Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials.

INTRODUCTION: Preoperative anxiety and depression symptoms among older surgical patients are associated with poor postoperative outcomes, yet evidence-based interventions for anxiety and depression have not been applied within this setting. We present a protocol for randomised controlled trials (RCTs) in three surgical cohorts: cardiac, oncological and orthopaedic, investigating whether a perioperative mental health intervention, with psychological and pharmacological components, reduces perioperative symptoms of depression and anxiety in older surgical patients. METHODS AND ANALYSIS: Adults ≥60 years undergoing cardiac, orthopaedic or oncological surgery will be enrolled in one of three-linked type 1 hybrid effectiveness/implementation RCTs that will be conducted in tandem with similar methods. In each trial, 100 participants will be randomised to a remotely delivered perioperative behavioural treatment incorporating principles of behavioural activation, compassion and care coordination, and medication optimisation, or enhanced usual care with mental health-related resources for this population. The primary outcome is change in depression and anxiety symptoms assessed with the Patient Health Questionnaire-Anxiety Depression Scale from baseline to 3 months post surgery. Other outcomes include quality of life, delirium, length of stay, falls, rehospitalisation, pain and implementation outcomes, including study and intervention reach, acceptability, feasibility and appropriateness, and patient experience with the intervention. ETHICS AND DISSEMINATION: The trials have received ethics approval from the Washington University School of Medicine Institutional Review Board. Informed consent is required for participation in the trials. The results will be submitted for publication in peer-reviewed journals, presented at clinical research conferences and disseminated via the Center for Perioperative Mental Health website. TRIAL REGISTRATION NUMBERS: NCT05575128, NCT05685511, NCT05697835, pre-results.

Flexor Pollicis Longus Reconstruction After Rupture Following Distal Radius Fixation With Volar Locking Plate: A Technique Guide.

Flexor pollicis longus rupture is an uncommon but potentially debilitating complication after volar locking plate fixation of distal radius fractures, occurring secondary to tendon attrition against the implant. This nature of tendon injury typically precludes primary repair. This paper will illustrate 2 reconstruction techniques, an interpositional tendon graft and a tendon transfer, that have been utilized successfully by the authors.

Trapeziectomy with Ligament Reconstruction/ Suspensionplasty Compared to Suture Tape Suspensionplasty for the Surgical Treatment of Advanced Thumb Carpometacarpal Osteoarthritis.

Purpose: Trapeziectomy with tendon reconstruction/suspensionplasty (TRS) is the most commonly performed surgical procedure in the United States for treatment of thumb carpometacarpal (CMC) osteoarthritis (OA). Trapeziectomy with suture tape suspensionplasty (STS) has been used recently at the study institution as an alternative surgical treatment option with perceived benefits of earlier return to function and reduced operative time. The purpose of this study was to compare patient outcomes following TRS versus STS for treatment of thumb CMC OA. Methods: All patients who underwent primary, isolated TRS or STS for treatment of thumb CMC OA between 1/1/2014 and 9/1/2020 were analyzed. We assessed demographics and preoperative and postoperative patient-rated outcome scores including Patient-reported outcomes measurement information system scores as well as pain outcomes, satisfaction, and appearance at a mean of 2.6 years after surgery (minimum 6 months). Time to return to work and activities was compared between groups. Bivariate statistics compared outcomes between groups. Results: Ninety-four patients were included in the final study cohort, of which 53 underwent TRS and 41 underwent STS. There were no differences in preoperative, postoperative, or final patient-rated outcome scores between groups. Patients reported high global and appearance satisfaction scores at final follow-up in both groups. Mean tourniquet time was 15 minutes (26%) shorter and return to work was on average 3 weeks faster for the STS group. Conclusions: There were no differences in postoperative patient-rated outcome scores between the STS and TRS groups. The STS group had a shorter surgical time and faster return-to-work after surgery. Type of study/level of evidence: Therapeutic III.

Behavioral Mechanisms That Mediate Mental and Physical Health Improvements in People With Chronic Pain Who Receive a Digital Health Intervention: Prospective Cohort Pilot Study.

BACKGROUND: Preliminary evidence suggests that digital mental health intervention (Wysa for Chronic Pain) can improve mental and physical health in people with chronic musculoskeletal pain and coexisting symptoms of depression or anxiety. However, the behavioral mechanisms through which this intervention acts are not fully understood. OBJECTIVE: The purpose of this study was to identify behavioral mechanisms that may mediate changes in mental and physical health associated with use of Wysa for Chronic Pain during orthopedic management of chronic musculoskeletal pain. We hypothesized that improved behavioral activation, pain acceptance, and sleep quality mediate improvements in self-reported mental and physical health. METHODS: In this prospective cohort, pilot mediation analysis, adults with chronic (≥3 months) neck or back pain received the Wysa for Chronic Pain digital intervention, which uses a conversational agent and text-based access to human counselors to deliver cognitive behavioral therapy and related therapeutic content. Patient-reported outcomes and proposed mediators were collected at baseline and 1 month. The exposure of interest was participants' engagement (ie, total interactions) with the digital intervention. Proposed mediators were assessed using the Behavioral Activation for Depression Scale-Short Form, Chronic Pain Acceptance Questionnaire, and Athens Insomnia Scale. Outcomes included Patient-Reported Outcomes Measurement Information System Anxiety, Depression, Pain Interference, and Physical Function scores. A mediation analysis was conducted using the Baron and Kenny method, adjusting for age, sex, and baseline mediators and outcome values. P<.20 was considered significant for this pilot study. RESULTS: Among 30 patients (mean age 59, SD 14, years; 21 [70%] female), the mediation effect of behavioral activation on the relationship between increased intervention engagement and improved anxiety symptoms met predefined statistical significance thresholds (indirect effect -0.4, 80% CI -0.7 to -0.1; P=.13, 45% of the total effect). The direction of mediation effect was generally consistent with our hypothesis for all other proposed mediator or outcome relationships, as well. CONCLUSIONS: In a full-sized randomized controlled trial of patients with chronic musculoskeletal pain, behavioral activation, pain acceptance, and sleep quality may play an important role in mediating the relationship between use of a digital mental health intervention (Wysa for Chronic Pain) and improved mental and physical health. TRIAL REGISTRATION: ClinicalTrials.gov NCT05194722; https://clinicaltrials.gov/ct2/show/NCT05194722.

Improvements in Physical Function and Pain Interference and Changes in Mental Health Among Patients Seeking Musculoskeletal Care.

Importance: Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients' mental health. Objective: To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care. Design, Setting, and Participants: This cohort study included adult patients treated by an orthopedic department of a tertiary care US academic medical center from June 22, 2015, to February 9, 2022. Eligible participants presented between 4 and 6 times during the study period for 1 or more musculoskeletal conditions and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit. Exposure: PROMIS Physical Function and Pain Interference scores. Main Outcomes and Measures: Linear mixed effects models were used to determine whether improvements in PROMIS Anxiety and PROMIS Depression scores were associated with improved PROMIS Physical Function or Pain Interference scores after controlling for age, gender, race, and PROMIS Depression (for the anxiety model) or PROMIS Anxiety (for the depression model). Clinically meaningful improvement was defined as 3.0 points or more for PROMIS Anxiety and 3.2 points or more for PROMIS Depression. Results: Among 11 236 patients (mean [SD] age, 57 [16] years), 7218 (64.2%) were women; 120 (1.1%) were Asian, 1288 (11.5%) were Black, and 9706 (86.4%) were White. Improvements in physical function (ß = -0.14; 95% CI, -0.15 to -0.13; P < .001) and pain interference (ß = 0.26; 95% CI, 0.25 to 0.26; P < .001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of 21 PROMIS points or more (95% CI, 20-23 points) on Physical Function or 12 points or more (95% CI, 12-12 points) on Pain Interference would be required. Improvements in physical function (ß = -0.05; 95% CI, -0.06 to -0.04; P < .001) and pain interference (ß = 0.04; 95% CI, 0.04 to 0.05; P < .001) were not associated with meaningfully improved depression symptoms. Conclusions and Relevance: In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms, and were not associated with any meaningful improvement in depression symptoms. Patients seeking musculoskeletal care clinicians providing treatment cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety.

Factors Influencing Patient Experience After Cubital Tunnel Syndrome Surgery.

PURPOSE: The purpose of this study was to use qualitative methodology to better understand patient experiences after cubital tunnel surgery, with the goal of identifying areas of improvement in delivery of care. METHODS: Patients who underwent surgery (in situ decompression or anterior transposition) for cubital tunnel syndrome within the last 12 months, which was performed by one of three fellowship-trained hand surgeons, were identified. Participants were invited to an interview regarding "their experiences with ulnar nerve surgery." An interview guide with semistructured, open-ended questions regarding the decision for surgery, treatment goals, and the recovery process was used. Interim data analyses were conducted to assess emerging themes, and interviews were continued until thematic saturation was achieved. RESULTS: Seventeen participants completed interviews; the mean age of study participants was 57 years, and 71% were women. The mean time between surgery and the interview was 6 months. Participants identified the following two key areas that could improve their surgical experience: (1) the need for detailed preoperative education about the surgery and recovery process, (2) and the importance of discussing treatment goals and expectations. Participants suggested providing both written and online resources to patients, including specific details about incision size and recovery process in education materials, and setting expectations for symptom resolution. CONCLUSIONS: Although the overall patient experience after cubital tunnel surgery was positive, participants noted that there is a need for providing improved educational resources and counseling before surgery. CLINICAL RELEVANCE: Addressing education and counseling needs before cubital tunnel surgery will help surgeons to improve delivery of care.

Study Design and Analysis in Hand Surgery Research: Tips for Success.

Hand surgeons are constantly faced with evaluation of new evidence to identify best practices in clinical care. However, even the most rigorous study designs have limitations due to biases, generalizability, and other flaws. Here, we highlight seven common aspects of study design and analysis that should be considered by hand surgeons when interpreting findings. The evaluation of these practices can optimize the peer-review process and assess the value of evidence to be incorporated into clinical practice.

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: a qualitative analysis.

BACKGROUND: Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perceptions regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care. METHODS: This single-center, qualitative study was conducted within a tertiary care orthopedic department. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention. RESULTS: Patients included 30 adults out of 85 approached (mean (SD) age 59 [14] years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person support from a mental health specialist into orthopedic care. CONCLUSIONS: Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients. TRIAL REGISTRATION: Not applicable.

General Principles of Flexor Tendon Repair.

Flexor tendon repair techniques and rehabilitation have advanced tremendously in the past 50 years. However, the attributes of the ideal tendon repair articulated by Dr Strickland in 1995 hold true today. The ideal repair requires sutures easily placed in the tendon, secure suture knots, a smooth juncture of the tendon ends, minimal gapping, least interference with tendon vascularity, and sufficient strength throughout healing. When accomplished, the modern flexor tendon repair is a stout repair, sufficient for early mobilization and intrinsic tendon healing.

Multi-stakeholder perspectives regarding preferred modalities for mental health intervention delivered in the orthopedic clinic: A qualitative analysis.

BACKGROUND: Although depressive and anxious symptoms negatively impact musculoskeletal health and orthopedic outcomes, a gap remains in identifying modalities through which mental health intervention can realistically be delivered during orthopedic care. The purpose of this study was to understand orthopedic stakeholders' perspectives regarding the feasibility, acceptability, and usability of digital, printed, and in-person intervention modalities to address mental health as part of orthopedic care. METHODS: This single-center, qualitative study was conducted within the orthopedic department of a tertiary care center. Semi-structured interviews were conducted between January and May 2022. Two stakeholder groups were interviewed using a purposive sampling approach until thematic saturation was reached. The first group included adult orthopedic patients who presented for management of ≥ 3 months of neck or back pain. The second group included early, mid, and late career orthopedic clinicians and support staff members. Stakeholders' interview responses were analyzed using deductive and inductive coding approaches followed by thematic analysis. Patients also performed usability testing of one digital and one printed mental health intervention. RESULTS: Patients included 30 adults out of 85 approached (mean (SD) age 59 (14) years, 21 (70%) women, 12 (40%) non-White). Clinical team stakeholders included 22 orthopedic clinicians and support staff members out of 25 approached (11 (50%) women, 6 (27%) non-White). Clinical team members perceived a digital mental health intervention to be feasible and scalable to implement, and many patients appreciated that the digital modality offered privacy, immediate access to resources, and the ability to engage during non-business hours. However, stakeholders also expressed that a printed mental health resource is still necessary to meet the needs of patients who prefer and/or can only engage with tangible, rather than digital, mental health resources. Many clinical team members expressed skepticism regarding the current feasibility of scalably incorporating in-person mental health support into orthopedic care. CONCLUSIONS: Although digital intervention offers implementation-related advantages over printed and in-person mental health interventions, a subset of often underserved patients will not currently be reached using exclusively digital intervention. Future research should work to identify combinations of effective mental health interventions that provide equitable access for orthopedic patients. TRIAL REGISTRATION: Not applicable.

Relationships between improvement in physical function, pain interference, and mental health in musculoskeletal patients.

Importance: Among patients seeking care for musculoskeletal conditions, there is mixed evidence regarding whether traditional, structure-based care is associated with improvement in patients' mental health. Objective: To determine whether improvements in physical function and pain interference are associated with meaningful improvements in anxiety and depression symptoms among patients seeking musculoskeletal care. Design: Retrospective cohort study from June 22, 2015 to February 9, 2022. Setting: Orthopedic department of a tertiary care US academic medical center. Participants: Consecutive sample of adult patients who presented to the musculoskeletal clinic 4 to 6 times during the study period and completed Patient-Reported Outcomes Measurement Information System (PROMIS) measures as standard care at each visit. Exposure: PROMIS Physical Function and Pain Interference scores. Main Outcomes and Measures: Linear mixed effects models were used to determine whether: 1) PROMIS Anxiety and 2) PROMIS Depression scores improved as a function of improved PROMIS Physical Function or Pain Interference scores, after controlling for age, gender, race, and PROMIS Depression (for the Anxiety model) and PROMIS Anxiety (for the Depression model). Clinically meaningful improvement was defined as ≥3.0 points for PROMIS Anxiety and ≥3.2 points for PROMIS Depression. Results: Among 11,236 patients (mean [SD] age 57 [16] years), 9,706 (86%) were White, and 7,218 (64%) were women. Improvements in physical function (ß=-0.14 [95% CI -0.15- -0.13], p<0.001) and pain interference (ß=0.26 [0.25-0.26], p<0.001) were each associated with improved anxiety symptoms. To reach a clinically meaningful improvement in anxiety symptoms, an improvement of ≥21 [20-23] PROMIS points on Physical Function or ≥12 [12-12] points on Pain Interference would be required. Improvements in physical function (ß=-0.05 [- 0.06- -0.04], p<0.001) and pain interference (ß=0.04 [0.04-0.05], p<0.001) were not associated with meaningfully improved depression symptoms. Conclusions and Relevance: In this cohort study, substantial improvements in physical function and pain interference were required for association with any clinically meaningful improvement in anxiety symptoms and were not associated with any meaningful improvement in depression symptoms. Among patients seeking musculoskeletal care, musculoskeletal clinicians and patients cannot assume that addressing physical health will result in improved symptoms of depression or potentially even sufficiently improved symptoms of anxiety. Key Points: Question: Among patients seeking musculoskeletal care, are improvements in physical function and pain interference associated with meaningful changes in symptoms of anxiety and depression?Findings: In this large cohort study, improvement by ≥2.3 population-level standard deviations (SD) on PROMIS Physical Function or ≥1.2 SD on PROMIS Pain Interference were required for any association with meaningful improvement in anxiety symptoms. Improvements in physical function and pain interference were not associated with meaningfully improved depression symptoms.Meaning: Musculoskeletal clinicians and patients cannot assume that exclusively addressing the physical aspect of a musculoskeletal condition will improve symptoms of depression or potentially even anxiety.

Did the Physical and Mental Health of Orthopaedic Patients Change After the Onset of the COVID-19 Pandemic?

BACKGROUND: The 2019 novel coronavirus (COVID-19) pandemic has been associated with poor mental health outcomes and widened health disparities in the United States. Given the inter-relationship between psychosocial factors and functional outcomes in orthopaedic surgery, it is important that we understand whether patients presenting for musculoskeletal care during the pandemic were associated with worse physical and mental health than before the pandemic's onset. QUESTIONS/PURPOSES: (1) Did patients seen for an initial visit by an orthopaedic provider during the COVID-19 pandemic demonstrate worse physical function, pain interference, depression, and/or anxiety than patients seen before the pandemic, as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) instrument? (2) During the COVID-19 pandemic, did patients living in areas with high levels of social deprivation demonstrate worse patterns of physical function, pain interference, depression, or anxiety on initial presentation to an orthopaedic provider than patients living in areas with low levels of social deprivation, compared with prepandemic PROMIS scores? METHODS: This was a retrospective, comparative study of new patient evaluations that occurred in the orthopaedic department at a large, urban tertiary care academic medical center. During the study period, PROMIS computer adaptive tests were routinely administered to patients at clinical visits. Between January 1, 2019, and December 31, 2019, we identified 26,989 new patients; we excluded 4% (1038 of 26,989) for being duplicates, 4% (1034 of 26,989) for having incomplete demographic data, 44% (11,925 of 26,989) for not having a nine-digit home ZIP Code recorded, and 5% (1332 of 26,989) for not completing all four PROMIS computer adaptive tests of interest. This left us with 11,660 patients in the "before COVID-19" cohort. Between January 1, 2021 and December 31, 2021, we identified 30,414 new patients; we excluded 5% (1554 of 30,414) for being duplicates, 4% (1142 of 30,414) for having incomplete demographic data, 41% (12,347 of 30,414) for not having a nine-digit home ZIP Code recorded, and 7% (2219 of 30,414) for not completing all four PROMIS computer adaptive tests of interest. This left us with 13,152 patients in the "during COVID-19" cohort. Nine-digit home ZIP Codes were used to determine patients' Area Deprivation Indexes, a neighborhood-level composite measure of social deprivation. To ensure that patients included in the study represented our overall patient population, we performed univariate analyses on available demographic and PROMIS data between patients included in the study and those excluded from the study, which revealed no differences (results not shown). In the before COVID-19 cohort, the mean age was 57 ± 16 years, 60% (7046 of 11,660) were women, 86% (10,079 of 11,660) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 47 ± 25. In the during COVID-19 cohort, the mean age was 57 ± 16 years, 61% (8051 of 13,152) were women, 86% (11,333 of 13,152) were White non-Hispanic, and the mean national Area Deprivation Index percentile was 46 ± 25. The main outcome measures in this study were the PROMIS Physical Function ([PF], version 2.0), Pain Interference ([PI], version 1.1), Depression (version 1.0), and Anxiety (version 1.0). PROMIS scores follow a normal distribution with a mean t-score of 50 and a standard deviation of 10. Higher PROMIS PF scores indicate better self-reported physical capability, whereas higher PROMIS PI, Depression, and Anxiety scores indicate more difficulty managing pain, depression, and anxiety symptoms, respectively. Clinically meaningful differences in PROMIS scores between the cohorts were based on a minimum clinically important difference (MCID) threshold of 4 points. Multivariable linear regression models were created to determine whether presentation to an orthopaedic provider during the pandemic was associated with worse PROMIS scores than for patients who presented before the pandemic. Regression coefficients (ß) represent the estimated difference in PROMIS scores that would be expected for patients who presented during the pandemic compared with patients who presented before the pandemic, after adjusting for confounding variables. Regression coefficients were evaluated in the context of clinical importance and statistical significance. Regression coefficients equal to or greater than the MCID of 4 points were considered clinically important, whereas p values < 0.05 were considered statistically significant. RESULTS: We found no clinically important differences in baseline physical and mental health PROMIS scores between new patients who presented to an orthopaedic provider before the COVID-19 pandemic and those who presented during the COVID-19 pandemic (PROMIS PF: ß -0.2 [95% confidence interval -0.43 to 0.03]; p = 0.09; PROMIS PI: ß 0.06 [95% CI -0.13 to 0.25]; p = 0.57; PROMIS Depression: ß 0.09 [95% CI -0.14 to 0.33]; p = 0.44; PROMIS Anxiety: ß 0.58 [95% CI 0.33 to 0.84]; p < 0.001). Although patients from areas with high levels of social deprivation had worse PROMIS scores than patients from areas with low levels of social deprivation, patients from areas with high levels of social deprivation demonstrated no clinically important differences in PROMIS scores when groups before and during the pandemic were compared (PROMIS PF: ß -0.23 [95% CI -0.80 to 0.33]; p = 0.42; PROMIS PI: ß 0.18 [95% CI -0.31 to 0.67]; p = 0.47; PROMIS Depression: ß 0.42 [95% CI -0.26 to 1.09]; p = 0.23; PROMIS Anxiety: ß 0.84 [95% CI 0.16 to 1.52]; p = 0.02). CONCLUSION: Contrary to studies describing worse physical and mental health since the onset of the COVID-19 pandemic, we found no changes in the health status of orthopaedic patients on initial presentation to their provider. Although large-scale action to mitigate the effects of worsening physical or mental health of orthopaedic patients may not be needed at this time, orthopaedic providers should remain aware of the psychosocial needs of their patients and advocate on behalf of those who may benefit from intervention. Our study is limited in part to patients who had the self-agency to access specialty orthopaedic care, and therefore may underestimate the true changes in the physical or mental health status of all patients with musculoskeletal conditions. Future longitudinal studies evaluating the impact of specific COVID-19-related factors (for example, delays in medical care, social isolation, or financial loss) on orthopaedic outcomes may be helpful to prepare for future pandemics or natural disasters. LEVEL OF EVIDENCE: Level II, prognostic study.

What Are Orthopaedic Patients' and Clinical Team Members' Perspectives Regarding Whether and How to Address Mental Health in the Orthopaedic Care Setting? A Qualitative Investigation of Patients With Neck or Back Pain.

BACKGROUND: Across virtually all orthopaedic subspecialties, symptoms of depression, anxiety, and unhelpful thinking are associated with worse patient-reported satisfaction with orthopaedic treatment and increased postoperative complications. In the orthopaedic community, there is growing interest in patients' mental health in the orthopaedic care setting, but addressing mental health is still not a focus of orthopaedic clinical training. There is a persistent awareness gap about how to address mental health in orthopaedic care in a manner that is simultaneously feasible in a busy orthopaedic practice and acceptable to patients who are presenting for treatment of a musculoskeletal condition. QUESTIONS/PURPOSES: (1) What are orthopaedic patients' and clinical team members' current perceptions and motivators regarding addressing mental health as part of orthopaedic care? (2) What barriers do patients and clinicians face regarding addressing mental health as part of orthopaedic care? (3) What are facilitators for patients and clinicians related to addressing mental health as part of orthopaedic care? (4) What are practical, acceptable implementation strategies to facilitate addressing mental health as part of orthopaedic care? METHODS: This was a single-center, qualitative study conducted from January through May 2022 in the orthopaedic department of a large, urban, tertiary care academic medical center. Semistructured interviews were conducted with members of two stakeholder groups: orthopaedic patients and orthopaedic clinical team members. We interviewed 30 adult patients (of 85 patients who were eligible and approached) who had presented to our orthopaedic department for management of neck or back pain lasting for 3 or more months. By prescreening clinic schedules, patients were purposively sampled to include representatives from varied sociodemographic backgrounds and with a range of severity of self-reported symptoms of depression and anxiety (from none to severe on the Patient-Reported Outcomes Measurement Information System Depression and Anxiety measures) (mean age 59 ± 14 years, 70% [21 of 30] women, 60% [18 of 30] White, median pain duration 3.3 [IQR 1.8 to 10] years). We also interviewed 22 orthopaedic clinicians and clinical support staff members (of 106 team members who were eligible and 25 who were approached). Team members were purposively sampled to include representatives from the full range of adult orthopaedic subspecialties and early-, mid-, and late-career physicians (11 of 22 were women, 16 of 22 were White, and 13 of 22 were orthopaedic surgeons). Interviews were conducted in person or via secure video conferencing by trained qualitative researchers. The interview guides were developed using the Capability, Opportunity, Motivation, Behavior model of behavior change. Two study team members used the interview transcripts for coding and thematic analysis, and interviews with additional participants from each stakeholder group continued until two study team members independently determined that thematic saturation of the components of the Capability, Opportunity, Motivation, Behavior model had been reached. Each participant statement was coded as a perception, motivator, barrier, facilitator, or implementation strategy, and inductive coding was used to identify themes in each category. RESULTS: In contrast to the perceptions of some orthopaedic clinicians, most patients with orthopaedic conditions expressed they would like their mental well-being to be acknowledged, if not addressed, as part of a thoughtful orthopaedic care plan. Motivation to address mental health was expressed the most strongly among orthopaedic clinical team members who were aware of high-quality evidence that demonstrated a negative impact of symptoms of depression and anxiety on metrics for which they are publicly monitored or those who perceived that addressing patients' mental health would improve their own quality of life. Barriers described by patients with orthopaedic conditions that were related to addressing mental health in the context of orthopaedic care included clinical team members' use of select stigmatizing words and perceived lack of integration between responses to mental health screening measures and the rest of the orthopaedic care encounter. Orthopaedic clinical team members commonly cited the following barriers: lack of available mental health resources they can refer patients to, uncertainty regarding the appropriateness for them to discuss mental health, and time pressure and lack of expertise or comfort in discussing mental health. Facilitators identified by orthopaedic clinical teams and patients to address mental health in the context of orthopaedic care included the development of efficient, adaptable processes to deliver mental health interventions that preferably avoid wasted paper resources; initiation of mental health-related discussion by an orthopaedic clinical team member in a compassionate, relevant context after rapport with the patient has been established; and the availability of a variety of affordable, accessible mental health interventions to meet patients' varied needs and preferences. Practical implementation strategies identified as suitable in the orthopaedic setting to increase appropriate attention to patients' mental health included training orthopaedic clinical teams, establishing a department or institution "mental health champion," and integrating an automated screening question into clinical workflow to assess patients' interest in receiving mental health-related information. CONCLUSION: Orthopaedic patients want their mental health to be acknowledged as part of a holistic orthopaedic care plan. Although organization-wide initiatives can address mental health systematically, a key facilitator to success is for orthopaedic clinicians to initiate compassionate, even if brief, conversations with their patients regarding the interconnectedness of mental health and musculoskeletal health. Given the unique challenges to addressing mental health in the orthopaedic care setting, additional research should consider use of a hybrid effectiveness-implementation design to identify effective methods of addressing mental health that are feasible and appropriate for this clinical setting. CLINICAL RELEVANCE: Orthopaedic clinicians who have had negative experiences attempting to address mental health with their patients should be encouraged to keep trying. Our results suggest they should feel empowered that most patients want to address mental health in the orthopaedic care setting, and even brief conversations using nonstigmatizing language can be a valuable component of an orthopaedic treatment plan.

The Responsiveness of the Patient-Reported Outcomes Measurement Information System Upper Extremity and Physical Function in Patients With Cubital Tunnel Syndrome.

PURPOSE: The Patient-Reported Outcomes Measurement Information System (PROMIS) Upper Extremity (UE) and PROMIS Physical Function (PF) are increasingly referenced patient-reported outcomes. To interpret treatment effects with these patient-reported outcomes, investigators must understand magnitudes of change that represent clinically relevant improvement. This study assessed the responsiveness of PROMIS UE and PF in patients with cubital tunnel syndrome. METHODS: A retrospective analysis of PROMIS UE and PROMIS PF computer adaptive test scores was performed for patients treated nonoperatively for cubital tunnel syndrome over 3 years at a tertiary institution. The Patient-Reported Outcomes Measurement Information System UE and PROMIS PF outcome scores were collected at initial and return clinic visits. At follow-up appointments, patients completed clinical anchor questions evaluating their degree of interval clinical improvement. Anchor questions allowed categorization of patients into groups that had experienced "no change," "minimal change," and "much change." Minimal clinically important difference (MCID) values were calculated for the PROMIS assessments with anchor-based and distribution-based methods. RESULTS: A total of 304 patients with PROMIS PF scores and 111 with PROMIS UE scores were analyzed. The MCID for the PROMIS UE was 3.1 (95% confidence interval, 1.4-4.8) using the anchor-based method and 3.7 (95% confidence interval, 2.9-4.4) using the distribution-based method. These point estimates exceeded the minimal detectable change of 2.3. The MCID for the PROMIS PF was unable to be determined in this patient sample because patients reporting mild change did not have score changes exceeding measurement error. CONCLUSIONS: The PROMIS UE v2.0 computer adaptive test detected minimal change in patients managed nonoperatively for cubital tunnel syndrome with an estimated MCID range of 3.1-3.7. While PROMIS PF has demonstrated acceptable performance in patients with a variety of upper extremity conditions, for cubital tunnel syndrome, it was less able to detect subtle change. PROMIS UE appears more responsive to subtle changes in cubital tunnel syndrome symptoms. CLINICAL RELEVANCE: Patient-reported outcomes may have varied responsiveness depending on the condition studied.

Firearm Injuries to the Wrist and Hand in Children and Adults: An Epidemiologic Study.

BACKGROUND: Gunshot wounds (GSWs) to the wrist and hand are a major health and economic burden in the United States. There are few studies examining the circumstances and epidemiological factors surrounding these injuries. This study assesses the epidemiological factors, as well as the shooting circumstances, injury details, and surgical management of wrist and hand GSWs in children and adults. METHODS: Medical records and radiographs were reviewed for all patients with ballistic injury to the wrist or hand treated at an urban academic level 1 trauma center from 2016 to 2019. Fisher exact and Pearson χ2 tests were used to assess differences between groups. RESULTS: Two hundred forty-nine victims (29 children, 220 adults) with complete documentation were identified. Among 180 victims with known shooting circumstances, 132 (70%) were shot by another person and 110 (65%) were injured by intentional gunfire. Eighty-seven victims (35%) suffered a concurrent GSW to another body region. Metacarpal fracture was the most commonly diagnosed bony injury (37%), followed by proximal phalanx fracture (25%). One hundred twenty-nine victims (52%) underwent surgery following their injuries. Nerve discontinuity was diagnosed in 27 victims (11%), while 20 victims (8%) had vascular disruption. There was no significant difference between children and adult victims' type of fracture, concurrent injuries, rates of surgery, or in the most common fracture fixation method. CONCLUSIONS: Most wrist and hand GSW victims were injured due to intentional, non-self-inflicted gunfire. Most patients present with hand fractures, and fortunately, nerve and vascular disruptions are uncommon.

Patient Perspectives after Trapeziectomy and Ligament Reconstruction Tendon Interposition: A Qualitative Analysis.

BACKGROUND: The authors aimed to explore patients' perioperative experience after trapeziectomy and ligament reconstruction tendon interposition through semistructured patient interviews to identify deficiencies in preoperative patient counseling. METHODS: The authors conducted semistructured interviews with 14 patients who had undergone ligament reconstruction tendon interposition either 10 to 14 weeks or 9 to 12 months postoperatively at the time of their interview. The semistructured interview guide was developed by a fellowship-trained hand surgeon and a qualitative research specialist to discuss each patient's perioperative experience. Inductive and deductive qualitative coding strategies were used to develop a codebook. All transcripts were then double-coded and discussed to develop recurrent major themes from the patient interviews. RESULTS: The authors' interviews identified three major themes discussed consistently on the patient perioperative experience. First, despite specific counseling about a 3- to 6-month postoperative rehabilitation period, patients were still surprised at the length of the recovery process in regaining function, range of motion, and strength. Second, patients repeatedly outlined that surgery on the dominant hand imparted specific limitations that made the postoperative course difficult. Third, patients discussed the importance of hand therapy both in rehabilitation and in guiding patient postoperative expectations. CONCLUSIONS: Preoperative counseling is of vital importance to set patient expectations in terms of overall expected outcomes, but also regarding early limitations, expectations, and overall recovery length. These themes have influenced how we counsel our patients about recovery after thumb carpometacarpal surgery and may help other surgeons identify areas for improvement in their discussions with patients.

The Utility of the Carpal Tunnel Syndrome-6 for Predicting the Outcomes of Carpal Tunnel Release.

PURPOSE: Considering the cost of, discomfort with, and time required for nerve conduction testing, the Carpal Tunnel Syndrome-6 (CTS-6) is often used to determine the likelihood of the presence of carpal tunnel syndrome. We sought to determine whether the CTS-6, designed as a diagnostic instrument, could serve a dual purpose and predict the outcome of carpal tunnel release (CTR) based on postoperative changes in the Boston Carpal Tunnel Questionnaire (BCTQ) score. METHODS: This prospective observational study enrolled 118 adults before they underwent open CTR at a tertiary center. A primary regression analysis was used to determine the association between preoperative CTS-6 scores and changes in the BCTQ score at ≥6 months after surgery. Additional demographic, social, electrodiagnostic, and mental health variables were assessed for associations with changes in the BCTQ score. The secondary outcomes included single questions rating satisfaction with the result of CTR as well as symptom changes and the Decision Regret Scale. Noneffective CTR was defined as a BCTQ score change of <1.0 point or reported dissatisfaction. RESULTS: Postoperatively, the BCTQ score improvement averaged 1.38 ± 0.77. Although 102 of 109 patients (94%) noted symptom improvement, 94 of 109 (86%) were satisfied with the result of CTR, and 78 of 109 patients (72%) demonstrated a meaningful change in the BCTQ score. Preoperative CTS-6 scores were not correlated with changes in BCTQ scores. CTS-6 scores were not associated with Decision Regret Scale scores, reported satisfaction, or the single-question assessment of symptom changes. Satisfaction, decision regret, and the single symptom change question were correlated with changes in the BCTQ score and each other. Dissatisfied patients were distinguished by a differential improvement in the BCTQ score (1.5 vs 0.7), but no preoperative variable consistently predicted noneffective CTR. CONCLUSIONS: The CTS-6 score does not predict changes in BCTQ scores after CTR. Patient satisfaction with surgical results is associated with postoperative changes in carpal tunnel symptoms but is not predictable using preoperative information. A single question of symptom change may offer an efficient assessment of CTR outcomes. TYPE OF STUDY/LEVEL OF EVIDENCE: Prognostic II.

Value-Based Health Care in Hand Surgery: Where Are We & Where Do We Go From Here?

Health care delivery is broken. The cost of care continues to skyrocket and the outcomes most important to patients are often a mystery. Further, care is often delivered via a fee-for-service model where surgeons are rewarded for the quantity, not the quality, of services provided. Such a health care delivery system is not sustainable and does not incentivize stakeholders to focus on the most important element of the health care delivery "puzzle": the patient. Fortunately, we are in the midst of transforming our health care delivery system, with a focus on optimizing the value of care delivery (ie, health outcomes achieved per dollar spent across a full care cycle). In hand surgery, progress has been made as part of this health system evolution. However, there remains much to accomplish. In this article, the authors review the 6 components of a strategic agenda for moving to a high-value health care delivery system for hand surgery, focusing on where we are today and where we need to go from here.

Depression and Anxiety Screening Identifies Patients That may Benefit From Treatment Regardless of Existing Diagnoses.

Background: This study investigated the utility of depression and anxiety symptom screening in patients scheduled for total knee arthroplasty to examine differences in active symptoms according to patients' mental health diagnoses and associated prescription medications. Material and methods: This cross-sectional study analyzed 594 patients scheduled for total knee arthroplasty at a tertiary practice between June 2018 and December 2018. Patients completed Patient-Reported Outcomes Measurements Information System (PROMIS) Depression and Anxiety Computerized Adaptive Tests in clinic quantifying active symptoms. Mental health diagnoses and associated medications were extracted from health records. Statistical analysis assessed between-group differences in mean PROMIS scores and the prevalence of heightened depressive and anxiety symptoms. Results: Multivariable linear regression modeling demonstrated that being diagnosed with depression without medication (ß 7.1; P < .001) and with medication (ß 8.6; P < .001) were each associated with higher PROMIS Depression scores. Similar modeling demonstrated that patients diagnosed with anxiety and prescribed an anxiolytic (ß 8.4; P < .001) were associated with higher PROMIS Anxiety scores than undiagnosed patients. Eighty-six (15%) patients experienced heightened anxiety and/or depressive symptoms. Heightened depressive symptoms were more prevalent among those diagnosed with depression (19% without medication, 24% with antidepressant vs 5% undiagnosed: P < .001). Heightened anxiety symptoms were most prevalent among those diagnosed with anxiety and on anxiolytic medication (25% vs 7% diagnosed with anxiety without medication, 8% undiagnosed: P < .001). Conclusion: One in seven arthroplasty patients screened reported heightened depressive and/or anxiety symptoms. Despite the majority of arthroplasty patients on antidepressants and anxiolytics having symptoms controlled, these patients remain at increased risk of heightened active symptoms.