL (ie, with symptoms specific for SEL); and (2) assess factors associated with overall SEL and subgroups. In addition, we assessed differences between SEL subgroups.We reviewed the records of 28,902 patients, aged 18 years and older with a spine MRI (2004 to 2015) at two tertiary care centers. We identified SEL cases by searching radiology reports for SEL, including synonyms and misspellings. Prevalence numbers were calculated as a percentage of the total number of patients. We used multivariate logistic regression analysis to identify factors associated with overall SEL and subgroups.The prevalence of overall SEL was 2.5% (731 of 28,902): incidental SEL, 0.6% (168 of 28,902); SEL with symptoms, 1.8% (526 of 28,902); and symptomatic SEL, 0.1% (37 of 28,902). Factors associated with overall SEL in multivariate analysis were the following: older age (odds ratio [OR]: 1.01, 95% confidence interval [CI]: 1.01-1.02, p.001), higher modified Charlson comorbidity index (OR: 1.10, 95% CI: 1.07-1.13, p.001), male sex (OR: 2.01, 95% CI: 1.71-2.37, p.001), BMI30 (OR: 2.59, 95% CI: 1.97-3.41, p.001), Black/African American race (OR: 1.66, 95% CI: 1.24-2.23, p=.001), systemic corticosteroid use (OR: 2.59, 95% CI: 1.69-3.99, p.001), and epidural corticosteroid injections (OR: 3.48, 95% CI: 2.82-4.30, p.001).We found that about 1 in 40 patients undergoing a spine MRI had SEL; 23% of whom with no symptoms, 72% with spine-related symptoms, and 5% with symptoms specific for SEL. Our data help identify patients who might warrant an increased index of suspicion for SEL.

General questionnaires are often used to assess quality of life in patients with spine metastases, although a disease-specific survey did not exist until recently. The Spine Oncology Study Group has developed an outcomes questionnaire (SOSG-OQ) to measure quality of life in these patients. However, a scoring system was not developed, and the questionnaire was not validated in a group of patients, nor was it compared with other general quality of life questionnaires such as the EuroQol 5 Dimensions (EQ-5D) questionnaire.Our primary null hypothesis is that there is no association between the SOSG-OQ and EQ-5D. Our secondary null hypothesis is that there is no difference in coverage and internal consistency between the SOSG-OQ and EQ-5D. We also assess coverage, consistency, and validity of the domains within the SOSG-OQ.A survey study from a tertiary care spine referral center was used for this study.The patient sample consisted of 82 patients with spine metastases, myeloma, or lymphoma.The SOSG-OQ (27 questions, 6 domains) score ranges from 0 to 80, with a higher score indicating worse quality of life. The EQ-5D (5 questions, 5 domains) index score ranges from 0 to 1, with a higher score indicating better quality of life.The association between the SOSG-OQ and EQ-5D index score was assessed using the Spearman rank correlation. Instrument coverage and precision were assessed by determining item completion rate, median score with range, and floor and ceiling effect. Internal consistency was assessed using Cronbach alpha. Multitrait analysis and exploratory factor analysis were used to analyze properties of the individual domains in the SOSG-OQ.The Spearman rank correlation between the SOSG-OQ and EQ-5D questionnaire was high (r=-0.83, p.001). Internal consistency of the SOSG-OQ (0.92, 95% CI: 0.89-0.94) was higher as compared to the internal consistency of the EQ-5D (0.73, 95% CI: 0.63-0.84; p.001). The SOSG-OQ score had no floor or ceiling effect indicating good coverage (median 30, range 3-64), whereas the EQ-5D had a ceiling effect of 10% (median 0.71, range 0.05-1).In conclusion, our study proposes a scoring methodology-after reversing four inversely scored items-for the SOSG-OQ and shows that the questionnaire is a valid tool for the assessment of quality of life in patients with metastatic spine disease. The SOSG-OQ is superior to the EQ-5D in terms of coverage and internal consistency but consists of more questions.

Background Context Patient-reported outcomes are becoming increasingly important when investigating results of patient and disease management. In sacral tumor, the symptoms of patients can vary substantially; therefore, no single questionnaire can adequately account for the full spectrum of symptoms and disability. Purpose The purpose of this study is to analyze redundancy within the current sacral tumor survey and make a recommendation for an updated version based on the results and patient and expert opinions. Study Design/Setting A survey study from a tertiary care orthopedic oncology referral center was used. Patient Sample The patient sample included 70 patients with sacral tumors (78% chordoma). Outcome Measures The following 10 questionnaires included in the current sacral tumor survey were evaluated: the Patient-Reported Outcomes Measurement Information System (PROMIS) Global Item short form, PROMIS Pain Intensity short form, PROMIS Pain Interference short form, PROMIS Neuro-QOL v1.0 Lower Extremity Function short form, PROMIS v1.0 Anxiety short form, the PROMIS v1.0 Depression short form, the International Continence Society Male short form, the Modified Obstruction-Defecation Syndrome questionnaire, the PROMIS Sexual Function Profile v1.0, and the Stoma Quality of Life tool. Methods We performed an exploratory factor analysis to calculate the possible underlying latent traits. Spearman rank correlation coefficients were used to measure to what extent the questionnaires converged. We hypothesized the existence of six domains based on current literature: mental health, physical health, pain, gastrointestinal symptoms, sexual function, and urinary incontinence. To assess content validity, we surveyed 32 patients, 9 orthopedic oncologists, 1 medical oncologist, 1 radiation oncologist, and 1 orthopedic oncology nurse practitioner with experience in treating sacral tumor patients on the relevance of the domains. Results Reliability as measured by Cronbach alpha ranged from 0.65 to 0.96. Coverage measured by floor and ceiling effects ranged from 0% to 52% and from 0% to 30%, respectively. Explanatory factor analysis identified three traits to which the questionnaires that were expected to measure a similar construct correlated the most: mental health, physical function, and pain. Content validity index demonstrated low disagreement among patients (range: 0.10–0.18) and high agreement among physicians (range: 0.91–1.0) on the relevance of the proposed domains. Social health was identified by 50% of the commenting patients as an important yet missing domain. Conclusions The current sacral tumor survey is incomplete and time-consuming, and not all surveys are appropriate for the sacral tumor population. Our recommended survey contains less than half the questions and includes the newly recognized social health domain.

Purpose We sought to determine and quantify which subspecialties of orthopedic surgeons are operating off hours in an urban, quaternary-care, level 1 trauma center. Materials and methods We used our clinical registry to identify 43,211 orthopedic surgeries performed between January 2008 and December 2011. Our outcome measures were the number and proportion of off-hour surgeries performed as well as the number and proportion of off-hours per subspecialty. The denominators were the total number of surgeries and the total number of surgical hours worked per subspecialty. Subspecialties—based on the primary surgeon who performed the surgery—were arthroplasty, foot and ankle, hand, pediatrics, shoulder, spine, sports, orthopedic trauma, and orthopedic oncology. Results A total of 2,431 (5.6%) surgeries were off-hours; the overall ratio of off-hour to on-hour surgeries was 1 to 17. There was a difference in the proportion of off-hour surgeries performed among orthopedic subspecialties: trauma (ratio, 1:5) and pediatric specialists (ratio, 1:5) had the lowest ratio, and shoulder (ratio, 1:152) and sports (ratio, 1:98) specialists the highest. The total number of surgical hours among all specialties was 59,026; of these hours, 3,833 (6.5%) were off-hour. The ratio of off-hour to on-hour surgical hours was 1 to 14. There was a difference in proportion of hours worked off-hour among orthopedic subspecialties; the ratios were greatest for trauma (1:5) and hand (1:5) specialists and the least for shoulder (1:157) and sports (1:92) specialists. Seven percent of hand surgery cases were off-hour, and 16% of the total surgical hours worked by hand surgeons were off-hour. Conclusions In an urban, academic, level 1 trauma and microvascular replantation regional referral hospital, there is a large difference in off-hour surgical volume and duration among orthopedic subspecialties: trauma, pediatric, and hand surgeons performed more off-hour work than their colleagues, with hand and pediatric surgeons the most likely to be working at night. Clinical relevance These data can inform how we organize, value, and incentivize off-hour care.

Background Context Perioperative allogeneic blood transfusions have been associated with decreased survival after surgical resection of primary and metastatic cancer. Studies investigating this association for patients undergoing resection of bone metastases are scarce and controversial. Purpose We assessed (1) whether exposure to perioperative allogeneic blood transfusions was associated with decreased survival after surgery for spinal metastases and (2) if there was a dose-response relationship per unit of blood transfused. Additionally, we explored the risk factors associated with survival after surgery for spinal metastases. Study Design/Setting This is a retrospective cohort study from two university medical centers. Patient Sample There were 649 patients who had operative treatment for metastatic disease of the spine between 2002 and 2014. Patients with lymphoma or multiple myeloma were also included. We excluded patients with a revision procedure, kyphoplasty, vertebroplasty, and radiosurgery alone. Outcome Measures The outcome measure was survival after surgery. The date of death was obtained from the Social Security Death Index and medical charts. Methods Blood transfusions within 7 days before and 7 days after surgery were considered perioperative. A multivariate Cox proportional hazard model was used to assess the relationship between allogeneic blood transfusion as exposure versus non-exposure, and subsequently as continuous value; we accounted for clinical, laboratory, and treatment factors. Results Four hundred fifty-three (70%) patients received perioperative blood transfusions, and the median number of units transfused was 3 (interquartile range: 2–6). Exposure to perioperative blood transfusion was not associated with decreased survival after accounting for all explanatory variables (hazard ratio [HR]: 1.03; 95% confidence interval [CI]: 0.80–1.31; p=.841). Neither did we find a dose-response relationship (HR: 1.01; 95% CI: 0.98–1.04; p=.420). Other factors associated with worse survival were older age, more severe comorbidity status, lower preoperativehemoglobin level, higher white blood cell count, higher calcium level, primary tumor type, previous systemic therapy, poor performance status, presence of lung, liver, or brain metastasis, and surgical approach. Conclusions Perioperative allogeneic blood transfusions were not associated with decreased survival after surgery for spinal metastases. More liberal transfusion policies might be warranted for patients undergoing surgery for spinal metastasis, although careful consideration is needed as other complications may occur.

Purpose The natural course of the pathophysiology of Kienbock disease is uncertain. Shortening of the radius is believed to modify the pathophysiology by addressing mechanical influences on the lunate. The aim of this study was to compare the radiographic progression of Kienbock disease among patients who had radial shortening osteotomy and patients who had no surgical treatment, with a minimum 1-year interval between radiographs. Methods Among 207 patients with Kienbock disease, we included all 48 eligible patients who had either radial shortening osteotomy or nonsurgical treatment and 2 sets of wrist radiographs available a minimum of 1 year apart. We compared changes in carpal height ratio, Stahl index, and carpal angles between the 2 sets of radiographs and between radial shortening osteotomy and nonsurgical treatment. Results We found, on average, a small decrease in the carpal height ratio and the Stahl index in patients who did and did not have surgery, with no differences between the 2 groups. Nearly half of the patients had no decrease in the carpal height ratio and/or the Stahl index. Conclusions Radiographic progression of Kienbock over 1 year or more seems slight on average regardless of treatment. Future research might address the probability of and factors associated with radiographic progression of Kienbock disease. Type of study/level of evidence Prognostic IV.

Individuals who experience musculoskeletal trauma may construe the experience as unjust and themselves as victims. Perceived injustice is a cognitive construct comprised by negative appraisals of the severity of loss as a consequence of injury, blame, injury-related loss, and unfairness. It has been associated with worse physical and psychological outcomes in the context of chronic health conditions. The purpose of this study is to explore the association of perceived injustice to pain intensity and physical function in patients with orthopaedic trauma.A total of 124 orthopaedic trauma patients completed the Injustice Experience Questionnaire (IEQ), the PROMIS Physical Function Computer Adaptive Testing (CAT), the PROMIS Pain Intensity instruments, the short form Patient Health Questionnaire for depression (PHQ-2), the short form Pain Self-Efficacy Questionnaire (PSEQ-2), and the short form Pain Catastrophizing Scale (PCS-4) on a tablet computer. A stepwise linear regression model was used to identify the best combination of predictors explaining variance in PROMIS Physical Function and PROMIS Pain Intensity.The IEQ was associated with PROMIS Physical Function (r=-0.36; P0.001) and PROMIS Pain Intensity (r=0.43; P0.001). In multivariable analysis, however, Caucasian race (β=5.1, SE: 2.0, P=0.013, 95% CI: 1.1-9.2), employed work status (β=5.1, SE: 1.5, P=0.001, 95% CI: 2.1-8.2), any cause of injury other than sports, mvc, or fall (β=7.7, SE: 2.1, P0.001, 95% CI: 3.5-12), and higher self-efficacy (PSEQ-2; β=0.93, SE: 0.23, P0.001, 95% CI: 0.48-1.4) were selected as part of the best model predicting variance in PROMIS Physical Function. Only a higher degree of catastrophic thinking (PCS-4; β=1.2, SE: 0.12, P0.001, 95% CI: 0.99 to 1.5) was selected as important in predicting higher PROMIS Pain Intensity.Perceived injustice was associated with both physical function and pain intensity in bivariate correlations, but was not deemed as an important predictor when assessed along with other demographic and psychosocial variables in multivariable analysis. This study confirms prior research on the pivotal role of catastrophic thinking and self-efficacy in reports of pain intensity and physical function in patients with acute traumatic musculoskeletal pain.

Olecranon fractures have variable size of the proximal fragment, patterns of fragmentation, and subluxation of the ulnohumeral joint that might be better understood and categorized on the basis of quantitative 3-dimensional computed tomography analysis. Mayo type I fractures are undisplaced, Mayo type II are displaced and stable, and Mayo type III are displaced and unstable. The last is categorized into anterior and posterior dislocations. The purpose of this study was to further clarify fracture morphology between Mayo type I, II, and III fractures.Three-dimensional models were created for a consecutive series of 78 patients with olecranon fractures that were evaluated with computed tomography. We determined the total number of fracture fragments, the volume and articular surface area of each fracture fragment, and the degree of displacement of the most proximal olecranon fracture fragment.Displaced olecranon fractures were more comminuted than nondisplaced fractures (P = .02). Displaced fractures without ulnohumeral subluxation were smallest in terms of both volume (P .001) and articular surface involvement (P .001) of the most proximal olecranon fracture fragment. There was no difference in average displacement of the proximal fragment between displaced fractures with and without ulnohumeral subluxation (P = .74). Anterior olecranon fracture-dislocations created more displaced (P = .04) and smaller proximal fragments than posterior fracture-dislocations (P = .005), with comparable fragmentation on average (P = .60).The ability to quantify volume, articular surface area, displacement, and fragmentation using quantitative 3-dimensional computed tomography should be considered when increased knowledge of fracture morphology and fracture patterns might be useful.

Hypothesis/Background This study measures the characteristics of glenoid fractures to determine if the AO Foundation and Orthopaedic Trauma Association (AO/OTA) classification captures the most common fracture patterns. The primary null hypothesis was that surface area and degree of fragmentation do not differ among the different fracture types. Secondarily, we tested if there was a relationship between high- vs. low-energy trauma and fracture classification. Methods Three-dimensional models were created for a consecutive series of 53 fractures. The fracture classifications, the number of fragments, and the fragmented articular surface area were related to the type of injury. The difference of articular surface size and number of fragments among classification groups was analyzed with the Kruskal-Wallis test. Results There is a significant difference in fractured articular surface area among classification groups. Compared with transverse and multifragmented fractures, both anterior and posterior fractures involved significantly less of the articular surface area. High-energy trauma is associated with transverse and multifragmented fractures in 93% of the cases. It is associated with a greater number of fracture fragments and fracture of a larger percentage of the glenoid surface area, with a mean fractured surface of 60% for high-energy fractures and 25% for low-energy injuries. Discussion/Conclusion Quantitative 3-dimensional CT analysis confirms that the current AO/OTA classification adequately characterizes and discriminates glenoid fracture patterns. The classification groups are related to the fragmented articular surface area and the number of fragments. Also, the mechanism of injury is related to the classification group, which supports the clinical relevance of the classification.

Background Illness (symptoms and disability) consistently correlates more with coping strategies and symptoms of depression than with pathophysiology or impairment. Objective This study tested the primary null hypothesis that there is no correlation between verbal and nonverbal communication of pain (pain behavior) and upper extremity–specific disability in patients with hand and upper extremity illness. Methods A total of 139 new and followed up adult patients completed the QuickDASH, an ordinal rating of pain, and 4 Patient-Reported Outcomes Measurement Information System (PROMIS) Computer Adaptive Testing instruments: (1) PROMIS pain behavior, (2) PROMIS pain interference (measuring the degree to which pain interferes with achieving ones physical goals), (3) PROMIS physical function, and (4) PROMIS depression. Results Factors associated with a higher QuickDASH score in bivariate analysis included a higher PROMIS pain behavior score, not working, being separated/divorced or widowed, having sought treatment before, having other pain conditions, a higher PROMIS pain interference score, a higher PROMIS depression score, and lower education level. The final multivariable model of factors associated with QuickDASH included PROMIS pain interference, having other pain conditions, and being separated/divorced or widowed, and it explained 64% of the variability. Conclusion PROMIS pain behavior (verbal and nonverbal communication of pain) correlates with upper extremity disability, but PROMIS pain interference (the degree to which pain interferes with activity) is a more important factor. Level of Evidence Level IV, cross-sectional study.

Allogeneic blood transfusions have an immunomodulating effect, and the previous studies in other fields of medicine demonstrated an increased risk of infections after administration of allogeneic blood transfusions.Our primary null hypothesis is that exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery is not associated with postoperative infections after controlling for patient and treatment characteristics. Second, we assessed if there was a dose-response relationship per unit of blood transfused.This is a retrospective cohort study from a tertiary care spine referral center.A total of 3,721 patients underwent laminectomy and/or arthrodesis of the lumbar spine.Postoperative infections, pneumonia, endocarditis, meningitis, urinary tract infection, central venous line infection, surgical site infection, and sepsis, within 90 days after lumbar spine surgery were included.Multivariable logistic regression analyses were used to assess the relationship of perioperative allogeneic blood transfusion with specific and overall postoperative infections accounting for age, duration of surgery, duration of hospital stay, comorbidity status, preoperative hemoglobin, sex, type of operation, multilevel treatment, operative approach, and year of surgery.The adjusted odds ratio for exposure to allogeneic blood transfusion from multivariable logistic regression analysis was 2.6 for any postoperative infection (95% confidence interval [CI]: 1.7-3.9, p.001); 2.2 for urinary tract infections (95% CI: 1.3-3.9, p=.004); 2.3 for pneumonia (95% CI: 0.96-5.3, p=.062); and 2.6 for surgical site infection requiring incision and drainage (95% CI: 1.3-5.3, p=.007). Secondary analyses demonstrated no dose-response relationship between the number of blood units transfused and any of the postoperative infections. Because of the low number of endocarditis (1 case, 0.031%), meningitis (1 case, 0.031%), central venous line infection (1 case, 0.031%), and sepsis (14 cases, 0.43%), we abstained from multivariable analysis.Conscious of the limitations of this retrospective study, our data suggest an increased risk of surgical site infection, urinary tract infection, and overall postoperative infections, but not pneumonia, after exposure to allogeneic blood transfusion in patients undergoing lumbar spine surgery. These findings should be taken into account when considering blood transfusion and developing transfusion policies for patients undergoing lumbar spine procedures.

Hypothesis This study assessed: if there was a difference in surgical decision making for metastatic humeral lesions based on orthopaedic subspecialty and tumor characteristics. Study type Cross-sectional survey study. Materials and methods Twenty-four case scenarios were created by combining: tumor type, life expectancy, fracture type, and anatomical location. Participants were asked for every case: what treatment would you recommend? Participants were 78 (48 %) orthopaedic oncologists and 83 (52 %) orthopaedic surgeons that were not regularly involved in the treatment of bone tumors. Results There was a difference between orthopaedic oncologists and other subspecialty surgeons in recommendation for specific treatments: intramedullary nailing was less often recommended by orthopaedic oncologists (53 %, 95 % CI: 47–59) compared to other surgeons (62 %, 95 % CI: 57–67) ( p = 0.023); while endoprosthetic reconstruction [orthopaedic oncologists: 8.8 % (95 % CI: 6.6–11), other surgeons: 3.6 % (95 % CI: 2.3–4.8), p p = 0.003] were more often recommended by orthopaedic oncologists. There was no difference in recommendation for non-operative management. There were differences in recommendation for specific treatments based on tumor type, life expectancy, and anatomical location, but not fracture type. Discussion Subspecialty training and patient and tumor characteristics influence the decision for operative management and the decision for a specific implant in metastatic humeral fractures. Level of evidence Level III.

Purpose Rising costs at the patient level have been recognized and shown to directly influence patient decisions. By understanding patient interests in discussing cost, hand surgeons may better prepare themselves and their practices to communicate costs with patients. Methods We surveyed 128 patients at an upper extremity surgery clinic at their 2-week postoperative visit. Survey domains included basic patient demographics and an assessment of patient financial distress, along with questions that rated patient interest with patient-physician financial conversations. These factors included patients' desire for a conversation regarding cost, whether or not patients have discussed cost with their surgeon, barriers to these discussions, and overall views concerning cost containment in hand care. Results Seven percent of patients discussed the costs of their surgical care with their physician. Eleven percent of patients reported that a doctor should not discuss the costs of their surgical care. Forty-eight percent of patients reported that a doctor should initiate a conversation regarding costs of care when a new treatment is being considered. Fifty-nine percent of patients agreed that physicians should consider the amount of money a patient will have to pay when choosing a new treatment. Conclusions Patients can experience financial hardship as a result of their surgery and some patients are interested in discussing costs with their doctor. Patients indicated that doctors should be concerned with lowering the costs of surgery and should initiate a conversation regarding costs of care when a new treatment is being considered. Clinical relevance Patients are interested in a conversation regarding their cost of hand surgery care. Making cost data more transparent and available to physicians and patients may facilitate communication regarding cost of care.

Purpose We assessed factors at the time of unilateral carpal tunnel release (CTR) for carpal tunnel syndrome to create a prediction formula for future CTR. Methods We retrospectively identified 1,013 patients who underwent CTR at a tertiary care referral center from July 2008 to June 2013. A multivariable logistic regression model was used to identify independent factors associated with future contralateral CTR. A prediction formula was created and its validity was assessed by calculating the C-statistic for model discrimination and the Hosmer-Lemeshow goodness-of-fit test and calibration slope for model calibration. We tested the external validity of our formula using a sample of 100 random patients who underwent CTR at a second tertiary care referral center from October 2004 to August 2016. Results Contralateral carpal tunnel symptoms and preoperative contralateral electrodiagnostic study severity were associated with increased likelihood of contralateral CTR, whereas black race and chronic kidney disease were associated with decreased likelihood of contralateral CTR. We constructed a prediction formula for the probability of undergoing contralateral CTR at 5.5 years’ follow-up. Conclusions The probability of future contralateral CTR may be useful in preoperative counseling for select patients who are reasonable candidates for unilateral, staged bilateral, or simultaneous bilateral CTR. Our prediction formula can be an adjunct tool for shared decision making but it does not replace the experienced clinician’s judgment based on the patient’s history, physical examination, and confirmatory testing. Type of study/level of evidence Prognostic III.

BACKGROUND CONTEXT The prevalence of symptomatic and asymptomatic synovial facet cysts in the lumbar spine has been incompletely established, and although many studies demonstrate an association with degenerative spine disease, no cumulative increase in prevalence of synovial facet cysts with increasing age has been presented. PURPOSE To assess the prevalence of incidental (ie, asymptomatic) and symptomatic lumbar synovial facet cysts on MRI. Secondarily, we will assess if the prevalence of lumbar synovial facet cysts increases with age and what other factors are associated with its prevalence. In addition, we will assess differences in patient and cyst characteristics between asymptomatic and symptomatic facet cysts. STUDY DESIGN/SETTING Retrospective cohort study from two affiliated tertiary care referral centers for spine disease. PATIENT SAMPLE A total of 19,010 consecutive patients who underwent a dedicated lumbar spine MRI between 2004 and 2015. OUTCOME MEASURES Symptomatic and asymptomatic facet cysts. METHODS A symptomatic cyst was defined as a cyst with symptoms of radiculopathy on the same side as the cyst. The prevalence of incidental, symptomatic, and overall synovial facet cysts was reported as a percentage with 95% confidence interval (95% CI). Multivariable logistic regression analysis was used to assess if age, sex, race, and indication for MRI were associated with having a facet cyst. Generalized estimating equation analysis was used to assess differences between symptomatic versus asymptomatic synovial facet cyst: age, sex, race, side, level, cyst size, and cyst location. RESULTS The overall synovial facet cyst prevalence was 6.5% (95% CI: 6.1–6.8) [1,228/19,010]. These 1,228 patients had 1,553 synovial facet cysts of which 46% cysts (721/1,553) were incidental and 54% cysts (832/1,553) were symptomatic. The prevalence of having one or more incidental synovial facet cysts was 2.7% (95% CI: 2.5%–3.0%) [518/19,010], the prevalence of having one or more symptomatic synovial facet cysts was 3.2% (95% CI: 3.0%–3.5%) [617/19,010], and the prevalence of having both one or more incidental and one or more symptomatic synovial facet cysts was 0.49% (95% CI: 0.39%–0.59%) [93/19,010]. Increased age was independently associated with a higher likelihood of having a synovial facet cyst (odds ratio [per 10years increase in age]: 1.24, 95%CI: 1.20–1.29, p CONCLUSIONS Approximately 1 in 15 patients has at least one synovial facet cyst and about half of them are symptomatic and half are asymptomatic. Having a facet cyst — symptomatic and asymptomatic — is strongly associated with increased age supporting the theory that degenerative spine disease underlies development of facet cysts. Large cyst size and anterior location of the cysts are associated with an increased likelihood of having neurological symptoms.