Journal of the American Academy of Orthopaedic Surgeons最新文献

Introduction: Patients have long turned to the Internet for answers to common medical questions. As the ability to access information evolves beyond standard search engines, patients with adolescent idiopathic scoliosis (AIS) and their parents may use artificial intelligence chatbots such as ChatGPT as a new source of information.

Methods: Ten frequently asked questions regarding AIS were posed to ChatGPT. The accuracy and adequacy of the responses were graded as excellent not requiring clarification, satisfactory requiring minimal clarification, satisfactory requiring moderate clarification, and unsatisfactory requiring substantial clarification.

Results: ChatGPT gave one response that was excellent not requiring clarification, four responses that were satisfactory requiring minimal clarification, three responses that were satisfactory requiring moderate clarification, and two responses that were unsatisfactory requiring substantial clarification, with information about higher level, more complex areas of discussion such as surgical options being less accurate.

Conclusion: ChatGPT provides answers to FAQs about AIS that were generally accurate, although correction was needed on specific surgical treatments. Patients may be at risk of developing a Dunning-Kruger effect by proxy from the superficial and sometimes inaccurate information provided by ChatGPT on more complex aspects of AIS.

Background: Successfully matching into orthopaedic surgery residency is a challenging endeavor due to the limited number of available positions. Implementation of the Standard Letter of Recommendation (SLOR) in 2017 was intended to allow better comparisons between applicants; however, the form suffered from notable rank inflation ultimately requiring introduction of an updated SLOR for the 2023 to 2024 application cycle. The purpose of this study was to evaluate whether the 2023 SLOR improves on deficiencies of the 2017 SLOR.

Methods: Applications submitted to our institution during the 2023 to 2024 orthopaedic surgery residency application cycle were analyzed. Applicant objective metrics were collected, including US Medical Licensing Exam scores, clerkship grades, AΩA status, and research productivity. Scores for each domain of the 2023 SLOR forms were recorded. Mean scores were calculated for each question, and cumulative scores per SLOR were determined. Intraclass correlation coefficients were determined per applicant and evaluator. The Spearman rank correlation coefficient was calculated for comparison of SLOR cumulative scores and objective metrics.

Results: Three hundred sixty-eight applications were reviewed, and 743 2023 SLORs were submitted in conjunction with these applications. Most of the 2023 SLORs (n = 399, 53.70%) had cumulative scores placing applicants in at least the 90th percentile. Furthermore, 267 evaluators (72.36%) consistently gave scores of 99s and 10s for each question. Intraclass correlation coefficients were rated as fair to moderate agreement between evaluators for each applicant. Objective applicant metrics did not meaningfully correlate with SLOR cumulative scores.

Discussion: The 2023 SLOR demonstrated notable rank inflation with only 22.7% of applicants receiving a score of less than 7 on any domain. By contrast, 69.9% of applicants received a score of "rare, perfect gem" on at least one domain of the form. We encourage the American Orthopaedic Association Council of Orthopaedic Residency Director to continue to improve the form and provide guidance to residency program leadership on proper use of the grading system.

The American Academy of Orthopaedic Surgeons, together with The Hip Society, American Association of Hip and Knee Surgeons, American College of Radiology, and American Physical Therapy Association, recently released the updated 2023 Management of Osteoarthritis of the Hip Evidence-Based Clinical Practice Guidelines. 8 recommendations and 9 options comprise these guidelines intended to optimize treatment outcomes in a patient population that is growing exponentially over time. In this article, we present case studies that illustrate utilization of the clinical practice guideline workgroup's evidence-based recommendations in clinical practice.

Introduction: Implicit racial bias has been well studied in adults, including among orthopaedic surgeons, through the Implicit Association Test (IAT). Recent studies suggest implicit race bias is also present among children. Explicit racial preference has been studied in children through The Clark Doll Test since the 1930s. The purpose of this study was to determine whether implicit and explicit racial biases are present among pediatric orthopaedic patients.

Methods: A prospective, cross-sectional survey was administered to pediatric orthopaedic patients aged 7 to 18 years at clinics in a tertiary pediatric hospital setting. The survey included a Clark Doll Test to determine whether pediatric patients expressed explicit bias, followed by a race IAT to determine whether pediatric patients expressed implicit bias. Preference and magnitude of implicit bias as demonstrated on the IAT was calculated using standard D-scores.

Results: A total of 96 patients were consented and included in this study. Overall, pediatric patients demonstrated a slight pro-White implicit bias (M = 0.22) on IAT testing. Pediatric patients who identified as White or European American and Hispanic or Latinx both had the strongest pro-White implicit bias (M = 0.35). Patients who identified as Black or African American demonstrated no implicit racial bias (M = -0.13) on IAT testing. No notable explicit bias was observed in participants of any racial background.

Discussion: This study contributes evidence that pediatric orthopaedic patients express implicit racial bias on IAT testing, with an overall slight pro-White bias. It also provides insight into the dissociation of implicit and explicit racial bias in childhood and adolescence.

Conclusion: We encourage future research on implicit bias among pediatric patients in the orthopaedic community to provide a better understanding and possible solutions to bias-related challenges in health care.

Introduction: The primary objective of this meta-analysis was to evaluate and compare the functional outcomes, postoperative reinfection rates, and complication rates in patients undergoing one-stage versus two-stage surgical revision for periprosthetic hip infection.

Methods: The study population included adult patients who had undergone revision hip arthroplasty. Comparative studies have compared two-stage and one-stage revision strategies. Searches were conducted using the major databases. Review Manager software was used to estimate the effects. A sensitivity analysis was also conducted.

Results: Nine cohort studies including 2,502 hips were included. The success rate did not show significant differences between the groups (odds ratio [OR] 0.42, 95% confidence interval 0.05 to 3.37). No difference was noted in reinfection (OR 0.81, 95% CI 0.56-1.19). Life quality per Harris Hip Score was higher for one-stage revision strategies (mean difference [MD] 9.00, 95% CI 2.23-15.78). No differences were noted in mortality, aseptic loosening, or revision rates. Age (MD 2.32, 95% CI 1.34-3.29) and body mass index (BMI) (MD 1.88, 95% CI 0.38-3.38) were lower in the two-stage group. Sinus tract presence was higher in the one-stage group (OR 1.44, 95% CI 1.05-1.95). Paprosky I acetabulum was higher in the one-stage group, and Paprosky III was higher in the two-stage group.

Conclusions: The results did not demonstrate notable clinical differences between one-stage and two-stage hip arthroplasties, regardless of the treated microorganism. However, the quality of life may be somewhat better in the one-stage group. Age, body mass index, and Paprosky classification are factors that influence procedure selection.

Personal finance is a topic that has historically been shunned as a point of conversation in academia, often avoided and seldom discussed in medical training. However, this aversion leaves trainees and early career surgeons to make complex financial decisions without sufficient understanding while simultaneously facing the pressures of building an orthopaedic practice-a recipe destined for burnout. This simple review serves to equip young orthopaedic surgeons with the fundamental personal financial concepts essential for making wise financial choices early in their careers. Prompt elimination of all high-interest consumer debt and devising a strategy to address student loans are crucial first steps in establishing the foundation for personal financial success. Progressing through training and entering practice bring about enhanced personal discretionary funds that are most effectively deployed through consistent budgeting and automated saving strategies. Malpractice, disability, and life insurances are keys to protecting current and future earnings as well as preventing financial catastrophe. Augmenting these items with a functional understanding of taxation systems, tax diversification, and asset protection is essential to recognize in the early years of practice to set the trajectory for financial independence and a well-deserved retirement.

Anterior cruciate ligament (ACL) injuries continue to increase in incidence despite extensive research into prevention strategies. Many extrinsic and intrinsic risk factors for sustaining ACL injuries have been identified and continue to be investigated. Extrinsic risk factors for ACL injury relate to the athlete's environment, such as the shoe-surface interaction, weather conditions, and sport played. Intrinsic risk factors relate to the athlete's sex, hormones, knee anatomy, landing and pivoting biomechanics, and neuromuscular control. Recent research has highlighted the role of the bony morphology of the proximal tibia and distal femur on primary ACL injury risk, as well as the risk for ACL graft failure. Sex differences in bony and ligamentous morphology of the knee, neuromuscular control, and hormonal factors, such as serum relaxin levels and variations within the menstrual cycle, have been correlated with a higher risk of noncontact primary ACL injuries in female athletes compared with male athletes.

Osteoporosis is a global health problem affecting over 200 million people worldwide and 54 million adults in the United States. Approximately half of all postmenopausal women will have an osteoporosis-related fracture during their lifetime. In the United States, the direct medical cost related to osteoporosis is expected to exceed $25 billion by 2025. Management of osteoporosis in vertebral fractures and elective spine surgery is of the utmost concern, given the high prevalence of osteoporosis in the general population and the increased risk of complication in this population. New pharmacologic treatment options such as anabolic medications and diagnostic tools including Hounsfield unit measurements on routine computed tomography scans are available to orthopaedic and spinal surgeons to help best manage this condition. This review serves as an update to diagnosis, management, and treatment of patients with osteoporosis undergoing spinal surgery.

Introduction: The surgical management of severe scoliosis in patients with osteogenesis imperfecta (OI) is challenging because of curve rigidity, small stature, and inherent bone fragility. This study evaluated the midterm outcomes of our multimodal approach to address these issues, integrating perioperative bisphosphonate therapy, preoperative/intraoperative traction, various osteotomies, segmental pedicle screw instrumentation with cement augmentation, and bone morphogenetic protein-2 application.

Methods: A single-center retrospective review of 30 patients (average age 14.1 ± 2.2 years; 18 were female) diagnosed with OI and scoliosis was conducted. These patients underwent posterior spinal fusion between 2008 and 2020 and completed a minimum follow-up of 2 years. We measured radiographic parameters at each visit and reviewed the incidence of complications. A mixed-effects model was used to evaluate changes in radiographic parameters from preoperative measurements to the first and latest follow-ups.

Results: The patient cohort consisted of 2 individuals with type I OI, 20 with type III, 6 with type IV, and 2 with other types (types V and VIII). Surgical intervention led to a notable improvement in the major curve magnitude from 76° to 36°, with no notable correction loss. In addition, the minor curve, apical vertical translation, lowest instrumented vertebra tilt, and pelvic obliquity were also improved. In the sagittal plane, thoracic kyphosis and lumbar lordosis remained unchanged while thoracolumbar kyphosis markedly improved. Two patients experienced proximal junctional kyphosis with screw pullout, one of whom required revision surgery. One patient developed a superficial infection that was successfully treated with oral antibiotics. No instances of neurologic deficits or cement extravasation were observed.

Discussion: This study demonstrated the effectiveness and safety of our multimodal approach to treating scoliosis in patients with OI, achieving a 53% major curve correction with minimal complications over 2-year follow-up. These findings provide notable insights into managing scoliosis in this population.

Level of evidence: Level IV (case series).

Introduction: Double-crush syndrome (DCS) represents a condition that involves peripheral nerve compression in combination with spinal nerve root impingement. The purpose of this study was to compare electrodiagnostic study (EDS) results in patients undergoing carpal tunnel release (CTR) for carpal tunnel syndrome with those undergoing both CTR and anterior cervical diskectomy and fusion for DCS.

Methods: Patients receiving an isolated CTR were compared with those undergoing CTR and anterior cervical diskectomy and fusion within two years of CTR. The latter group was defined as our DCS cohort. Electrodiagnostic study results were collected which included sensory and motor nerve conduction data as well as electromyogram (EMG) findings. All electrodiagnostic studies were done before CTR in both sets of patients.

Results: Fifty-four patients with DCS and 137 CTR-only patients were included. Patients with DCS were found to have decreased sensory onset latency (3.51 vs 4.01; P = 0.015) and peak latency (4.25 vs 5.17; P = 0.004) compared with the CTR-only patients. Patients with DCS had slower wrist motor velocity (30.5 vs 47.7; P = 0.012), decreased elbow motor latency (9.62 vs 10.6; P = 0.015), and faster elbow motor velocity (56.0 vs 49.4; P = 0.031). EMG results showed that patients with DCS were more likely to have positive findings in the biceps (31.9% vs 1.96%; P < 0.001) and triceps (24.4% vs 2.97%; P < 0.001), but not abductor pollicis brevis (APB) (45.7% vs 37.9%; P = 0.459).

Conclusion: We identified changes on EDS between patients with and without DCS. In patients with DCS, sensory nerve studies showed shorter peak and onset latency than in CTR-only patients. Interestingly, DCS and CTR-only patients had different patterns of wrist and elbow motor nerve conduction. Providers observing positive EMG findings proximal to the APB should raise their suspicion for possible cervical radiculopathy and when present with carpal tunnel syndrome-like symptoms, should also consider DCS in their diagnostic differential.