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Background and purpose — There is ongoing debate as to whether commercial funding influences reporting of medical studies. We asked: Is there a difference in reported tones between abstracts, introductions, and discussions of orthopedic journal studies that were commercially funded and those that were not commercially funded? Methods — We conducted a systematic PubMed search to identify commercially funded studies published in 20 orthopedic journals between January 1, 2000 and December 1, 2019. We identified commercial funding of studies by including in our search the names of 10 medical device companies with the largest revenue in 2019. Commercial funding was designated when either the study or 1 or more of the authors received funding from a medical device company directly related to the content of the study. We matched 138 commercially funded articles 1 to 1 with 138 non-commercially funded articles with the same study design, published in the same journal, within a time range of 5 years. The IBM Watson Tone Analyzer was used to determine emotional tones (anger, fear, joy, and sadness) and language style (analytical, confident, and tentative). Results — For abstract and introduction sections, we found no differences in reported tones between commercially funded and non-commercially funded studies. Fear tones (non-commercially funded studies 5.1%, commercially funded studies 0.7%, p = 0.04), and analytical tones (non-commercially funded studies 95%, commercially funded studies 88%, p = 0.03) were more common in discussions of studies that were not commercially funded. Interpretation — Commercially funded studies have comparable tones to non-commercially funded studies in the abstract and introduction. In contrast, the discussion of non-commercially funded studies demonstrated more fear and analytical tones, suggesting them to be more tentative, accepting of uncertainty, and dispassionate. As text analysis tools become more sophisticated and mainstream, it might help to discern commercial bias in scientific reports.

Background For fracture care, radiographs and two-dimensional (2-D) and three-dimensional (3-D) CT are primarily used for preoperative planning and postoperative evaluation. Intraarticular distal radius fractures are technically challenging to treat, and meticulous preoperative planning is paramount to improve the patient's outcome. Three-dimensionally printed handheld models might improve the surgeon's interpretation of specific fracture characteristics and patterns preoperatively and could therefore be clinically valuable; however, the additional value of 3-D printed handheld models for fractures of the distal radius, a high-volume and commonly complex fracture due to its intraarticular configuration, has yet to be determined. Questions/purposes (1) Does the reliability of assessing specific fracture characteristics that guide surgical decision-making for distal radius fractures improve with 3-D printed handheld models? (2) Does surgeon agreement on the overall fracture classification improve with 3-D printed handheld models? (3) Does the surgeon's confidence improve when assessing the overall fracture configuration with an additional 3-D model? Methods We consecutively included 20 intraarticular distal radius fractures treated at a Level 1 trauma center between May 2018 and November 2018. Ten surgeons evaluated the presence or absence of specific fracture characteristics (volar rim fracture, die punch, volar lunate facet, dorsal comminution, step-off > 2 mm, and gap > 2 mm), fracture classification according to the AO/Orthopaedic Trauma Association (OTA) classification scheme, and their confidence in assessing the overall fracture according to the classification scheme, rated on a scale from 0 to 10 (0 = not at all confident to 10 = very confident). Of 10 participants regularly treating distal radius fractures, seven were orthopaedic trauma surgeons and three upper limb surgeons with experience levels ranging from 1 to 25 years after completion of residency training. Fractures were assessed twice, with 1 month between each assessment. Initially, fractures were assessed using radiographs and 2-D and 3-D CT images (conventional assessment); the second time, the evaluation was based on radiographs and 2-D and 3-D CT images with an additional 3-D handheld model (3-D printed handheld model assessment). On both occasions, fracture characteristics were evaluated upon a surgeon's own interpretation, without specific instruction before assessment. We provided a sheet demonstrating the AO/OTA classification scheme before evaluation on each session. Multi-rater Fleiss's kappa was used to determine intersurgeon reliability for assessing fracture characteristics and classification. Confidence regarding assessment of the overall fracture classification was assessed using a paired t-test. Results We found that 3-D printed models of intraarticular distal radius fractures led to no change in kappa values for the reliability of all characteristics: volar rim (conventional kappa 0.19 [95% CI 0.06 to 0.32], kappa for 3-D handheld model 0.23 [95% CI 0.11 to 0.36], difference of kappas 0.04 [95% CI -0.14 to 0.22]; p = 0.66), die punch (conventional kappa 0.38 [95% CI 0.15 to 0.61], kappa for 3-D handheld model 0.50 [95% CI 0.23 to 0.78], difference of kappas 0.12 [95% CI -0.23 to 0.47]; p = 0.52), volar lunate facet (conventional kappa 0.31 [95% CI 0.14 to 0.49], kappa for 3-D handheld model 0.48 [95% CI 0.23 to 0.72], difference of kappas 0.17 [95% CI -0.12 to 0.46]; p = 0.26), dorsal comminution (conventional kappa 0.36 [95% CI 0.13 to 0.58], kappa for 3-D handheld model 0.31 [95% CI 0.11 to 0.51], difference of kappas -0.05 [95% CI -0.34 to 0.24]; p = 0.74), step-off > 2 mm (conventional kappa 0.55 [95% CI 0.29 to 0.82], kappa for 3-D handheld model 0.58 [95% CI 0.31 to 0.85], difference of kappas 0.03 [95% CI -0.34 to 0.40]; p = 0.87), gap > 2 mm (conventional kappa 0.59 [95% CI 0.39 to 0.79], kappa for 3-D handheld model 0.69 [95% CI 0.50 to 0.89], difference of kappas 0.10 [95% CI -0.17 to 0.37]; p = 0.48). Although there appeared to be categorical improvement in kappa values for some fracture characteristics, overlapping CIs indicated no change. Fracture classification did not improve (conventional diagnostics: kappa 0.27 [95% CI 0.14 to 0.39], conventional diagnostics with an additional 3-D handheld model: kappa 0.25 [95% CI 0.15 to 0.35], difference of kappas: -0.02 [95% CI -0.18 to 0.14]; p = 0.81). There was no improvement in self-assessed confidence in terms of assessment of overall fracture configuration when a 3-D model was added to the evaluation process (conventional diagnostics 7.8 [SD 0.79 {95% CI 7.2 to 8.3}], 3-D handheld model 8.5 [SD 0.71 {95% CI 8.0 to 9.0}], difference of score: 0.7 [95% CI -1.69 to 0.16], p = 0.09). Conclusions Intersurgeon reliability for evaluating the characteristics of and classifying intraarticular distal radius fractures did not improve with an additional 3-D model. Further studies should evaluate the added value of 3-D printed handheld models for teaching surgical residents and medical trainees to define the future role of 3-D printing in caring for fractures of the distal radius. Level of evidence Level II, diagnostic study.

Using Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF) computerized adaptive test instead of the Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS, JR) could reduce question burden for patients with knee pain. We aimed to prospectively determine the correlation between PROMIS PF and KOOS, JR to assess whether PROMIS PF could be a useful alternative measure for both research and clinical care of patients with knee pain. This was a cross-sectional study of 88 patients. We assessed the correlation between PROMIS PF and KOOS, JR using a Pearson's correlation test. Two multivariable linear regression models were used to determine the amount of variation explained by various patient-level factors. There was a strong correlation between PROMIS PF and KOOS, JR (r = 0.74, p

Introduction: The objective of this study is to determine factors associated with myonecrosis at the time of fasciotomy in patients with acute leg compartment syndrome. Methods: A retrospective cohort study was conducted of 546 patients with acute leg compartment syndrome treated with fasciotomies from January 2000 to June 2015 at two tertiary trauma centers. The main outcome measurement was clinical myonecrosis diagnosed by the treating surgeon at the time of fasciotomy. Results: Eighty-two patients (15.0%) with acute leg compartment syndrome had myonecrosis at time of fasciotomy. Multivariable logistic regression analyses showed that younger age (p = 0.004) and diabetes mellitus (p < 0.001) were associated with myonecrosis at time of fasciotomy in acute leg compartment syndrome. Serum creatine kinase at presentation greater than 2405 U/L was found to be associated with myonecrosis at time of fasciotomy in post hoc analysis (p < 0.001). Conclusions: Myonecrosis is associated with patient-related factors. Younger age by 10 years is associated with a 1.3 times increase and diabetes mellitus with a 3-time increase in the odds of myonecrosis. Serum creatine kinase at presentation greater than 2405 U/L denotes an almost 3 times increase in odds of myonecrosis and may be useful for preoperative counseling.

Introduction: The primary objective of this study is to determine whether time from injury to fasciotomy is associated with increased risk for death or limb amputation in patients with acute leg compartment syndrome. The secondary objective of this study is to identify other risk factors for death or limb amputation in patients with acute leg compartment syndrome. Methods: In an institutional review board approved retrospective study, we identified 546 patients with acute compartment syndrome of 558 legs treated with fasciotomies from January 2000 to June 2015 at two Level I trauma centers. Our primary outcome measures were death and limb amputation during inpatient hospital admission. Electronic medical records were analyzed for patient-related factors and treatment-related factors. Bivariate analyses were used to screen for variables associated with our primary outcome measures, and explanatory variables with a p value below 0.05 were included in our multivariable logistic regression analyses. Results: In-hospital death occurred in 6.6% and in-hospital limb amputation occurred in 9.5% of acute leg compartment syndrome patients. Neither death nor limb amputation was found to be associated with time from injury to fasciotomy. Multivariable logistic regression analyses showed that older age (p = 0.03), higher modified Charlson Comorbidity Index (p = 0.009), higher potassium (p = 0.02), lower hemoglobin (p = 0.002), and higher lactate (p < 0.001) were associated with death, and diabetes mellitus (p = 0.05), no compartment pressure measurement (p = 0.009), higher PTT (p = 0.03), and lower albumin (p = 0.01) were associated with limb amputation. Conclusions: Time to fasciotomy is not found to be associated with death or limb amputation in acute leg compartment syndrome. Death and limb amputation are associated with patient-related factors and injury severity. Level of evidence: Level III Prognostic.

BACKGROUND: Patient reported outcome data in bone metastatic disease are scarce and it would be useful to have normative data and understand what patients are at risk for poor function and more pain. OBJECTIVES: We aimed to assess what factors are independently associated with physical function and pain intensity in patients with bone metastasis. METHODS: We included data from 211 patients with bone metastasis who completed a survey (2014-2016) including the PROMIS Physical Function Cancer and PROMIS Pain Intensity questionnaires. RESULTS: Prostate (P

Background There is growing interest in measuring and improving patient experience. Machine learning-based natural language processing techniques may help identify instructive themes in online comments written by patients about their healthcare provider. Separating individual surgeon and orthopaedic office reviews, we analyzed themes that are discussed based on the rating category, the association with review length, the number of people posting more than one review for a surgeon or office, the mean number of reviews per rating category, and the difference in review tones. Methods On Yelp.com, we collected 11,614 free-text reviews-together with a one- to five-star rating-of orthopaedic surgeons. Using natural language processing, we identified the most frequently occurring word combinations among rating categories. Themes were derived by categorizing word combinations. Dominant tones (emotional and language styles) were assessed by the IBM Watson Tone Analyzer. We calculated chi-square tests for linear trend and Spearman's rank correlation coefficients to assess differences among rating category. Results For individual surgeons and orthopaedic offices, themes such as logistics, care and compassion, trust, recommendation, and customer service varied among rating categories. More positive reviews are shorter for individual surgeons and orthopaedic offices, while rating category was comparable among people posting more than one review for both groups. Tones of joy and confidence were associated with higher ratings. Sadness and tentative tones were associated with lower ratings. Discussion For individual orthopaedic surgeons and orthopaedic offices, patient experience may be influenced mostly by the patient-clinician relationship. Training in more effective communication strategies may help improve self-reported patient experience.

Background: There is limited literature on risk stratification of patients with acute forearm compartment syndrome. The primary objective of this study was to identify factors associated with poor outcomes in patients with acute forearm compartment syndrome. Methods: We retrospectively identified 130 patients with acute compartment syndrome of 130 forearms treated with fasciotomies from January 2000 to June 2015 at 2 Level 1 trauma centers. Poor outcome was defined as a composite variable, including: (1) death; (2) limb amputation; (3) persistent neurological deficit; and (4) contracture. Patient- and treatment-related variables were collected. Bivariate analyses were used to screen for variables associated with poor outcome, and explanatory variables with a value of P < .05 were included in our multivariable logistic regression analyses. Results: Of the 130 patients, 43 (33%) with acute forearm compartment syndrome had poor outcomes, including 5 deaths, 5 limb amputations, 21 persistent neurological deficits, and 31 contractures. Multivariable logistic regression analyses showed that elevated serum creatine kinase at presentation ( P < .05) was associated with poor outcomes in patients with acute forearm compartment syndrome. Receiver operating characteristic curve analysis showed that a serum creatine kinase cutoff of 300 U/L yields 92% sensitivity and a serum creatine kinase cutoff of 10 000 U/L yields 95% specificity for poor outcomes in acute forearm compartment syndrome. Conclusions: Elevated creatine kinase levels above 300 U/L are a useful screening test for the highest risk patients with acute forearm compartment syndrome. Levels above 10 000 U/L may play a role in informed consent and counseling regarding expectations.

Background The purpose of this study was to evaluate the impact of pronator quadratus (PQ) repair on reoperation rates after distal radius open reduction internal fixation (ORIF) using a volar locking plate. Methods A retrospective study of all patients undergoing distal radius ORIF with a volar locking plate between January 2012 and December 2016 at 2 urban, academic level I trauma centers was performed. Patient demographics, fracture and procedure characteristics, surgeon subspecialty, PQ repair, and reoperations were recorded. Descriptive statistics were used to determine whether patient-related or injury-related characteristics were associated with PQ repair. Bivariate and multivariable regression analyses were used to assess the effect of PQ repair on subsequent reoperations. Results In total, 509 patients were included, including 31 patients with bilateral injuries. The average follow-up time was 3.7 ± 2.8 years. Patients undergoing PQ repair were younger (57 ± 17 years vs 61 ± 17 years) and were more likely to have a lower Soong grade (53% vs 44% with Soong grade 0) than patients without PQ repair. Pronator quadratus repair was not found to have a significant impact on hardware removal, reoperations for flexor tendon pathology, or overall reoperations. Conclusions Pronator quadratus repair was more commonly performed in younger patients and in patients with a lower Soong grade. Hand-subspecialized surgeons are more likely to pursue PQ repair than trauma-subspecialized surgeons. This study did not detect statistically significant differences in hardware removal, flexor tendon pathology, or overall reoperations between groups.

Contains fulltext : 220936.pdf (Publisher’s version ) (Closed access) Introduction: Shoulder abnormalities on imaging are increasingly common with advancing age.We tested the difference in the accuracy of diagnosing the injured shoulder between surgeons who reviewed MRI reports and who did and did not receive information about the patients. METHODS: Thirty people aged 40 or older that experienced new shoulder symptoms after an event at work had MRI of both shoulders. Members of the Science of Variation Group (SOVG) were invited to review the radiologist's reports and diagnose the symptomatic side. Ninety-seven surgeons participated. RESULTS: Surgeon observers provided with patient information were not more accurate in diagnosing the symptomatic shoulder (Odds Ratio: 0.90; 95% CI: 0.75 to 1.1; P = 0.29). There was slight agreement between surgeons (kappa = 0.10). The sensitivity and specificity for diagnosing the symptomatic side were 51% (CI: 48%-54%) and 67% (CI: 64%-70%) respectively. A binomial test showed that surgeons indicated the injured shoulder slightly more frequently than expected by random chance (59%; P

The aim of this study was to evaluate risk factors for symptomatic hardware and removal of hardware (ROH) after olecranon open reduction and internal fixation (ORIF) and to assess differences between olecranon locking plate and screws (P&S) or tension band (TB) wire cohorts. The medical records of 331 patients with olecranon fractures treated at two academic level I trauma centers with ORIF from 2012 to 2016 were reviewed. A total of 189 patients were included in the study. Complications, ROH, and subsequent surgery were assessed and compared between cohorts. There were 124 cases in the P&S cohort and 65 in the TB cohort. The overall reoperation rate was 31.2% (59 of 189). The overall incidence of ROH for all cases was 29.1% (55 of 189). Patients who required ROH or developed symptomatic hardware were significantly younger than those who did not (P&S, P P Orthopedics . 2020;43(3):141–146.]

BACKGROUND: Preliminary experience suggests that deep learning algorithms are nearly as good as humans in detecting common, displaced, and relatively obvious fractures (such as, distal radius or hip fractures). However, it is not known whether this also is true for subtle or relatively nondisplaced fractures that are often difficult to see on radiographs, such as scaphoid fractures. QUESTIONS/PURPOSES: (1) What is the diagnostic accuracy, sensitivity, and specificity of a deep learning algorithm in detecting radiographically visible and occult scaphoid fractures using four radiographic imaging views? (2) Does adding patient demographic (age and sex) information improve the diagnostic performance of the deep learning algorithm? (3) Are orthopaedic surgeons better at diagnostic accuracy, sensitivity, and specificity compared with deep learning? (4) What is the interobserver reliability among five human observers and between human consensus and deep learning algorithm? METHODS: We retrospectively searched the picture archiving and communication system (PACS) to identify 300 patients with a radiographic scaphoid series, until we had 150 fractures (127 visible on radiographs and 23 only visible on MRI) and 150 non-fractures with a corresponding CT or MRI as the reference standard for fracture diagnosis. At our institution, MRIs are usually ordered for patients with scaphoid tenderness and normal radiographs, and a CT with radiographically visible scaphoid fracture. We used a deep learning algorithm (a convolutional neural network [CNN]) for automated fracture detection on radiographs. Deep learning, an advanced subset of artificial intelligence, combines artificial neuronal layers to resemble a neuron cell. CNNs-essentially deep learning algorithms resembling interconnected neurons in the human brain-are most commonly used for image analysis. Area under the receiver operating characteristic curve (AUC) was used to evaluate the algorithm's diagnostic performance. An AUC of 1.0 would indicate perfect prediction, whereas 0.5 would indicate that a prediction is no better than a flip of a coin. The probability of a scaphoid fracture generated by the CNN, sex, and age were included in a multivariable logistic regression to determine whether this would improve the algorithm's diagnostic performance. Diagnostic performance characteristics (accuracy, sensitivity, and specificity) and reliability (kappa statistic) were calculated for the CNN and for the five orthopaedic surgeon observers in our study. RESULTS: The algorithm had an AUC of 0.77 (95% CI 0.66 to 0.85), 72% accuracy (95% CI 60% to 84%), 84% sensitivity (95% CI 0.74 to 0.94), and 60% specificity (95% CI 0.46 to 0.74). Adding age and sex did not improve diagnostic performance (AUC 0.81 [95% CI 0.73 to 0.89]). Orthopaedic surgeons had better specificity (0.93 [95% CI 0.93 to 0.99]; p < 0.01), while accuracy (84% [95% CI 81% to 88%]) and sensitivity (0.76 [95% CI 0.70 to 0.82]; p = 0.29) did not differ between the algorithm and human observers. Although the CNN was less specific in diagnosing relatively obvious fractures, it detected five of six occult scaphoid fractures that were missed by all human observers. The interobserver reliability among the five surgeons was substantial (Fleiss' kappa = 0.74 [95% CI 0.66 to 0.83]), but the reliability between the algorithm and human observers was only fair (Cohen's kappa = 0.34 [95% CI 0.17 to 0.50]). CONCLUSIONS: Initial experience with our deep learning algorithm suggests that it has trouble identifying scaphoid fractures that are obvious to human observers. Thirteen false positive suggestions were made by the CNN, which were correctly detected by the five surgeons. Research with larger datasets-preferably also including information from physical examination-or further algorithm refinement is merited. LEVEL OF EVIDENCE: Level III, diagnostic study.

Tumor resection followed by reconstruction with a proximal femoral endoprosthesis or an allograft-prosthesis composite are the two main alternatives for treatment of proximal femoral malignancies. This review describes the revision rate, implant survival, limb salvage rate, and function. Overall revision rates are high and reasons for failure differ between treatment modalities. Rate and reasons for amputation are comparable between both methods. Functional outcome was reasonable to good on average for both treatment modalities. Level of evidence: IV, systematic review and meta-analysis.

Background Previous studies have shown that venous thromboembolism (VTE) is a complication associated with neoplastic disease and major orthopaedic surgery. However, many potential risk factors remain undefined. Questions/purposes (1) What proportion of patients develop symptomatic VTE after surgery for long bone metastases? (2) What factors are associated with the development of symptomatic VTE among patients receiving surgery for long bone metastases? (3) Is there an association between the development of symptomatic VTE and 1-year survival among patients undergoing surgery for long bone metastases? (4) Does chemoprophylaxis increase the risk of wound complications among patients undergoing surgery for long bone metastases? Methods A retrospective study identified 682 patients undergoing surgical treatment of long bone metastases between 2002 and 2013 at the Massachusetts General Hospital and Brigham and Women's Hospital. We included patients 18 years of age or older who had a surgical procedure for impending or pathologic metastatic long bone fracture. We considered the humerus, radius, ulna, femur, tibia, and fibula as long bones; metastatic disease was defined as metastases from solid organs, multiple myeloma, or lymphoma. In general, we used 40 mg enoxaparin daily for lower extremity surgery and 325 mg aspirin daily for lower or upper extremity surgery. The primary outcome was a VTE defined as any symptomatic pulmonary embolism (PE) or symptomatic deep vein thrombosis (DVT; proximal and distal) within 90 days of surgery as determined by chart review. The tertiary outcome was defined as any documented wound complication that might be attributable to chemoprophylaxis within 90 days of surgery. At followup after 90 days and 1 year, respectively, 4% (25 of 682) and 8% (53 of 682) were lost to followup. Statistical analysis was performed using multivariable logistic and Cox regression and Kaplan-Meier. Results Overall, 6% (44 of 682) of patients had symptomatic VTE; 22 patients sustained a DVT, and 22 developed a PE. After controlling for relevant confounding variables, higher preoperative hemoglobin level was independently associated (odds ratio [OR], 0.75; 95% confidence interval [CI], 0.60-0.93; p = 0.011) with decreased symptomatic VTE risk, the presence of symptomatic VTE was associated with a worse 1-year survival rate (VTE: 27% [95% CI, 14%-40%] and non-VTE: 39% [95% CI, 35%-43%]; p = 0.041), and no association was found between wound complications and the use of chemoprophylaxis (OR, 3.29; 95% CI, 0.43-25.17; p = 0.252). Conclusions The risk of symptomatic 90-day VTE is high in patients undergoing surgery for long bone metastases. Further study would be needed to determine the VTE prevention strategy that best balances risks and benefits to address this complication. Level of evidence Level III, therapeutic study.

Purposes: The primary objective of this study is to compare the likelihood of acute compartment syndrome in the leg versus the forearm in patients who undergo fasciotomy for a clinical diagnosis of suspected acute compartment syndrome. The secondary objective is to identify factors associated with higher likelihood of acute compartment syndrome or with the use of split-thickness skin graft in these patients. Methods: We identified 449 patients diagnosed with suspected acute compartment syndrome of 468 legs and 119 patients diagnosed with suspected acute compartment syndrome of 119 forearms, treated with fasciotomy, from January 2000 to June 2015. Patients clinically diagnosed with suspected acute compartment syndrome were scored for likelihood of acute compartment syndrome based on muscle appearance, time to closure, neurologic deficit at final follow-up, and contracture at final follow-up. Results: There was no difference in likelihood of acute compartment syndrome between the leg and the forearm, with about 70% having relatively high likelihood. Forearm fasciotomy was associated with documentation of poorer muscle appearance (p = 0.01) and contracture (p < 0.001) compared with leg fasciotomy. Multivariable logistic regression analyses showed that compartment pressure measurement (p = 0.01) was associated with higher likelihood of acute compartment syndrome in legs and that male sex (p = 0.001) and non-vascular mechanism of injury (p = 0.02) were associated with split-thickness skin graft in legs. Conclusions: The likelihood and severity of acute compartment syndrome are comparable in the leg and the forearm.

STUDY DESIGN This was a retrospective cohort study from 2 affiliated tertiary care referral centers for spine disease. OBJECTIVE The purpose of this article was to assess the prevalence of incidental (ie, asymptomatic) and symptomatic lumbar synovial facet cysts on magnetic resonance imaging. Secondarily, we assessed whether the prevalence increases with age. In addition, we assessed differences in patient and cyst characteristics between asymptomatic and symptomatic facet cysts. SUMMARY OF BACKGROUND 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. METHODS We included 19,010 consecutive patients who underwent a dedicated lumbar spine magnetic resonance imaging between 2004 and 2015. Our outcome measures were symptomatic and asymptomatic facet cysts. A symptomatic cyst was defined as a cyst with symptoms of radiculopathy on the same side as the cyst. RESULTS The overall synovial facet cyst prevalence was 6.5% [95% confidence interval (CI), 6.1-6.8]; 46% of the facet cysts were incidental and 54% were symptomatic. Increased age was independently associated with a higher likelihood of having a synovial facet cyst [odds ratio (per 10 y), 1.24, 95% CI, 1.20-1.29; P

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.

Background: Wrist pain is often nonspecific. Magnetic resonance imaging (MRI) is regularly obtained to evaluate wrist pain. Variations and pathophysiology identified on MRI may not account for patient’s clinical symptoms. This study aims to quantify the prevalence of flexor carpi radialis (FCR) tendinopathy on MRI and the coexistence of trapeziometacarpal (TMC) or scaphotrapeziotrapezoid (STT) osteoarthritis. Methods: Using an institutional research database, we identified 3631 adult patients who obtained an MRI of the wrist during a 15-year period. Text search in the radiology reports identified 302 patients with possible FCR signal abnormalities. After reviewing the medical records, 98 patients were identified with FCR tendinopathy. Furthermore, medical records were used to identify pain located on the volar radial part of the wrist. In the absence of a documented examination consistent with FCR tendinopathy, we considered any signal change in the FCR incidental. Results: We identified 55 patients (55%) with incidental FCR tendinopathy. In a bivariate analysis, we found FCR signal changes on the MRI were associated with older age, white race, clinically suspected FCR tendinopathy, volar-radial sided wrist pain, and TMC and STT arthritis. Using multivariable logistic regression to account for confounding, older age and volar-radial sided wrist pain were independently associated with FCR signal changes on MRI. Conclusions: Signal changes in the FCR are infrequent and often incidental (asymptomatic) or associated with peritrapezial osteoarthritis.

This is a retrospective study.To compare (1) recurrence of radiculopathy and (2) back pain after decompression with and without fusion for patients with a symptomatic synovial cyst.Previous work described favorable outcomes following cyst excision with and without fusion. Because of the association of facet cysts with spinal instability it is hypothesized that a decompression with fusion will lead to better outcomes. However, previous studies present contradicting results.We included 314 consecutive patients that underwent operative treatment for a facet cyst between 2003 and 2013 at 2 tertiary spine referral centers: 224 (71%) underwent decompression without fusion (35% spondylolisthesis), 90 (29%) underwent decompression with fusion (63% spondylolisthesis). Baseline data were compared between the groups. Bivariate log-rank analysis was used to compare outcomes between groups, followed by multivariable Cox regression analysis accounting for differences in baseline characteristics.Patients undergoing decompression with fusion presented with a higher incidence of back pain (P=0.004) and spondylolisthesis (P0.001), had more often bilateral decompressions (P0.001), more facetectomies (P0.001), and more levels of decompression (P=0.004) than those who underwent decompression alone. We found a difference in recurrence of radiculopathy (no fusion: 25% vs. fusion: 9.4%, P=0.029) in bivariate analysis. However, this difference did not hold when accounting for confounders (hazard ratio, 0.50, 95% confidence interval, 0.19-1.31, P=0.16). There was no difference in recurrence of back pain in bivariate (no fusion: 29% vs. fusion: 22%, P=0.51) and multivariable analysis (hazard ratio 0.51, 95% confidence interval, 0.23-1.14, P=0.10).We found, with the numbers evaluated, no difference in recurrence of radiculopathy or back pain between patients undergoing decompression with or without fusion after accounting for confounders. The decision for fusion should be considered in light of the extent of decompression and the existence of other pathology.Level III-therapeutic study.

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.

The United States and Canada are in the midst of an epidemic of the use, misuse and overdose of opioids, and deaths related to overdose. This is the direct result of overstatement of the benefits and understatement of the risks of using opioids by advocates and pharmaceutical companies. Massive amounts of prescription opioids entered the community and were often diverted and misused. Most other parts of the world achieve comparable pain relief using fewer opioids. The misconceptions about opioids that created this epidemic are finding their way around the world. There is particular evidence of the increased prescription of strong opioids in Europe. Opioids are addictive and dangerous. Evidence is mounting that the best pain relief is obtained through resilience. Opioids are often prescribed when treatments to increase resilience would be more effective. Cite this article: Bone Joint J 2017;99-B:856–64.

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.

It would be helpful for the decision-making process of patients with metastatic bone disease to understand which patients are at risk for worse quality of life (QOL), pain, anxiety, and depression. Normative data, and where these stand compared with general population scores, can be useful to compare and interpret results of similar patients or patient groups, but to our knowledge, there are no such robust data. We wished (1) to assess what factors are independently associated with QOL, pain interference, anxiety, and depression in patients with metastatic bone disease, and (2) to compare these outcomes with general US population values. Between November 2011 and February 2015, 859 patients with metastatic bone disease presented to our orthopaedic oncology clinic; 202 (24%) were included as they completed the EuroQOL-5 Dimension (EQ-5D(TM)), PROMIS(®) Pain Interference, PROMIS(®) Anxiety, and PROMIS(®) Depression questionnaires as part of a quality improvement program. We did not record reasons for not responding and found no differences between survey respondents and nonrespondents in terms of age (63 versus 64 years; p = 0.916), gender (51% men versus 47% men; p = 0.228), and race (91% white versus 88% white; p = 0.306), but survey responders were more likely to be married or living with a partner (72%, versus 62%; p = 0.001). We assessed risk factors for QOL, pain interference, anxiety, and depression using multivariable linear regression analysis. We used the one-sample signed rank test to assess whether scores differed from US population averages drawn from earlier large epidemiologic studies. Younger age (β regression coefficient [β], < 0.01; 95% CI, 0.00-0.01; p = 0.041), smoking (β, -0.12; 95% CI, -0.22 to -0.01; p = 0.026), pathologic fracture (β, -0.10; 95% CI, -0.18 to -0.02; p = 0.012), and being unemployed (β, -0.09; 95% CI, -0.17 to -0.02; p = 0.017) were associated with worse QOL. Current smoking status was associated with more pain interference (β, 6.0; 95% CI, 1.6-11; p = 0.008). Poor-prognosis cancers (β, 3.8; 95% CI, 0.37-7.2; p = 0.030), and pathologic fracture (β, 6.3; 95% CI, 2.5-7.2; p = 0.001) were associated with more anxiety. Being single (β, 5.9; 95% CI, 0.83-11; p = 0.023), and pathologic fracture (β, 4.4; 95% CI, 0.8-8.0; p = 0.017) were associated with depression. QOL scores (0.68 versus 0.85; p < 0.001), pain interference scores (65 versus 50; p < 0.001), and anxiety scores (53 versus 50; p = 0.011) were worse for patients with bone metastases compared with general US population values, whereas depression scores were comparable (48 versus 50; p = 0.171). Impending pathologic fractures should be treated promptly to prevent deterioration in QOL, anxiety, and depression. Our normative data can be used to compare and interpret results of similar patients or patient groups. Future studies could focus on specific cancers metastasizing to the bone, to further understand which patients are at risk for worse patient-reported outcomes. Level III, prognostic study

Study Design: Retrospective cohort study. Objectives: (1) To assess patient-reported outcomes—physical function, pain, and quality of life—in patients who underwent resection of a mobile spine chondrosarcoma. (2) To assess complications (90 days), readmissions, reoperations, oncological outcomes, and neurologic status. Methods: Thirty-three patients with spinal conventional chondrosarcoma resection between 1984 and 2014 at one hospital were included. The primary outcome measures were—minimally 6 months after surgery—the EuroQol 5 Dimensions (EQ5D), PROMIS–Physical Function, PROMIS–Pain Intensity, and Oswestry (ODI) Disability Index, or Neck (NDI) Disability established in 14 out of 20 alive (70.0%) patients. Complications, readmission, reoperations, oncological outcomes, and neurological status were reported for the complete cohort of 33 patients. Results: After spine chondrosarcoma resection, patients (n = 14) reported worse physical function (median 43, range 22-61, P = .026), worse quality of life (median EQ5D 0.70, range 0.04-1, P = .022), and comparable pain intensity (median 47, range 31-56, P = .362) when compared with US general population values. The median NDI/ODI was 25 (range 0-72) indicating mild to moderate disability. Patients undergoing reoperation had worse patient-reported outcomes than those who did not. Eighteen (55.5%) out of 33 patients suffered complications (90 days), 14 (42.4%) had unplanned readmission, and 13 (39.4%) underwent reoperation. Intralesional resection was associated with increased readmission, reoperation, and recurrence rate. Conclusions: Chondrosarcoma affects quality of life and physical function and its treatment frequently results in complications and reoperations. Our findings can be used to inform future patients about expected outcomes.

BACKGROUND: Artificial-intelligence algorithms derive rules and patterns from large amounts of data to calculate the probabilities of various outcomes using new sets of similar data. In medicine, artificial intelligence (AI) has been applied primarily to image-recognition diagnostic tasks and evaluating the probabilities of particular outcomes after treatment. However, the performance and limitations of AI in the automated detection and classification of fractures has not been examined comprehensively. QUESTION/PURPOSES: In this systematic review, we asked (1) What is the proportion of correctly detected or classified fractures and the area under the receiving operating characteristic (AUC) curve of AI fracture detection and classification models? (2) What is the performance of AI in this setting compared with the performance of human examiners? METHODS: The PubMed, Embase, and Cochrane databases were systematically searched from the start of each respective database until September 6, 2018, using terms related to “fracture”, “artificial intelligence”, and “detection, prediction, or evaluation.” Of 1221 identified studies, we retained 10 studies: eight studies involved fracture detection (ankle, hand, hip, spine, wrist, and ulna), one addressed fracture classification (diaphyseal femur), and one addressed both fracture detection and classification (proximal humerus). We registered the review before data collection (PROSPERO: CRD42018110167) and used the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA). We reported the range of the accuracy and AUC for the performance of the predicted fracture detection and/or classification task. An AUC of 1.0 would indicate perfect prediction, whereas 0.5 would indicate a prediction is no better than a flip-of-a-coin. We conducted quality assessment using a seven-item checklist based on a modified methodologic index for nonrandomized studies instrument (MINORS). RESULTS: For fracture detection, the AUC in five studies reflected near perfect prediction (range, 0.95-1.0), and the accuracy in seven studies ranged from 83% to 98%. For fracture classification, the AUC was 0.94 in one study, and the accuracy in two studies ranged from 77% to 90%. In two studies AI outperformed human examiners for detecting and classifying hip and proximal humerus fractures, and one study showed equivalent performance for detecting wrist, hand and ankle fractures. CONCLUSIONS: Preliminary experience with fracture detection and classification using AI shows promising performance. AI may enhance processing and communicating probabilistic tasks in medicine, including orthopaedic surgery. At present, inadequate reference standard assignments to train and test AI is the biggest hurdle before integration into clinical workflow. The next step will be to apply AI to more challenging diagnostic and therapeutic scenarios when there is absence of certitude. Future studies should also seek to address legal regulation and better determine feasibility of implementation in clinical practice. LEVEL OF EVIDENCE: Level II, diagnostic study.

The primary aim of this paper is to introduce Quantitative 3-dimensional Computed Tomography (Q3DCT) for odontoid fractures to assess if fracture characteristics differ between the Anderson and d'Alonso subclasses. Secondarily, we assessed if high energy injury and older age influenced fracture morphology. This retrospective imaging study includes 66 patients who visited one of two level I trauma centers for an odontoid fracture. With the use of 3-Dimensional polygon mesh models we determined the total number of fragments, the volume of each fragment, the degree of displacement of the odontoid, and the fracture surface area. We found that type III fractures consisted of more fracture fragments (median:3, IQR:2–3) than type II odontoid fractures (median:2, IQR:2–3) (p < 0.001). The volume of the odontoid fracture fragment was almost twice as large in type III odontoid fractures (median:19%, IQR:14–25%) as compared to type II fractures (median:10%, IQR:8.5–12%) (p < 0.001). Type II fractures were more displaced (median:3.8 mm, IQR:2.9–6.3 mm) compared to type III fractures (median:2.2 mm, IQR:1.0–3.5 mm) (p < 0.001). This 3-dimensional displacement was predominantly due to substantially more posterior displacement of type II odontoid fractures. In conclusion, type III odontoid fractures were more comminuted, had a larger odontoid fragment, had a larger fracture surface, but were less (posteriorly) displaced when compared to type II fractures. The mechanism of injury and age at diagnosis both dictated the fracture type, but when accounting for fracture type the influence of these two factors on fracture morphology was limited.

Purpose Operative treatment of trapeziometacarpal osteoarthritis (TMC OA) is discretionary. There is substantial surgeon-to-surgeon variation in offers of surgery. This study assessed factors associated with variation in recommendation of operative treatment to patients with TMC OA. Secondarily, we studied factors associated with preferred operative technique and surgeon demographic factors variability in recommendation for operative treatment. Methods We invited all hand surgeon members of the Science of Variation Group to review 16 scenarios of patients with TMC OA and asked the surgeons whether they would recommend surgical treatment for each patient and, if yes, which surgical technique they would offer (trapeziectomy, trapeziectomy with ligament reconstruction and/or tendon interposition, joint replacement, or arthrodesis). Scenarios varied in pain intensity, relief after injection, radiographic severity, and psychosocial symptoms. Results Patient characteristics associated with greater likelihood to recommend surgical treatment were substantial pain, a previous injection that did not relieve pain, radiograph with severe TMC OA, and few symptoms of depression. Practice region was the only factor associated with preferred surgical technique and trapeziectomy with ligament reconstruction and/or tendon interposition the most commonly recommended treatment. There was low agreement among surgeons regarding treatment recommendations. Conclusions The notable variation in offers of operative treatment for TMC OA is largely associated with variable attention to subjective factors. Future studies might address the relative influence of surgeon incentives and beliefs, objective pathophysiology, and subjective patient factors on variation in surgeon recommendations. Clinical relevance Surgeons’ awareness of the potential influence of subjective factors on their recommendations might contribute to efforts to ensure that patient choices reflect what matters most to them and are not based on misconceptions.

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 and Objectives We assessed whether allogeneic blood transfusions were associated with infection—within 90 days—after surgery for bone metastatic disease. Furthermore, we assessed other risk factors associated with infection. Methods We included 1,266 patients surgically treated for a bone metastasis at two hospitals between 2002 and 2013. Blood transfusions within 7 days before and after surgery were considered perioperative. Results We found no independent association between exposure to blood transfusion and infection (odds ratio [OR] 1.02, 95% confidence interval [CI]: 0.76–1.37, P = 0.889), nor a dose–response relationship (OR 1.02, 95%CI: 0.98–1.07, P = 0.245). Older age (OR 1.01, 95%CI: 1.00–1.02, P = 0.035), a higher modified Charlson comorbidity index (OR 1.13, 95%CI: 1.05–1.22, P = 0.002), surgery to the axial skeleton (OR 1.89, 95%CI: 1.42–2.51, P

Study design Retrospective study. Objective To assess the relation between exposure to epidural steroid injection (ESI) before surgery and occurrence of surgical site infection (SSI) for degenerative lumbar spine conditions. Summary of background data The effect of local ESI on the occurrence of SSI is controversial. Methods Patients who underwent surgery for degenerative lumbar spine conditions at two centers between 2005 and 2015 were identified. Primary outcome measure was SSI within 90 days requiring surgical intervention. Results A total of 5311 patients (age 57 ± 16 years) were analyzed of which 945 (18%) had at least one ESI within 90 days of surgery. One hundred thirty-four (2.5%) patients developed an SSI requiring reoperation. No association of exposure or dose-response relationship was identified between ESI and SSI for any of the time periods (90-, 30-, and 30-90-day). Five (1.7%) of the 290 patients who had at least one ESI within 30 days before surgery had a postoperative infection compared to 129 (2.6%) of the 5021 in the non-ESI group (unadjusted odds ratio: 0.67, 95% CI: 0.27-1.64, P = 0.376). Fifteen (2.0%) of the 761 patients who had at least one ESI within 30 to 90 days before surgery had a postoperative infection, compared to 119 (2.6%) of the 4550 in the non-ESI group (unadjusted odds ratio: 0.75, 95% CI: 0.44-1.29, P = 0.296). Conclusion In this retrospective study we investigated whether an ESI and its timing influences the postoperative risk of an SSI. We found no association-exposure or dose-response relationship-between ESI and postoperative infection, even after adjusting for potential confounders, for any of the time periods (90-, 30-, and 30-90-day ESI). In addition, we did find that longer hospital stay, greater EBL, posterior approach, and drain placement were associated with higher infection rates. Level of evidence 3.

Objectives To assess, (i) the degree to which the: PROMIS Physical Function Cancer, PROMIS Neuro-QoL Mobility, Toronto Extremity Salvage Score (TESS), Lower Extremity Function Score (LEFS), and Musculoskeletal Tumor Society score (MSTS), measure physical function; (ii) differences in coverage and reliability; and (iii) difference in completion time. Methods One hundred of 115 (87%) patients with lower extremity metastases participated in this prospective study. We used exploratory factor analysis—correlating questionnaires with an underlying trait—to assess if questionnaires measure the same. Coverage was assessed by floor and ceiling effect and reliability by the standard error of measurement (SEM). Completion time was compared using the Friedman test. Results All questionnaires measured the same concept; demonstrated by high correlations (>0.7). Floor effect was absent, while ceiling effect was present in all, but highest for the PROMIS Neuro-QoL Mobility (7%). The SEM was below the threshold—indicating reliability—over a wide range of ability levels for the PROMIS-Physical Function, TESS, and LEFS. Completion time differed between questionnaires (P

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.

Much of the decision-making in orthopaedics rests on uncertain evidence. Uncertainty is therefore part of our normal daily practice, and yet physician uncertainty regarding treatment could diminish patients' health. It is not known if physician uncertainty is a function of the evidence alone or if other factors are involved. With added experience, uncertainty could be expected to diminish, but perhaps more influential are things like physician confidence, belief in the veracity of what is published, and even one's religious beliefs. In addition, it is plausible that the kind of practice a physician works in can affect the experience of uncertainty. Practicing physicians may not be immediately aware of these effects on how uncertainty is experienced in their clinical decision-making. We asked: (1) Does uncertainty and overconfidence bias decrease with years of practice? (2) What sociodemographic factors are independently associated with less recognition of uncertainty, in particular belief in God or other deity or deities, and how is atheism associated with recognition of uncertainty? (3) Do confidence bias (confidence that one's skill is greater than it actually is), degree of trust in the orthopaedic evidence, and degree of statistical sophistication correlate independently with recognition of uncertainty? We created a survey to establish an overall recognition of uncertainty score (four questions), trust in the orthopaedic evidence base (four questions), confidence bias (three questions), and statistical understanding (six questions). Seven hundred six members of the Science of Variation Group, a collaboration that aims to study variation in the definition and treatment of human illness, were approached to complete our survey. This group represents mainly orthopaedic surgeons specializing in trauma or hand and wrist surgery, practicing in Europe and North America, of whom the majority is involved in teaching. Approximately half of the group has more than 10 years of experience. Two hundred forty-two (34%) members completed the survey. We found no differences between responders and nonresponders. Each survey item measured its own trait better than any of the other traits. Recognition of uncertainty (0.70) and confidence bias (0.75) had relatively high Cronbach alpha levels, meaning that the questions making up these traits are closely related and probably measure the same construct. This was lower for statistical understanding (0.48) and trust in the orthopaedic evidence base (0.37). Subsequently, combining each trait's individual questions, we calculated a 0 to 10 score for each trait. The mean recognition of uncertainty score was 3.2 ± 1.4. Recognition of uncertainty in daily practice did not vary by years in practice (0-5 years, 3.2 ± 1.3; 6-10 years, 2.9 ± 1.3; 11-20 years, 3.2 ± 1.4; 21-30 years, 3.3 ± 1.6 years; p = 0.51), but overconfidence bias did correlate with years in practice (0-5 years, 6.2 ± 1.4; 6-10 years, 7.1 ± 1.3; 11-20 years, 7.4 ± 1.4; 21-30 years, 7.1 ± 1.2 years; p < 0.001). Accounting for a potential interaction of variables using multivariable analysis, less recognition of uncertainty was independently but weakly associated with working in a multispecialty group compared with academic practice (β regression coefficient, -0.53; 95% confidence interval [CI], -1.0 to -0.055; partial R(2), 0.021; p = 0.029), belief in God or any other deity/deities (β, -0.57; 95% CI, -1.0 to -0.11; partial R(2), 0.026; p = 0.015), greater confidence bias (β, -0.26; 95% CI, -0.37 to -0.14; partial R(2), 0.084; p < 0.001), and greater trust in the orthopaedic evidence base (β, -0.16; 95% CI, -0.26 to -0.058; partial R(2), 0.040; p = 0.002). Better statistical understanding was independently, and more strongly, associated with greater recognition of uncertainty (β, 0.25; 95% CI, 0.17-0.34; partial R(2), 0.13; p < 0.001). Our full model accounted for 29% of the variability in recognition of uncertainty (adjusted R(2), 0.29). The relatively low levels of uncertainty among orthopaedic surgeons and confidence bias seem inconsistent with the paucity of definitive evidence. If patients want to be informed of the areas of uncertainty and surgeon-to-surgeon variation relevant to their care, it seems possible that a low recognition of uncertainty and surgeon confidence bias might hinder adequately informing patients, informed decisions, and consent. Moreover, limited recognition of uncertainty is associated with modifiable factors such as confidence bias, trust in orthopaedic evidence base, and statistical understanding. Perhaps improved statistical teaching in residency, journal clubs to improve the critique of evidence and awareness of bias, and acknowledgment of knowledge gaps at courses and conferences might create awareness about existing uncertainties. Level 1, prognostic study

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.

Background The mainstay of treatment for bone metastases from renal cell carcinoma is surgery. We assessed if there was a difference in local recurrence, reoperation, and survival between patients who underwent metastasectomy, intralesional curettage, or stabilization only for renal cell carcinoma metastasis to the appendicular skeleton, and if there was a difference in these outcomes based on margin status. Methods This retrospective study included 183 patients; 48% underwent metastasectomy (n = 88, margins: 64 negative; 20 positive; 4 unclear), 30% intralesional curettage (n = 54), and 22% stabilization only (n = 41). Results The recurrence rate differed and was highest after stabilization only (39%), followed by intralesional curettage (22%), and metastasectomy (12%) (P = 0.003). However, we found no difference in reoperation rate (P = 0.847). Survival was better in patients who underwent metastasectomy (P = 0.020). The recurrence rate was lower in patients who had a negative margin (5%) as compared to those with a positive margin (26%) (P

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.

For greater tuberosity fractures, 5-mm displacement is a commonly used threshold for recommending surgery; however, it is unclear if displacement can be assessed with this degree of precision and reliability using plain radiographs. It also is unclear if CT images provide additional information that might change decision making. We asked: (1) Does interobserver agreement for assessment of the amount and direction of fracture-fragment displacement vary based on imaging modality (radiographs only; 2-dimensional [2-D] CT images and radiographs; and 3-dimensional [3-D] and 2-D CT images and radiographs)? (2) Does the likelihood of recommending surgery vary based on imaging modality? (3) Does the level of confidence regarding the decision for treatment vary based on imaging modality? We invited 791 orthopaedic surgeons to complete a survey on greater tuberosity fractures. One hundred eighty (23%) responded and were randomized on a 1:1:1 basis in one of the three imaging modality groups and evaluated the same set of 22 fractures. We described age, sex, mechanism of injury, days between injury and imaging, and that patients had no comorbidities or signs of neurovascular damage for every case. One hundred sixty-four of the 180 respondents completed the study and there was an imbalance in noncompletion between the three groups (two of 67 [3.0%] in the radiograph only group; nine of 57 [16%] in the 2-D CT and radiograph group; and five of 56 [8.9%] in the 3-D CT, 2-D CT, and radiograph group; p = 0.043 by Fisher’s exact test). Participants assessed amount (in millimeters) and direction (posterosuperior/posteroinferior/anterosuperior/anteroinferior/no displacement) of displacement; recommended treatment (surgical or nonoperative); and indicated their level of confidence regarding the recommended treatment on a scale from 0 to 10 for every case. Overall recommendation for treatment was expressed as a surgery score per surgeon by dividing the amount of cases they would operate on by the total number of cases (n = 22) and presented as a percentage. Confidence regarding the decision for treatment was calculated by averaging the confidence score per surgeon, ranging from 0 to 10. We compared interobserver agreement using kappa for categorical variables and intraclass correlation (ICC) for continuous variables. We used multivariable linear regression to assess difference in surgery score and confidence level between imaging groups, controlling for surgeon characteristics. Interobserver agreement for assessment of amount (radiographs: ICC, 0.55, 2-D CT + radiographs ICC, 0.53, 3-D CT + 2-D CT + radiographs ICC, 0.57; p values on all comparisons >0.7) and direction (radiographs: kappa, 0.30, 2-D CT + radiographs kappa, 0.43, 3-D CT + 2-D CT + radiographs kappa, 0.40; p values for all comparisons >0.096) of displacement did not vary by imaging modality. 2-D CT and radiographs (β regression coefficient [β], 3.1; p = 0.253) and 3-D CT, 2-D CT and radiographs (β, 1.6; p = 0.561) did not result in a difference in recommendation for surgery compared with radiographs alone. 2-D CT and radiographs (β, 0.40; p = 0.021) and 3-D CT, 2-D CT and radiographs (β, 0.44; p = 0.011) were associated with slightly higher levels of confidence compared with radiographs alone. Imaging modality, with the numbers evaluated, does not influence interobserver agreement of greater tuberosity fracture assessment, nor did it influence the recommendation for surgical treatment. However, surgeons did feel slightly more confident about their treatment recommendation when assessing CT images with radiographs compared with radiographs alone. Our results therefore suggest no additional value of CT scans for assessment of greater tuberosity fractures when displacement seems to be minimal on plain radiographs. CT scans could be helpful in borderline cases, or in case other fractures can be expected (eg, an occult surgical neck fracture). Level III, diagnostic study.

Background: Skeletal metastases are a common problem in patients with cancer, and surgical decision making depends on multiple factors including life expectancy. Identification of new prognostic factors can improve survival estimation and guide healthcare providers in surgical decision making. In this study, we aim to determine the prognostic value of neutrophil/lymphocyte ratio (NLR) and platelet/lymphocyte ratio (PLR) in patients with bone metastasis. Methods: One thousand and twelve patients from two tertiary referral centers between 2002 and 2014 met the inclusion criteria. Bivariate and multivariate Cox regression analyses were performed to determine the association of NLR and PLR with survival. Results: At 3 months, 84.0% of the patients with low NLR were alive versus 61.3% of the patients with a high NLR (p < 0.001), and 75.8% of the patients with a low PLR were alive versus 55.6% of the patients with a high PLR (p < 0.001). Both elevated NLR and elevated PLR were independently associated with worse survival (hazard ratio (HR): 1.311; 95% confidence interval (CI): 1.117–1.538; p = 0.001) and (HR: 1.358; 95% CI: 1.152–1.601; p < 0.001), respectively. Conclusion: This study showed both NLR and PLR to be independently associated with survival in patients who were treated for skeletal metastasis.

Background: Radiographic fracture classification helps with research on prognosis and treatment. AO/OTA classification into fracture type has shown to be reliable, but further classification of fractures into subgroups reduces the interobserver agreement and takes a considerable amount of practice and experience in order to master. Questions/purposes: We assessed: (1) differences between more and less experienced trauma surgeons based on hip fractures treated per year, years of experience, and the percentage of their time dedicated to trauma, (2) differences in the interobserver agreement between classification into fracture type, group, and subgroup, and (3) differences in the interobserver agreement when assessing fracture stability compared to classifying fractures into type, group and subgroup. Methods: This study used the Science of Variation Group to measure factors associated with variation in interobserver agreement on classification of proximal femur fractures according to the AO/OTA classification on radiographs. We selected 30 anteroposterior radiographs from 1061 patients aged 55 years or older with an isolated fracture of the proximal femur, with a spectrum of fracture types proportional to the full database. To measure the interobserver agreement the Fleiss’ kappa was determined and bootstrapping (resamples = 1000) was used to calculate the standard error, z statistic, and 95% confidence intervals. We compared the Kappa values of surgeons with more experience to less experienced surgeons. Results: There were no statistically significant differences in the Kappa values on each classification level (type, group, subgroup) between more and less experienced surgeons. When all surgeons were combined into one group, the interobserver reliability was the greatest for classifying the fractures into type (kappa, 0.90; 95% CI, 0.83 to 0.97; p < 0.001), reflecting almost perfect agreement. When comparing the kappa values between classes (type, group, subgroup), we found statistically significant differences between each class. Substantial agreement was found in the clinically relevant groups stable/unstable trochanteric, displaced/non-displaced femoral neck, and femoral head fractures (kappa, 0.60; 95% CI, 0.53 to 0.67, p < 0.001). Conclusions: This study adds to a growing body of evidence that relatively simple distinctions are more reliable and that this is independent of surgeon experience.

Introduction: To asses physical function and quality of life after distal biceps tendon repair and compare suture anchor and cortical button fixation. Secondarily, we assessed the impact of other factors: acute repair, graft use, concomitant arm conditions, contralateral rupture, and complications. Methods: We approached all 50 patients that underwent distal biceps tendon rupture repair (2009–2016) to participate in our study and complete a questionnaire including: patient demographics, QuickDASH, Quality of life EQ-5D-5L, pain score, and Mayo Elbow Performance score (MEPS). Results: In total, 37 (76%) of 49 alive patients participated in our study. All were men, with a median age of 47 years. Median follow-up was 34 months (range 8–100 months). On average, we found perfect upper extremity (QuickDASH, median: 0, IQR 0–7.9; 53% had no [QuickDASH = 0] upper extremity disability) and elbow function (MEPS, median: 100, IQR 100–100; 83% had perfect [MEPS > 90] clinical elbow function), perfect quality of life (EQ-5D-5L, median: 1, IQR 0.85–1; 59% had perfect [EQ-5D-5L = 1] quality of life), and no pain (median 0, IQR 0–0; 68% had no pain). We found no difference in upper extremity (QuickDASH: anchor, median 1.1, IQR 0–6.8; endobutton, median 0, IQR 0–9.1, p = 0.972) and elbow (MEPS: anchor, median 100, IQR 100–100; endobutton, median 100, IQR 100–100, p = 0.895) function, quality of life (EQ-5D-5L: anchor, median 1, IQR 0.85–1; endobutton, median 1, IQR 0.84–1, p = 0.507), and pain score (anchor, median 0, IQR 0–0.5; endobutton, median 0, IQR 0–0, p = 0.742) when comparing the anchor to endobutton fixation technique. Conclusions: Overall, patients have excellent outcome after distal biceps tendon rupture repair. There was no difference in patient-reported outcome measures between suture anchor and endobutton fixation. Level of evidence: Level III, retrospective comparative study.

Background: The appearance of early Kienböck disease on radiographs and magnetic resonance imaging (MRI) may be difficult to distinguish from other conditions that affect the lunate. We aimed to assess the interobserver agreement in the diagnosis of early Kienböck disease when evaluated on different imaging modalities. Methods: Forty-three hand surgeon members of the Science of Variation Group were randomized to evaluate radiographs and 35 hand surgeons to evaluate radiographs and MRI scans of 26 patients for the presence of Kienböck disease, the lunate type, and the ulnar variance. We used Fleiss’ kappa analysis to assess the interobserver agreement for categorical variables and compared the κ values between the 2 groups. Results: We found that agreement on the diagnosis of early Kienböck disease was fair (κ, 0.36) among observers who evaluated radiographs alone and moderate (κ, 0.58) among observers who evaluated MRI scans in addition to radiographs, and that the difference in κ values was not statistically significant ( P = .057). Agreement did not differ between observers based on imaging modality with regard to the assessment of the lunate type ( P = .75) and ulnar variance ( P = .15). Conclusions: We found, with the numbers evaluated, a notable but nonsignificant difference in agreement in favor of observers who evaluated MRI scans in addition to radiographs compared with radiographs alone. Surgeons should be aware that the diagnosis of Kienböck disease in the precollapse stages is not well defined, as evidenced by the substantial interobserver variability.

Assessing quality of life, functional outcome, and pain has become important in assessing the effectiveness of treatment for metastatic spine disease. Many questionnaires are able to measure these outcomes; few are validated in patients with metastatic spine disease. As a result, there is no consensus on the ideal questionnaire to use in these patients. Our study aim was to assess whether certain questionnaires measuring quality of life, functional outcome, and pain (1) correlated with each other, (2) measured the construct they claim to measure, (3) had good coverage-floor and ceiling effects, (4) were reliable, and (5) whether there were differences in completion time between them. This is a prospective cross-sectional survey study from three outpatient clinics (two orthopedic oncology clinics and one neurosurgery clinic) from two affiliated tertiary hospital care centers. We included 100 consecutive patients with metastatic spine disease between July 2014 and February 2016. We excluded non-English-speaking patients. The following questionnaires were given in random order: Oswestry Disability Index (ODI) or Neck Disability Index (NDI), Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function, PROMIS Pain Intensity, EuroQol-5 Dimensions (EQ-5D), and the Spine Oncology Study Group Outcome Questionnaire (SOSG-OQ). We used exploratory factor analysis-correlating questionnaires with an underlying mathematically derived trait-to assess if questionnaires measured the same concept. Coverage was assessed by floor and ceiling effects, and reliability was assessed by standard error of measurement as a function of ability. Differences in completion times were tested using the Friedman test. Questionnaires measured the construct they were developed for, as demonstrated with high correlations (>0.7) with the underlying trait. A floor effect was present in the PROMIS Pain Intensity (7.0%), ODI or NDI (4.0%), and the PROMIS Physical Function (1.0%) questionnaires. A ceiling effect was present in the EQ-5D questionnaire (6.0%). The SOSG-OQ had no floor or ceiling effect. The PROMIS Physical Function and PROMIS Pain Intensity proved to be the most reliable, whereas the EQ-5D was the least reliable. Completion time differed among questionnaires (p

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: Current prognostication models for survival estimation in patients with metastatic spine disease lack accuracy. Identifying new risk factors could improve existing models. We assessed factors associated with survival in patients surgically treated for spine metastases, created a classic scoring algorithm, nomogram, and boosting algorithm, and tested the predictive accuracy of the three created algorithms at estimating survival. Methods: We included 649 patients from two tertiary care referral centers in this retrospective study (2002 to 2014). A multivariate Cox model was used to identify factors independently associated with survival. We created a classic scoring system, a nomogram, and a boosting (i.e., machine learning) algorithm and calculated their accuracy by receiver operating characteristic analysis. Results: Older age (hazard ratio [HR], 1.01; p = 0.009), poor performance status (HR, 1.54; p = 0.001), primary cancer type (HR, 1.68; p 1 spine metastasis (HR, 1.32; p = 0.009), lung and/or liver metastasis (HR, 1.35; p = 0.005), brain metastasis (HR, 1.90; p < 0.001), any systemic therapy for cancer prior to a surgical procedure (e.g., chemotherapy, immunotherapy, hormone therapy) (HR, 1.65; p < 0.001), higher white blood-cell count (HR, 1.03; p = 0.002), and lower hemoglobin levels (HR, 0.92; p = 0.009) were independently associated with decreased survival. The boosting algorithm was best at predicting survival on the training data sets (p < 0.001); the nomogram was more reliable at estimating survival on the test data sets, with an accuracy of 0.75 (30 days), 0.73 (90 days), and 0.75 (365 days). Conclusions: We identified risk factors associated with survival that should be considered in prognostication. Performance of the boosting algorithm and nomogram were comparable on the testing data sets. However, the nomogram is easier to apply and therefore more useful to aid surgical decision-making. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Objective The management of terrible triad injuries has evolved over the last 2 decades to include routine radial head fixation or replacement, reattachment of the lateral collateral ligament, with or without coronoid fixation. Our objective was to determine the likelihood of and factors associated with subluxation or dislocation after operative treatment of terrible triad injuries among a large group of surgeons using current techniques. Design Retrospective cohort study. Setting Two level I trauma centers. Patients/participants A total of 107 patients with operatively treated terrible triad injuries from January 2000 to June 2015. Intervention Review of patient- and surgery-related factors during the first postoperative month. Main outcome measurement Radiographic subluxation of the ulnohumeral joint. Results One hundred of the 107 patients (93%) treated with open fixation of terrible triad injuries had no radiographic subluxation or redislocation. Two patients (2%) had slight transient radiographic subluxation ("drop sign") that corrected with active exercises within weeks of surgery. Five patients (5%) had persistent radiographic subluxation, 3 treated with a second surgery (3%). When treated within 2 weeks of injury, recurrent subluxation or dislocation after operative fixation of terrible triad injuries was rare (1%), provided that the radial head was replaced and the lateral collateral ligament reattached. Conclusions Radiographic subluxation is very uncommon with current operative management of terrible triad injuries of the elbow within 2 weeks. Patients treated more than 2 weeks after injury might benefit from ancillary fixation to limit subluxation (ie, cross pinning, external fixation, or internal joint stabilizer). Level of evidence Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Burnout is common in professions such as medicine in which employees have frequent and often stressful interpersonal interactions where empathy and emotional control are important. Burnout can lead to decreased effectiveness at work, negative health outcomes, and less job satisfaction. A relationship between burnout and job satisfaction is established for several types of physicians but is less studied among surgeons who treat musculoskeletal conditions.We asked: (1) For surgeons treating musculoskeletal conditions, what risk factors are associated with worse job dissatisfaction? (2) What risk factors are associated with burnout symptoms?Two hundred ten (52% of all active members of the Science of Variation Group [SOVG]) surgeons who treat musculoskeletal conditions (94% orthopaedic surgeons and 6% trauma surgeons; in Europe, general trauma surgeons do most of the fracture surgery) completed the Global Job Satisfaction instrument, Shirom-Malamed Burnout Measure, and provided practice and surgeon characteristics. Most surgeons were male (193 surgeons, 92%) and most were academically employed (186 surgeons, 89%). Factors independently associated with job satisfaction and burnout were identified with multivariable analysis.Greater symptoms of burnout (beta, -7.13; standard error [SE], 0.75; 95% CI, -8.60 to -5.66; p Among an active research group of largely academic surgeons treating musculoskeletal conditions, most are satisfied with their job. Efforts to limit burnout and job satisfaction by optimizing engagement in and deriving meaning from the work are effective in other settings and merit attention among surgeons.Level II, prognostic study.