Online Studies on Variation in Orthopedic Surgery: Computed Tomography in MPEG4 Versus DICOM Format.

The purpose of this study was to compare the observer participation and satisfaction as well as interobserver reliability between two online platforms, Science of Variation Group (SOVG) and Traumaplatform Study Collaborative, for the evaluation of complex tibial plateau fractures using computed tomography in MPEG4 and DICOM format. A total of 143 observers started with the online evaluation of 15 complex tibial plateau fractures via either the SOVG or Traumaplatform Study Collaborative websites using MPEG4 videos or a DICOM viewer, respectively. Observers were asked to indicate the absence or presence of four tibial plateau fracture characteristics and to rate their satisfaction with the evaluation as provided by the respective online platforms. The observer participation rate was significantly higher in the SOVG (MPEG4 video) group compared to that in the Traumaplatform Study Collaborative (DICOM viewer) group (75 and 43%, respectively; P < 0.001). The median observer satisfaction with the online evaluation was seven (range, 0-10) using MPEG4 video compared to six (range, 1-9) using DICOM viewer (P = 0.11). The interobserver reliability for recognition of fracture characteristics in complex tibial plateau fractures was higher for the evaluation using MPEG4 video. In conclusion, observer participation and interobserver reliability for the characterization of tibial plateau fractures was greater with MPEG4 videos than with a standard DICOM viewer, while there was no difference in observer satisfaction. Future reliability studies should account for the method of delivering images.

Do Orthopaedic Surgeons Acknowledge Uncertainty?

BACKGROUND: 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. QUESTIONS/PURPOSES: 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? METHODS: 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. RESULTS: 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 (ß 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 (ß, -0.57; 95% CI, -1.0 to -0.11; partial R(2), 0.026; p = 0.015), greater confidence bias (ß, -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 (ß, -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 (ß, 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). CONCLUSIONS: 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 OF EVIDENCE: Level 1, prognostic study.

Among Musculoskeletal Surgeons, Job Dissatisfaction Is Associated With Burnout.

BACKGROUND: 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. QUESTIONS/PURPOSES: 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? METHODS: 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. RESULTS: Greater symptoms of burnout (ß, -7.13; standard error [SE], 0.75; 95% CI, -8.60 to -5.66; p < 0.001; adjusted R(2), 0.33) was the only factor independently associated with lower job satisfaction. Having children (ß, -0.45; SE, 0.0.21; 95% CI, -0.85 to -0.043; p = 0.030; adjusted R(2), 0.046) was the only factor independently associated with fewer symptoms of burnout. CONCLUSIONS: 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 OF EVIDENCE: Level II, prognostic study.

Greater Tuberosity Fractures: Does Fracture Assessment and Treatment Recommendation Vary Based on Imaging Modality?

BACKGROUND: 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. QUESTION/PURPOSES: 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? METHODS: 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. RESULTS: 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 (ß regression coefficient [ß], 3.1; p = 0.253) and 3-D CT, 2-D CT and radiographs (ß, 1.6; p = 0.561) did not result in a difference in recommendation for surgery compared with radiographs alone. 2-D CT and radiographs (ß, 0.40; p = 0.021) and 3-D CT, 2-D CT and radiographs (ß, 0.44; p = 0.011) were associated with slightly higher levels of confidence compared with radiographs alone. CONCLUSIONS: 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 OF EVIDENCE: Level III, diagnostic study.

Interobserver Agreement of the Eaton-Glickel Classification for Trapeziometacarpal and Scaphotrapezial Arthrosis.

PURPOSE: To determine whether simplification of the Eaton-Glickel (E-G) classification of trapeziometacarpal (TMC) joint arthrosis (eliminating evaluation of the scaphotrapezial [ST] joint) and information about the patient's symptoms and examination influence interobserver reliability. We also tested the null hypotheses that no patient and/or surgeon factors affect radiographic rating of TMC joint arthrosis and that no surgeon factors affect the radiographic rating of ST joint arthrosis. METHODS: In an on-line survey, 92 hand surgeons rated TMC joint arthrosis and ST joint arthrosis separately on 30 radiographs (Robert, true lateral, and oblique views) according to the (modified) E-G classification. We randomly assigned 42 observers to review radiographs alone and also informed 50 of the patient's symptoms and examination. Information about symptoms and examination was randomized. Interobserver reliability was determined with the s* statistic. Because of the hierarchical data structure, cross-classified ordinal multilevel regression analyses were performed to identify factors associated with the severity of arthrosis. RESULTS: Shortening the E-G classification to the first 3 stages significantly improved the interobserver reliability, which approached substantial agreement. Providing clinical information to observers marginally improved interobserver reliability. Factors associated with a lower E-G stage for TMC joint arthrosis, among observers who rated the severity of TMC joint arthrosis based on radiographs and clinical information, included female surgeon, practice setting, supervising surgical trainees in the operating room, self-reported number of patients with TMC joint arthrosis typically treated annually, male patient, higher patient age, pain limiting daily activities, and shoulder sign. A self-reported larger number of patients with TMC joint arthrosis treated annually was the only variable associated with a higher modified E-G classification to rate ST joint arthrosis. CONCLUSIONS: Our findings suggest that simpler classifications that focus on a single anatomical area are reliable and that surgeon and patient factors can bias interpretation of objective pathophysiology such as radiographic findings. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Interpretation of Post-operative Distal Humerus Radiographs After Internal Fixation: Prediction of Later Loss of Fixation.

PURPOSE: Stable fixation of distal humerus fracture fragments is necessary for adequate healing and maintenance of reduction. The purpose of this study was to measure the reliability and accuracy of interpretation of postoperative radiographs to predict which implants will loosen or break after operative treatment of bicolumnar distal humerus fractures. We also addressed agreement among surgeons regarding which fracture fixation will loosen or break and the influence of years in independent practice, location of practice, and so forth. METHODS: A total of 232 orthopedic residents and surgeons from around the world evaluated 24 anteroposterior and lateral radiographs of distal humerus fractures on a Web-based platform to predict which implants would loosen or break. Agreement among observers was measured using the multi-rater kappa measure. RESULTS: The sensitivity of prediction of failure of fixation of distal humerus fracture on radiographs was 63%, specificity was 53%, positive predictive value was 36%, the negative predictive value was 78%, and accuracy was 56%. There was fair interobserver agreement (κ = 0.27) regarding predictions of failure of fixation of distal humerus fracture on radiographs. Interobserver variability did not change when assessed for the various subgroups. CONCLUSIONS: When experienced and skilled surgeons perform fixation of type C distal humerus fracture, the immediate postoperative radiograph is not predictive of fixation failure. Reoperation based on the probability of failure might not be advisable. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

6-week radiographs unsuitable for diagnosis of suspected scaphoid fractures.

INTRODUCTION: Six week follow-up radiographs are a common reference standard for the diagnosis of suspected scaphoid fractures. The main purpose of this study was to evaluate the interobserver reliability and diagnostic performance characteristics of 6-weeks radiographs for the detection of scaphoid fractures. In addition, two online techniques for evaluating radiographs were compared. MATERIALS AND METHODS: A total of 81 orthopedic surgeons affiliated with the Science of Variation Group assessed initial and 6-week scaphoid-specific radiographs of a consecutive series of 34 patients with suspected scaphoid fractures. They were randomized in two groups for evaluation, one used a standard website showing JPEG files and one a more sophisticated image viewer (DICOM). The goal was to identify the presence or absence of a (consolidated) scaphoid fracture. Interobserver reliability was calculated using the multirater kappa measure. Diagnostic performance characteristics were calculated according to standard formulas with CT and MRI upon presentation in the emergency department as reference standards. RESULTS: The interobserver agreement of 6-week radiographs for the diagnosis of scaphoid fractures was slight for both JPEG and DICOM (k = 0.15 and k = 0.14, respectively). The sensitivity (range 42-79 %) and negative predictive value (range 79-94 %) were significantly higher using a DICOM viewer compared to JPEG images. There were no differences in specificity (range 53-59 %), accuracy (range 53-58 %), and positive predictive value (range 14-26 %) between the groups. CONCLUSIONS: Due to low agreement between observers for the recognition of scaphoid fractures and poor diagnostic performance, 6-week radiographs are not adequate for evaluating suspected scaphoid fractures. The online evaluation of radiographs using a DICOM viewer seem to improve diagnostic performance characteristics compared to static JPEG images and future reliability and diagnostic studies should account for variation due to the method of delivering medical images. LEVEL OF EVIDENCE: Diagnostic level II.

Coaching of patients with an isolated minimally displaced fracture of the radial head immediately increases range of motion.

STUDY DESIGN: Prospective cohort. INTRODUCTION: Elbow stiffness is the most common adverse event after isolated radial head fractures. PURPOSE OF THE STUDY: To assess the effect of coaching on elbow motion during the same office visit in patients with such fractures. METHODS: We enrolled 49 adult patients with minimally displaced radial head fractures, within 14 days of injury. After diagnosis, we measured demographics, catastrophic thinking, health anxiety, symptoms of depression, upper extremity-specific symptoms and disability, pain, and elbow and wrist motion. The patient was taught to apply an effective stretch in spite of the pain to limit stiffness, and elbow motion was measured again. RESULTS: With the exception of radial deviation and pronation, motion measures improved slightly but significantly on average immediately after coaching. Elbow flexion improved from 79% (110° ± 22°) of the uninjured side to 88% (122° ± 18°) after coaching (P < .001); elbow extension improved from 71% (29° ± 14°) to 78% (22° ± 15°) (P = .0012). DISCUSSION: Instruction that stretching exercises are healthy even when painful resulted in immediate improvements in motion. Prospective studies comparing different strategies for coaching patients regarding painful stretches might help clarify the optimal approach. LEVEL OF EVIDENCE: Therapeutic level 4.

Do Surgeons Treat Their Patients Like They Would Treat Themselves?

BACKGROUND: There is substantial unexplained geographical and surgeon-to-surgeon variation in rates of surgery. One would expect surgeons to treat patients and themselves similarly based on best evidence and accounting for patient preferences. QUESTIONS/PURPOSES: (1) Are surgeons more likely to recommend surgery when choosing for a patient than for themselves? (2) Are surgeons less confident in deciding for patients than for themselves? METHODS: Two hundred fifty-four (32%) of 790 Science of Variation Group (SOVG) members reviewed 21 fictional upper extremity cases (eg, distal radius fracture, De Quervain tendinopathy) for which surgery is optional answering two questions: (1) What treatment would you choose/recommend: operative or nonoperative? (2) On a scale from 0 to 10, how confident are you about this decision? Confidence is the degree that one believes that his or her decision is the right one (ie, most appropriate). Participants were orthopaedic, trauma, and plastic surgeons, all with an interest in treating upper extremity conditions. Half of the participants were randomized to choose for themselves if they had this injury or illness. The other half was randomized to make treatment recommendations for a patient of their age and gender. For the choice of operative or nonoperative, the overall recommendation for treatment was expressed as a surgery score per surgeon by dividing the number of cases they would operate on by the total number of cases (n = 21), where 100% is when every surgeon recommended surgery for every case. For confidence, we calculated the mean confidence for all 21 cases per surgeon; overall score ranges from 0 to 10 with a higher score indicating more confidence in the decision for treatment. RESULTS: Surgeons were more likely to recommend surgery for a patient (44.2% ± 14.0%) than they were to choose surgery for themselves (38.5% ± 15.4%) with a mean difference of 6% (95% confidence interval [CI], 2.1%-9.4%; p = 0.002). Surgeons were more confident in deciding for themselves than they were for a patient of similar age and gender (self: 7.9 ± 1.0, patient: 7.5 ± 1.2, mean difference: 0.35 [CI, 0.075-0.62], p = 0.012). CONCLUSIONS: Surgeons are slightly more likely to recommend surgery for a patient than they are to choose surgery for themselves and they choose for themselves with a little more confidence. Different perspectives, preferences, circumstantial information, and cognitive biases might explain the observed differences. This emphasizes the importance of (1) understanding patients' preferences and their considerations for treatment; (2) being aware that surgeons and patients might weigh various factors differently; (3) giving patients more autonomy by letting them balance risks and benefits themselves (ie, shared decision-making); and (4) assessing how dispassionate evidence-based decision aids help inform the patient and influences their decisional conflict. LEVEL OF EVIDENCE: Level III, diagnostic study.

What middle phalanx base fracture characteristics are most reliable and useful for surgical decision-making?

BACKGROUND: Fracture-dislocations of the proximal interphalangeal joint are vexing because subluxation and articular damage can lead to arthrosis and the treatments are imperfect. Ideally, a surgeon could advise a patient, based on radiographs, when the risk of problems merits operative intervention, but it is unclear if middle phalanx base fracture characteristics are sufficiently reliable to be useful for surgical decision making. QUESTIONS/PURPOSES: We evaluated (1) the degree of interobserver agreement as a function of fracture characteristics, (2) the differences in interobserver agreement between experienced and less-experienced hand surgeons, and (3) what fracture characteristics and surgeon characteristics were associated with the decision for operative treatment. METHODS: Ninety-nine (33%) of 296 hand surgeons evaluated 21 intraarticular middle phalanx base fractures on lateral radiographs. Eighty-one surgeons (82%) were in academic practice and 57 (58%) had less than 10 years experience. Participants assessed six fracture characteristics and recommended treatment (nonoperative or operative: extension block pinning, external fixation, open reduction and internal fixation, volar plate arthroplasty, or hemihamate autograft arthroplasty) for all cases. RESULTS: With all surgeons pooled together, the interobserver agreement for fracture characteristics was substantial for assessment of a 2-mm articular step or gap (kappa, 0.73; 95% CI, 0.60-0.86; p < 0.001), subluxation or dislocation (kappa, 0.72; 95% CI, 0.58-0.86; p < 0.001), and percentage of articular surface involved (intraclass correlation coefficient [ICC], 0.67; 95% CI, 0.54-0.81; p < 0.001); moderate for comminution (kappa, 0.55; 95% CI, 0.39-0.70; p < 0.001) and stability (kappa, 0.54; 95% CI, 0.39-0.69; p < 0.001); and fair for the number of fracture fragments (ICC, 0.39; 95% CI, 0.27-0.57; p < 0.001). When recommending treatment, interobserver agreement was substantial (kappa, 0.69; 95% CI, 0.50-0.88; p < 0.001) for the recommendation to operate or not to operate, but only fair (kappa, 0.34; 95% CI, 0.21-0.47; p < 0.001) for the specific type of treatment, indicating variation in operative techniques. There were no differences in agreement for any of the fracture characteristics or treatment preference between less-experienced and more-experienced surgeons, although statistical power on this comparison was low. None of the surgeon characteristics was associated with the decision for operative treatment, whereas all fracture characteristics were, except for stable and uncertain joint stability. Articular step or gap (ß, 0.90; R-squared, 0.89; 95% CI, 0.75-1.05; p < 0.001), likelihood of subluxation or dislocation (ß, 0.80; R-squared, 0.76; 95% CI, 0.59-1.02; p < 0.001), and unstable fractures (ß, 0.88; R-squared, 0.81; 95% CI, 0.67-1.1; p < 0.001), are most strongly associated with the decision for operative treatment. CONCLUSIONS: We found that assessment of a step or gap and likelihood of subluxation were most reliable and are strongly associated with the decision for operative treatment. Surgeons largely agree on which fractures might benefit from surgery, and the variation seems to be with the operative technique. Efforts at improving the care of these fractures should focus on the comparative effectiveness of the various operative treatment options. LEVEL OF EVIDENCE: Level III, diagnostic study.

How prevalent are hazardous attitudes among orthopaedic surgeons?

BACKGROUND: So-called "hazardous attitudes" (macho, impulsive, antiauthority, resignation, invulnerable, and confident) were identified by the Federal Aviation Administration and the Canadian Air Transport Administration as contributing to road traffic incidents among college-aged drivers and felt to be useful for the prevention of aviation accidents. The concept of hazardous attitudes may also be useful in understanding adverse events in surgery, but it has not been widely studied. QUESTIONS/PURPOSES: We surveyed a cohort of orthopaedic surgeons to determine the following: (1) What is the prevalence of hazardous attitudes in a large cohort of orthopaedic surgeons? (2) Do practice setting and/or demographics influence variation in hazardous attitudes in our cohort of surgeons? (3) Do surgeons feel they work in a climate that promotes patient safety? METHODS: We asked the members of the Science of Variation Group-fully trained, practicing orthopaedic and trauma surgeons from around the world-to complete a questionnaire validated in college-aged drivers measuring six attitudes associated with a greater likelihood of collision and used by pilots to assess and teach aviation safety. We accepted this validation as applicable to surgeons and modified the questionnaire accordingly. We also asked them to complete the Modified Safety Climate Questionnaire, a questionnaire assessing the absence of a safety climate that is based on the patient safety cultures in healthcare organizations instrument. Three hundred sixty-four orthopaedic surgeons participated, representing a 47% response rate of those with correct email addresses who were invited. RESULTS: Thirty-eight percent (137 of 364 surgeons) had at least one score that would have been considered dangerously high in pilots (> 20), including 102 with dangerous levels of macho (28%) and 41 with dangerous levels of self-confidence (11%). After accounting for possible confounding variables, the variables most closely associated with a macho attitude deemed hazardous in pilots were supervision of surgical trainees in the operating room (p = 0.003); location of practice in Canada (p = 0.059), Europe (p = 0.021), and the United States (p = 0.005); and being an orthopaedic trauma surgeon (p = 0.046) (when compared with general orthopaedic surgeons), but accounted for only 5.3% of the variance (p < 0.001). On average, 19% of surgeon responses to the Modified Safety Climate Questionnaire implied absence of a safety climate. CONCLUSIONS: Hazardous attitudes are common among orthopaedic surgeons and relate in small part to demographics and practice setting. Future studies should further validate the measure of hazardous attitudes among surgeons and determine if they are associated with preventable adverse events. We agree with aviation safety experts that awareness of amelioration of such attitudes might improve safety in all complex, high-risk endeavors, including surgery-a line of thinking that merits additional research.

Quantitative 3-dimensional computed tomography measurements of coronoid fractures.

PURPOSE: Using quantitative 3-dimensional computed tomography (Q3DCT) modeling, we tested the null hypothesis that there was no difference in fracture fragment volume, articular surface involvement, and number of fracture fragments between coronoid fracture types and patterns of traumatic elbow instability. METHODS: We studied 82 patients with a computed tomography scan of a coronoid fracture using Q3DCT modeling. Fracture fragments were identified and fragment volume and articular surface involvement were measured within fracture types and injury patterns. Kruskal-Wallis test was used to evaluate the Q3DCT data of the coronoid fractures. RESULTS: Fractures of the coronoid tip (n = 45) were less fragmented and had the smallest fragment volume and articular surface area involvement compared with anteromedial facet fractures (n = 20) and base fractures (n = 17). Anteromedial facet and base fractures were more fragmented than tip fractures, and base fractures had the largest fragment volume and articular surface area involvement compared with tip and anteromedial facet fractures. We found similar differences between fracture types described by Regan and Morrey. Furthermore, fractures associated with terrible triad fracture dislocation (n = 42) had the smallest fragment volume, and fractures associated with olecranon fracture dislocations (n = 17) had the largest fragment volume and articular surface area involvement compared with the other injury patterns. CONCLUSIONS: Analyzing fractures of the coronoid using Q3DCT modeling demonstrated that fracture fragment characteristics differ significantly between fracture types and injury patterns. Detailed knowledge of fracture characteristics and their association with specific patterns of traumatic elbow instability may assist decision making and preoperative planning. CLINICAL RELEVANCE: Quantitative 3DCT modeling can provide a more detailed understanding of fracture morphology, which might guide decision making and implant development.

The factors influencing the decision making of operative treatment for proximal humeral fractures.

BACKGROUND: The factors influencing the decision making of operative treatment for fractures of the proximal humerus are debated. We hypothesized that there is no difference in treatment recommendations between surgeons shown radiographs alone and those shown radiographs and patient information. Secondarily, we addressed (1) factors associated with a recommendation for operative treatment, (2) factors associated with recommendation for arthroplasty, (3) concordance with the recommendations of the treating surgeons, and (4) factors affecting the inter-rater reliability of treatment recommendations. METHODS: A total of 238 surgeons of the Science of Variation Group rated 40 radiographs of patients with proximal humerus fractures. Participants were randomized to receive information about the patient and mechanism of injury. The response variables included the choice of treatment (operative vs nonoperative) and the percentage of matches with the actual treatment. RESULTS: Participants who received patient information recommended operative treatment less than those who received no information. The patient information that had the greatest influence on treatment recommendations included age (55%) and fracture mechanism (32%). The only other factor associated with a recommendation for operative treatment was region of practice. There was no significant difference between participants who were and were not provided with information regarding agreement with the actual treatment (operative vs nonoperative) provided by the treating surgeon. CONCLUSION: Patient information-older age in particular-is associated with a higher likelihood of recommending nonoperative treatment than radiographs alone. Clinical information did not improve agreement of the Science of Variation Group with the actual treatment or the generally poor interobserver agreement on treatment recommendations.

Osteochondritis dissecans of the humeral capitellum: reliability of four classification systems using radiographs and computed tomography.

BACKGROUND: The radiographic appearance of osteochondritis dissecans (OCD) of the humeral capitellum varies according to the stage of the lesion. It is important to evaluate the stage of OCD lesion carefully to guide treatment. We compared the interobserver reliability of currently used classification systems for OCD of the humeral capitellum to identify the most reliable classification system. METHODS: Thirty-two musculoskeletal radiologists and orthopaedic surgeons specialized in elbow surgery from several countries evaluated anteroposterior and lateral radiographs and corresponding computed tomography (CT) scans of 22 patients to classify the stage of OCD of the humeral capitellum according to the classification systems developed by (1) Minami, (2) Berndt and Harty, (3) Ferkel and Sgaglione, and (4) Anderson on a Web-based study platform including a Digital Imaging and Communications in Medicine viewer. Magnetic resonance imaging was not evaluated as part of this study. We measured agreement among observers using the Siegel and Castellan multirater κ. RESULTS: All OCD classification systems, except for Berndt and Harty, which had poor agreement among observers (κ = 0.20), had fair interobserver agreement: κ was 0.27 for the Minami, 0.23 for Anderson, and 0.22 for Ferkel and Sgaglione classifications. The Minami Classification was significantly more reliable than the other classifications (P < .001). CONCLUSIONS: The Minami Classification was the most reliable for classifying different stages of OCD of the humeral capitellum. However, it is unclear whether radiographic evidence of OCD of the humeral capitellum, as categorized by the Minami Classification, guides treatment in clinical practice as a result of this fair agreement.

Long-term outcome of displaced, transverse, noncomminuted olecranon fractures.

BACKGROUND: Operative treatment of a displaced, transverse, noncomminuted fracture of the olecranon is associated with good to excellent elbow function in retrospective short-term followup studies. However, to our knowledge, no studies have evaluated objective and subjective outcomes using standardized outcome instruments (ie, DASH and Mayo Elbow Performance Index [MEPI]) to quantify long-term outcome of these specific fractures. QUESTIONS/PURPOSES: We evaluated (1) factors associated with disability, as measured with the DASH questionnaire; (2) factors associated with ulnohumeral motion; (3) factors associated with pain intensity; and (4) general descriptive findings for posttraumatic arthrosis, MEPI, ulnar neuropathy symptoms, and return to work between 10 and 32 years after open reduction and internal fixation (ORIF) of a transverse, noncomminuted fracture of the olecranon. METHODS: Between 1977 and 1997, we performed ORIFs of transverse, noncomminuted olecranon fractures in 109 patients, of whom 35 had died, 14 had incomplete data in our registry, and 19 were lost to followup or declined participation, leaving 41 patients available for followup at a minimum of 10 years after surgery. During that time, our general indication for performing ORIF was greater than 2 mm displacement. The average age of these patients at the time of injury was 35 years (range, 18-73 years). Patient-reported outcome was quantified using the DASH questionnaire, and physician-based outcome was evaluated using the MEPI. To identify factors associated with disability (DASH), impairment (MEPI), ulnohumeral motion, and pain, we examined demographic and clinical data in bivariate analyses, and subsequently significant factors in multivariate analysis to identify independent predictors of outcome. RESULTS: The sole factor associated with higher DASH scores in multivariable analysis was age at surgery, explaining 20% of the variability, with younger patients performing better. The mean arc of elbow flexion was 142° (range, 110°-160°), and the variation was associated with arthrosis alone (ie, a greater arc of motion was associated with a lesser grade of arthrosis according to the system of Broberg and Morrey). Pain was uncommon and generally was correlated with adverse events. CONCLUSIONS: The good results of operative fixation (tension-band wiring) of a transverse, displaced olecranon fracture are durable with time. Patient-reported outcomes are excellent in the majority of patients. Residual patient-rated disability does not correlate with arthrosis or loss of extension. LEVEL OF EVIDENCE: Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

Interobserver variability in the treatment of little finger metacarpal neck fractures.

PURPOSE: To address the null hypothesis that surgeons shown radiographs of little finger metacarpal neck fractures with measured fracture angulation would recommend surgery as often as surgeons shown unmarked radiographs. METHODS: Members of the Science of Variation Group, an international collaboration of fully trained orthopedic and trauma surgeons, were asked to review 20 little finger metacarpal neck fracture cases, which included a vignette and 3 high-quality radiographs. Members were then randomized to review radiographs with or without measured fracture angulation on the lateral view and select operative or nonoperative management. RESULTS: Surgeons shown radiographs with measured angulation were more likely to recommend surgery, and there was less variability among these surgeons, particularly for fractures with less angular deformity. CONCLUSIONS: Measured fracture angulation has a small but significant influence on treatment recommendations for little finger metacarpal neck fractures. TYPE OF STUDY/LEVEL OF EVIDENCE: Diagnostic III.

Carpal tunnel syndrome: assessment of surgeon and patient preferences and priorities for decision-making.

PURPOSE: This study tested the null hypothesis that there are no differences between the preferences of hand surgeons and those patients with carpal tunnel syndrome (CTS) facing decisions about management of CTS (ie, the preferred content of a decision aid). METHODS: One hundred three hand surgeons of the Science of Variation Group and 79 patients with CTS completed a survey about their priorities and preferences in decision making regarding the management of CTS. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. RESULTS: Important areas on which patient and hand surgeon interests differed included a preference for nonpainful, nonoperative treatment and confirmation of the diagnosis with electrodiagnostic testing. For patients, the main disadvantage of nonoperative treatment was that it was likely to be only palliative and temporary. Patients preferred, on average, to take the lead in decision making, whereas physicians preferred shared decision making. Patients and physicians agreed on the value of support from family and other physicians in the decision-making process. CONCLUSIONS: There were some differences between patient and surgeon priorities and preferences regarding decision making for CTS, particularly the risks and benefits of diagnostic and therapeutic procedures. CLINICAL RELEVANCE: Information that helps inform patients of their options based on current best evidence might help patients understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.

Trigger finger: assessment of surgeon and patient preferences and priorities for decision making.

PURPOSE: To test the null hypothesis that there are no differences in the priorities and preferences of patients with idiopathic trigger finger (TF) and hand surgeons. METHODS: One hundred five hand surgeons of the Science of Variation Group and 84 patients with TF completed a survey about their priorities and preferences in decision making regarding the management of TF. The questionnaire was structured according the Ottawa Decision Support Framework for the development of a decision aid. RESULTS: Patients desired orthotics more and surgery less than physicians. Patients and physicians disagreed on the main advantage of several treatment options for TFs and on disadvantages of the treatment options. Patients preferred to decide for themselves after receiving advice, whereas physicians preferred a shared decision. Patients preferred booklets, and physicians opted for Internet and video decision aids. CONCLUSIONS: Comparing patients and hand surgeons, there were some differences in treatment preferences and perceived advantages and disadvantages regarding idiopathic TF-differences that might be addressed by a decision aid. CLINICAL RELEVANCE: Information that helps inform patients of their options based on current best evidence might help them understand their own preferences and values, reduce decisional conflict, limit surgeon-to-surgeon variations, and improve health.

Diagnosis of elbow fracture patterns on radiographs: interobserver reliability and diagnostic accuracy.

BACKGROUND: Studies of traumatic elbow instability suggest that recognition of a pattern in the combination and character of the fractures and joint displacements helps predict soft tissue injury and guide the treatment of traumatic elbow instability, but there is no evidence that patterns can be identified reliably. QUESTIONS/PURPOSES: We therefore determined (1) the interobserver reliability of identifying specific patterns of traumatic elbow instability on radiographs for subgroups of orthopaedic surgeons; and (2) the diagnostic accuracy of radiographic diagnosis. METHODS: Seventy-three orthopaedic surgeons evaluated 53 sets of radiographs and diagnosed one of five common patterns of traumatic elbow instability by using a web-based survey. The interobserver reliability was analyzed using Cohen's multirater kappa. Intraoperative diagnosis was the reference for fracture pattern in calculations of the sensitivity, specificity, accuracy, and positive predictive and negative predictive values of radiographic diagnosis. RESULTS: The overall interobserver reliability for patterns of traumatic elbow instability on radiographs was κ=0.41. Treatment of greater than five such injuries a year was associated with greater interobserver agreement, but years in practice were not. Diagnostic accuracy ranged from 76% to 93% and was lowest for the terrible triad pattern of injury. CONCLUSIONS: Specific patterns of traumatic elbow instability can be diagnosed with moderate interobserver reliability and reasonable accuracy on radiographs. LEVEL OF EVIDENCE: Level III, diagnostic study. See Guidelines for Authors for a complete description of levels of evidence.

How surgeons make decisions when the evidence is inconclusive.

PURPOSE: To address the factors that surgeons use to decide between 2 options for treatment when the evidence is inconclusive. METHODS: We tested the null hypothesis that the factors surgeons use do not vary by training, demographics, and practice. A total of 337 surgeons rated the importance of 7 factors when deciding between treatment and following the natural history of the disease and 12 factors when deciding between 2 operative treatments using a 5-point Likert scale between "very important" and "very unimportant." RESULTS: According to the percentages of statements rated very important or somewhat important, the most popular factors influencing recommendations when evidence is inconclusive between treatment and following the natural course of the illness were "works in my hands," "familiarity with the treatment," and "what my mentor taught me." The most important factors when evidence shows no difference between 2 surgeries were "fewer complications," "quicker recovery," "burns fewer bridges," "works in my hands" and "familiarity with the procedure." Europeans rated "works in my hands" and "cheapest/most resourceful" of significantly greater importance and "what others are doing," "highest reimbursement," and "shorter procedure" of significantly lower importance than surgeons in the United States. Observers with fewer than 10 years in independent practice rated "what my mentor taught me," "what others are doing" and "highest reimbursement" of significantly lower importance compared to observers with 10 or more years in independent practice. CONCLUSIONS: Surgeons deciding between 2 treatment options, when the evidence is inconclusive, fall back to factors that relate to their perspective and reflect their culture and circumstances, more so than factors related to the patient's perspective, although this may be different for younger surgeons. CLINICAL RELEVANCE: Hand surgeons might benefit from consensus fallback preferences when evidence is inconclusive. It is possible that falling back to personal comfort makes us vulnerable to unhelpful commercial and societal influences.