A Systematic Review of Distinction of Colonization and Infection in Studies that Address C. Acnes and Shoulder Surgery.

BACKGROUND: After shoulder surgery, infection is often diagnosed in the absence of an inflammatory host response (purulence, sepsis). In the absence of inflammation, the more appropriate diagnoses may be colonization or contamination. We reviewed the available data regarding culture of Cutibacterium Acnes during primary and revision shoulder surgery and asked; 1. What is the prevalence of air, skin, and deep tissue colonization? 2. How often is an inflammatory host response associated with diagnosis of postoperative shoulder infection diagnosed on the basis of culture of C. Acnes? 3. Is there any relation between culture of C. Acnes and outcomes of shoulder surgery? METHODS: Three databases were searched for studies that address C. Acnes and colonization or infection related to shoulder surgery. We analyzed data from 80 studies addressing the rates of C. Acnes colonization/infection in patients undergoing shoulder surgery, evidence of an inflammatory host response, and relationship of C. Acnes culture to surgery outcomes. RESULTS: C. Acnes is often cultured in the air in the operating room (mean 10%), the skin before preparation (mean 47%), and deep tissue in primary shoulder arthroplasty (mean 29%), arthroscopy (mean 27%), and other shoulder surgery (mean 21%). C. Acnes was cultured from a mean of 39% of deep tissue samples during revision arthroplasty. C. Acnes was believed to be the causative organism of a high percentage of the infections diagnosed after surgery, 39% in primary shoulder arthroplasties, 53% in revisions, 55% in arthroscopic surgeries, and 44% in a mixture of shoulder surgeries. Infection was nearly always diagnosed in the absence of an inflammatory host response. Documented purulence and sepsis were not specifically ascribed to C. Acnes (rather than more virulent organisms such as S. Aureus). Diagnosis of infection, or unexpected positive culture, with C. Acnes during shoulder surgery is associated with outcomes comparable to shoulders with no bacterial growth. CONCLUSIONS: The evidence to date supports conceptualization of C. Acnes as a common commensal (colonization), and perhaps a frequent contaminant, and an uncommon cause of an inflammatory host response (infection). This is supported by the observations that 1) Unexpected positive culture for C. Acnes is not associated with adverse outcomes after shoulder surgery, and 2) Diagnosed infection with C. Acnes is associated with outcomes comparable to non-infected revision shoulder arthroplasty. We speculate that diagnosis of C. Acnes infection might represent an attempt to account for unexplained discomfort, incapability or stiffness after technically sound shoulder surgery. If so, the hypothesis that stiffness and pain are host responses to C. Acnes needs better experimental support.

Do Surgeons Experience Moral Dissonance When There Is Misalignment Between Evidence and Action? A Survey and Scenario-based Study.

BACKGROUND: Moral dissonance is the psychological discomfort associated with a mismatch between our moral values and potentially immoral actions. For instance, to limit moral dissonance, surgeons must develop a rationale that the potential for benefit from performing surgery is meaningfully greater than the inherent harm of surgery. Moral dissonance can also occur when a patient or one's surgeon peers encourage surgery for a given problem, even when the evidence suggests limited or no benefit over other options. Clinicians may not realize the degree to which moral dissonance can be a source of diminished joy in practice. Uncovering potential sources of moral dissonance can help inform efforts to help clinicians enjoy their work. QUESTIONS/PURPOSES: In a scenario-based experiment performed in an online survey format, we exposed musculoskeletal specialists to various types of patient and practice stressors to measure their association with moral dissonance and asked: (1) What factors are associated with the level of pressure surgeons feel to act contrary to the best evidence? (2) What factors are associated with the likelihood of offering surgery? METHODS: We performed a scenario-based experiment by inviting members of the Science of Variation Group (SOVG; an international collaborative of musculoskeletal surgeons that studies variation in care) to complete an online survey with randomized elements. The use of experimental techniques such as randomization to measure factors associated with specific ratings makes participation rate less important than diversity of opinion within the sample. A total of 114 SOVG musculoskeletal surgeons participated, which represents the typical number of participants from a total of about 200 who tend to participate in at least one experiment per year. Among the 114 participants, 94% (107) were men, 49% (56) practiced in the United States, and 82% (94) supervised trainees. Participants viewed 12 scenarios of upper extremity fractures for which surgery is optional (discretionary) based on consensus and current best evidence. In addition to a representative age, the scenario included randomized patient and practice factors that we posit could be sources of moral distress based on author consensus. Patient factors included potential sources of pressure (such as "The patient is convinced they want a specific treatment and will go to a different surgeon if they don't get it") or experiences of collaboration (such as "The patient is collaborative and involved in decisions"). Practice factors included circumstances of financial or reputational pressure (such as "The practice is putting pressure on you to generate more revenue") and factors of limited pressure (such as "Your income is not tied to revenue"). For each scenario, the participant was asked to rate both of the following statements on a scale from 0 to 100 anchored with "I don't feel it at all" at 0, "I feel it moderately" at 50, and "I feel it strongly" at 100: (1) pressure to act contrary to best evidence and (2) likelihood of offering surgery. Additional explanatory variables included surgeon factors: gender, years in practice, region, subspecialty, supervision of trainees, and practice setting (academic/nonacademic). We sought factors associated with pressure to act contrary to evidence and likelihood of offering surgery, accounting for potential confounding variables in multilevel mixed-effects linear regression models. RESULTS: Accounting for potential confounding variables, greater pressure to act contrary to best evidence was moderately associated with greater patient despair (regression coefficient [RC] 6 [95% confidence interval 2 to 9]; p = 0.001) and stronger patient preference (RC 4 [95% CI 0 to 8]; p = 0.03). Lower pressure to act contrary to evidence was moderately associated with surgeon income independent of revenue (RC -6 [95% CI -9 to -4]; p < 0.001) and no financial benefit to operative treatment (RC -6 [95% CI -8 to -3]; p < 0.001). Marketing concerns were the only factor associated with greater likelihood of offering surgery (RC 6 [95% CI 0 to 11]; p = 0.04). CONCLUSION: In this scenario-based survey experiment, patient distress and strong preferences and surgeon financial incentives were associated with greater surgeon feelings of moral dissonance when considering discretionary fracture surgery. CLINICAL RELEVANCE: To support enjoyment of the practice of musculoskeletal surgery, we recommend that surgeons, surgery practices, and surgery professional associations be intentional in both anticipating and developing strategies to ameliorate potential sources of moral dissonance in daily practice.

Variation in Interpretation of Provocative Tests for Carpal Tunnel Syndrome.

PURPOSE: We studied variation in interpretation of specific symptoms during clinical tests for carpal tunnel syndrome to estimate the degree to which surgeons consider pain without paresthesia characteristic of median neuropathy. METHODS: We invited all upper-extremity surgeon members of the Science of Variation Group to complete a scenario-based experiment. Surgeons read 5-10 clinical vignettes of patients with variation in patient demographics and random variation in symptoms and signs as follows: primary symptoms (nighttime numbness and tingling, constant numbness and loss of sensibility, pain with activity), symptoms elicited by a provocative test (Phalen, Durkan, or Tinel) (tingling, pain), and location of symptoms elicited by the provocative test (index and middle fingers, thumb and index fingers, little and ring fingers, entire hand). RESULTS: Patient factors associated with surgeon interpretation of provocative tests as negative included pain rather than paresthesia during the Phalen, Durkan, or Tinel test and location of symptoms in the entire hand rather than the median nerve distribution. CONCLUSIONS: Specialists do not consider pain without paresthesia or a noncharacteristic symptom distribution as characteristic of carpal tunnel syndrome. CLINICAL RELEVANCE: Awareness that elicitation of pain with Phalen, Durkan, and Tinel tests is regarded by specialists as relatively uncharacteristic of median neuropathy can help limit the potential for both overdiagnosis and overtreatment of median neuropathy as well as underdiagnosis and undertreatment of mental and social health contributions to illness (notable correlates of the intensity and distribution of pain).

Kinesiotaping Is Not Better Than a Placebo: Kinesiotaping for Postural Control in Anterior Cruciate Ligament-Reconstructed Patients-A Randomized Controlled Trial.

OBJECTIVE: The primary aim of this study was to investigate the immediate and delayed effects of kinesiotape (KT) on postural control and patient-reported outcome measures under challenging conditions in individuals with anterior cruciate ligament reconstructions. METHODS: Thirty-two anterior cruciate ligament-reconstructed patients for whom 6 months had passed since their operation were randomly assigned to either the KT (n = 16, aged 21.8 [5.5] y) or the placebo KT (n = 16, aged 24.0 [5.1] y) groups. Initially, both groups stood barefoot on a force platform while performing postural tasks in 4 randomized conditions (eyes open, eyes closed, cognitive task, and foam). Before the experiment, patients would bring the 4 conditions, which were written on folded papers, one by one, and in this way, the order of conditions for the examiners was determined. The patients' evaluations were conducted immediately and 48 hours after KT application. Postural control measures, with area and displacement of the center of pressure (CoP) in anterior-posterior and medial-lateral directions, and mean total velocity displacement of CoP (MVELO CoP) served as dependent variables. In addition, the International Knee Documentation Committee score was measured pretreatment and 48 hours posttreatment. RESULTS: Significant group-by-time interactions were observed for displacement of COP in medial-lateral direction (P = .002) and MVELO CoP (P = .034). MVELO CoP significantly decreased (mean difference = 0.60, P = .009) immediately after KT application compared with preapplication measures. In the placebo group, a statistically significant decrease in MVELO CoP (mean difference = 0.869, P = .001) was observed at 48 hours post-KT compared with preapplication values. International Knee Documentation Committee scores significantly improved at 48 hours post-KT application in both groups (P < .05). CONCLUSIONS: Though observed at different time points, both KT (immediately after the intervention) and placebo KT (48 h after the intervention) were found to improve postural control measures. It appears that the changes in postural control may be more related to proprioceptive enhancement due to KT rather than the specific KT pattern.

Inordinate attention to minor pathophysiology variations in musculoskeletal research: example of rotator cuff tendinopathy.

BACKGROUND: Evidence suggests variation in pathophysiology is less relevant to musculoskeletal illness than variation in mental health factors. For diseases such as rotator cuff tendinopathy, attention may be placed on aspects of tendon thinning and suture techniques when studies show that variations in muscle quality and defect size have limited association with comfort and capability compared with variations in thoughts and feelings regarding symptoms. Using rotator cuff tendinopathy as an example, we studied the degree to which research addresses relatively minor degrees of variation in pathophysiology and relatively minor differences in treatments to better understand the relative emphasis on pathophysiology. We asked the following questions: What factors are associated with relative pathophysiology severity in comparative therapeutic studies of musculoskeletal conditions? What factors are associated with relative differences in interventions in comparative therapeutic studies of musculoskeletal conditions? METHODS: We systematically reviewed clinical trials of patients with rotator cuff tendinopathy for the relative severity of pathophysiology (low, moderate, or high) and variation in interventions (minimal, moderate, or large). An example of a relatively minor variation in rotator cuff tendon pathophysiology is bursal- vs. articular-sided thinning of the tendon. An example of a relatively minor variation in treatment is single- vs. double-row defect closure. RESULTS: Most studies of rotator cuff tendinopathy treatment addressed low (39%) or medium (50%) levels of pathophysiology. Greater relative pathology severity was independently associated with operative treatment (odds ratio, 12 [95% confidence interval, 3.2-45]; P < .001). Of 127 studies, 113 (89%) were rated as comparing treatments with minimal difference. CONCLUSION: Despite the evidence of limited variation in comfort and capability due to pathophysiological variations, a large percentage of research on rotator cuff tendinopathy addresses relatively limited severity of pathophysiology and relatively minor variations in treatment. This may be typical of musculoskeletal research and suggests a possibility of focusing, on the one hand, on more impactful interventions such as treatments that can delay or avoid rotator cuff arthropathy and, on the other hand, on management strategies that optimize accommodation of common age-related changes in the rotator cuff tendons.

Amputation as a Complication after Total Knee Replacement, is it a Real Concern to be Discussed?: A Systematic Review.

Total knee replacement (TKR) is a growing attractive treatment for a degenerative knee disease. However, there remain some certain devastating complications to be discussed with patients preoperatively, including limb amputation. This systematic review aimed to determine the rate of amputation following TKR. In this study, the literature was searched up to 2019. The papers were included in which knee amputation was reported following TKR. The primary search concluded the articles from EMBASE, SCOPUS, PubMed, Web of Science, MEDLINE, OvidSP, CINAHL, EBSCO, Web of Science™, and CENTRAL. After screening and excluding case reports, 40 papers were included in the present study. The present review showed that amputation is a real end result of knee replacements either in primary or revision knee arthroplasties, which needs to be discussed with patients for their decision-making. Prevalence of amputation in terms of failure or complications after TKR procedures was estimated between 0.1-10% in different studies , with 5.1% amputation rate in infected TKR and 0.025% amputation rate in primary TKR as a result of infection in our review. Deep infection was the main cause of amputation. Vascular complications and fractures associated with bone loss and compartment syndrome were other reasons for amputation.