Upper Extremity Surgeon Recommendations for Imaging Do Not Correspond with Imaging Appropriateness Guidelines.

Background: Utilization of magnetic resonance imaging (MRI) and computed tomography (CT) increases annually, raising concerns about overuse. Imaging appropriateness guidelines have the potential to standardize decisions regarding imaging based on best evidence, which might reduce unhelpful or potentially misleading imaging. We studied expert use of advanced imaging for musculoskeletal illness compared to published appropriateness recommendations. Methods: First, 15 imaging guidelines with recommendations for advanced imaging of the upper extremity were collated. Next, members of the Science of Variation Group (SOVG) were invited to participate in a survey of 11 patient scenarios of common upper extremity illnesses and asked whether they would recommend MRI or CT. Guideline recommendations for imaging were compared with surgeon recommendations using Fisher's exact tests. We used Fleiss' kappa to measure the interobserver agreement among surgeons. Results: For the 11 scenarios, most imaging appropriateness guidelines suggested that MRI or CT is useful, while most surgeons (n = 108) felt it was not. There was no correlation between surgeons and guidelines recommendations for imaging (ρ = 0.28; p = 0.40). There was slight agreement among surgeons regarding imaging recommendations (kappa: 0.17; 95% confidence interval: 0.023-0.32). Conclusion: The available imaging appropriateness guidelines appear to be too permissive and therefore seem to have limited clinical utility for upper extremity surgeons. The notable surgeon-to-surgeon variation (unreliability) in recommendations for advanced imaging in this and other studies suggests a role for strategies to ensure that patient decisions about imaging are consistent with their values (what matters most to them) and not unduly influenced by patient misconceptions about imaging or by surgeon beliefs and habits. Level Of Evidence: II, diagnostic.

What Are the Underlying Mental Health Constructs Associated With Level of Capability in People With Knee and Hip Osteoarthritis?

BACKGROUND: Mental health characteristics such as negative mood, fear avoidance, unhelpful thoughts regarding pain, and low self-efficacy are associated with symptom intensity and capability among patients with hip and knee osteoarthritis (OA). Knowledge gaps remain regarding the conceptual and statistical overlap of these constructs and which of these are most strongly associated with capability in people with OA. Further study of these underlying factors can inform us which mental health assessments to prioritize and how to incorporate them into whole-person, psychologically informed care. QUESTIONS/PURPOSES: (1) What are the distinct underlying factors that can be identified using statistical grouping of responses to a multidimensional mental health survey administered to patients with OA? (2) What are the associations between these distinct underlying factors and capability in knee OA (measured using the Knee Injury and Osteoarthritis Outcome Score, Joint Replacement [KOOS JR]) and hip OA (measured using Hip Disability and Osteoarthritis Outcome Score, Joint Replacement [HOOS JR]), accounting for sociodemographic and clinical factors? METHODS: We performed a retrospective cross-sectional analysis of adult patients who were referred to our program with a primary complaint of hip or knee pain secondary to OA between October 2017 and December 2020. Of the 2006 patients in the database, 38% (760) were excluded because they did not have a diagnosis of primary osteoarthritis, and 23% (292 of 1246) were excluded owing to missing data, leaving 954 patients available for analysis. Seventy-three percent (697) were women, with a mean age of 61 ± 10 years; 65% (623) of patients were White, and 52% (498) were insured under a commercial plan or via their employer. We analyzed demographic data, patient-reported outcome measures, and a multidimensional mental health survey (the 10-item Optimal Screening for Prediction of Referral and Outcome-Yellow Flag [OSPRO-YF] assessment tool), which are routinely collected for all patients at their baseline new-patient visit. To answer our first question about identifying underlying mental health factors, we performed an exploratory factor analysis of the OSPRO-YF score estimates. This technique helped identify statistically distinct underlying factors for the entire cohort based on extracting the maximum common variance among the variables of the OSPRO-YF. The exploratory factor analysis established how strongly different mental health characteristics were intercorrelated. A scree plot technique was then applied to reduce these factor groupings (based on Eigenvalues above 1.0) into a set of distinct factors. Predicted factor scores of these latent variables were generated and were subsequently used as explanatory variables in the multivariable analysis that identified variables associated with HOOS JR and KOOS JR scores. RESULTS: Two underlying mental health factors were identified using exploratory factor analysis and the scree plot; we labeled them "pain coping" and "mood." For patients with knee OA, after accounting for confounders, worse mood and worse pain coping were associated with greater levels of incapability (KOOS JR) in separate models but when analyzed in a combined model, pain coping (regression coefficient -4.3 [95% confidence interval -5.4 to -3.2], partial R 2 0.076; p < 0.001) had the strongest relationship, and mood was no longer associated. Similarly, for hip OA, pain coping (regression coefficient -5.4 [95% CI -7.8 to -3.1], partial R 2 0.10; p < 0.001) had the strongest relationship, and mood was no longer associated. CONCLUSION: This study simplifies the multitude of mental health assessments into two underlying factors: cognition (pain coping) and feelings (mood). When considered together, the association between capability and pain coping was dominant, signaling the importance of a mental health assessment in orthopaedic care to go beyond focusing on unhelpful feelings and mood (assessment of depression and anxiety) alone to include measures of pain coping, such as the Pain Catastrophizing Scale or Tampa Scale for Kinesiophobia, both of which have been used extensively in patients with musculoskeletal conditions. LEVEL OF EVIDENCE: Level III, prognostic study.

Shoulder and Elbow Injuries in National Basketball Association Athletes and Their Effects on Player Performance.

Background: Shoulder and elbow function is essential to basic basketball actions. Outside of anterior shoulder instability, injuries in these joints are not well characterized in National Basketball Association (NBA) players. Purpose: To describe the epidemiology and associated risk factors of shoulder and elbow injuries in NBA players and identify factors that influence player performance upon return to play. Study Design: Descriptive epidemiology study. Methods: Historical injury data from the 2015-2020 NBA seasons were retrieved from Pro Sports Transactions, a public online database. An injury was defined as a health-related concern resulting in an absence of ≥1 NBA games. Primary measures included pre- and postinjury player efficiency rating (PER) and true shooting percentage (TS%) with interquartile ranges (IQRs), stratified by extremity dominance. Multivariate logistic regression analyses with stepwise regression were performed to identify risk factors associated with return-to-play performance. Results: A total of 192 shoulder and elbow injuries were sustained among 126 NBA athletes, with incidence rates of 1.11 per 1000 game exposures (GEs) and 0.30 per 1000 GEs, respectively. Sprain/strain and general soreness were the most common injury types in both the shoulder and the elbow. In the 2 years after injury, baseline PER was achieved in all groups, except for players with dominant shoulder injuries (baseline PER, 16 [IQR, 14-18] vs 2-year PER, 13 [IQR 11-16]; P = .012). Younger age was associated with quicker return to baseline PER (odds ratio, 0.77 [95% CI, 0.67-0.88]). Shoulder and elbow injuries did not negatively influence TS% upon return to play (baseline TS%, 0.55% [IQR, 0.51%-0.58%] vs 1-year TS%, 0.55% [IQR, 0.52%-0.58%]; P = .13). Conclusion: Dominant shoulder injuries negatively influenced PER during the first 2 seasons upon return to play in NBA players. Therefore, expectations that players with this type of injury immediately achieve baseline statistical production should be tempered. Shooting accuracy appears to remain unaffected after shoulder or elbow injury.

Routine MRI Among Patients With a Suspected Scaphoid Fracture Risks Overdiagnosis.

BACKGROUND: In the setting of a suspected scaphoid fracture, MRI may result in overdiagnosis and potential overtreatment. This is in part because of the low prevalence of true fractures among suspected fractures, but also because of potentially misleading variations in signal that may be more common than fracture-related signal changes. To better understand the risk of overdiagnosis, we first need insight into the relative prevalence of useful and potentially distracting signal changes among patients with a suspected scaphoid fracture. QUESTION/PURPOSE: What is the proportion of signal changes representing definite and possible scaphoid fractures relative to other types of signal changes on MRI among patients with a suspected scaphoid fracture? METHODS: In a retrospective study in an orthopaedic trauma clinic associated with a Level I trauma center, we evaluated MR images of patients 16 years and older with a clinically suspected scaphoid fracture. At our institution, patients with symptoms and signs of a possible scaphoid fracture and negative radiographs undergo MRI scanning. Between January 1, 2012, and September 1, 2019, a total of 310 patients 16 years or older had an MRI to evaluate a suspected scaphoid fracture. Exclusion criteria included a scaphoid fracture that was visible on radiographs before MRI as reported by the radiologist (four patients), no available radiographs before MRI (two), MRI more than 3 weeks after injury (28), unknown date of injury (nine), and repeat or bilateral MRI scans (11), leaving 256 MR images for analysis. Sixty percent (153) of patients were women, and the median age was 34 years (IQR 21 to 50 years). The images were taken a median of 8 days (IQR 2 to 12 days) after injury. MR images were screened for the presence of scaphoid signal changes. We identified the following patterns of signal change with a reliability of kappa 0.62: definite scaphoid fracture, possible scaphoid fracture, signal in the waist area other than possible or definite fractures, and other signal changes. A definite scaphoid fracture was defined as a linear, focal, and bicortical signal abnormality, with adjacent edema and a relatively transverse orientation relative to the scaphoid long axis. The transverse linear signal was visible on more than one cut in multiple planes. A possible scaphoid fracture had a transverse linear signal on more than one cut on sagittal or coronal planes, with or without adjacent edema. RESULTS: Six percent (16 of 256) of MR images were categorized as revealing definite (2% [four of 256]) or possible (5% [12 of 256]) scaphoid fractures, whereas 29% (74 of 256) were categorized as revealing nonspecific signal changes at the waist (14% [35 of 256]) and other areas (15% [39 of 256]). Of the 51 patients with scaphoid waist signal changes, 69% (35) were categorized as having distracting and potentially misleading MRI findings. CONCLUSION: The high prevalence of signal changes that are distracting and potentially misleading, the low prevalence of signal changes that clearly represent a scaphoid fracture, and the low pretest odds of a true fracture among patients with a suspected scaphoid fracture illustrate that routine MRI of suspected scaphoid fractures carries a notable risk of overdiagnosis and potential overtreatment. Two alternative strategies are supported by preliminary evidence and merit additional attention: more-selective use of MRI in people deemed at higher risk according to a clinical prediction rule and strategies for involving the patient in decisions regarding how to manage the notably small risk of future symptomatic nonunion. LEVEL OF EVIDENCE: Level IV, diagnostic study.

Characterization of Ankle Injuries and Associated Risk Factors in the National Basketball Association: Minutes Per Game and Usage Rate Associated With Time Loss.

Background: Ankle injuries are more common in the National Basketball Association (NBA) compared with other professional sports. Purpose/Hypothesis: The purpose of this study was to report the incidence and associated risk factors of ankle injuries in NBA athletes. It was hypothesized that factors associated with an increased physiologic burden, such as minutes per game (MPG), usage rate, and associated lower extremity injury, would be associated with increased ankle injury risk and time loss. Study Design: Descriptive epidemiology study. Methods: Ankle injury data from the 2015-2016 through 2020-2021 NBA seasons were evaluated. The truncated 2019-2020 season due to the COVID-19 pandemic was omitted. The primary outcome was the incidence of ankle injuries, reported per 1000 game-exposures (GEs). Secondary analysis was performed to identify risk factors for ankle injuries through bivariate analysis and multivariable logistic regression of player demographic characteristics, performance statistics, injury characteristics, and previous lower extremity injuries. Factors influencing the time loss after injury were assessed via a negative binomial regression analysis. Results: A total of 554 ankle injuries (4.06 injuries per 1000 GEs) were sustained by NBA players over 5 NBA seasons, with sprain/strain the most common injury type (3.71 injuries per 1000 GEs). The majority of ankle injury events (55%) resulted in 2 to 10 game absences. The likelihood of sustaining an ankle injury was significantly associated with a greater number of games played (P = .029) and previous injury to the hip, hamstring, or quadriceps (P = .004). Increased length of absence due to ankle injury was associated with greater height (P = .019), MPG (P < .001), usage rate (P = .025), points per game (P = .011), and a prior history of foot (P = .003), ankle (P < .001), and knee injuries (P < .001). Conclusion: The incidence of ankle injuries was 4.06 per 1000 GEs in professional basketball players. Games played and prior history of hip, hamstring, or quadriceps injuries were found to be risk factors for ankle injuries. Factors associated with physiologic burden such as MPG and usage rate were associated with an increased time loss after injury.

Factors Associated With Comfort Using Telemedicine for Upper Limb Specialty Care.

PURPOSE: There is a growing interest in diagnosis and treatment through telemedicine because of its convenience, accessibility, and lower costs. There are clinician and patient barriers to wider adoption of telemedicine. To support the effective and equitable use of telemedicine, we investigated the patient, illness, and surgeon factors associated with the specialist level of comfort in providing upper limb care via telemedicine. METHODS: Seventy-five upper-extremity musculoskeletal specialists completed an online survey-based experiment in which they viewed 12 patient scenarios with randomized patient age, gender, diagnosis, pain intensity, and patient preference for surgical treatment (yes or no) and rated their comfort with telemedicine from 0, no comfort, to 10, complete comfort. The participants were able to provide a rationale for their stance in open text boxes. We recorded the following specialist factors: gender, location of practice, years in practice, subspecialty, the supervision of trainees, and surgeon-rated importance of a physical examination. RESULTS: In a multivariable analysis, greater surgeon comfort using telemedicine was associated with nontrauma conditions, four specific diagnoses, and patients who did not have severe pain. Lower surgeon comfort with telemedicine was associated with the higher clinician-rated importance of a hands-on physical examination and supervising trainees. Text-based reasons provided for relative comfort with telemedicine included nonsurgical treatment and facility of diagnosis based on interviews alone. Text-based reasons for relative discomfort with telemedicine included a perceived need for a hands-on physical examination and a preference for an in-person conversation for specific discussions, including scheduling surgery. CONCLUSIONS: Greater specialist enthusiasm for telemedicine is associated with personal preferences regarding the upper-extremity condition, patients with less severe pain, and a willingness to forego a hands-on examination. CLINICAL RELEVANCE: Utilization of telemedicine for upper-extremity specialty care may be facilitated by diagnosis-specific care strategies and strategies for video examination, with a focus on tactics that are effective for people with more intense symptoms.

Do surgeons postpone offer of discretionary surgery when patients are experiencing difficult life events?

AIMS AND OBJECTIVES: There is substantial surgeon-to-surgeon variation in offering discretionary surgery. Part of this variation may relate to awareness of, and sensitivity to, mental and social health priorities. This survey-based experiment randomized features of patient scenarios to measure the relative association of a patient's difficult life event (DLE) in the last year on surgeon decision to (1) delay consideration of discretionary surgery and (2) suggest prioritizing mental and social health with appropriate referral. METHODS: We invited hand and upper extremity surgeon members of the Science of Variation Group to review six scenarios of patients considering discretionary surgery for de Quervain tendinopathy, lateral epicondylitis, trapeziometacarpal arthritis, wrist osteoarthritis, non-displaced scaphoid wrist fracture and displaced partial articular radial head fracture and 106 participated. The following aspects of the scenarios were randomized: gender, age, symptoms and limitations, socioeconomic status, feelings of worry and despair regarding symptoms, and experience of a DLE in the last 12 months. Multi-level logistic regression was used to seek patient and surgeon factors associated with offer of operative treatment now (vs. postponing) and formal referral for counselling. RESULTS: Accounting for potential confounders, surgeons were less likely to offer discretionary surgery to patients who experienced a DLE in the last year, women and non-trauma diagnosis. Surgeon referral for mental and social health support was associated with disproportionate symptom intensity and magnitude of incapability, notable symptoms of worry or despair and a DLE in the last year. CONCLUSION: The observation that a recent DLE is associated with surgeon delay in offer of discretionary surgery reflects that surgeons may prioritize mental and social health in this context.

Variation in radial head fracture treatment recommendations in terrible triad injuries is not influenced by viewing two-dimensional computed tomography.

BACKGROUND: We analyzed association between viewing two-dimensional computed tomography (2D CT) images in addition to radiographs with radial head treatment recommendations after accounting for patient and surgeon factors in a survey-based experiment. METHODS: One hundred and fifty-four surgeons reviewed 15 patient scenarios with terrible triad fracture dislocations of the elbow. Surgeons were randomized to view either radiographs only or radiographs and 2D CT images. The scenarios randomized patient age, hand dominance, and occupation. For each scenario, surgeons were asked if they would recommend fixation or arthroplasty of the radial head. Multi-level logistic regression analysis identified variables associated with radial head treatment recommendations. RESULTS: Reviewing 2D CT images in addition to radiographs had no statistical association with treatment recommendations. A higher likelihood of recommending prosthetic arthroplasty was associated with older patient age, patient occupation not requiring manual labor, surgeon practice location in the United States, practicing for five years or less, and the subspecialties "trauma" and "shoulder and elbow." CONCLUSIONS: The results of this study suggest that in terrible triad injuries, the imaging appearance of radial head fractures has no measurable influence on treatment recommendations. Personal surgeon factors and patient demographic characteristics may have a larger role in surgical decision making. Level of evidence: Level III, therapeutic case-control study.

Is there an association between sleep quality and magnitude of capability?

PURPOSE: Given the stigma surrounding mental health, a discussion of how symptoms interfere with sleep might be a useful first step to identify unhelpful thoughts or feelings of distress. We asked: 1) Does sleep quality have an association with magnitude of incapability and pain intensity independent of mental health? and 2) Are mental health factors associated with sleep quality? METHODS: We performed a cross-sectional study of one hundred and fifty-four patients seeking musculoskeletal care who completed measures of magnitude of capability, pain intensity, unhelpful thoughts regarding symptoms (catastrophic thinking, negative pain thoughts), distress (symptoms of anxiety and depression), and sleep disturbance. We tested factors associated with the magnitude of capability and pain intensity, accounting for sleep quality and mental health in multivariable models. RESULTS: Accounting for potential confounding in multivariable analysis, lower magnitude of capability was independently associated with greater sleep disturbance, more unhelpful thoughts about symptoms (negative pain thoughts), and older age. Greater pain intensity was independently associated with greater unhelpful thoughts about symptoms (catastrophic thinking) and not using of an electronic device before bed. Greater sleep disturbance was independently associated with use of sleep medication, greater symptoms of anxiety, and greater unhelpful thoughts regarding symptoms (PCS). CONCLUSION: Given the observation that sleep disturbance is associated with feelings of anxiety, clinicians can consider starting mental health discussions by focusing on sleep quality. App and web-based cognitive behavioral therapy-based treatments for sleep are readily available and have the potential to improve mental health.

Moderators and Mediators of the Relationship of Shared Decision-Making and Satisfaction.

Background:Evidence suggests that health literacy, perceived availability of information and guidance to adapt to challenges (informational support), and symptoms of depression all have the potential to mediate or moderate the relationship between patient-rated involvement in decisions and satisfaction with care. If so these could be useful targets for improving patient experience. Methods: We prospectively enrolled 130 new adult patients visiting an orthopedic surgeon over a 4-month period. All patients were asked to complete measures of satisfaction with care (21-item Medical Interview Satisfaction Scale), perceived involvement in decisions (9-item Shared Decision-Making Questionnaire), symptoms of depression (the Patient-Reported Outcomes Measurement Information Scale [PROMIS] Depression Computerized Adaptive Test [CAT]), perceived availability of information and guidance to adapt to challenges (PROMIS Informational Support CAT), and the Newest Vital Sign test of health literacy. Results: The strong correlation between satisfaction with care (ρ = 0.60, P < .001) and perceived involvement in decisions was neither mediated nor moderated by health literacy, perceived availability of information and guidance, and symptoms of depression. Conclusions: The observation that patient-rated shared decision-making is strongly related to satisfaction with an office visit, independent of health literacy, perceived support, and symptoms of depression, is consistent with evidence that various measures of patient experience tend to correlate and emphasizes the importance of the patient-clinician relationship. Level of Evidence: Level II, prospective study.

Accuracy and Reliability of MRI Reports in Diagnosing the Symptomatic Knee in Patients Who Had Bilateral MRI.

Background: Newly symptomatic chronic musculoskeletal illness is often misinterpreted as new pathology, particularly when symptoms are first noticed after an event. In this study, we were interested in the accuracy and reliability of identifying the symptomatic knee based on bilateral MRI reports. Methods: We selected a consecutive sample of 30 occupational injury claimants, presenting with unilateral knee symptoms who had bilateral MRI on the same date. A group of blinded musculoskeletal radiologists dictated diagnostic reports, and all members of the Science of Variation Group (SOVG) were asked to indicate the symptomatic side based on the blinded reports. We compared diagnostic accuracy in a multilevel mixed-effects logistic regression model, and calculated interobserver agreement using Fleiss' kappa. Results: Seventy-six surgeons completed the survey. The sensitivity of diagnosing the symptomatic side was 63%, the specificity was 58%, the positive predictive value was 70%, and the negative predictive value was 51%. There was slight agreement among observers (kappa= 0.17). Case descriptions did not improve diagnostic accuracy (Odds Ratio: 1.04; 95% CI: 0.87 to 1.3; P=0.65). Conclusion: Identifying the more symptomatic knee in adults based on MRI is unreliable and has limited accuracy, with or without information about demographics and mechanism of injury. When there is a dispute concerning the extent of the injury to a knee in a litigious, medico-legal setting such as Workers' Compensation, consideration should be given to obtaining a comparison MRI of the uninjured, asymptomatic extremity.

Does Addressing Mental Health During a Musculoskeletal Specialty Care Visit Affect Patient-rated Clinician Empathy?

BACKGROUND: Unhelpful thoughts and feelings of worry or despair about symptoms account for a notable amount of the variation in musculoskeletal symptom intensity. Specialists may be best positioned to diagnose these treatable aspects of musculoskeletal illness. Musculoskeletal specialists might be concerned that addressing mental health could offend the patient, and avoidance might delay mental health diagnosis and treatment. Evidence that conversations about mental health are not associated with diminished patient experience might increase specialist confidence in the timely diagnosis and initial motivation to treat unhelpful thoughts and feelings of worry or despair. QUESTIONS/PURPOSES: Using transcripts of videotaped and audiotaped specialty care visits in which at least one instance of patient language indicating an unhelpful thought about symptoms or feelings of worry or despair surfaced, we asked: (1) Is clinician discussion of mental health associated with lower patient-rated clinician empathy, accounting for other factors? (2) Are clinician discussions of mental health associated with patient demographics, patient mental health measures, or specific clinicians? METHODS: Using a database of transcripts of 212 patients that were audio or video recorded for prior studies, we identified 144 transcripts in which language reflecting either an unhelpful thought or feelings of distress (worry or despair) about symptoms was detected. These were labeled mental health opportunities. Patients were invited on days when the researcher making video or audio records was available, and people were invited based on the researcher's availability, the patient's cognitive ability, and whether the patient spoke English. Exclusions were not tracked in those original studies, but few patients declined. There were 80 women and 64 men, with a mean age of 45 ± 15 years. Participants completed measures of health anxiety, catastrophic thinking, symptoms of depression, and perceived clinician empathy. Factors associated with perceived clinician empathy and clinician discussion of mental health were sought in bivariate and multivariable analyses. RESULTS: Greater patient-rated clinician empathy was not associated with clinician initiation of a mental health discussion (regression coefficient 0.98 [95% confidence interval 0.89 to 1.1]; p = 0.65). A clinician-initiated mental health discussion was not associated with any factors. CONCLUSION: The observation that a clinician-initiated mental health discussion was not associated with diminished patient ratings of clinician empathy and was independent from other factors indicates that generally, discussion of mental health does not harm patient-clinician relationship. Musculoskeletal clinicians could be the first to notice disproportionate symptoms or misconceptions and distress about symptoms, and based on the evidence from this study, they can be confident about initiating a discussion about these mental health priorities to avoid delays in diagnosis and treatment. Future studies can address the impact of training clinicians to notice unhelpful thoughts and signs of distress and discuss them with compassion in a specialty care visit; other studies might evaluate the impact of timely diagnosis of opportunities for improvement in mental health on comfort, capability, and optimal stewardship of resources.

Surgeons Receiving Information About Patient Language Reflecting Unhelpful Thoughts or Distress About Their Symptoms Identify Such Language More Often Than Those Who Do Not Receive This Information.

BACKGROUND: Unhelpful thoughts and feelings of distress regarding symptoms account for a large proportion of variation in a patient's symptom intensity and magnitude of capability. Clinicians vary in their awareness of this association, their ability to identify unhelpful thoughts or feelings of distress regarding symptoms, and the skills to help address them. These nontechnical skills are important because they can improve treatment outcomes, increase patient agency, and foster self-efficacy without diminishing patient experience. QUESTIONS/PURPOSES: In this survey-based study, we asked: (1) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the total number of identified instances of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? (2) Are there any factors, including exposure of surgeons to information about language reflecting unhelpful thoughts about symptoms, associated with the interobserver reliability of a surgeon's identification of language rated as reflecting unhelpful thoughts or feelings of distress regarding symptoms in transcripts of patient encounters? METHODS: Surgeons from an international collaborative consisting of mostly academic surgeons (Science of Variation Group) were invited to participate in a survey-based experiment. Among approximately 200 surgeons who participate in at least one experiment per year, 127 surgeons reviewed portions of transcripts of actual new musculoskeletal specialty encounters with English-speaking patients (who reported pain and paresthesia as primary symptoms) and were asked to identify language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. The included transcripts were selected based on the rated presence of language reflecting unhelpful thinking as assessed by four independent researchers and confirmed by the senior author. We did not study accuracy because there is no reference standard for language reflecting unhelpful thoughts or feelings of distress regarding symptoms. Observers were randomized 1:1 to receive supportive information or not regarding definitions and examples of unhelpful thoughts or feelings of distress regarding symptoms (referred to herein as "priming") once at the beginning of the survey, and were not aware that this randomization was occurring. By priming, we mean the paragraph was intended to increase awareness of and attunement to these aspects of human illness behavior immediately before participation in the experiment. Most of the participants practiced in the United States (primed: 48% [29 of 60] versus not primed: 46% [31 of 67]) or Europe (33% [20 of 60] versus 36% [24 of 67]) and specialized in hand and wrist surgery (40% [24 of 60] versus 37% [25 of 67]) or fracture surgery (35% [21 of 60] versus 28% [19 of 67]). A multivariable negative binomial regression model was constructed to seek factors associated with the total number of identified instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms. To determine the interobserver agreement, Fleiss kappa was calculated with bootstrapped 95% confidence intervals (resamples = 1000) and standard errors. RESULTS: After controlling for potential confounding factors such as location of practice, years of experience, and subspecialty, we found surgeons who were primed with supportive information and surgeons who had 11 to 20 years of experience (compared with 0 to 5 years) identified slightly more instances of language believed to reflect unhelpful thoughts or feelings of distress regarding symptoms (regression coefficient 0.15 [95% CI 0.020 to 0.28]; p = 0.02 and regression coefficient 0.19 [95% CI 0.017 to 0.37]; p = 0.03). Fracture surgeons identified slightly fewer instances than hand and wrist surgeons did (regression coefficient -0.19 [95% CI -0.35 to -0.017]; p = 0.03). There was limited agreement among surgeons in their ratings of language as indicating unhelpful thoughts or feelings of distress regarding symptoms, and priming surgeons with supportive information had no influence on reliability (kappa primed: 0.25 versus not primed: 0.22; categorically fair agreement). CONCLUSION: The observation that surgeons with brief exposure to supportive information about language associated with unhelpful thoughts and feelings of distress regarding symptoms identified slightly more instances of such language demonstrates the potential of training and practice to increase attunement to these important aspects of musculoskeletal health. The finding that supportive information did not improve reliability underlines the complexity, relative subjectivity, and imprecision of these mental health concepts. LEVEL OF EVIDENCE: Level I, therapeutic study.

There is Little or No Association Between Independently Assessed Communication Strategies and Patient Ratings of Clinician Empathy.

BACKGROUND: Quality of care is increasingly assessed and incentivized using measures of patient-reported outcomes and experience. Little is known about the association between measurement of clinician communication strategies by trained observers and patient-rated clinician empathy (a patient-reported experience measure). An effective independent measure could help identify and promote clinician behaviors associated with good patient experience of care. QUESTIONS/PURPOSES: (1) What is the association between independently assessed clinician communication effectiveness and patient-rated clinician empathy? (2) Which factors are associated with independently assessed communication effectiveness? METHODS: One hundred twenty adult (age > 17 years) new or returning patients seeking musculoskeletal specialty care between September 2019 and January 2020 consented to video recording of their visit followed by completion of questionnaires rating their perceptions of providers' empathy levels in this prospective study. Patients who had operative treatment and those who had nonoperative treatment were included in our sample. We pooled new and returning patients because our prior studies of patient experience found no influence of visit type and because we were interested in the potential influences of familiarity with the clinician on empathy ratings. We did not record the number of patients or baseline data of patients who were approached, but most patients (> 80%) were willing to participate. For 7% (eight of 120 patients), there was a malfunction with the video equipment or files were misplaced, leaving 112 records available for analysis. Patients were seen by one provider among four attending physicians, four residents, or four physician assistants or nurse practitioners. The primary study question addressed the correlation between patient-rated clinician empathy using the Jefferson Scale of Patient Perceptions of Physician Empathy and clinician communication effectiveness, independently rated by two communication scholars using the Liverpool Communication Skills Assessment Scale. Based on a subset of 68 videos (61%), the interrater reliability was considered good for individual items on the Liverpool Communication Skills Assessment Scale (intraclass correlation coefficient [ICC] 0.78 [95% confidence interval (CI) 0.75 to 0.81]) and excellent for the sum of the items (that is, the total score) (ICC = 0.92 [95% CI 0.87 to 0.95]). To account for the potential association of personal factors with empathy ratings, patients completed measures of symptoms of depression (the Patient-Reported Outcome Measurement Information System depression computerized adaptive test), self-efficacy in response to pain (the two-item Pain Self-Efficacy Questionnaire), health anxiety (the five-item Short Health Anxiety Inventory), and basic demographics. RESULTS: Accounting for potentially confounding variables, including specific clinicians, marital status, and work status in the multivariable analysis, we found higher independent ratings of communication effectiveness had a slight association (odds ratio [OR] 1.1 [95% CI 1.0 to 1.3]; p = 0.02) with higher (dichotomized) ratings of patient-rated clinician empathy, while being single was associated with lower ratings (OR 0.40 [95% CI 0.16 to 0.99]; p = 0.05). Independent ratings of communication effectiveness were slightly higher for women (regression coefficient 1.1 [95% CI 0.05 to 2.2]); in addition, two of the four attending physicians were rated notably higher than the other 10 participants after controlling for confounding variables (differences up to 5.8 points on average [95% CI 2.6 to 8.9] on a 36-point scale). CONCLUSION: The observation that ratings of communication effectiveness by trained communication scholars have little or no association with patient-rated clinician empathy suggests that either effective communication is insufficient for good patient experience or that the existing measures are inadequate or inappropriate. This line of investigation might be enhanced by efforts to identify clinician behaviors associated with better patient experience, develop reliable and effective measures of clinician behaviors and patient experience, and use those measures to develop training approaches that improve patient experience. LEVEL OF EVIDENCE: Level I, prognostic study .

Imposter Syndrome Among Surgeons Is Associated With Intolerance of Uncertainty and Lower Confidence in Problem Solving.

BACKGROUND: Feelings of imposter syndrome (inadequacy or incompetence) are common among physicians and are associated with diminished joy in practice. Identification of modifiable factors associated with feelings of imposter syndrome might inform strategies to ameliorate them. To this point, though, no such factors have been identified. QUESTION/PURPOSE: Are intolerance of uncertainty and confidence in problem-solving skills independently associated with feelings of imposter syndrome after accounting for other factors? METHODS: This survey-based experiment measured the relationship between feelings of imposter syndrome, intolerance of uncertainty, and confidence in problem-solving skills among musculoskeletal specialist surgeons. Approximately 200 surgeons who actively participate in the Science of Variation Group, a collaboration of mainly orthopaedic surgeons specializing in upper extremity illnesses primarily across Europe and North America, were invited to this survey-based experiment. One hundred two surgeons completed questionnaires measuring feelings of imposter syndrome (an adaptation of the Clance Imposter Phenomenon Scale), tolerance of uncertainty (the Intolerance of Uncertainty Scale-12), and confidence in problem-solving skills (the Personal Optimism and Self-Efficacy Optimism questionnaire), as well as basic demographics. The participants were characteristic of other Science of Variation Group experiments: the mean age was 52 ± 5 years, with 89% (91 of 102) being men, most self-reported White race (81% [83 of 102]), largely subspecializing in hand and/or wrist surgery (73% [74 of 102]), and with just over half of the group (54% [55 of 102]) having greater than 11 years of experience. We sought to identify factors associated with greater feelings of imposter syndrome in a multivariable statistical model. RESULTS: Accounting for potential confounding factors such as years of experience or supervision of trainees in the multivariable linear regression analysis, greater feelings of imposter syndrome were modestly associated with higher intolerance of uncertainty (regression coefficient [ß] 0.34 [95% confidence interval (CI) 0.16 to 0.51]; p < 0.01) and with lower confidence in problem-solving skills (ß -0.70 [95% CI -1.0 to -0.35]; p < 0.01). CONCLUSION: The finding that feelings of imposter syndrome may be modestly to notably associated with modifiable factors, such as difficulty managing uncertainty and lack of confidence in problem-solving, spark coaching opportunities to support and sustain a surgeon's mindset, which may lead to increased comfort and joy at work. CLINICAL RELEVANCE: Beginning with premedical coursework and throughout medical training and continuing medical education, future studies can address the impact of learning and practicing tactics that increase comfort with uncertainty and greater confidence in problem solving on limiting feelings of imposter syndrome.

Surgeon preferences are associated with utilization of telehealth in fracture care.

BACKGROUND: The SARS-CoV-2 (COVID-19) pandemic has the potential to evoke lasting changes in the delivery of care, and the utilization of telehealth. We sought associations between surgeon personal factors and greater use of telehealth to treat fractures relative to in-person care. METHODS: Seventy-five fracture surgeons participated in a survey-based experiment. All surgeons were asked about their preferences regarding remote compared to in-person communication. Participants rated the following items on slider scales: their degree of introversion, the importance of a hands-on/physical exam and surgeon preferences regarding telehealth. We identified factors associated with the use of, and comfort with, telehealth. RESULTS: The use of telehealth during the pandemic was associated with comfort evaluating wounds via telehealth. A greater proportion of remote visits was associated with comfort evaluating wounds and confidence teaching exercises via telehealth. There was consensus that telehealth did not alter utilization rates of radiographs or offer of discretionary surgery. The use of absorbable sutures to limit in-person visits was associated with a preference for working from home and greater comfort with evaluating wounds remotely. The use of 2- and 6-week post-operative telehealth visits and plans to use telehealth after the pandemic (52%) were associated with greater comfort in evaluating wounds through telehealth and greater confidence with video instruction of exercises. CONCLUSIONS: The finding that personal factors are associated with utilization of telehealth helps target strategies for increased use of telehealth and other technologies as the pandemic wanes. Given that telehealth adds convenience for people with ambulatory difficulties or in remote areas, such efforts are warranted. LEVEL OF EVIDENCE: Not applicable.

Linguistic tones in MRI reports correlate with severity of pathology for rotator cuff tendinopathy.

BACKGROUND: Written communication can convey one's emotions, personality, and sentiments. Radiology reports employ medical jargon and serve to document a patients' condition. Patients might misinterpret this medical jargon in a way that increases their anxiety and makes them feel unwell. We were interested whether linguistic tones in MRI reports vary between radiologists and correlate with the severity of pathology. QUESTIONS/PURPOSES: (1) Is there variation in linguistic tones among different radiologists reporting MRI results for rotator cuff tendinopathy? (2) Is the retraction of the supraspinatus tendon in millimeters associated with linguistic tones? METHODS: Two hundred twenty consecutive MRI reports of patients with full-thickness rotator cuff defects were collected. Supraspinatus retraction was measured on the MRI using viewer tools. Using Kruskal-Wallis H tests, we measured variation between 11 radiologists for the following tones: positive emotion, negative emotion, analytical thinking, cause, insight, tentativeness, certainty, and informal speech. We also measured the correlation of tones and the degree of tendon retraction. Multilevel mixed-effects linear regression models were constructed, seeking factors associated with the tone, accounting for retraction, the presence of prior imaging, and for the effects of each radiologist (nesting). RESULTS: There were statistically significant differences for all of the tones by radiologist. In bivariate analysis, greater retraction of the supraspinatus muscle in millimeters was associated with more negative emotion and certainty, and with less tentativeness. In multilevel mixed-effects linear regression, more negative tones were associated with greater retraction and absence of prior imaging. Greater tentativeness was associated with the absence of prior imaging, but not with retraction. CONCLUSIONS: Radiology reports have emotional content that is relatively negative, varies by radiologist and is affected by pathology. Strategies for more hopeful, positive, optimistic descriptions of pathology have the potential to help patients feel better without introducing inaccuracies even if unlikely. LEVEL OF EVIDENCE: Level III, Diagnostic.

Knee Injuries and Associated Risk Factors in National Basketball Association Athletes.

Purpose: To determine structural knee injury rates and to identify risk factors and the number of games missed associated with these injuries in National Basketball Association (NBA) players from the 2015 to 2020 seasons. Methods: Publicly available player records of active NBA players between the 2015 and 2020 seasons (excluding the shortened 2019 season) were reviewed to identify players with a knee injury associated with missing one or more games. Player demographics, anthropometric measurements, statistics, injury characteristics, and history of other lower-extremity injuries were recorded. We sought factors associated with having a structural knee injury in bivariate analysis and multivariable logistic regression. Negative binomial regression was conducted to evaluate factors associated with the total number of games missed. Results: Two hundred twelve players (of 1,011, 21%) sustained a structural knee injury. Accounting for potential confounders, having a structural knee injury was associated with more minutes per game played (odds ratio [OR] 1.1; 95% confidence interval [CI] 1.0-1.2; P = .002), a greater usage rate (OR 1.1; 95% CI 1.0-1.2; P = .004), and a lower player efficiency rating (OR 0.94; 95% CI 0.89-1.0; P = .041). A greater number of missed games was associated with more minutes per game (regression coefficient [RC] 0.065; 0.028-0.10; P = .001), fewer points per game (RC -0.078; -0.14 to -0.017; P = .013), and greater usage rate (RC 0.032; 0.0040-0.060; P = .025). Conclusions: Structural knee injuries occurred in 21% of players in this study with an overall rate of 5.42 injuries per 1,000 game exposures. Significant risk factors associated with injury were minutes per game, usage rate, and true shooting percentage. Player efficiency was significantly associated with a decreased risk of injury. Increased minutes per game and usage rate were significantly associated with a longer duration of game loss. Level of Evidence: Level IV, case series.

The Interobserver Reliability of Grading of Distal Radius Volar Plate Prominence.

PURPOSE: The 3-category rating of volar plate prominence in relation to the most volar edge of the distal radius (the watershed line) on lateral radiographs was reliable among a small group of surgeons and associated with the probability of flexor tendon irritation and potential rupture. Classifications are often less reliable when tested among a large group of practicing surgeons in different environments. METHODS: In this survey-based experiment, an international group of 115 fracture and upper extremity surgeons viewed 1 of 4 sets of 24 lateral radiographs (96 unique lateral radiographs) of patients with distal radius fractures who underwent volar plating in the practice of a single surgeon using 2 types of plates. Surgeons were asked to rate the following metrics: (1) the grade of plate prominence according to Soong, (2) whether the plate was more prominent than the watershed line, (3) whether the plate was separate from the bone distally, and (4) whether there is more than 5° of dorsal angulation of the distal radius articular surface. RESULTS: The interobserver agreement of the classification was "fair" (κ = 0.32; 95% confidence interval [CI] = 0.27-0.36), and grading was more reliable among surgeons who do not supervise trainees. Volar prominence was less reliable (κ = 0.034; 95% CI = 0.013-0.055) than plate separation from bone (κ = 0.50; 95% CI = 0.42-0.59) and more than 5° of dorsal angulation (κ = 0.42; 95% CI = 0.35-0.48). CONCLUSIONS: Among a large number of international practicing surgeons, the classification of volar plate prominence in 3 categories was fair. CLINICAL RELEVANCE: The diagnosis of plate prominence might develop toward criteria with moderate reliability, such as separation of the plate from the bone and residual angulation of the distal radius.