Background Occult scaphoid fractures on initial radiographs of an injury are a diagnostic challenge to physicians. Although artificial intelligence models based on the principles of deep convolutional neural networks (CNN) offer a potential method of detection, it is unknown how such models perform in the clinical setting. Questions/purposes (1) Does CNN-assisted image interpretation improve interobserver agreement for scaphoid fractures? (2) What is the sensitivity and specificity of image interpretation performed with and without CNN assistance (as stratified by type: normal scaphoid, occult fracture, and apparent fracture)? (3) Does CNN assistance improve time to diagnosis and physician confidence level? Methods This survey-based experiment presented 15 scaphoid radiographs (five normal, five apparent fractures, and five occult fractures) with and without CNN assistance to physicians in a variety of practice settings across the United States and Taiwan. Occult fractures were identified by follow-up CT scans or MRI. Participants met the following criteria: Postgraduate Year 3 or above resident physician in plastic surgery, orthopaedic surgery, or emergency medicine; hand fellows; and attending physicians. Among the 176 invited participants, 120 completed the survey and met the inclusion criteria. Of the participants, 31% (37 of 120) were fellowship-trained hand surgeons, 43% (52 of 120) were plastic surgeons, and 69% (83 of 120) were attending physicians. Most participants (73% [88 of 120]) worked in academic centers, whereas the remainder worked in large, urban private practice hospitals. Recruitment occurred between February 2022 and March 2022. Radiographs with CNN assistance were accompanied by predictions of fracture presence and gradient-weighted class activation mapping of the predicted fracture site. Sensitivity and specificity of the CNN-assisted physician diagnoses were calculated to assess diagnostic performance. We calculated interobserver agreement with the Gwet agreement coefficient (AC1). Physician diagnostic confidence was estimated using a self-assessment Likert scale, and the time to arrive at a diagnosis for each case was measured. Results Interobserver agreement among physicians for occult scaphoid radiographs was higher with CNN assistance than without (AC1 0.42 [95% CI 0.17 to 0.68] versus 0.06 [95% CI 0.00 to 0.17], respectively). No clinically relevant differences were observed in time to arrive at a diagnosis (18 ± 12 seconds versus 30 ± 27 seconds, mean difference 12 seconds [95% CI 6 to 17]; p < 0.001) or diagnostic confidence levels (7.2 ± 1.7 seconds versus 6.2 ± 1.6 seconds; mean difference 1 second [95% CI 0.5 to 1.3]; p < 0.001) for occult fractures. Conclusion CNN assistance improves physician diagnostic sensitivity and specificity as well as interobserver agreement for the diagnosis of occult scaphoid fractures. The differences observed in diagnostic speed and confidence is likely not clinically relevant. Despite these improvements in clinical diagnoses of scaphoid fractures with the CNN, it is unknown whether development and implementation of such models is cost effective. Level of Evidence Level II, diagnostic study.
BackgroundReported complication frequencies after distal radius fracture (DRF) treatment vary widely in the literature and are based mostly on observational evidence. Whether that evidence is sufficiently robust to use in practice is controversial. The E-value is an innovative sensitivity analysis that quantitates the robustness of observational evidence against unmeasured confounders, whereby a greater E-value usually implies more robust evidence and vice versa; with DRF complications, this approach can help guide readers to a more confident interpretation of the available evidence.Questions/purposesIn this study, we sought (1) to compare the complication frequencies among different DRF treatment modalities, and (2) to evaluate the robustness of these observational studies using the E-value as an index for unmeasured confounding.MethodsWe searched PubMed, Embase, and SCOPUS for observational studies on the management of DRFs that were published from January 2001 to July 2021 with the last database search performed on July 31, 2021. All articles that compared different DRF treatment modalities with reported complication frequencies were included to accurately capture the quality of the observational studies in research about DRF. Risk ratios (RRs) of the overall complication and major complication risks were calculated for each subgroup comparison: volar plating versus dorsal plating, casting, external fixation, and percutaneous K-wire fixation. The RRs and their corresponding lower limits of the 95% confidence intervals (CIs) were used to derive the E-values. E-values can have a minimum possible value of 1, which signifies that the treatment-outcome association is not strong and can readily be overturned by unmeasured confounders. By contrast, a large E-value means that the observed treatment-outcome association is robust against unmeasured confounders. We averaged RRs and E-values for the effect estimates and lower limits of CIs across studies in each treatment comparison group. We identified 36 comparative observational studies that met the inclusion criteria. Seven studies compared volar with dorsal plating techniques. Volar plating was also compared with casting (eight studies), external fixation (15 studies), and percutaneous K-wire fixation (six studies).ResultsTotal and major complication risks did not differ among different DRF treatments. The mean RRs for total and major complications were 1.2 (95% CI 0.4 to 3.9; p = 0.74) and 1.8 (95% CI 0.4 to 11.4; p = 0.52) for the volar versus dorsal plating group; 1.2 (95% CI 0.3 to 11.2; p = 0.87) and 1.5 (95% CI 0.3 to 14.9; p = 0.74) for the volar plating versus casting group; 0.6 (95% CI 0.2 to 2.2; p = 0.33) and 0.8 (95% CI 0.2 to 6.7; p = 0.86) for the volar plating versus external fixation group; and 0.6 (95% CI 0.2 to 2.6; p = 0.47) and 0.7 (95% CI 0.2 to 4.0; p = 0.67) for the volar plating versus K-wire fixation group. The mean E-values for total and major complication frequencies for the between-group comparison ranged from 3.1 to 5.8; these were...
Background: The increase in virtual conferences during the COVID-19 pandemic provided unexpected advantages such as increased accessibility, while also creating concern about the effectiveness of online networking and career development. Given that a variety of conference attributes are impacted by changes in conference format, we sought to investigate how plastic surgeons prioritize key aspects of conference conduct. Methods: We sent a survey based on conjoint analysis, a statistical method for evaluating consumer preferences, to active members of the American Society of Plastic Surgeons. Respondents were asked to choose between pairs of conference options, each with unique attributes. Their answers were used to calculate feature importance values and utility coefficients for the conference attributes. Subgroup analyses were conducted based on demographic factors. Results: A total of 263 respondents completed the survey. Respondents were mostly White (181 individuals [68.8%]) and men (186 [70.7%]). Nearly half (122 [46.4%]) had been practicing 20 or more years. Conference attributes with the highest feature importance values (SDs) were cost of attendance (30.4% [14.2%]) and conference format (28.8% [14.2%]). Equity initiatives (14.5% [10.1%]), reimbursement for cost (11.1% [5.7%]), and opportunities for networking (9.5% [6.0%]) had intermediate feature importance values. Environmental impact had the lowest feature importance (5.7% [3.8%]). Conclusions: Surgeons’ conference preferences depend highly on format and the presence of equity initiatives, both of which can be incorporated or modified in future conferences to ensure inclusive and successful events. Meanwhile, environmental impact is less important to surgeons, suggesting a pressing need to bring sustainability issues to their attention.
Multiple treatment options are available to patients with Dupuytren contracture, making shared decision-making complex. Our rigorous qualitative analysis sought to understand patient perceptions of shared decision-making in Dupuytren contracture treatment and create a conceptual framework to optimize patient-physician communication. We interviewed 30 patients with Dupuytren contracture to learn about their experience with treatment selection. The following themes were integral to shared decision-making for Dupuytren contracture treatment: discussing disease progression and treatment initiation, presenting all available treatment options, assessing patients’ pre-existing biases towards treatment, patient values and preferences for treatment trade-offs, treatment risks and benefits, physician recommendation and active patient participation. This model can optimize communication about treatment options and expectations for relevant outcomes including, recovery time, contracture recurrence, complications, and treatment-related expenses. Level of evidence: V
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