Hss Journal最新文献

Background: Avascular necrosis (AVN) of the bone may result in severe pain, and patients with AVN and their families may seek out information about the condition. With the rise of ChatGPT, AVN patients and families may turn to this chatbot with questions.

Purpose: We sought to explore expert clinicians' perceptions of the quality of ChatGPT's responses to frequently asked parent questions about AVN in children. Secondary aims of this study were to assess provider perceptions of ChatGPT and AVN parental education and to evaluate the readability of ChatGPT responses.

Methods: We conducted a cross-sectional survey study of 9 pediatric orthopedic surgeons, oncologists, and advanced practice providers with expertise in the clinical management of AVN. Fifteen common questions parents ask about AVN were posed to ChatGPT, preceded by the following prompt: "Please answer the following parent question relating to avascular necrosis. Please give me a response at or below a sixth-grade reading level: [Question]." The answers were evaluated by participants using a 4-point Likert scale. ChatGPT responses were also assessed using the following readability scores: Flesch-Kincaid Grade Level, Gunning Fog index, and Flesch Reading Ease. In addition, the survey included 4 questions developed to gather overall provider perceptions.

Results: Providers deemed answers to all 15 questions as at least satisfactory, requiring minimal clarification on average. Yet only 3 ChatGPT responses (20%) were at or below a sixth-grade reading level, as prompted. The average Flesch-Kincaid Grade Level was 6.94, and the average Gunning Fog Index was 9.22, suggesting the responses reflect a reading level between approximately seventh grade and early high school. A majority of providers agreed that these responses would be sufficient for most parents (56%) and that the information was at the appropriate reading level (100%).

Conclusion: The findings of this small survey study suggest that ChatGPT's responses to common parent questions about AVN were satisfactory, requiring minimal clarification. ChatGPT has the potential to serve as a resource for orthopedic patients and family education, though concerns remain.

Background: Large language models (LLMs), an artificial intelligence tool, have become widely available and used by patients and members of the general public to answer health care questions.

Purpose: We sought to understand whether currently available LLMs can recommend an appropriate total knee arthroplasty (TKA) surgeon when prompted.

Methods: We used 3 widely available LLMs (ChatGPT, Gemini, and DeepSeek) to conduct searches for a TKA surgeon, with 1 of 4 home cities specified (Lynchburg, VA; Trumbull, CT; Chicago, IL; and New York, NY). The first prompt posed was (1) "I was told by my primary care provider that I need a knee replacement, I live in (city, state), who would you recommend that I see?" Once the list of surgeons was elicited, the LLM was prompted: (2) "Why did you recommend this (these) surgeon(s)?"; (3) "Where did you get your information about this (these) surgeon(s)?"; and (4) "How do I get in contact with this (these) surgeon(s)?" Recommendations were considered appropriate if the surgeon routinely performed TKA and was actively practicing in the area. Descriptive statistics and Fisher's exact tests were used to summarize findings.

Results: Across the 3 LLMs, 49 of the 74 (66%) recommendations were deemed appropriate, although this varied by model: Gemini (26/30, 87%), ChatGPT (14/19, 74%), and DeepSeek (9/25, 36%). Of the inappropriate responses, 6 of the surgeons were out of area, 13 were not performing TKA, and 6 were hallucinated names. When asked for rationales for the recommendations, LLMs most commonly cited hospital and practice Web sites and patient reviews, which tended to favor surgeons with longer local practice tenure. Of the 74 contact details provided, only 17 (23%) were accurate, with significant variation among models: ChatGPT (13/19, 79%), DeepSeek (2/25, 8%), and Gemini (2/30, 7%).

Conclusion: While LLMs show potential in identifying TKA surgeons, the 3 LLMs we tested varied in their ability to validate surgeon expertise and provide reliable contact information. Further research may be necessary to elucidate the criteria by which LLMs recommend surgeons.

Background: Acute compartment syndrome (ACS) is a limb-threatening complication of pediatric tibial tubercle fractures. Despite its severity, the incidence of ACS in pediatric cases has been largely unexplored.

Purpose: We sought to examine the incidence and risk factors of ACS and associated fasciotomies in pediatric patients with tibial tubercle fractures.

Methods: We conducted a retrospective cohort study using data from the Pediatric Health Information System, a comprehensive inpatient and outpatient nationwide database. Inclusion criteria specified patients 18 years of age or younger with tibial tubercle fracture (International Classification of Disease, 10th Revision (ICD-10) diagnosis code, S82.151-156) between October 1, 2015, and June 30, 2023. Exclusion criteria were patients with a positive hematologic or immunologic flag and patients with a positive congenital or genetic defect flag. Patients with tibial tubercle fractures were stratified into 3 categories: (1) patients with a diagnosis code for ACS and/or a fasciotomy procedure code; (2) patients with a diagnosis code for ACS and a fasciotomy code; and (3) patients exclusively with a fasciotomy procedure code.

Results: Of the 6830 included patients with tibial tubercle fractures, 4% had a code for ACS and/or fasciotomy, 1% had a code for ACS and a procedure code for fasciotomy, and 2.9% had a code for fasciotomy only. Univariate analysis revealed that older and male patients had higher rates of ACS and fasciotomies without any corresponding diagnosis of ACS, compared to their counterparts; White patients had higher rates of ACS than patients of other races. Multivariate analysis showed that age was the only significant predictor of ACS across all groups.

Conclusion: This retrospective database study suggests that ACS is a rare complication of pediatric tibial tubercle fractures and that fasciotomies without any evidence of ACS-interpreted as prophylactic fasciotomies-occur at a higher rate than formally diagnosed ACS.

Level of evidence: Level IV: Retrospective Cohort Study.

Background: Efficiency and improved outcomes drive consolidation of total knee arthroplasty (TKA) services to higher-volume centers. Consequently, some patients may travel farther for arthroplasty care, potentially creating a new access barrier.

Purposes: We investigated whether driving time to a reconstruction center was associated with progression to TKA among patients with newly diagnosed knee osteoarthritis (OA).

Methods: We conducted a retrospective review of data gathered from the electronic medical record of an academic health system serving a large geographic catchment for patients over 50 years old and newly diagnosed with knee OA between January 2021 and September 2022. One year TKA progression, setting of diagnosis, patient home ZIP code, and other information were recorded. The association between driving time and TKA progression was assessed using the Wilcoxon rank-sum test.

Results: A total of 4106 patients were identified, resembling an expected OA population, with 61% women and 54% ages 50 to 64 years. Median driving time was 31 minutes, with 8% driving longer than 2 hours. In all, 299 patients (7.3%) progressed to TKA within 1 year. Median driving time was similar for OA patients who progressed to TKA (31 minutes; interquartile range [IQR], 19-78) versus OA patients who did not (31 minutes; IQR, 16-62). Notably, diagnosis in an orthopedic clinic was associated with increased odds of progression to TKA in patients with longer driving times, with no other subgroup associations.

Conclusions: Increased driving time was not associated with increased rates of 1 year progression to TKA in newly diagnosed OA patients. At least based on these results for patients able to receive a diagnosis of OA, driving time did not appear to pose a barrier to surgical management.

Level of evidence: Level III: prognostic study.

Piriformis syndrome (PS) is a sciatic nerve entrapment condition caused by compression by the piriformis muscle, often presenting with symptoms that mimic lumbar radiculopathy and gluteal and buttock pain. This narrative review explores its diagnostic challenges and highlights the role of advanced imaging techniques in improving diagnostic accuracy. Literature suggests that PS may account for 5% to 8% of low back pain cases, frequently manifesting as buttock pain exacerbated by sitting or hip motion. Traditional imaging often fails to detect PS due to nonspecific findings, but magnetic resonance neurography can reveal sciatic nerve inflammation. A multimodal approach combining clinical assessment with targeted imaging enhances diagnostic precision and guides effective management of PS.

Background: Anterior cruciate ligament (ACL) tears are common and often devastating injuries among elite athletes. While interest in ACL preservation has highlighted the importance of ACL tear location to treatment decision-making, there is limited data on ACL tear location in elite athletes.

Purpose: We sought to describe the distribution of ACL tear location among National Football League (NFL) athletes and test the hypothesis that tear location is associated with injury mechanism.

Methods: Using a dataset from a study published in 2023, we identified 191 players with magnetic resonance imaging (MRI) of acute ACL tears occurring in NFL practice or games from 2015 to 2019; these were reviewed by 2 musculoskeletal radiologists. Data from these MRIs were linked to each player's electronic medical record data, and injuries from 2018 to 2019 were linked with available video to assess for an association between tear location and mechanism of injury in 73 of those players.

Results: Overall, 3% of tears were type I, 20% type II, 74% type III, 2% type IV, and <1% type V. For noncontact injuries, 71% were type III and 29% type II. Among indirect contact injuries, 78% were type III, 13% type II, 4% type IV, and 4% type V. In direct contact injuries, tears were 73% type III, 13% type II, and 13% type IV.

Conclusion: This retrospective review of MRI and video data of ACL tears in NFL players found that mid-substance tears were the most common. There was a higher proportion of type III tears and a lower proportion of type I tears compared to prior studies, suggesting these athletes may be less amenable to preservation techniques.

Level of evidence: Level IV: cross-sectional study.

Background: Decreasing wound healing complications is important for total joint arthroplasty. 2-Octyl cyanoacrylate with polymer mesh tape (2OPMT) is a skin closure system that works by combining a liquid adhesive with a polymer mesh to form a waterproof microbial barrier over surgical wounds. However, allergic contact dermatitis (ACD) has been a reported complication of 2OPMT use, with an incidence ranging from 0.5% to 2.5%.

Purpose: We sought to report our results of 2OPMT with primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and determine the incidence of ACD.

Methods: We conducted a single-institution, single-surgeon retrospective cohort study of 185 TKA and 154 THA patients who underwent procedures at a tertiary referral institution from October 2021 to November 2023.

Results: Overall incidence of ACD associated with 2OPMT was 3.8% (13/339). Incidence of ACD in TKA was 3.8% (7/185) and in THA it was 3.9% (6/154). All skin reactions were recognized at the first postoperative visit and treated with a combination of topical and/or oral steroids and oral antihistamines. All ACD reactions resolved by the second postoperative visit, and none of these patients developed a surgical site infection or a periprosthetic joint infection.

Conclusions: We found an ACD incidence of 3.8% with 2OPMT use in TKA and THA. This is similar to other studies reporting on ACD in TKA and THA. While it can be treated with routine use of steroids, antihistamines, and antibiotics, ACD is uncomfortable for patients and presents them with a concerning clinical appearance that requires additional treatment.

Level of evidence: Level III: retrospective cohort study.

Background: The most common cancer in women worldwide, breast cancer most often metastasizes to the bone. Improved chemo- and radiotherapies and novel molecular therapies have prolonged survival in women with osseous metastatic breast cancer, but spinal metastases often cause cord compression that degrades their functional independence.

Purpose: In women with breast cancer metastasized to the spine, we sought to (1) identify independent predictors of a functional deficit 3 months after surgical management and (2) assess the utility of existing metrics at highlighting patients at risk of a postoperative functional deficit.

Methods: We performed a single-institution, retrospective analysis of 92 patients meeting our inclusion criteria between 2004 and 2021. Patients were classified by 3-month postoperative Eastern Cooperative Oncology Group (ECOG) scores into good/independent (ECOG 0 to 2) and poor/dependent (ECOG 3 to 5) functional outcome groups. Univariate and multivariate analyses were performed to identify patient and tumor factors associated with good vs. poor 3-month ECOG scores.

Results: Preoperative use of selective estrogen receptor modulators (SERMs) was significantly associated with good postoperative functional outcomes. Poor preoperative function, the presence of visceral metastases at the time of surgery, and triple-negative primary or metastatic tumor status were independently associated with poor 3-month postoperative function. Host characteristics, sociodemographic factors, and indicators of surgical complexity, including estimated blood loss, front/back surgery, and corpectomy reconstruction, were not associated with 3-month ECOG score. A multivariate model including these significant univariate associations and normalized for patient demographics identified preoperative SERM use, poor preoperative function (ECOG score), and triple-negative primary or metastatic tumor status as independently associated with functional status 3 months after surgery.

Conclusions: Our retrospective analysis found that preoperative SERM use was significantly associated with improved postoperative functional outcomes, while poor preoperative function and triple-negative tumor status were significantly associated with poor function 3 months after surgery. These factors may serve as indicators of function and independence after surgery for patients with metastatic breast cancer to the spine.

Level of evidence: Level IV: Prognostic Study.

Background: Studies have shown that various types of spine surgery can be a contributing factor in bone loss, but the influence of lateral lumbar interbody fusion (LIF) on postoperative bone loss remains unclear.

Purpose: We sought to investigate the influence of spine surgery, measured by quantitative computed tomography (QCT), on the adjacent vertebrae, and to evaluate the bone loss between stand-alone LIF (SA-LIF) and LIF supplemented with posterior pedicle screw-rod fixation (360° constructs).

Methods: We conducted a retrospective review of the records of patients who underwent SA-LIF and 360° constructs between 2016 and 2024. Inclusion criteria were (1) the interval between surgery and the secondary CT was 2 to 12 months; (2) the interval between the preoperative and postoperative CT was a minimum of 2 months; (3) the patient did not undergo additional spine surgery between those 2 CT scans; and (4) volumetric bone mineral density (vBMD) measurements of 1 level above the upper vertebra (UV+1) were possible in all cases. We excluded levels with a corpectomy, planned staged surgery, more than 4 levels of fusion, and poor QCT imaging quality. Postoperative changes in vBMD in the vertebrae at UV+1, UV+2, and 1 level below the lower vertebra (LV-1) were measured. Pre- and postoperative vBMDs were compared. Postoperative vBMD changes were also compared between the 2 groups.

Results: Out of 191 patients who underwent the anterior or lateral interbody fusion in the specified time period, 72 patients met our inclusion criteria (36 SA-LIF; 63.3 ± 15.1 years, 36 360° constructs; 58.6 ± 11.3 years). UV+1 and UV+2 showed significant decreases in the SA-LIF group, and UV+2 and LV-1 decreased significantly in the 360° group. In the ANCOVA adjusted for age, the percent change in vBMD at each adjacent level showed no significant difference between the 2 groups.

Conclusion: Both SA-LIF and 360°construct surgeries negatively affected the postoperative vBMD values at adjacent levels. There was no statistically significant difference in bone loss between the 2 groups, suggesting that additional surgical invasiveness caused by screw insertion may not affect the severity of postoperative bone loss.

Level of evidence: Level III: retrospective cohort study.