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There is no consensus reference standard for diagnosing prosthetic shoulder joint infection (PJI). There may be inadequate distinction between colonization and infection. It is not clear that culture of a common shoulder commensal organism can account for unexpected pain or stiffness after shoulder arthroplasty. In this survey-based experiment, we asked: 1) What patient and surgeon variables are associated with diagnosis of shoulder PJI? And 2) What is the surgeon interobserver agreement for diagnosis of shoulder PJI? One hundred seven members of the Science of Variation Group reviewed ten hypothetical patient scenarios with five randomized variables: examination findings, serum markers, synovial fluid markers, histological assessment, and organism cultured from deep tissue specimens. Participants diagnosed the presence or absence of shoulder PJI. Mixed multilevel logistic regression sought variables associated with PJI diagnosis. Interobserver agreement was measured with Fleiss kappa. Surgeon diagnosis of shoulder PJI was independently associated with deep tissue culture growth of C. acnes (OR=235 [95% CI 19 to 2933]; P < 0.01), S. epidermidis (OR=147 [95% CI 8.4 to 2564]; P < 0.01), and S. aureus (OR=110 [95% CI 6.9 to 1755]; P < 0.01) much more so than presence of a sinus tract on examination (OR=43 [95% CI 3.7 to 505]; P < 0.01), inflammatory histology (OR=15 [95% CI 4.0 to 58]; P < 0.01), inflammatory synovial fluid markers (OR=13 [95% CI 3.9 to 45]; P < 0.01), and serum inflammatory markers (OR=5.8  [95% CI 2.0 to 17]; P < 0.01). The reliability of surgeon diagnosis for shoulder PJI was poor (Fleiss kappa = 0.013 [95% CI -0.0039 to 0.031]). The observation that surgeons may not adequately distinguish colonization and infection – considering any positive culture as an infection – combined with the low reliability of diagnosis observed, suggests possible overdiagnosis and overtreatment of shoulder PJI.          Level of evidence: IV

 Whitin 6 weeks prior to an in-person musculoskeletal specialty care visit, ​​1) Is the number of self-reported in-person contacts associated with psychological and social factors? and 2) Is the number of remote and total contacts associated with psychological and social factors? 

We enrolled 148 adult patients in a cross-sectional study of people visiting a musculoskeletal specialist for a new or return visit. Patients completed a survey of social health, indicated the number of self-reported remote and in-person care episodes, and completed measures of unhelpful thoughts regarding symptoms, general distress, and demographics.

Accounting for potential confounding in multivariable analysis, more self-reported in-person care episodes were independently associated with more unhelpful thoughts about symptoms (higher score on NPTQ; RC 0.05; 95% CI: 0.02 to 0.09; P < 0.05) and household income between $15,000 and $29,999 or $30,000 and $49,999. No factors were associated with total remote and in-person care contacts.

The observation that patients with greater unhelpful thinking seek out more in-person care episodes for musculoskeletal symptoms supports the concept that comprehensive care strategies attentive to common unhelpful thoughts regarding symptoms could limit unhelpful resource utilization.

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

Studies that compare routine immediate operative treatment of fractures with selective later reconstructive surgery for malunion or nonunion may be misleading because it discounts the people who did well with nonoperative treatment. We identified 20 studies comparing routine operative fracture treatment and later reconstruction in the hip, clavicle, proximal humerus, elbow, and distal radius. Fifteen of 20 studies favored immediate operative treatment on the basis of lower reoperation rates, fewer complications, better patient reported outcome scores, and higher satisfaction. Five studies were neutral, and none favored delayed reconstruction for malunion or nonunion. These findings emphasize the potential benefits of routine early surgery and raise questions about the validity of studies comparing different timings of fracture treatment.

Newly symptomatic chronic musculoskeletal illness is often misinterpreted as new pathology, particularly when symptoms are first noticed after a noxious event. In this study, we were interested in the accuracy and reliability of identifying the symptomatic knee based on bilateral MRI reports. 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.  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). 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. With 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.Level of evidence: II

Clinicians often use metaphors to explain complex ideas. Metaphors also have the potential to reinforce unhelpful thinking regarding symptoms. We surveyed musculoskeletal specialists regarding use of metaphors in their daily practice and then assessed the contexts in which they are used, the themes of metaphors, and potential for reinforcement of common misconceptions (unhelpful thinking). Two primary research questions were posed: 1- What are the common characteristics of the medical metaphors used in patient-clinician communication by musculoskeletal specialists? And, 2- What percentage of medical metaphors used in patient-clinician communication have potential to induce unhelpful thinking and what are the characteristics of those metaphors?

Eighty-one orthopedic and trauma specialists provided examples of metaphors they use in daily practice. Qualitative analysis of responses was performed through open coding of the data with the use of a constant-comparative technique involving several rounds of reading and rereading the data.

The 157 metaphors were categorized into 15 different themes. The most common themes were mechanical, objects, and sports and leisure. We also classified metaphors as addressing the natural history of the disease, treatment, mechanism, anatomy, or other. Thirty-five metaphors (22%) were identified as having the potential to reinforce unhelpful thinking. The most common purpose of these metaphors was for explaining the mechanism or natural history of the disease.

Metaphors can either reinforce or reorient potentially unhealthy misconceptions. They can also reinforce despair and worry, or they can improve hope and sense of control. Orthopedic surgeons can be strategic and thoughtful in their use of metaphors, planning and practicing specific metaphors for optimal mental, social, and physical health.

Orthopedic surgeons are sometimes hesitant to assess and address psychosocial factors.Surgeon-specific modifiable factors may contribute to surgeon attitudes and beliefs regarding the mental andsocial aspects of illness. A better understanding of these factors could help inform interventions to supportsurgeons and improve patient outcomes. We aimed to investigate whether orthopedic surgeons’ self-reportedcompassion, perceived stress, and experiential avoidance are independently associated with various surgeonattitudes and beliefs regarding psychosocial aspects of health. This is a cross-sectional study of 165 members of the Science of Variation Group (SOVG).Surgeons completed measures of compassion, stress, experiential avoidance, and demographics. Theyanswered questions addressing attitudes and beliefs regarding psychosocial aspects of care, which werecondensed to the following 6 dimensions through factor analysis: (1) confidence, (2) perceived resourceavailability, (3) blame towards patients, (4) fear of offending patients, (5) professional role resistance, and(6) fear of negative patient reactions. We performed 6 multivariable hierarchical regression analyses todetermine whether self-reported compassion, perceived stress, and experiential avoidance were associatedwith aspects of surgeons’ attitudes and beliefs regarding psychosocial care. After accounting for the influence of relevant covariates, experiential avoidance explained 2.9-6.6% of the variance (P-values .002 to .031) in all aspects of surgeon attitudes and beliefs regardingpsychosocial care, except for perceived resource availability. Perceived stress and compassion towardothers were not associated with any outcome variable. Targeting orthopedic surgeons’ tendency to avoid discomfort (i.e., experiential avoidance) viasupportive/educational programs may decrease barriers and increase their abilities to address psychosocialfactors, resulting in improved patient outcomes.Level of evidence: III

Most surgeons used, or are currently using telehealth during the SARS-CoV-2 (COVID-19) pandemic.We studied surgeon personal factors associated with relative use of telehealth during the worldwide height of thepandemic.Questions/ (1) Are there any personal factors/characteristics associated with use and utilization of telehealth?(2) What are surgeon’s perspectives/ opinions with regard to use of telehealth for five common upper extremityconditions in terms of future prospects and viability? Hand and upper extremity surgeons in the Science of Variation Group (SOVG) were invited to participate ina web-based survey. The first part of the survey focused on surgeon characteristics and work preferences. The secondpart focused on care strategies during the pandemic and utilization of telehealth. The final part of the survey addressedthe care of five common upper extremity conditions during the pandemic. Ninety percent of surgeons used telehealth during the first few months of the pandemic, but only 20% ofvisits were virtual. A greater percentage of telehealth visits compared to office visits was independently associated witha policy of only seeing people with emergencies in person (RC: 0.64; CI 95%: 0.21 to 1.1; P<0.01). Surgeons foundit difficult to reproduce most parts of the physical examination on video, but relatively easy to make a diagnosis, withboth ratings associated with less belief that the physical exam is essential. Comfort in offering surgery by video visitwas associated with having young children, preference for remote meetings, and less belief that the physical exam isessential. Utilization of, and comfort with, telehealth is related to personal factors and preferences, acceptance ofa more limited physical examination in particular. Utilization of early adopters and training to increase comfort with theprobabilistic aspects of medicine could facilitate incorporation of telehealth into standard practice.Level of evidence: N/a

Given the influence of psychosocial factors on musculoskeletal symptoms and limitations, this study assessed if the ability of resilience (an individual's ability to adapt under stress) mediates the association of psychological adaptability with magnitude of physical limitations and pain intensity during recovery from an upper extremity injury. A total of 107 patients were enrolled in this prospective, longitudinal, observational cohort study. Patients completed the Patient-Reported Outcomes Measurement Information System Physical Function (PROMIS PF), an 11-point ordinal measure of pain intensity, the Brief Resilience Scale (BRS), and the Psychological Adaptation Scale (PAS). We used structural equation modeling to assess the mediation effect by resiliency and psychological adaptability on patient-reported disability and pain at initial assessment and after three months. PAS and BRS were not independently associated with PROMIS PF or pain intensity at enrollment or after three months, so it was not possible to assess if resiliency mediated the association of psychological adaptability with physical function or pain. There were no factors independently associated with resilience. General measures of psychological adaptability and resiliency do not correlate with symptoms and limitations as well as specific measures of adaptiveness in response to nociception. Level of evidence: II

Remote video visits (aka telemedicine, virtual care) have the potential to increase access to orthopaedicspecialty evaluation while decreasing the overall cost of care. Clinical implementation of remote video visits may benefitfrom an understanding of potential barriers to participation. We enrolled one hundred and thirty participants from a university-based musculoskeletal clinic with a largeuninsured population. We asked participants to complete a survey, including demographics and scaled perceptionquestions about remote video visits. Data from these surveys were analyzed with multivariable logistic regression todetermine factors associated with willingness to participate in video visits, as well as the situations in which patientswould consider a video visit. Willingness to participate in video visits was associated with the perception of video visits being moreconvenient (OR 3.0) and a decreased perceived importance of physical exam (OR 0.36) but not age, technologycomfort, or travel distance to the clinic. Additionally, those with prior video visit experience were more comfortablewith technology, perceived video visits to be more convenient, and were more willing to have another video visit.Fifteen percent were willing to have a video visit for their first visit, while 78% would participate for a routine nonsurgicalfollow-up. Musculoskeletal telemedicine programs can become established by focusing on people that prioritizeconvenience, place less importance on a hands-on exam, and are established patients.Level of evidence: II

An understanding of patient and clinician opinions about remote video musculoskeletal consultationsmight help determine how to increase appeal and utilization. The purpose of this study was to evaluate perceptions ofremote video musculoskeletal consultations. Our research questions was what are patient and clinician facilitators andbarriers for the use of remote video consultations? Prior to the COVID-19 pandemic 27 English speaking adult patients seeking ambulatory care for amusculoskeletal problem, and 10 English-speaking musculoskeletal clinicians were interviewed using a guide.Interviews were audio-recorded, transcribed, and coded using applied thematic analysis. Patient and clinician incentives for remote video consultations included increased convenience, lower costs,less waiting time, and a better experience. Patient and clinician barriers to remote video consultations included concernsabout familiarity with technology, lack of personal interaction and physical examination, inability to perform procedures,difficulties with reimbursement (clinicians), as well as technical, logistical, and privacy issues. This qualitative study performed prior to the pandemic found that adoption of remote video consultation formusculoskeletal problems may improve with seamless, efficient, and effective care, at an affordable price, particularly ifthe human connection is similar to what occurs in person.Level of evidence: Not applicable

Shortened versions of validated PRO measures of coping strategies e.g. PSEQ-2, may facilitatescreening and monitoring of psychological conditions such as depression and anxiety. The primary researchquestion in this study assesses the sensitivity and specificity of a PSEQ-2 score of less than 10 for importantsymptoms of depression (a PHQ-2 score greater than 2), anxiety (GAD-2 score greater than 2), any impactfulprior episode of psychological trauma, and QuickDASH greater than 49. Secondarily we assess the associationsbetween self-efficacy and other demographic and psychological factors on the magnitude of limitations and painintensity. We performed a retrospective PRO evaluation in 926 adult patients attending upper extremity clinicbetween 1st January 2018 and 31st January 2019. Demographic factors were assessed using electronic medicalrecords and PRO data using an online platform. Patients included 556 (60%) women, 370 (40%) men (mean 51years + 14 (range, 19-88), mostly (n=584, 63%) with safety net insurance. A PSEQ-2 scoring threshold of less than 10 was 81% sensitive for a PHQ-2 score of 3 or greater, 84%sensitive for a GAD-2 score of 3 or greater, 84% sensitive for one or more important psychological traumas, and 82%sensitive for a QuickDASH of 50 or greater. PSEQ-2 less than 10 was independently associated with greater upperextremity limitations (β=11 [6.3 to 17, 95% Confidence interval [C.I], p <0.001) and pain intensity (β=0.92 (0.31 to 1.5,95% C.I) P=0.003) amongst other psychological and demographic factors. A PSEQ-2 score less than 10 might, along with verbal and non-verbal signs of distress, be a usefulway to introduce the use of more sensitive screening questionnaires about anxiety or depression, or open up the option of speaking directly to mental or social health professionals. Future studies are required to test thishypothesis. Level of evidence: III

Treatment recommendations for trapeziometacarpal (TMC) arthrosis are highly variable from surgeonto surgeon. This study addressed the influence of viewing radiographs on a decision to offer surgery for TMC arthrosis. In an online survey, 92 hand surgeons viewed clinical scenarios and were asked if they would offer surgeryto 30 patients with TMC arthrosis. Forty-two observers were randomly assigned to review clinical information aloneand 50 to review clinical information as well as radiographs. The degree of limitation of daily activities, time sincediagnosis, prior treatment, pain with grind, crepitation with grind, and metacarpal adduction with metacarpophalangealhyperextension were randomized for each patient scenario to determine the influence of these factors on offers ofsurgery. A cross-classified binary logistic multilevel regression analysis identified factors associated with surgeon offerof surgery. Surgeons were more likely to offer surgery when they viewed radiographs (42% vs. 32%, P = 0.01). Otherfactors associated variation in offer of surgery included greater limitation of daily activities, symptoms for a year,prior splint or injection, deformity of the metacarpophalangeal joint. Factors not associated included limb dominance,prominence of the TMC joint, crepitation with the grind test, and pinch and grip strength. Surgeons that view radiographs are more likely to offer surgery to people with TMC arthrosis.Surgeons are also more likely to offer surgery when people do not adapt with time and nonoperative treatment.Given the notable influence of surgeon bias, and the potential for surgeon and patient impatience with theadaptation process, methods for increasing patient participation in the decision-making process merit additionalattention and study.Level of evidence: Not applicable.

There is a growing interest in engaging patients in research priorities and project design. This studycompared topics patients and surgeons would like to address in upper extremity musculoskeletal research. We invited patients on social media-based support groups for specific musculoskeletal illnesses andmembers of the Science Of Variation Group to indicate the three most important research topics by disease. Wealso measured agreement that patients should participate in research on a five-point Likert scale. We categorizedresearch priorities into the following categories: treatment, cause and natural history, recovery, diagnostic process,and economic impact. Bivariate analysis was used to detect differences between surgeons and patient responses.Multivariable regression models sought factors associated with agreement whether patients should participate inresearch. Sixty-two surgeons and 350 patients completed the survey, who had one of the following musculoskeletalillnesses: Dupuytren contracture, adhesive capsulitis, Kienböck disease, complex regional pain syndrome, rotator cufftendinopathy, carpal- or cubital tunnel syndrome, and rheumatoid arthritis. Both patients and surgeons were most interested in research into treatment options. There were fewdifferences in the number of responses per category between surgeons and patients. Patients and surgeons with feweryears of practice agree most with involving patients in research. Patients and surgeons prioritize research about treatment. Surgeons were more interested in naturalhistory of disease and surgical techniques, while patients were more interested in alleviation of pain.Level of evidence: I

Remote video consultations on musculoskeletal illness are relatively convenient and accessible,and use fewer resources. However, there are concerns about technological and privacy issues, the possibility ofmissing something important, and equal access to all patients. We measured patient characteristics associated withwillingness to conduct a remote video musculoskeletal upper extremity consultation.

One hundred and five patients seeking specialty musculoskeletal care completed questionnairesaddressing (1) demographics, (2) access to a device, internet, and space to conduct a remote video consultation,(3) health literacy, (4) pain intensity, (5) magnitude of limitations of the upper extremity, (6) self-efficacy, and (7)rated willingness to conduct a remote video musculoskeletal consultation (11-point ordinal scale). A multivariablelinear regression analysis sought factors independently associated with patient willingness to conduct remote videomusculoskeletal upper extremity consultations.

Patient education level (4 years of college) and accessibility to a space suitable for remote video consultationswere independently associated with interest in remote video consultations. Sociodemographic factors, health literacy,accessibility to a device or internet, and amount of perceived pain and disability were not.

We speculate that education level and suitable space might be surrogates for trust and privacy concerns.Future research might measure the ability of interventions to gain trust and ensure privacy to increase willingness toengage in remote video musculoskeletal consultations.Level of evidence: II

We compared the amount of variation in Patient-Reported Outcomes Measurement Information SystemPhysical Function (PROMIS PF) Computer Adaptive Test (CAT) accounted for by The Tampa Scale for Kinesiophobia(TSK) and its short form (TSK-4) independent of other factors. Questionnaire coverage, reliability, and validitywere compared for both TSK and TSK-4 using mean scaled scores, internal consistency, floor and ceiling effects,interquestionnaire correlations, and collinearity with other measures as the Pain Catastrophizing Scale short form(PCS-4), PROMIS Depression CAT, and PROMIS Pain Interference (PROMIS PI) CAT. One hundred forty eight consecutive new or return patients were enrolled. Patients were seen in an outpatientsetting in several orthopaedic clinics in a large urban area. All patients completed the TSK, PROMIS PF CAT, PROMISPI CAT, PROMIS Depression CAT, and PCS-4. Greater fear of movement (higher TSK) was associated with worse physical function (lower PROMIS PF CAT)and the full TSK explained more variation in physical function than the short form (TSK-4). In contrast to prior studiesPCS-4 was not independent of TSK. Flooring and ceiling effects were seen with TSK-4. Worse physical function wasassociated with older age, traumatic condition, and more symptoms of depression. The short form of the Tampa Scale for Kinesiophobia can be used as a brief screening measure in patientcare and research in order to identify an independent influence of kinesiophobia on lower extremity specific limitations.Additional study is needed to determine whether there is utility in screening for both TSK and PCS or if one or theother provides sufficient information about cognitive biases regarding pain to guide treatment with cognitive behavioraltherapy and related techniques.Level of evidence: II

No consensus regarding optimal treatment or etiology of Preiser disease exists. We described the epidemiology,classification and treatment characteristics of 18 patients with Preiser disease. Patients with changes related to previoustrauma, and without radiographs were excluded. Based on the radiographs at diagnosis, we classified 13 scaphoids asHerbert Lanzetta stage II, four as stage III, and one as stage IV. In 12 patients nonspecific treatment was offered andonly two patients received surgical treatment. We found that chosen treatment is not associated with the severity ofHerbert Lanzetta stage and the outcome is not influenced by chosen treatment.Level of evidence: I

Enthesopathy of the extensor carpi radialis brevis origin [eECRB] is a common idiopathic, noninflammatorydisease of middle age that is characterized by excess glycosaminoglycan production and frequentlyassociated with radiographic calcification of its origin. The purpose of our study was to assess the relationship ofcalcification of the ECRB and advancing age. We included 28,563 patients who received an elbow radiograph and assessed the relationship of calcificationsof the ECRB identified on radiograph reports with patient age, sex, race, affected side, and ordering indication usingmultivariable logistic regression. Calcifications of the ECRB were independently associated with age (OR:1.04; P<0.001); radiographsordered for atraumatic pain (OR2.6; P<0.001) or lateral epicondylitis (OR5.5; P<0.001); and Hispanic ethnicity (OR1.5;P<0.001) and less likely to be found at the left side (OR0.68; P<0.001). Similarly, incidental calcifications of the ECRB,those on radiographs not ordered for atraumatic pain or lateral epicondylitis, were independently associated withage (OR1.03; P<0.001) and Hispanic ethnicity (OR1.5; P<0.024) and less likely to be found on the left side (OR0.71;P<0.001). We observed that about nine percent of people have ECRB calcification by the time they are in their sixthdecade of life and calcifications persist in the absence of symptoms which supports the idea that eECRB is a common,self-limited diagnosis of middle age.Level of evidence: II

The general population’s understanding of musculoskeletal health is likely influenced by media reports of the ailments of prominent athletes. We assessed factors independently associated with debatable or potentially misleading medical statements in mainstream sports media coverage of the ailments of professional and college athletes. We identified and assessed 200 Internet media reports of musculoskeletal ailments of prominent athletes between February 19th and March 26th, 2018. We recorded medical statements about mechanism, diagnosis, treatment, and prognosis. We then classified those statements as accurate, debatable, or possibly misleading. We created a multivariable logistic regression model to identify factors independently associated with debatable or possibly misleading statements. Forty-five percent of statements were debatable or possibly misleading. Statements about diagnosis (Odds Ratio [OR]=0.17; P< 0.001), treatment (OR=0.33; P=0.007), or prognosis (OR=0.27; P=0.003) and statements about shoulder and elbow ailments were more likely to be inaccurate compared to statements about mechanism and statements about knee ailments (OR=3.3; P=0.04) respectively. Coverage of sports ailments in the mainstream media are a common source of misinformation. Ailments of prominent athletes may represent a useful opportunity to teach people about musculoskeletal health.Level of evidence: Not applicable.

We used a database of patients treated at three hospitals to study the primary null hypothesis that thereare no factors associated with unplanned reoperations or adverse events after surgical repair for diaphyseal claviclefracture. Additionally we addressed the following secondary study questions: 1. What is the prevalence of unplannedreoperations or adverse events after surgical repair for diaphyseal clavicle fracture? 2. Is early implant loosening orbreakage after surgical repair for diaphyseal clavicle fracture related to fixation type? 3. Is the type of fixation associatedwith the prevalence of brachial plexus palsy after surgical repair of a diaphyseal clavicle fracture? We retrospectively analyzed 249 adult patients who had surgery for a diaphyseal clavicle fracture todetermine factors associated with unplanned reoperations or adverse events. Thirty-two patients (13%) had at least oneunplanned reoperation or adverse event. Four of 249 patients (1.6%) developed early implant loosening or breakage.Patients that had local implant irritation, planned implant removal, or sensory symptoms thought to be due to nerveirritation were not included in the reported unplanned reoperations or adverse event rate. Only female sex was associated with unplanned reoperations or adverse events after surgery for diaphysealclavicle fracture. No other patient, technical, or injury related factors tested in this study were associated with unplannedreoperations or adverse events. Patients that have surgery for diaphyseal clavicle fracture have an approximately 13% risk of an unplannedsecond surgery or an adverse event. Women can be counseled that they are three times as likely as men to have anunplanned reoperations or adverse event.Level of evidence: III

The Single Assessment Numeric Evaluation (SANE) is a simple, one-question patient-reported outcomemeasure (PROM). We systematically reviewed correlations between SANE and more extensive PROMs. We identified studies with correlation coefficients between SANE and other shoulder, knee, and anklespecificPROMs. We calculated mean, median and range across studies and time points of data collection. Eleven studies provided 14 correlations, six shoulder-specific PROMs in four studies, six knee-specific PROMsin six studies and two ankle specific PROMs in one study. The mean correlation comparing SANE and knee-specificPROMs was 0.60 (SD 0.24), median 0.66, and range 0.12 to 0.88. Among studies comparing SANE and shoulderspecificPROMs mean correlation was 0.59 (SD 0.20), median 0.62 and range 0.20 to 0.89. The mean correlationbetween SANE and ankle-specific PROMs was 0.69 (SD 0.17), median 0.69 and range 0.75 to 0.81. There seems to be moderate correlation amongst PROMs, even those that are a single question. Futureresearch might address whether patient reported outcome measure a common underlying construct even when theyconsist of a single question.Level of evidence: V

When the best treatment option is uncertain, a patient’s preference based on personal values should bethe source of most variation in diagnostic and therapeutic interventions. Unexplained surgeon-to-surgeon variation intreatment for hand and upper extremity conditions suggests that surgeon preferences have more influence than patientpreferences. A total of 184 surgeons reviewed 18 fictional scenarios of upper extremity conditions for which operativetreatment is discretionary and preference sensitive, and recommended either operative or non-operative treatment.To test the influence of six specific patient preferences the preference was randomly assigned to each scenario in anaffirmative or negative manner. Surgeon characteristics were collected for each participant. Of the six preferences studied, four influenced surgeon recommendations. Surgeons were more likelyto recommend non-operative treatment when patients; preferred the least expensive treatment (adjusted OR,0.82; 95% CI, 0.71 – 0.94; P=0.005), preferred non-operative treatment (adjusted OR, 0.82; 95% CI, 0.72 – 0.95;P=0.006), were not concerned about aesthetics (adjusted OR, 1.15; 95% CI, 1.0 – 1.3; P=0.046), and when patientsonly preferred operative treatment if there is consensus among surgeons that operative treatment is a useful option(adjusted OR, 0.78; 95% CI, 0.68 – 0.89; P<0.001). Patient preferences were found to have a measurable influence on surgeon treatment recommendationsthough not as much as we expected-and surgeons on average interpreted surgery as more aesthetic. This emphasizesthe importance of strategies to help patients reflect on their values and ensure their preferences are consistent withthose values (e.g. use of decision-aids).Level of evidence: III

The aim of this study was to assess differences in fracture morphology and displacement between isolated greater tuberosity (GT) fractures (i.e. fractures of the greater tuberosity without other fractures of the proximal humerus) with and without shoulder dislocation utilizing quantitative 3-dimensional CT imaging. Thirty-four CT-scans of isolated greater tuberosity fractures were measured with 3-dimensional modeling. Twenty patients (59%) had concomitant dislocation of the shoulder that was reduced prior to CT-scanning. We measured: degree and direction of GT displacement, size of the main fracture fragment, the number of fracture fragments, and overlap of the GT fracture fragment over the intact proximal humerus. We found: (1) more overlap –over the intact humerus– in patients without concomitant shoulder dislocation as compared to those with shoulder dislocation (P=0.03), (2) there was a trend towards greater magnitude of displacement between those without (mean 19mm) and those with (mean 11mm) a concomitant shoulder dislocation (P=0.07), and (3) fractures were comparable in direction of displacement (P=0.50) and size of the fracture fragment
(P=0.53). We found substantial variation in degree and direction of displacement of GT fracture fragments. Variation in degree of overlap and displacement is partially explained by concomitant shoulder dislocation.

A better understanding of how bone mineral density and vitamin D levels are associated with femoral neck and intertrochanteric hip fractures may help inform healthcare providers. We asked: 1) In patients age ≥ 55 years, is there a difference in quantitative ultrasound of the heel (QUS) t-score between patients with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors 2) In patients age ≥ 55 years, is there a difference in vitamin D level between those with fractures of the femoral neck and those with fractures of the intertrochanteric region, accounting for other factors? 3) Is there an association between vitamin D level and QUS t-score? In this retrospective cohort study, 1,030 patients were identified using CPT codes for fixation of hip fractures between December 2010 and September 2013. Patients ≥ 55 years of age who underwent operative management for a hip fracture following a fall from standing height were included. Three orthopaedic surgeons categorized fracture type using patient radiographs. Upon hospital admission, QUS t-scores and vitamin D levels were determined. Descriptive statistics, bivariate analyses and multivariable regression were performed. Accounting for potential confounders, patients with lower QUS t-scores were more likely to have intertrochanteric femur fractures than femoral neck fractures. In a bivariate analysis, there was no association between vitamin D level and either fracture type. There was no association between vitamin D level and bone mineral density. Patients with lower bone density that fracture their hips are more likely to fracture in the intertrochanteric region than the femoral neck, but vitamin D levels are unrelated. Awareness of this association emphasizes the importance of bone mineral density screening to assist with intertrochanteric hip fracture prevention.
Level of evidence: III

Proximal femur fractures are prevalent among the elderly and associated with substantial morbidity, mortality, and early readmission. Early readmission is gaining popularity as a measure of quality of hospital care and can lower reimbursement. A better understanding of the patient and treatment characteristics associated with readmission may help inform program improvement initiatives. This study tested the primary null hypothesis that length of stay is not associated with higher rates of readmission within 30 days and 1 year in patients having operative treatment of a proximal femur fracture, accounting for discharge destination and other factors. We performed a secondary analysis on a database of 1,061 adult patients, age 55 years or older, admitted for treatment of a proximal femoral fracture in an urban level 2 trauma center. Multivariable logistic and linear regression models were created to account for the influence of age, sex, race, BMI, American Society of Anesthesiologists score (ASA), fracture type (AO/OTA), fixation type, operating surgeon, operative duration, and discharge destination. In multivariable logistic regression analysis, treatment by surgeon 4 was independently associated with a lower 30-day readmission rate. Higher one-year readmission rate was associated with a longer length of stay, ASA class 3, 4 and 5. The observation that patients cared for by specific surgeons are more likely to experience readmission within one year of surgery for a fracture of the proximal femur, suggests that program improvements to identify and disseminate best practices might reduce readmission rates.
Level of evidence: III