The Professional Future in Operated Carpal Tunnel Syndrome: A Cross-Sectional Study of Recognized Occupational Cases.

BACKGROUND: Carpal tunnel syndrome (CTS) is frequently present among workers. This syndrome's professional and economic impact makes it a priority in occupational health. We aimed to describe the professional future of workers suffering from occupational CTS after surgery and the factors that could influence their retention at the job. -Methods: A retrospective descriptive study of workers operated on occupational CTS was conducted from 2014 to 2019. The data was collected using pre-established and phone questionnaires to determine their professional future after surgery. RESULTS: We included 99 workers with operated CTS. They had a mean age of 45±6.5 years, were predominantly female (97%), and had two dependent children in 72.7% of cases. They worked as a seamstress in 44.4% of patients with a mean professional seniority of 18±7.2 years. The professional future was a return to work with a job transfer at 44.4% and job maintenance with ergonomic adjustments at 39.4%. A job loss was noticed in 12.2% of cases. Early retirement was noticed in 8.2%, dismissal in 3%, and resignation in 1% of cases. The factors influencing the professional future were age 50 to 59 years (p=0.01) and dependent children (p=0.02). CONCLUSIONS: In our survey, most operated-CTS workers benefited from a job transfer and kept their job with ergonomic adjustments to their work conditions. Therefore, interventions aiming to improve the professional future of workers operated on CTS by ensuring sufficient staff and adjusting workplaces are needed.

Surgery for subacromial impingement syndrome and occupational biomechanical risk factors in a 16-year prospective study among male construction workers.

OBJECTIVE: The aim of this study was to assess the association between occupational biomechanical exposures and the occurrence of surgical treatment for subacromial impingement syndrome (SIS). METHODS: A cohort of 220 295 male constructions workers who participated in a national occupational health surveillance program (1971-1993) were examined prospectively over a 16-year follow-up period (2001-2016) for surgically treated SIS. Worker job title, smoking status, height, weight, and age were registered on health examination. Job titles were mapped to 21 occupational groups based on tasks and training. A job exposure matrix (JEM) was developed with exposure estimates for each occupational group. Surgical cases were determined through linkage with the Swedish national in- and outpatient registers. Poisson regression was used to assess the relative risks (RR) for each biomechanical exposure. RESULTS: The total incidence rate of surgically treated SIS over the 16-year observation period was 201.1 cases per 100 000 person-years. Increased risk was evident for workers exposed to upper-extremity loading (push/pull/lift) (RR 1.45-2.30), high hand grip force (RR 1.47-2.23), using handheld tools (RR 1.52-2.09), frequent work with hands above shoulders (RR 1.62-2.11), static work (RR 1.77-2.26), and hand-arm vibration (RR 1.78-2.13). There was an increased risk for SIS surgery for all occupational groups (construction trades) compared with white-collar workers (RR 1.56-2.61). CONCLUSIONS: Occupational upper-extremity load and posture exposures were associated with increased risk for surgical treatment of SIS, which underlines the need for reducing workplace exposures and early symptom detection in highly exposed occupational groups.

Associations between single and combined occupational mechanical exposures and surgery for subacromial impingement syndrome: a nationwide Danish cohort study.

OBJECTIVE: This study aimed to evaluate whether the risk of surgery for subacromial impingement syndrome (SIS) increases with the number of combined occupational mechanical exposures compared with single exposure. METHODS: We reanalyzed data from a register-based cohort study of the entire Danish working population (N=2 374 403) with 14 118 events of surgery for SIS (2003-2008). Exposure information in 10-year windows was obtained by combining occupational codes with a job exposure matrix. For single and combined mechanical exposures, we created three exposure variables of the number of years with specific exposure intensities with or without co-existing mechanical exposures. We used logistic regression as survival analysis. RESULTS: We found exposure-response relations for duration and intensity of each single mechanical exposure except for repetition. The single effect of arm elevation >90º reached a maximum adjusted odds ratio (ORadj) of 1.7 [95% confidence interval (CI) 1.5-2.0], which increased to 1.8 (95% CI 1.5-2.0), 2.0 (95% CI 1.9-2.2), and 2.2 (95% CI 2.0-2.5) when combined with repetition, force, and both. When combining repetition with arm elevation >90º, force, and both, ORadj increased from 1.5 (95% CI 1.3-1.8) to 2.1 (95% CI 1.8-2.4), 2.5 (95% CI 2.4-2.9), and 2.7 (95% CI 2.4-3.0). For force, ORadj increased from 2.5 (95% CI 2.1-2.9) to 2.6 (95% CI 2.3-2.8), 2.8 (95% CI 2.4-3.2), and 3.0 (95% CI 2.6-3.4). CONCLUSION: We found an increased risk of surgery for SIS with the number of combined exposures; the risk was especially pronounced when the combined exposures included force.

Preliminary Investigation and Imaging Analysis of Early Lung Cancer Screening Among Petroleum Workers in North China.

BACKGROUND: The detection rate of lung nodules has increased significantly among petroleum workers in North China since the low-dose CT (LDCT) screening has been widely carried out. What's more, the number of confirmed early lung cancers is increasing continuously. Therefore, a great deal of concern for the high risk of lung cancer has been shown among petroleum workers. PURPOSE: To improve the screening efficiency and maximize the benefits of the subjects, the current situation of LDCT lung cancer screening should be understood and the imaging characteristics of early lung cancer should be analyzed for petroleum workers in North China. MATERIALS AND METHODS: Firstly, the dynamic changes of LDCT early lung cancer screening for petroleum workers in North China were analyzed in recent years. Then, the survey data of 3121 petroleum workers was compared with that of 1868 non-petroleum workers, which was analyzed. Finally, 91 patients (129 nodular lung cancer) confirmed by pathology were retrospectively analyzed, and the data of which was compared with the clinical features obtained from survey data above. The imaging characteristics and related factors of different subtypes of lung adenocarcinoma were discussed and analyzed. RESULTS: Lung nodules were found in 810 cases (25.95%) out of 3121 petroleum workers; and the surgery was chosen by 42 patients, 38 of whom were confirmed as lung cancer. Compared with the data of screened petroleum workers, there were more older people and more females as well as a higher proportion of people with family malignancy history, and a lower proportion of smoking people in 91 patients with lung cancer. As the pathological grade of tumor nodules increased, the volume and diameter of nodules gradually increased, and the mean density, maximum density and standard deviation of density also increased (p < 0.001). The volume and diameter of nodules were positively correlated with ages (p < 0.05). CONCLUSION: The occurrence of lung adenocarcinoma is closely related to the family history of malignant tumors, and the constituent ratio of young women without a history of smoking increased significantly. At the same time, the quantitative information obtained by using CT images has important value in predicting its pathological subtypes.

Postural ergonomics and work-related musculoskeletal disorders in neurosurgery: lessons from an international survey.

BACKGROUND: Work-related musculoskeletal disorders (WMSDs) affect a significant percentage of the neurosurgical workforce. The aim of the current questionnaire-based study was to examine the prevalence of WMSDs amongst neurosurgeons, identify risk factors, and study the views of neurosurgeons regarding ergonomics. METHODS: From June to August 2020, members of the "European Association of Neurosurgical Societies," the "Neurosurgery Research Listserv," and the "Latin American Federation of Neurosurgical Societies" were asked to complete an electronic questionnaire on the topics of WMSDs and ergonomics. RESULTS: A total of 409 neurosurgeons responded to the survey, with a 4.7 male to female ratio. Most of the surgeons worked in Europe (76.9%) in academic public hospitals. The vast majority of the participants (87.9%) had experienced WMSDs, mainly affecting the shoulder, neck, and back muscles. The most common operations performed by the participants were "Craniotomy for convexity/intrinsic tumors" (24.1%) and "Open lumbar basic spine" (24.1%). Neurosurgeons agreed that ergonomics is an underexposed area in the neurosurgical field (84.8%) and that more resources should be spend (87.3%) and training curricula changes should be made (78.3%) in order to alleviate the burden of WMSDs on neurosurgeons. Univariate analysis did not reveal any associations between the development of WMSDs and age, gender, tenure, average duration of operation, operating time per week, type of operation, and surgical approach. CONCLUSIONS: The problem of WMSDs ought to be more closely addressed and managed by the neurosurgical community. More studies ought to be designed to investigate specific ergonomic parameters in order to formulate practice recommendations.

Surgery for trapeziometacarpal osteoarthritis in relation to cumulative occupational hand force requirements: a Danish nationwide cohort study.

OBJECTIVES: To evaluate if higher cumulative occupational hand force requirements are associated with higher risks of surgery for trapeziometacarpal osteoarthritis and with surgery earlier in life. METHODS: The study was based on Danish national registers. Among all persons born in Denmark 1931 to 1990, we included those who had been employed for at least 5 years since 1991 by the end of 2000, or later when this employment criterion was reached, up until the end of 2016. Cumulative exposure estimates for 10-year time windows (force-years) were assessed by combining individual year-by-year information on occupational codes with an expert based hand-arm job exposure matrix. First-time events of surgery for trapeziometacarpal osteoarthritis 2001 to 2017 constituted the outcome. Surgery rates were analysed by a logistic regression technique equivalent to discrete survival analysis using a 1-year lag. We also calculated rate advancement periods. RESULTS: A total of 2 860 448 persons contributed with around 48 million person-years of follow-up, during which 3977 cases appeared (821 among men and 3156 among women). Compared with <5 force-years, the adjusted OR (ORadj) for ≥5 to <10 force-years was 1.39 (95% CI 1.14 to 1.68) and for ≥10 to 30 force-years 1.47 (95% CI 1.26 to 1.71) among men and 1.64 (95% CI 1.50 to 1.78) and 1.29 (95% CI 1.16 to 1.43) among women. The sex combined ORadj were 1.59 (95% CI 1.47 to 1.72) and 1.36 (95% CI 1.25 to 1.48). Among the exposed, surgery was advanced by 3 to 7 years. CONCLUSION: Medium/high cumulative hand force requirements were associated with elevated hazard rates of surgery for trapeziometacarpal osteoarthritis and advanced the time of surgery by several years.

Transplantation for work-related lung disease in the USA.

OBJECTIVES: Work-related lung diseases (WRLDs) are entirely preventable. To assess the impact of WRLDs on the US transplant system, we identified adult lung transplant recipients with a WRLD diagnosis specified at the time of transplant to describe demographic, payer and clinical characteristics of these patients and to assess post-transplant survival. METHODS: Using US registry data from 1991 to 2018, we identified lung transplant recipients with WRLDs including coal workers' pneumoconiosis, silicosis, asbestosis, metal pneumoconiosis and berylliosis. RESULTS: The frequency of WRLD-associated transplants has increased over time. Among 230 lung transplants for WRLD, a majority were performed since 2009; 79 were for coal workers' pneumoconiosis and 78 were for silicosis. Patients with coal workers' pneumoconiosis were predominantly from West Virginia (n=31), Kentucky (n=23) or Virginia (n=10). States with the highest number of patients with silicosis transplant were Pennsylvania (n=12) and West Virginia (n=8). Patients with metal pneumoconiosis and asbestosis had the lowest and highest mean age at transplant (48.8 and 62.1 years). Median post-transplant survival was 8.2 years for patients with asbestosis, 6.6 years for coal workers' pneumoconiosis and 7.8 years for silicosis. Risk of death among patients with silicosis, coal workers' pneumoconiosis and asbestosis did not differ when compared with patients with idiopathic pulmonary fibrosis. CONCLUSIONS: Lung transplants for WRLDs are increasingly common, indicating a need for primary prevention and surveillance in high-risk occupations. Collection of patient occupational history by the registry could enhance case identification and inform prevention strategies.

Young patients with divergence insufficiency related to excessive near work.

The purpose of this study is to explore the relationships between excessive near work and divergence insufficiency esotropia in young adults. A prospective study described a series of young patients with divergence insufficiency esotropia related to excessive near work between 2012 and 2017. The medical records of twelve young patients with divergence insufficiency esotropia and a history of excessive near work were reviewed, and the duration of near work, angle of primary position deviations at distance and at near, and angle of primary position deviations after refraining from near work for 3 months were analyzed. All patients with divergence insufficiency esotropia (age range: 21-35 years) showed an initial esodeviation ranging from 18 to 35 prism diopters for distance fixation and ranging from 8 to 20 prism diopters for near. Neurological evaluation in all cases was normal. Myopic refractive errors were detected in twelve patients. Every patient persisted near work for more than 6 h a day over a period of several months (minimum 4 months). Reductions in esodeviation were noted in twelve patients after refraining from near work for more than 3 months. Only one patient was diplopia free in all positions of gaze. The remaining eleven patients were treated successfully, six with prisms and five with surgery. They were all orthophoric and demonstrated restored binocularity at the post-treatment examinations. Our findings suggested that excessive near work might influence the development of divergence insufficiency esotropia in young adults. Refraining from excessive near work could decrease the degree of esodeviation in these patients.

[Ultrasound-guided percutaneous tenotomy in chronic wrist extensor enthesopathy]. / Tenotomía percutánea ecoguiada en entesopatía crónica de extensores de muñeca.

Epicondylitis causes disability and tends to become chronic. Histologically, degenerative lesions are found in the common extensor tendon, which are visible on ultrasound or magnetic resonance imaging. Several conservative therapeutic measures are available, including corticosteroid infiltration by anatomical landmark. However, these measures sometimes fail, in which case patients are proposed for surgery. Ultrasound is a therapeutic tool that allows procedures on tendons to be performed without skin incisions. The technique of ultrasound-guided percutaneous tenotomy for the treatment of chronic epicondylitis was first reported in 2006. This procedure, demonstrated to date by surgeons and radiologists, attempts to transform a chronic degenerative process with failure to repair into an acute inflammatory process with self-regeneration. The aim of this study was to describe 5 cases of epicondylitis that failed to respond to routine therapeutic measures, in which we used ultrasound-guided percutaneous tenotomy with favourable results.

Work-relatedness of inguinal hernia: a systematic review including meta-analysis and GRADE.

PURPOSE: Clinicians need to know whether inguinal hernia (IH) can be attributed to work to answer questions regarding prevention and medical causation. This review describes whether work-related risk factors are associated with IH. METHODS: A systematic review was performed in Medline via PubMed until February 3rd, 2020. Inclusion criteria were that IH was diagnosed by a clinician, and workers exposed to work-related risk factors were compared to workers less exposed or not at all. A quality assessment and a meta-analysis using Cochrane's RevMan 5.3 were performed, including GRADE for quality of evidence. RESULTS: The search resulted in 540 references. Fourteen studies fulfilled the inclusion criteria, of which three were included in a meta-analysis, all three being of high quality, including 621 workers diagnosed with IH. The meta-analysis revealed significant associations with physically demanding work (OR 2.30, 95% CI 1.56-3.40). Two prospective studies, including 382 and 22,926 cases revealed associations that this was true for male workers with a lateral IH that reported standing or walking for more than six hours per workday (OR 1.45, 95% CI 1.12-1.88) or lifting cumulative loads of more than 4000 kg per workday (OR 1.32, 95% CI 1.27-1.38). The level of certainty for the latter two work-related risk factors was moderate and high according to GRADE. CONCLUSION: Lateral IH among males is associated with work-related risk factors depending on the level of exposure to the time standing/walking per workday, or the amount of load lifted per workday.

Occupation classification predicts return to work after carpal tunnel decompression.

BACKGROUND: The relationship between hand function, employment status and return to work (RTW) after carpal tunnel decompression (CTD) is unclear. AIMS: To investigate predictors of RTW following CTD. METHODS: We prospectively collected pre-operative and 1-year post-operative outcomes and RTW data for all patients undergoing CTD at one centre between 29 May 2014 and 29 May 2017. We used the Standard Occupation Classification 2010. RESULTS: Pre- and post-operative results were available for 469 (79%) of the 597 patients who had CTD surgery. Pre-operatively, 219 (47%) were employed, 216 (46%) were retired, 26 (6%) were not working due to long-term illness and eight (2%) were unemployed. Complete data sets were available for 178 (81%) of the 219 employed patients, of whom 161 (90%) were able to RTW. Of the rest, five (3%) had changed jobs and 12 (7%) were unable to work. Median RTW time was 4 weeks (interquartile range [IQR] 2-6 weeks). Significantly more patients undertaking manual labour were unable to RTW (15% versus 5%; P < 0.05). There was no significant difference in mean number of weeks absent between manual (5.7; 95% confidence interval [CI] 4.9-6.5) and non-manual workers (6.2; 95% CI 4.8-7.6) (P > 0.05). Median pre-operative (difference 15.9; 95% CI 4.5-25) and post-operative (difference 43.2; 95% CI 13.6-43.2) hand function scores were significantly worse in patients who did not RTW (P < 0.05). CONCLUSIONS: Most patients can RTW within 1 year of CTD. Failure to RTW is more likely in manual workers and patients with poorer pre-operative hand function.

Hand disorders demographics in rural areas: A 15-year analysis of demographic characteristics overtime in a stable population.

OBJECTIVE: The aim of this study was to determine the incidence of hand disorders in a general rural area, record the demographic characteristics for each condition, and evaluate the tendencies overtime in the incidence of these conditions. METHODS: Using nationwide census data, we identified a health network system serving a geographic area with stable population. Subsequently, we retrospectively analyzed all the patient records (n=731 patients) with hand disorders documented between 2001 and 2015. We performed a retrospective review and collected demographic data for the patients and disorders treated surgically. We calculated the incidence of these conditions based on the census data and performed qualitative and categorical analysis with different demographic and disease-related variables. RESULTS: We reviewed surgically treated 204 male and 527 female patients with hand disorders. The mean annual incidence was 222.5 cases per 100,000 individuals per year. More than 55% of the patients were between 50 and 69 years old. Trigger finger (TF) accounted for approximately 42% of patients, followed by 35% with carpal tunnel syndrome (CTS). TF and CTS were related to hand dominance, and right hand was affected in 53.4% of the patients. CONCLUSION: Hand disorders in a rural area seem to correlate with the occupational sector activities, such as farming and agriculture. CTS was the most common disorder in the past; however, the dramatic increase in the incidence rate of TF made it the most common hand disorder in the last decade. Incidence rates in both males and females showed an increasing trend.

Mini-Open Surgical Fasciotomy for Chronic Exertional Compartment Syndrome of the Forearm in Professional Motorcycling Adolescents.

OBJECTIVE: Evaluate treatment and outcome of mini-open fasciotomy (MOF) in a population of adolescent motorcycling racers affected by forearm chronic exertional compartment syndrome (CECS). DESIGN: Prospective case series. SETTING: University hospital/private practice. PATIENTS: Nine professional motorcycling adolescents were diagnosed with forearm CECS. All were treated with MOF between 2007 and 2012 and followed for a minimum of 5 years (range 5-10 years). Age, sex, body mass index, laterality, and profession were recorded. INTERVENTIONS: A MOF to obtain decompression of all compartments was performed in all patients. MAIN OUTCOME MEASURES: Visual analog scale; a subjective scale to measure strength; and Quick-DASH functional scores. Time to resume full riding capacities as the short-term evaluation. RESULTS: A significant decrease in visual analog scale (P < 0.001) and Quick-DASH (P < 0.001) scores was observed in the first 3 months, stabilizing during follow-up (P = 0.521; P = 0.217). Average time to return to sport was 2.8 ± 1 week. No symptom recurrence was reported, but one patient suffered a minor complication. There were no cases of infection, hematoma, or peripheral nerve injury. CONCLUSIONS: We assess that MOF can be a valid alternative for the treatment of forearm CECS in adolescent competitive motorcycling racers, as demonstrated by the good success rate and minimal incidence of complications during follow-up. LEVEL OF EVIDENCE: IV, case series.

Update: Gallbladder disease and cholecystectomies, active component, U.S. Armed Forces, 2014-2018.

The term gallbladder disease refers to a variety of conditions of the gallbladder and the biliary tract. The more common of these conditions are cholelithiasis (gallstones) and cholecystitis (inflammation of the gallbladder), and these conditions often are treated with cholecystectomy (gallbladder removal). During the 2014-2018 surveillance period, 8,008 active component service members were identified as incident cases of gallbladder disease. The crude overall incidence rate of gallbladder disease was 1.2 per 1,000 person-years; the crude annual rate decreased very slightly during the period. A total of 6,470 active component service members underwent incident cholecystectomies. Almost all (97.4%) were performed laparoscopically, and the majority were performed in outpatient settings (65.2%). The number of hospital bed days per open cholecystectomy far exceeded those per laparoscopic cholecystectomy. However, the number of hospital bed days per open cholecystectomy markedly decreased throughout the period. Gallbladder disease and cholecystectomies were more common among service members who were female, American Indian/Alaska Native or Hispanic, older, in the Air Force, and in healthcare occupations. Clinicians should continue to advocate for lifestyle changes, such as maintaining a healthy weight and a diet low in fat and cholesterol, that could prevent gallbladder disease. Similarly, continued Department of Defense-wide initiatives to promote healthy lifestyles could also help prevent gallbladder disease and maintain the health of the force.

Clinical Experience and Management of Squat-Induced Lower Extremity Arterial Ischemia.

Popliteal artery entrapment syndrome (PAES) is a rare cause of intermittent claudication in young patients. Unlike the atherosclerotic and degenerative etiologies typically associated with arterial disease, PAES is primarily of anatomic origin. PAES is rarely associated with aneurysmal disease. We present a case and subsequent surgical management of a 47-year-old male who experienced acute limb ischemia secondary to thrombosis of a popliteal artery aneurysm (PAA), who was found to have bilateral PAES and PAAs.

In commemoration of the 2018 Mataro Nagayo Prize: A road to early diagnosis and monitoring of asbestos-related mesothelioma.

Primarily caused by exposure to asbestos, mesothelioma is a typical occupational disease. The latency of mesothelioma is as long as 20-40 years, and the cancer initially progresses mainly along the surfaces of pleura or peritoneum without forming masses. As symptoms do not develop until late stages, it has been challenging to diagnose this disease in its early stages and to carry out complete surgical removal. In responding to Japan's asbestos crisis in the mid-2000s, we have developed and improved ERC/MSLN-based serum and radiological markers and pioneered the use of an N-ERC ELISA kit for screening populations at risk for asbestos exposure. In the present article, we review our research toward early diagnosis of asbestos-related mesothelioma before symptoms develop and share our clinical experience of screening, diagnosing and monitoring of this disease. This paper is dedicated to the author (Dr Okio Hino) to commemorate the honor bestowed upon him as the recipient of the Mataro Nagayo Prize in 2018.

Primary and Posttraumatic Knee Osteoarthritis in the Military.

Osteoarthritis is a particularly burdensome and career-limiting condition for military service members. The daily demands of military service place the service members at a baseline increased risk of developing primary OA as well as increased risk of acute knee injuries that further predispose to developing posttraumatic OA. There are multiple treatment options available for primary and posttraumatic OA from osteotomy to arthroplasty.

Arthroscopic treatment of work-related lateral epicondylitis - prognostic factors.

Lateral epicondylitis is a condition whose pathophysiology is poorly understood and whose optimal treatment divides physicians. Arthroscopy has proven its worth, with results similar to or better than open surgery. The purpose of this study was to look for prognostic factors for the outcomes of arthroscopic treatment of lateral epicondylitis. This was a retrospective, single-center study involving 39 cases (36 patients). Patients were split into two groups based on the Mayo Elbow Performance score (MEPS). A good result was defined as a score of 75 or better. The variables of interest were gender, age, body mass index, smoking habits, recognition as an occupational disease, duration of absence from work, cartilage involvement, presence of a capsular lesion and length of follow-up. The mean follow-up at review was 37.2 months (± 17.4). The average MEPS was 77.44 (± 15.51). Smoking was statistically related to a poor result (P = 0.0422) and a longer follow-up was statistically related to a good result (P = 0.0396). We identified two prognostic factors for lateral epicondylitis treated by arthroscopy. Smoking has a negative effect and ideally, patients should quit before surgical treatment. Time has a positive effect; thus patients should be informed that it will take several months or even years for their ailment to improve. Taking these factors into consideration will improve the functional outcomes of this surgery.

Discretionary Surgery: A Comparison of Workers' Compensation and Commercial Insurance.

BACKGROUND: Workers' compensation is intended for injuries that occur at work and is expected to be mostly for trauma and mostly nondiscretionary conditions. We tested the null hypothesis that there is no difference in the ratio of likely discretionary to likely nondiscretionary surgery between patients treated under workers' compensation compared with commercial insurance controlling for age, sex, and anatomical site for either traumatic or nontraumatic diagnoses. METHODS: Using claims data from the Texas workers' compensation database and Truven Health commercial claims we classified International Statistical Classification of Diseases and Related Health Problems, Ninth Revision, Clinical Modification (ICD-9-CM) diagnoses and procedure codes as likely discretionary or likely nondiscretionary, and as traumatic or nontraumatic. Ratios of likely discretionary to likely nondiscretionary surgery were calculated and compared. RESULTS: Among patients treated under workers' compensation, the ratio of likely discretionary to likely nondiscretionary surgery was significantly higher for traumatic diagnoses (0.57 [95% confidence interval, CI, = 0.56-0.61] vs 0.38 [95% CI = 0.37-0.40], P < .05) and significantly lower for nontraumatic diagnoses (9.4 [95% CI = 9.20-9.42] vs 13.2 [95% CI = 12.9-13.3], P < .05) compared with commercial insurance. CONCLUSIONS: Workers' compensation often covers likely discretionary musculoskeletal surgery, and insurance type may influence treatment.