Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: The introduction of generative artificial intelligence (AI) may have a profound effect on residency applications. In this study, we explore the abilities of AI-generated letters of recommendation (LORs) by evaluating the accuracy of orthopaedic surgery residency selection committee members to identify LORs written by human or AI authors.

Methods: In a multicenter, single-blind trial, a total of 45 LORs (15 human, 15 ChatGPT, and 15 Google BARD) were curated. In a random fashion, seven faculty reviewers from four residency programs were asked to grade each of the 45 LORs based on the 11 characteristics outlined in the American Orthopaedic Associations standardized LOR, as well as a 1 to 10 scale on how they would rank the applicant, their desire of having the applicant in the program, and if they thought the letter was generated by a human or AI author. Analysis included descriptives, ordinal regression, and a receiver operator characteristic curve to compare accuracy based on the number of letters reviewed.

Results: Faculty reviewers correctly identified 40% (42/105) of human-generated and 63% (132/210) of AI-generated letters (P < 0.001), which did not increase over time (AUC 0.451, P = 0.102). When analyzed by perceived author, letters marked as human generated had significantly higher means for all variables (P = 0.01). BARD did markedly better than human authors in accuracy (3.25 [1.79 to 5.92], P < 0.001), adaptability (1.29 [1.02 to 1.65], P = 0.034), and perceived commitment (1.56 [0.99 to 2.47], P < 0.055). Additional analysis controlling for reviewer background showed no differences in outcomes based on experience or familiarity with the AI programs.

Conclusion: Faculty members were unsuccessful in determining the difference between human-generated and AI-generated LORs 50% of the time, which suggests that AI can generate LORs similarly to human authors. This highlights the importance for selection committees to reconsider the role and influence of LORs on residency applications.

Introduction: Patient satisfaction is associated with communication-related measures, empathy, and meeting expectations. However, it is not clear what surgeon characteristics are associated with patient satisfaction. As such, the purpose of this study was to investigate the surgeon sociodemographic, training, and practice parameters that may be associated with patient satisfaction.

Methods: A retrospective study of patient satisfaction scores was conducted from 7,856 patients who rated 62 orthopaedic surgeons in 2021 within a single hospital system. Three questions from the National Research Corporation survey were used to assess patient satisfaction. Bivariate analyses and multiple linear regression analyses were performed. For chi-square analyses, patient satisfaction scores were recoded into either above the mean or below/equal to the mean score.

Results: Overall, 57 male (91.9%) and five female orthopaedic surgeons (8.1%) participated. Mean age was 49.3 ± 9.9 years. Median years in practice was 14 years (range, 1 to 38 years). More years in practice was associated with lower patient satisfaction scores for careful listening (P = 0.048), likelihood to recommend the provider (P = 0.021), and total score (P = 0.029). Older surgeon age was associated with lower total scores (P = 0.039). Surgeons with 30 or more years of practice were more likely to be recommended (P = 0.030). Surgeons who trained in the Northeast for fellowship and/or residency were more likely to be recommended. Older surgeon age and training in the Northeast were associated with higher patient satisfaction.

Conclusion: Older surgeon age and fellowship and/or residency training in the Northeast were associated with higher patient satisfaction, whereas 30 or more years of practice was associated with lower patient satisfaction. In bivariate analysis, female surgeons and foot and ankle training were associated with higher patient satisfaction, whereas spine surgeons had lower patient satisfaction scores. These findings suggest that patient-centered communication, patient-surgeon concordance, and appropriate help may improve patient satisfaction.

Level of evidence: Level IV.

Lumbar pedicle screw placement in spinal surgery is complex and prone to errors, with notable risks to patients. Standard training methods, such as mentorship in operating rooms, pose safety concerns, prompting the need for alternative training tools. This study aimed to validate and use a three-dimensional (3D)-printed simulation model for lumbar pedicle screw insertion training and assess its effectiveness compared with standard methods. The study proceeded through four phases: model design and validation, construct validation, learning curve assessment, and transfer to a cadaver model. A 3D-printed lumbar spine model was created and refined based on expert feedback. Construct validation demonstrated the model's ability to differentiate between experts and novices. Training sessions with residents showed a notable improvement in performance over multiple attempts, but performance still lagged that of experts. However, skills learned on the simulation model were effectively transferred to a cadaver model, with no notable difference in performance observed. The trained group outperformed a control group trained using standard methods in the cadaver test. The study concludes that the 3D-printed simulation model is a valid training tool for lumbar pedicle screw insertion, effectively transferring skills to a cadaver setting and improving resident performance compared with standard training methods. Additional research is warranted to explore the sustainability of acquired skills and optimize training protocols.

Introduction: Shoulder arthroplasty is increasing in incidence over time. One potential complication that is not well studied following shoulder arthroplasty is heterotopic ossification (HO), the abnormal growth of extraskeletal bone in soft tissue. HO has been described as a complication in total hip arthroplasty literature but less described in the setting of shoulder arthroplasty. The aim of this systematic review is to present available evidence regarding the incidence, risk factors, and potential management of HO after shoulder arthroplasty.

Methods: A systematic search was conducted in June 2023 using Pubmed, Embase, and Ovid Medline databases to retrieve all relevant studies evaluating the occurrence of HO after shoulder arthroplasty. The search was done in duplicate, and a quality assessment of all studies was included.

Results: A total of 170 studies were retrieved, of which 6 were included, involving 1,028 patients undergoing shoulder arthroplasty with 1,038 operated shoulders. HO developed postoperatively in 28% of the included shoulders and was symptomatic in 12% with most cases occurring in shoulders that developed osteoarthritis and cuff tear arthropathy. Men appear to have an increased risk of developing HO post shoulder arthroplasty. Fewer than 2% of HO shoulders went on to have revision surgery, and no notable differences were observed in the postoperative mean elevation and external rotation angles of non-HO and HO shoulders. In addition, no reported benefit of the use of nonsteroidal anti-inflammatory drugs was found against the formation of HO after shoulder arthroplasty.

Conclusion: HO occurs in 28% of shoulder arthroplasties in our review. Most of these were asymptomatic in the reviewed articles. Male patients and revision surgery with osteoarthritis and cuff tear arthroplasty seem to be at higher risk of developing HO post shoulder arthroplasty. Nonsteroidal anti-inflammatory drugs seem to not prevent the development of HO after shoulder arthroplasty; yet, future studies are needed to verify this claim.

Level of evidence: Level III; Systematic Review.

International medical graduates (IMGs) are integral to the US healthcare system but are scarce in orthopaedic residency classes. Positive contributions of IMGs to the field of orthopaedic surgery in the United States are well documented, but successfully matching into an orthopaedic residency position as an IMG remains very challenging. The purpose of this study was to review current processes, strategies, and potential barriers of IMGs applying for orthopaedic surgery residency in the United States as an IMG.

Introduction: There remains ongoing controversy regarding the optimal treatment strategy of hip dysplasia, with some advocating for the addition of hip arthroscopy to periacetabular osteotomy (PAO) to address concomitant labral tears. The purpose of this systematic review was to compare the clinical outcomes, complications, and joint preservation of PAO and PAO with hip arthroscopy.

Methods: A literature search was done, and studies were included if they reported outcomes of PAO with concomitant hip arthroscopy, PAO with staged hip arthroscopy, or compared outcomes of PAO alone versus PAO with hip arthroscopy. A meta-analysis was conducted with respect to studies who compared preoperative to postoperative change in modified Harris Hip Score between PAO and PAO with hip arthroscopy.

Results: Twenty studies were included in this review. Most patients demonstrated preoperative labral pathology. Pooled analysis of the postoperative change in modified Harris Hip Score showed no difference between PAO with concomitant hip arthroscopy and PAO alone (P = 0.238). Three of six studies comparing both surgical techniques demonstrated a notable postoperative improvement for select outcome scores for the PAO plus hip arthroscopy group but not for the PAO alone group. Of note, no studies demonstrated a notable improvement in the PAO alone group compared with PAO plus hip arthroscopy. The rates of complications and conversion to total hip arthroplasty for both procedures were notably similar.

Conclusion: Favorable and comparable clinical outcomes were observed for both PAO alone and PAO with hip arthroscopy. Although PAO with hip arthroscopy demonstrated statistically superior clinical outcomes for some measures, it was never inferior to PAO alone. Randomized controlled studies with extended follow-up are needed to better understand the potential difference in long-term outcomes and rates of conversion to total hip arthroplasty between these procedures.

Introduction: This study quantifies the state of sex diversity in orthopaedic trauma training and analyzes fellowship program characteristics associated with greater sex diversity among trainees. We hypothesized that greater sex diversity among orthopaedic trauma fellows would be associated with the presence of female faculty.

Methods: This was a retrospective, cross-sectional study of orthopaedic trauma faculty (2023 to 2024) and fellows (2009 to 2024). A trainee analysis for orthopaedic trauma fellows was done relative to orthopaedic surgery residents and allopathic medical students. Fellowship program characteristics associated with increased sex diversity among fellows were elucidated with chi square tests. Temporal analyses were done with linear regression.

Results: Overall, 1,266 orthopaedic trauma fellows and 200 were female (15.8%). Sex diversity in orthopaedic trauma fellowships was similar to orthopaedic surgery residency programs (14.2%, P = 0.135) but less than allopathic medical schools (47.5%, P < 0.001). Female representation in orthopaedic trauma fellowship training increased over the study period (9.1% vs. 31.5%, P < 0.001); 349 orthopaedic trauma faculty at 65 orthopaedic trauma fellowships and 41 were female (11.7%). Of the 65 fellowship program directors, only four were female (6.2%). The presence of female faculty was associated with greater sex diversity among orthopaedic trauma fellows (P = 0.017). Additional program characteristics, like geographic region, accreditation status, and number of faculty, were not associated with greater sex diversity.

Discussion: Sex diversity is increasing in orthopaedic trauma fellowship training and is associated with the presence of female faculty. Efforts to mentor and recruit female trainees in orthopaedic trauma fellowship training may lead to greater workforce diversity in orthopaedic trauma.

Statistical interpretation is foundational to evidence-based medicine. Frequentist (P value testing) and Bayesian statistics are two major approaches for hypothesis testing. Studies analyzed with Bayesian methods are increasingly common with a 4-fold increase in the past 10 years. The Bayesian approach can align with clinical decision making by interpreting smaller differences that are not limited by P values and misleading claims of "trends toward significance." Both methods follow a workflow that includes sampling, hypothesis testing, interpretation, and iteration. Frequentist methodology is familiar and common. However, the limitations are the misunderstanding, misuse, and deceptively simple utility of interpreting dichotomous P values. Bayesian approaches are relatively less common and provide an alternative approach to trial design and data interpretation. Marginal differences elucidated by Bayesian methods may be perceived as less decisive than a P value that may reject a null hypothesis. The purposes of this review are to introduce Bayesian principles and Bayes theorem, define how pretest probability and known information may inform diagnostic testing using an example from prosthetic joint infection, contrast Bayesian and frequentist approaches using an example from the VANCO orthopaedic prospective trial, and describe the criteria for critically reviewing Bayesian studies.

Introduction: Standard references for determining rotational alignment are often unavailable when performing distal femoral replacement (DFR) surgery. This study aimed to describe the rotational profile of the distal femoral osteology at common resection levels.

Methods: Adults with CT scans of the bilateral legs were included. Exclusion criteria included fractures, congenital deformity, prior arthroplasty, or inadequate imaging. Referencing the transepicondylar axis, angles were measured in the axial plane using the following reference lines: anterior condylar axis or anterior femoral cortex axis (AFCA), posterior condylar axis or posterior femoral cortex axis (PFCA), lateral projection of the linea aspera (LAA), and Whiteside line (WL). These rotational measurements were assessed at 3, 5, 7, and 9 cm proximal of the joint line. External and internal rotation were denoted as positive and negative, respectively.

Results: Fifty-one patients (102 femora) were included (mean age: 62.6 ± 13.4 years; mean body mass index: 26.0 ± 6.7 kg/m2). Proximally, the anterior condylar axis/anterior femoral cortex axis became increasingly internally rotated (3-cm: -13.1 ± 3.5°, 9-cm: -21.2 ± 6.6°), whereas the posterior condylar axis/PFCA became increasingly externally rotated (3-cm: -6.7 ± 2.3°, 9-cm: 9.6 ± 6.1°). WL remained nearly perpendicular (3-cm: 88.8 ± 2.3°, 5-cm: 89.8 ± 3.7°) but was not reliably measured beyond 5 cm. The LAA was measurable proximal to 5 cm from the joint line and was internally rotated (5-cm: -58.5 ± 14.3°, 9-cm: -45.6 ± 13.4°).

Conclusion: Distally, WL is a reliable anatomic landmark for femoral implant rotation. At more proximal resection levels, the posterior cortex may be a valuable landmark as referencing the linea aspera may lead to gross internal rotation of the femoral implant.