Ill-defined return to sport criteria and inconsistent unsuccessful return rates caused by various reasons not necessarily related to treatment after superior labral treatments: A systematic review.

PURPOSE: The aims of this systematic review were to determine (1) which criteria are used to determine return to sport (RTS), (2) the number of patients that are unable to RTS following any superior labral pathophysiology treatment and (3) which reasons are reported for not returning. METHODS: A systematic review was performed across 5 databases, including studies that report rates for RTS following any treatment of superior labral pathophysiology. Study quality was assessed using the MINORS criteria. Definitions for nRTS were extracted as reported in the studies. The ranges of no return to sport (nRTS) and no return to pre-injury level (nRTPL) were summarized. Reasons for nRTS and nRTPL were categorized using a predefined coding scheme. RESULTS: Among 45 studies with level of evidence ranging from II to IV, 1857 patients were involved in sports, 78% (n=1453) of whom underwent superior labral reattachment, 21% (n=381) biceps tenodesis, and 9.4% (n=175) non-operative treatment. None of the studies provided criteria for RTS and two studies provided criteria for return to pre-injury level (RTPL). The ranges of nRTS and nRTPL varied following superior labral reattachment (0-60%, n=206; 0-89%, n=424, respectively), biceps tenodesis (0-25%, n=43; 3,8-48%, n =78) and nonoperative treatment (11-75%, n=62; 18-100%, n=78). Reasons for nRTS and nRTPL were related to physical sensations (pain, feeling of instability, discomfort, weakness, lack of motion), psychological factors (fear of reinjury, lack of confidence), personal factors (lifestyle change, social reasons) and injury at another site. CONCLUSION: Criteria for determining successful RTS and RTPL following superior labral pathophysiology treatment were not reported by the majority of studies. The nRTS and nRTPL rates varied greatly within and between treatments. The reasons for this unsuccessful return were diverse and related to physical sensations, psychological factors, personal factors and injury unrelated to treatment. LEVEL OF EVIDENCE: Level IV; Systematic Review.

How to Run a Cost-Effective Subspecialty Practice.

Cost-effective hand specialty practice is based in ethical principles and evidence. Visits, tests, and treatments are limited to those with specific, notable improvements in capability and comfort. Critical thinking, culture change, and growth mindset principles manifested in a learning health system can help improve cost-effectiveness. The limited moral distress of providing cost-effective care has the potential to improve joy in practice.

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.

Determinants of pain intensity and magnitude of incapability more than two years after arthroscopic Bankart repair for anterior shoulder instability.

Background: Individuals treated with arthroscopic Bankart repair after anterior shoulder dislocations experience varied discomfort and incapability. The aim of this study was to determine the relative association of mental health and physical health factors with 1) magnitude of capability and 2) pain intensity 2 or more years after surgery. Methods: This cross-sectional study evaluated 80 military patients that experienced one or more traumatic anterior shoulder dislocations a minimum of 2 years after arthroscopic Bankart repair without remplissage. We measured capability (Oxford Shoulder Instability Score), pain intensity using an 11-point ordinal scale, symptoms of anxiety (Generalized Anxiety Disorder-2 questionnaire), symptoms of depression (Patient Health Questionnaire-2), catastrophic thinking (Pain Catastrophizing Scale-4), and kinesiophobia (Tampa scale for kinesiophobia-4). We also identified preoperative presence of a Hill-Sachs lesion on radiographs and postoperative occurrence of subluxation or a dislocation episode. A negative binominal regression analysis sought factors associated with magnitude of incapability and pain intensity. Results: Greater incapability was strongly associated with both greater kinesiophobia (Regression Coefficient [RC] = -0.50; 95% confidence interval [CI] = -0.73 to -0.26; P ≤ .01) and repeat surgery (RC = -0.27; 95% CI = -0.41 to -0.13; P ≤ .01). Greater pain intensity was only strongly associated with greater kinesiophobia (RC = 0.25; 95% CI = 0.039 to 0.46; P = .021). Conclusion: The observation that greater unhelpful thinking is associated with greater pain intensity and greater magnitude of incapability after a Bankart repair for anterior shoulder instability, whereas pathophysiological factors such as glenoid bone loss were not, emphasizes the degree to which mindset is associated with musculoskeletal health.

Misinformation about upper extremity conditions in guidelines for clinicians.

The potential for reinforcement of unhelpful thinking and feelings of distress was present in half the sentences from the general description of the condition and management recommendation sections in three sources of information describing upper extremity conditions for clinicians.

Surgeon Factors Rather Than Patient Factors Account for Variation in Recommended Treatment Strategy for Patients With Multiligament Knee Injury.

OBJECTIVES: To seek the factors associated with timing, staging, and type of surgery in the management of multiligament knee injuries. DESIGN: Cross-sectional scenario-based experiment. SETTING: Fifteen fictional patient scenarios with randomized elements. PARTICIPANTS: Fracture surgeons of the Science of Variation Group, an international collaborative of musculoskeletal surgeons who studies variation in care, were invited to participate. Surgeons with limited experience treating multiligament knee injuries were asked to self-exclude. OUTCOME MEASURES AND COMPARISONS: Surgeon recommendations for operative treatment, timing of surgery, and use of open surgery in addition to arthroscopy were measured. Patient factors (age, time from injury, contralateral fracture, knee dislocation, combinations of ruptured ligaments, and preexisting osteoarthritis) and surgeon factors (gender, practice location, years of experience, and supervision of trainees) associated with surgeon recommendations were assessed. RESULTS: Eighty-five surgeons participated, of which most were men (89%) and practiced in the United States (44%) or Europe (38%). Operative treatment was less likely among older patients (odds ratio [OR] = 0.051) and preexisting osteoarthritis (OR = 0.32) and more likely in knee dislocation (OR = 1.9) and disruption of anterior cruciate ligament, posterior cruciate ligament, and lateral collateral ligament with or without medial collateral ligament (MCL; OR = 5.1 and OR = 3.1, respectively). Disruption of anterior cruciate ligament, posterior cruciate ligament, and medial collateral ligament was associated with shorter time to surgery (ß = -11). Longer time to surgery was associated with contralateral fracture (ß = 9.2) and surgeons supervising trainees (ß = 23) and practicing in Europe (ß = 13). Surgeon factors accounted for more variation in timing than patient and injury factors (5.1% vs. 1.4%, respectively). Open surgery was more likely in patients with lateral collateral ligament injury (OR = 2.9 to 3.3). CONCLUSIONS: The observation that surgeons were more likely to operate in younger patients with more severe injury has face validity, while the finding that surgeon factors accounted for more variation in timing of surgery than patient or injury factors suggests that treatment variation is based on opinion more so than evidence. LEVEL OF EVIDENCE: Prognostic Level V. See Instructions for Authors for a complete description of levels of evidence.

Recovery of Comfort and Capability After Upper Extremity Fracture Is Predominantly Associated With Mindset: A Longitudinal Cohort From the United Kingdom.

OBJECTIVES: To determine the relative influence of mindset and fracture severity on 9-month recovery trajectories of pain and capability after upper extremity fractures. DESIGN: Secondary use of longitudinal data. SETTING: Single Level-1 trauma center in Oxford, United Kingdom. PATIENT SELECTION: English-speaking adults with isolated proximal humerus, elbow, or distal radius fracture managed operatively or nonoperatively were included, and those with multiple fractures or cognitive deficit were excluded. OUTCOME MEASURES AND COMPARISONS: Incapability (Quick-DASH) and pain intensity (11-point rating scale) were measured at baseline, 2-4 weeks, and 6-9 months after injury. Cluster analysis was used to identify statistical groupings of mindset (PROMIS Depression and Anxiety, Pain Catastrophizing Scale, and Tampa Scale for Kinesiophobia) and fracture severity (low/moderate/high based on OTA/AO classification). The recovery trajectories of incapability and pain intensity for each mindset grouping were assessed, accounting for various fracture-related aspects. RESULTS: Among 703 included patients (age 59 ± 21 years, 66% women, 16% high-energy injury), 4 statistical groupings with escalating levels of distress and unhelpful thoughts were identified (fracture severity was omitted considering it had no differentiating effect). Groups with less healthy mindset had a worse baseline incapability (group 2: ß = 4.1, 3: ß = 7.5, and 4: ß = 17) and pain intensity (group 3: ß = 0.70 and 4: ß = 1.4) (P < 0.01). Higher fracture severity (ß = 4.5), high-energy injury (ß = 4.0), and nerve palsy (ß = 8.1) were associated with worse baseline incapability (P < 0.01), and high-energy injury (ß = 0.62) and nerve palsy (ß = 0.76) with worse baseline pain intensity (P < 0.01). Groups 3 and 4 had a prolonged rate of recovery of incapability (ß = 1.3, ß = 7.0) and pain intensity (ß = 0.19, ß = 1.1) (P < 0.02). CONCLUSIONS: Patients with higher levels of unhelpful thinking and feelings of distress regarding symptoms experienced worse recovery of pain and incapability, with a higher effect size than fracture location, fracture severity, high-energy injury, and nerve palsy. These findings underline the importance of anticipating and addressing mental health concerns during recovery from injury. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Subsidence after Trapeziometacarpal Arthroplasty.

PURPOSE: Surgeons sometimes ascribe inadequate comfort and capability after trapeziometacarpal (TMC) arthroplasty to movement of the trapezium toward the scaphoid (subsidence or reduced trapezial space height [TSH]). We asked the following: (1) What percentage of studies found a relationship between subsidence of the metacarpal toward the distal scaphoid and measures of grip strength, capability, pinch strength, pain intensity, or patient satisfaction after TMC arthroplasty and what study characteristics are associated with having notable correlation? (2) What study factors are associated with greater postoperative TSH? (3) What is the mean subsidence over time? METHODS: We conducted a systematic review by querying PubMed, Cochrane, and Web of Science databases from 1986 and onward. Using inclusion criteria of TMC arthroplasty inclusive of trapeziectomy, ligament reconstruction and tendon interposition, tendon interposition, and prosthetic arthroplasty and a measure of subsidence, 91 studies were identified. RESULTS: Seven of 31 study groups reported a correlation of subsidence with pinch strength, 5 of 21 with magnitude of incapability, 1 of 16 with grip strength, 2 of 20 with pain intensity, and none of 10 with satisfaction. Study factors associated with a relationship between subsidence and one of these measures included continents other than Europe. Among the 9 studies that measured TSH over time, the mean change in TSH was 5.0 mm ± 2.2 mm SD for visits less than 1 year after surgery and 5.5 mm ± SD 1.0 mm for visits 1 to 3.5 years after surgery. CONCLUSION: The observation that most studies find no relationship between radiographic subsidence of an average of 5 millimeters and levels of strength, capability, comfort, or satisfaction after TMC arthroplasty suggests that primary surgeries may not benefit from a focus on limiting subsidence and revision arthroplasty ought not be offered based on this radiographic measure.

Associations of Mental, Social and Pathophysiological factors with Pain Intensity and Capability in Patients with Shoulder Osteoarthritis Prior to Shoulder Arthroplasty: A Dutch Arthroplasty Register study.

BACKGROUND: Mounting evidence suggests that mental health accounts for greater variation in levels of comfort and capability than pathophysiology severity across a range of musculoskeletal conditions. Using nationwide Dutch Arthroplasty Register (LROI) data, we tested the null hypothesis that none of the available mental, social, and pathophysiological factors are associated with variation in levels of comfort and capability among people with shoulder osteoarthritis prior to arthroplasty. METHODS: We included all adult patients who underwent primary total shoulder arthroplasty for osteoarthritis in the period 2014-2021 with complete measures of shoulder specific capability (Oxford Shoulder Score), pain intensity (10-point Numeric Rating Scale), general wellbeing (the EQ-5D 3-L), the grade of pathophysiology (Walch classification) and categorized social health based on a social deprivation index. In total, 1342 patients with shoulder osteoarthritis preparing for shoulder arthroplasty were included in a regression analysis to seek factors associated with variation in levels of pain intensity and capability. RESULTS: Greater pain intensity at rest was associated with greater symptoms of anxiety and depression (Regression Coefficient [RC] = -0.41; 95% Confidence Interval [CI] = 0.17 to 0.64; P = <0.01), and women (RC = 0.38; 95% CI = 0.11 to 0.66; P = <0.01). Greater incapability was associated with greater symptoms of anxiety and depression (RC = -3.2; 95% CI = -4.0 to -2.4; P = <0.01), an ASA score of III and IV (RC = -3.1; 95% CI = -4.8 to -1.4; P = <0.01), older age (RC = -0.098; 95% CI = -0.15 to -0.047; P = <0.01), and women (RC = -3.9; 95% CI = -4.9 to -3.0; P = <0.01). Neither comfort nor capability were associated with Walch classification or social deprivation index. CONCLUSION: The confirmation that variation in levels of comfort and capability among people preparing for shoulder arthroplasty are associated with mindset rather than a measure of glenoid pathophysiology points to the potential benefits of addressing mental health in musculoskeletal health strategies.

Is the feeling of 'weakness' associated with unhelpful thoughts or distress regarding symptoms?

This cross-sectional study looked for factors associated with feelings of weakness, level of capability and pain intensity in people seeking musculoskeletal speciality care for non-traumatic upper extremity conditions. A survey was conducted in 139 English-speaking adults, with 135 participants completing it. We found that greater intensity of feelings of weakness correlated with higher distress regarding symptoms and with older age. Lower level of capability was associated with greater intensity of feelings of weakness, greater distress regarding symptoms and older age. Higher pain intensity was associated with greater distress regarding symptoms and greater intensity of feelings of weakness. These findings suggest that the symptom of weakness may be a cue to explore potential distress about symptoms in addition to examining for actual weakness. This understanding could be a guide to a more compassionate approach to alleviate distress rather than focusing on neuromuscular pathophysiology alone, with the potential to reduce unnecessary tests and treatments.Level of evidence: IV.

Potential misinformation in large language model descriptions of upper extremity diseases.

When a large language model was prompted to discuss upper extremity conditions and correct instances of misinformation in responses, there was notable persistent misinformation, reinforcement of unhelpful thinking and reduction of independent management of one's health (agency).

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.

The Central Sensitization Inventory Measures Thoughts and Emotions.

To determine if the Central Sensitization Inventory questionnaire (CSI) functions as a mental health measure among a cross-section of people seeking musculoskeletal specialty care, we asked: (1) What is the association of CSI total score and item groupings identified in factor analysis with mental health measures? and (2) What is the association between specific CSI items that represent each factor well and specific mental health measures? One hundred and fifty-seven adults seeking specialty care for musculoskeletal symptoms completed the CSI, a measure of catastrophic thinking, and 3 measures of distress (symptoms of health anxiety, general anxiety, and depression). Exploratory factor analysis was used to identify item groupings. Exploratory factor analysis identified 4 item groupings (factors): (1) thoughts and feelings (mental health), accounting for 52% of the variation in the CSI, (2) urinary and visual symptoms (15%) (3) body aches (10%), and (4) jaw pain (8.1%). More than half the variation in both the CSI total score (51%) and the thoughts and feelings factor (57%) were accounted for by variation in measures of catastrophic thinking and distress. Specific items that account for large amounts of the variation in the CSI also had notable correlations with mental health measures. The strong relationship between the CSI and thoughts and emotions suggests that the CSI functions largely as a mental health measure. If the concept of central sensitization is to help people get and stay healthy, it will depend on evidence that central sensitization can be measured and quantified distinct from mental health.

Potential misinformation in websites on carpal tunnel syndrome.

Objective: We sought to evaluate the potential reinforcement of misconceptions in websites discussing carpal tunnel syndrome (CTS). Methods: After removing all cookies to limit personalization, we entered "carpal tunnel syndrome" into five search engines and collected the first 50 results displayed for each search. For each of the 105 unique websites, we recorded publication date, author background, and number of views. The prevalence of potential reinforcement and/or reorientation of misconceptions for each website was then scored using a rubric based on our interpretation of the best current evidence regarding CTS. The informational quality of websites was graded with the DISCERN instrument, a validated tool for assessing online health information. Results: Every website contained at least one potentially misleading statement in our opinion. The most common misconceptions reference "excessive motion" and "inflammation." Greater potential reinforcement of misinformation about CTS was associated with fewer page views and lower informational quality scores. Conclusions: Keeping in mind that this analysis is based on our interpretation of current best evidence, potential misinformation on websites addressing CTS is common and has the potential to increase symptom intensity and magnitude of incapability via reinforcement of unhelpful thoughts regarding symptoms. Innovation: The prevalence of patient-directed health information that can increase discomfort and incapability by reinforcing common unhelpful thoughts supports the need for innovations in how we develop, oversee, and evolve healthy online material.

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).