The Impact of a Computer-Based Interactive Informed Consent for Surgery on Decision Conflict.

PURPOSE: Informed consent for surgery can address the legal aspects of care while also being simple, informative, and empathic. We developed interactive informed consents and compared them with standard printed informed consents asking: (1) are there any factors associated with lower decision conflict or greater patient-rated clinician empathy including consent format? (2) Are there any factors associated with rating the consent process as informative, comfortable, and satisfying including consent format? METHODS: Ninety-four adult patients accepted an offer of surgery from one of three hand surgeons to address one of six common hand surgery diagnoses: carpal tunnel release, cubital tunnel release, trigger finger release, plate and screw fixation of a distal radius fracture, removal of a benign mass, including a ganglion cyst, and Dupuytren contracture release. Fifty-three patients were randomized to complete an interactive consent, and 41, a standard written consent. Symptoms of anxiety, depression, and unhelpful thoughts were measured. Patients completed the Decision Conflict Scale and the Jefferson Scale of Patient's Perceptions of Physician Empathy and rated the consent as informative, comfortable, and satisfactory on a scale of 0-10. RESULTS: Greater decisional conflict was slightly associated with greater patient unhelpful thoughts about symptoms and was not associated with consent format. A higher rating of comfort with the consent process was slightly associated with patient choice to proceed with surgical treatment, but not with consent format. Accounting for potential confounding in multivariable analysis, a higher rating of the consent process as informative was slightly associated with patient preference for surgical over nonsurgical treatment, CONCLUSIONS: The observation that an interactive consent form was not related to decision conflict or other aspects of patient experience suggests that such tools may not have much weight relative to the interaction between patient and clinician. CLINICAL RELEVANCE: Efforts to improve informed consent may need to focus on the dialog between patient and surgeon rather than how information is presented.

Surgeon variation in rates of surgery for trapeziometacarpal osteoarthritis in the United States.

We identified wide variation in surgery for trapeziometacarpal osteoarthritis among surgeons in the United States, with 42% performing no surgery, a median rate of surgery of 1.9/year, and 2% performed more than 30 procedures annually, representing 15% of all surgical procedures for TMC arthritis.

Does lidocaine reduce pain intensity during corticosteroid injection? A double-blind randomized controlled equivalence trial.

Of the strategies considered to limit the discomfort of corticosteroid injection, one is to inject without lidocaine to reduce the total volume and avoid acidity. In a Bayesian trial, adults receiving corticosteroid injections were randomized to receive 0.5 mL of triamcinolone with or without 0.5 mL of lidocaine. Serial analysis was performed until a 95% probability of presence or absence of a 1.0-point difference in pain intensity on the 0-10 Numerical Rating Scale was reached. Injections with lidocaine were associated with a median of 2.4-point lower pain intensity during injection with a 95% probability of at least a 1-point reduction. The 95% probability was confirmed in 90% of the repeated analysis (36/40). Lidocaine is associated with lower immediate pain intensity during corticosteroid injection for hand and wrist conditions.Level of evidence: I.

Machine Learning Did Not Outperform Conventional Competing Risk Modeling to Predict Revision Arthroplasty.

BACKGROUND: Estimating the risk of revision after arthroplasty could inform patient and surgeon decision-making. However, there is a lack of well-performing prediction models assisting in this task, which may be due to current conventional modeling approaches such as traditional survivorship estimators (such as Kaplan-Meier) or competing risk estimators. Recent advances in machine learning survival analysis might improve decision support tools in this setting. Therefore, this study aimed to assess the performance of machine learning compared with that of conventional modeling to predict revision after arthroplasty. QUESTION/PURPOSE: Does machine learning perform better than traditional regression models for estimating the risk of revision for patients undergoing hip or knee arthroplasty? METHODS: Eleven datasets from published studies from the Dutch Arthroplasty Register reporting on factors associated with revision or survival after partial or total knee and hip arthroplasty between 2018 and 2022 were included in our study. The 11 datasets were observational registry studies, with a sample size ranging from 3038 to 218,214 procedures. We developed a set of time-to-event models for each dataset, leading to 11 comparisons. A set of predictors (factors associated with revision surgery) was identified based on the variables that were selected in the included studies. We assessed the predictive performance of two state-of-the-art statistical time-to-event models for 1-, 2-, and 3-year follow-up: a Fine and Gray model (which models the cumulative incidence of revision) and a cause-specific Cox model (which models the hazard of revision). These were compared with a machine-learning approach (a random survival forest model, which is a decision tree-based machine-learning algorithm for time-to-event analysis). Performance was assessed according to discriminative ability (time-dependent area under the receiver operating curve), calibration (slope and intercept), and overall prediction error (scaled Brier score). Discrimination, known as the area under the receiver operating characteristic curve, measures the model's ability to distinguish patients who achieved the outcomes from those who did not and ranges from 0.5 to 1.0, with 1.0 indicating the highest discrimination score and 0.50 the lowest. Calibration plots the predicted versus the observed probabilities; a perfect plot has an intercept of 0 and a slope of 1. The Brier score calculates a composite of discrimination and calibration, with 0 indicating perfect prediction and 1 the poorest. A scaled version of the Brier score, 1 - (model Brier score/null model Brier score), can be interpreted as the amount of overall prediction error. RESULTS: Using machine learning survivorship analysis, we found no differences between the competing risks estimator and traditional regression models for patients undergoing arthroplasty in terms of discriminative ability (patients who received a revision compared with those who did not). We found no consistent differences between the validated performance (time-dependent area under the receiver operating characteristic curve) of different modeling approaches because these values ranged between -0.04 and 0.03 across the 11 datasets (the time-dependent area under the receiver operating characteristic curve of the models across 11 datasets ranged between 0.52 to 0.68). In addition, the calibration metrics and scaled Brier scores produced comparable estimates, showing no advantage of machine learning over traditional regression models. CONCLUSION: Machine learning did not outperform traditional regression models. CLINICAL RELEVANCE: Neither machine learning modeling nor traditional regression methods were sufficiently accurate in order to offer prognostic information when predicting revision arthroplasty. The benefit of these modeling approaches may be limited in this context.

Round table discussion: the management of idiopathic cubital tunnel syndrome.

Idiopathic cubital tunnel syndrome is the second most common neuropathy in the upper limb. Best evidence regarding the surgical management of this condition has evolved from anterior or submuscular transposition as the former reference standard, to in situ simple release. Differences of opinion remain regarding the timing of surgery, type of surgery and adjunctive surgery. Four surgeons with Level 5 expertise were asked to answer specific questions regarding this condition.

Steroid versus placebo injections and wrist splints in patients with carpal tunnel syndrome: a systematic review and network meta-analysis.

A network meta-analysis of randomized controlled trials compared the effectiveness of corticosteroid injections with placebo injections and wrist splints for carpal tunnel syndrome, focusing on symptom relief and median nerve conduction velocity. Within 3 months of the corticosteroid injection, there was a modest statistically significant difference in symptom relief compared to placebo injections and wrist splints, as measured by the Symptom Severity Subscore of the Boston Carpal Tunnel Questionnaire; however, this did not meet the minimum clinically important difference. Pain reduction with corticosteroids was slightly better than with wrist splints, but it also failed to reach clinical significance. Electrodiagnostic assessments showed transient changes in distal motor and sensory latencies in favour of corticosteroids at 3 months, but these changes were not evident at 6 months. The best current evidence suggests that corticosteroid injections provide minimal transient improvement in nerve conduction and symptomatology compared with placebo or wrist splints.

Are There Racial and Ethnic Variations in Patient Attitudes Toward Hip and Knee Arthroplasty for Osteoarthritis? A Systematic Review.

BACKGROUND: It is not clear why people who identify as Black or Hispanic are less likely to undergo discretionary musculoskeletal surgery such as arthroplasty for osteoarthritis of the hip or knee. Inequities and mistrust are important factors to consider. The role of socioeconomic factors and variation in values, attitudes, and beliefs regarding discretionary procedures are less well understood. A systematic review of the evidence regarding mindsets toward knee and hip arthroplasty among Black and Hispanic people could inform attempts to limit disparities in care. QUESTIONS/PURPOSES: In a systematic review of qualitative and quantitative evidence, we asked: (1) What factors are associated with racial and ethnic variations in attitudes toward discretionary hip and knee arthroplasty for osteoarthritis? (2) Do studies that investigate racial and ethnic variations in mindsets toward discretionary orthopaedic care control for potential confounding by socioeconomic factors? METHODS: A systematic search of PubMed, Cochrane, and Embase (last searched August 2023) for studies that addressed racial and ethnic variations in mindsets toward discretionary musculoskeletal care use was conducted. We excluded studies that were not published in English, lacked full-text availability, and those that documented patient approaches without comparing them to the willingness to undergo a discretionary procedure. Twenty-one studies were included-14 quantitative and seven qualitative-including 8472 patients. The Mixed Methods Appraisal Tool was used for quality assessment of included studies. The studies included demonstrated low risk of bias: five quantitative studies lacked detail regarding nonresponse bias and one qualitative study lacked details regarding the racial and ethnic composition of its cohort. To answer our first research question, we categorized themes associated with racial differences in mindsets toward discretionary care and recorded the presence of associations in quantitative studies. To answer our second question, we identified whether quantitative studies address potential confounding with socioeconomic factors. There were no randomized trials, so no meta-analysis was performed. RESULTS: In general, self-identified Black and Hispanic patients had a lower preference for hip and knee arthroplasty than self-identified White patients. Black patients were more likely to regard osteoarthritis as a natural and irremediable part of aging and prefer home remedies. Both Black and Hispanic patients valued support from religion and were relatively cost-conscious. Black and Hispanic patients had lower perception of benefit, were less familiar with the procedure, had higher levels of fear regarding surgery and recovery, and had more-limited trust in care. Generally, Black and Hispanic social networks tended to address these concerns, whereas White social networks were more likely to discuss the benefits of surgery. Thirteen of 14 quantitative studies considered and accounted for potential confounding socioeconomic variables in their analyses. CONCLUSION: The observation that lower preference for discretionary arthroplasty among Black and Hispanic patients is independent from socioeconomic factors and is related to accommodation of aging, preference for agency (home remedies), greater consideration of costs, recovery concerns, and potential harms directs orthopaedic surgeons to find ways to balance equitable access to specialty care and discretionary surgery while avoiding undermining effective accommodation strategies. It is important not to assume that lower use of discretionary surgery represents poorer care or is a surrogate marker for discrimination. LEVEL OF EVIDENCE: Level III, therapeutic study.

AOA Critical Issues: A Culture of Safety Across All Orthopaedic Professional Endeavors.

ABSTRACT: Medical professionals strive for a culture of safety in which error is anticipated, systems are designed to catch an error before it causes harm, and each event is an opportunity for specific clinicians and the system they work in to improve. A culture of safety is based on behavioral ethics, which recognizes that the automatic functions of the human mind can lead good people to misstep, and it incorporates tools such as checklists that embody critical thinking in order to help limit missteps and associated harm. Although the discussion surrounding a culture of safety often focuses on patient care, the social contract between physicians and society involves expectations that physicians will use their expertise to promote the public good in all of their professional endeavors. For example, lapses in professional conduct in the management of conflicts of interest and in ethical marketing have led to restrictions in physician self-regulation. Orthopaedic surgeons can cultivate a culture of safety and a growth mindset across all aspects of the profession, including media coverage of musculoskeletal illness, surgeon participation in informational media (e.g., podcasts and blogs), the marketing of oneself or one's practice, practice patterns and variations, academic discourse, expert legal testimony, the development and implementation of policy and law, and commercial ventures. Systems that anticipate the human potential for missteps; create tools, tactics, and structures to limit missteps and associated harm; and support surgeons and their teams in all professional endeavors can contribute to the effective and fulfilling promotion of the public good.

Variations in 1-year Trajectories of Levels of Pain and Capability After Shoulder Arthroplasty Are Associated With Baseline Mental Health.

BACKGROUND: There is variability in the trajectories of pain intensity and magnitude of incapability after shoulder arthroplasty. A better understanding of the degree to which variation in recovery trajectories relates to aspects of mental health can inform the development of comprehensive biopsychosocial care strategies. QUESTIONS/PURPOSES: (1) Do pain intensities at baseline and the trajectories during recovery differ between groups when stratified by mental health composite summary score, arthroplasty type, and revision surgery? (2) Do magnitudes of capability at baseline and the trajectories during recovery differ between these groups? METHODS: We used a registry of 755 patients who underwent shoulder arthroplasty by a single surgeon at a specialized urban orthopaedic hospital that recorded the mental component summary (MCS) score of the Veterans RAND 12, a measure of shoulder-specific comfort and capability (American Shoulder and Elbow Surgeons [ASES] score, which ranges from 0 to 100 points, with a score of 0 indicating worse capability and pain and 100 indicating better capability and pain and a minimum clinically important difference of 6.4), and the VAS for pain intensity (range 0 [representing no pain] to 10 [representing the worst pain possible], with a minimum clinically important difference of 1.4) preoperatively, 2 weeks postoperatively, and 6 weeks, 3 months, 6 months, and 1 year after surgery. Forty-nine percent (368 of 755) of the patients were men, with a mean age of 68 ± 8 years, and 77% (585) were treated with reverse total shoulder arthroplasty (rTSA). Unconditional linear and quadratic growth models were generated to identify the general shape of recovery for both outcomes (linear versus quadratic). We then constructed conditional growth models and curves for pain intensity and the magnitude of capability showing mean baseline scores and the rates of recovery that determine the trajectory, accounting for mental health (MCS) quartiles, primary or revision arthroplasty, and TSA or reverse TSA in separate models. Because pain intensity and capability showed quadratic trends, we created trajectories using the square of time. RESULTS: Patients in the worst two MCS quartiles had greater pain intensity at baseline than patients in the best quartile (difference in baseline for bottom quartile: 0.93 [95% CI 0.72 to 1.1]; p < 0.01; difference in baseline for next-worst quartile: 0.36 [95% CI 0.16 to 0.57]; p < 0.01). The rates of change in recovery from pain intensity were not different among groups (p > 0.10). Patients with revision surgery had greater baseline pain (difference: 1.1 [95% CI 0.7 to 1.5]; p < 0.01) but no difference in rates of recovery (difference: 0.031 [95% CI 0.035 to 0.097]; p = 0.36). There were no differences in baseline pain intensity and rates of recovery between patients with reverse TSA and those with TSA (baseline pain difference: -0.20 [95% CI -0.38 to -0.03]; p = 0.18; difference in rate of recovery: -0.005 [95% CI -0.035 to 0.025]; p = 0.74). Patients in the worst two MCS quartiles had worse baseline capability than patients in the best quartile (difference in baseline for bottom quartile: -8.9 [95% CI -10 to -7.4]; p < 0.001; difference in baseline for the next-worst quartile: -4.9 [95% CI -6.4 to -3.4]; p < 0.01), with no differences in rates of recovery (p > 0.10). Patients with revision surgery had lower baseline capability (difference in baseline: -13 [95% CI -15 to -9.7]; p < 0.01), with a slower rate of recovery (difference in rate of recovery: -0.56 [95% CI -1.0 to -0.079]; p = 0.021). There were no differences in baseline capability or rates of recovery between TSA and reverse TSA. CONCLUSION: The observation that preoperative and 1-year comfort and capability are associated with mental health factors and with similar recovery trajectories reminds us that assessment and treatment of mental health is best considered an integral aspect of musculoskeletal care. Future studies can address how prioritization of mental health in musculoskeletal care strategies might reduce variation in the 1-year outcomes of discretionary surgeries such as shoulder arthroplasty. LEVEL OF EVIDENCE: Level III, therapeutic study.

Surgeon Implicit Association of Women With Supportive Roles in Medicine.

BACKGROUND: In a previous study, we documented patient implicit bias that surgeons are men. As a next step, we tested the implicit bias of surgeons that women in medicine have leading (chair, surgeon) or supporting roles (medical assistant, physician assistant). QUESTIONS/PURPOSE: (1) What is the relationship between the implicit associations and expressed beliefs of surgeons regarding women as leaders in medicine? (2) Are there factors associated with surgeon implicit association and explicit preference regarding the roles of women in medicine? METHODS: A total of 102 musculoskeletal surgeon members of the Science of Variation Group (88 men and 12 women) completed an implicit association test (IAT) of implicit bias regarding sex and lead/support roles in medicine and a questionnaire that addressed respondent demographics and explicit preference regarding women's roles. The IAT consisted of seven rounds with five rounds used for teaching and two rounds for evaluation. RESULTS: On average, there was an implicit association of women with supportive roles (D-score: -48; SD 4.7; P < 0.001). The mean explicit preference was for women in leadership roles (median: 73; interquartile ranges: 23 to 128; P < 0.001). There was a correlation between greater explicit preference for women in a leading role and greater implicit bias toward women in a supporting role (ρ = 0.40; P < 0.001). Women surgeons and shoulder and elbow specialists had less implicit bias that women have supporting roles. CONCLUSION: The observation that musculoskeletal surgeons have an explicit preference for women in leading roles in medicine but an implicit bias that they have supporting roles-more so among men surgeons-documents the gap between expressed opinions and ingrained mental processing that is the legacy of the traditional "roles" of women in medicine and surgery. To resolve this gap, we will need to be intentional about promotion of and emersion in experiences where the leader is a woman. LEVEL OF EVIDENCE: III.

Contralateral Arm Pain as a Sign of Distress Regarding Symptoms.

BACKGROUND: Pain intensity and magnitude of incapability are associated with common unhelpful thoughts about symptoms such as catastrophic thinking and kinesiophobia. To determine whether reports of pain in the upper limb contralateral to a non-trauma condition were associated with unhelpful thoughts, we measured the relationship between pain intensity in the opposite limb and levels of unhelpful thinking. METHODS: In a cross-sectional study, 152 new and return patients seeking care of an upper-limb musculoskeletal condition completed measures of upper-extremity-specific magnitude of capability, pain intensity of the involved and contralateral arms, unhelpful thoughts regarding symptoms, symptoms of distress regarding symptoms, and general symptoms of depression. Factors associated with contralateral and ipsilateral pain intensity and upper-extremity-specific magnitude of capability were assessed using multivariable statistics. RESULTS: In bivariate analysis, contralateral arm pain was associated with symptoms of distress regarding pain, but not in multivariable analysis. Accounting for potential confounding in negative binominal regression analysis, greater pain intensity of the affected side was independently associated with greater feelings of distress regarding symptoms and no prior surgery. Greater upper-extremity-specific capability was independently associated with less distress regarding symptoms, married/partnered, men, and no prior surgery. CONCLUSIONS: The observation that greater pain intensity in the opposite arm was associated with greater distress regarding symptoms suggests that, in combination with other verbal and non-verbal signs of distress, patient concerns about pain in the contralateral limb can help direct patients and surgeons to evidence-based care strategies for alleviating stress regarding symptoms.

Nonoperatively Treated Proximal Humerus Fractures: Randomized Trial of Immediate Versus Delayed Initiation of Exercises.

Objectives: There is debate about when to start exercises in the nonoperative treatment of a proximal humerus fracture. This randomized trial compared immediate and one-month delayed shoulder exercises in the nonoperative treatment of fractures of the proximal humerus. Methods: Twenty-six patients with a fracture of the proximal humerus who chose nonoperative treatment were randomized to start pendulum exercises within a few days and 24 were randomized to delayed exercises and started with active self-assisted stretching 1 month after fracture. Three and six months after the injury, patients completed the Disabilities of the Arm Shoulder and Hand questionnaire to measure capability, a measure of pain intensity, and had motion measurements. Results: There was no significant difference in forward flexion (primary outcome) six months after injury between patients that started motion exercises immediately compared to 1 month after injury (p = 0.85). There was no difference in any motion measurement, pain intensity, upper extremity specific disability (DASH score) three or six months after injury. Conclusion: Delaying exercises for a month does not affect recovery from nonoperative treatment of a fracture of the proximal humerus. People can choose whether to start exercises immediately or wait until they feel comfortable.

Coronoid fractures and traumatic elbow instability.

The coronoid process is key to concentric elbow alignment. Malalignment can contribute to post-traumatic osteoarthritis. The aim of treatment is to keep the joint aligned while the collateral ligaments and fractures heal. The injury pattern is apparent in the shape and size of the coronoid fracture fragments: (1) coronoid tip fractures associated with terrible triad (TT) injuries; (2) anteromedial facet fractures with posteromedial varus rotational type injuries; and (3) large coronoid base fractures with anterior (trans-) or posterior olecranon fracture dislocations. Each injury pattern is associated with specific ligamentous injuries and fracture characteristics useful in planning treatment. The tip fractures associated with TT injuries are repaired with suture fixation or screw fixation in addition to repair or replacement of the radial head fracture and reattachment of the lateral collateral ligament origin. Anteromedial facet fractures are usually repaired with a medial buttress plate. If the elbow is concentrically located on computed tomography and the patient can avoid varus stress for a month, TT and anteromedial facet injuries can be treated nonoperatively. Base fractures are associated with olecranon fractures and can usually be fixed with screws through the posterior plate or with an additional medial plate. If the surgery makes elbow subluxation or dislocation unlikely, and the fracture fixation is secure, elbow motion and stretching can commence within a week when the patient is comfortable.

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.

Factors Associated With Concerns the Day After Office Hand Surgery.

PURPOSE: Pain after minor hand surgery can be misinterpreted as a problem. The sense that something may be wrong intensifies the pain. Some surgeons anticipate these feelings and call patients the evening or day after surgery to guide them through the recovery process. A study of routine, next day, postoperative phone calls can help determine the frequency of concerns and associated factors. We asked: 1) What factors are associated with concern the day after office hand surgery? 2) What factors are associated with pain intensity, satisfaction with care, and patient's perceived recovery trajectory the day after office hand surgery? METHODS: In a cross-sectional study, 82 patients who had office hand and upper extremity surgery completed a survey recording age, gender, insurance, income level, measures of symptoms of depression and anxiety, a measure of catastrophic thinking regarding pain, 10-point ordinal ratings of pain intensity and satisfaction with care, whether the patient was concerned about their hand (yes or no) and whether they felt their recovery was on track (yes or no). RESULTS: Ten patients (12%) were concerned about their hand. In bivariate analysis, concern the day after surgery was associated with greater catastrophic thinking and male gender. Greater pain intensity was associated with greater catastrophic thinking. There was insufficient variation in satisfaction or a sense that recovery was on track for a meaningful analysis. CONCLUSIONS: The finding that concerns were common the day after minor office hand surgery supports the practice of contacting patients for support and helping to reorient unhelpful catastrophic thoughts. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic IV.