Arthroscopy-The Journal of Arthroscopic and Related Surgery最新文献

There has been an exponential growth in the number of artificial intelligence (AI) and machine learning (ML)-related publications in recent years. For example, in shoulder and elbow surgery, there was a 6-fold increase in the number of publications between 2018 and 2021. AI shows potential to improve diagnostic precision, generate precise surgical templates, direct personalized treatment plans, and reduce administrative costs. However, while AI and ML technologies have the ability to positively impact biomedical research, it should be closely monitored and used with extreme caution in the realm of research and scientific writing. Of concern, current large language models raise concerns regarding veracity of AI-generated content, copyright and ownership infringement, fabricated references, lack of in-text citation, plagiarism, and questions of authorship. Recent research shows that even the most experienced surgeons are unable to consistently detect AI-generated scientific writing. Of note, AI detection software is more adept in this role. AI should be used with caution in the development and production of scholarly work.

The search for the ideal pain management strategy after knee arthroscopy continues. For patients unable to receive regional anesthesia, peri-articular or intra-articular injections of local anesthetics with other medications offer a promising solution. Dexmedetomidine, (a short-term sedative analgesic marketed under the names Dexdor and Precedex), when added to local anesthetics, may offer an increase in the length of time between surgery and the need for a rescue analgesic agent. Whether the addition of dexmedetomidine results in lower pain scores or decreased opioid consumption remains to be proven. Systemic effects of dexmedetomidine, such as sedation and hypotension, appear less likely to occur with intra-articular injections, suggesting a favorable safety profile. The effects of dexmedetomidine on chondrocytes, as well as the effects of combining medications in the intra-articular environment, is less well understood and should be a focus of further research. Similarly, there is still a need to identify the best patients, best procedures, best combination of medications and best doses to optimize our approach to post-operative pain management via intra-articular injection.

Purpose: The primary aim of this study was to compare patient-reported outcome measures (PROMs) at 1-year and 2-year follow-up following treatment for anterior shoulder instability.

Methods: Randomized controlled trials and prospective studies that evaluated and reported PROMs following a capsulolabral repair (with or without remplissage), bone augmentation or non-operative treatment to treat anterior shoulder instability at both 1-year and 2-year follow-up were included. PROMs were compared between 1-year and 2-year follow-up, forest plots with mean difference were created to compare baseline, 1-year and 2-year follow-up and scatterplots were created to visualize clinical improvement over time.

Results: Fourteen studies, comprising 923 patients, with level of evidence I and II were included. Nine PROMs, of which predominantly the Western Ontario Shoulder Instability Index (WOSI; 11 studies; 79%), were evaluated. Minimal to no statistically significant change in WOSI, Oxford Shoulder Instability Score (OSIS), American Shoulder and Elbow Surgeons (ASES), Subjective Shoulder Value (SSV), Simple Shoulder Test (SST), Disabilities of Arm, Shoulder, and Hand (DASH), Quick DASH, Single Assessment Numeric Evaluation (SANE) or Visual Analogue Scale (VAS) was observed between 1-year and 2-year follow-up. Pooling of the WOSI, OSIS, ASES and SANE demonstrated improvement from baseline to 1-year follow-up and minimal to no change between 1-year and 2-year follow-up. Scatterplots of the WOSI and ASES demonstrated the most improvement within 6 months and no clear improvement after 1-year follow-up. Recurrence rates increased with time but varied between studies.

Conclusion: In contrast to recurrence rates which have been shown to increase with time, minimal to no statistically significant change was observed for any of the included PROMs between 1-year and 2-year follow-up. This finding questions whether it is necessary to evaluate PROMs in long term follow-up of patients following shoulder stabilization treatment.

Level of evidence: Level II, systematic review of Level I - II studies.

Given the known immunosuppressive effects of glucocorticoids, the relationship between corticosteroid injections (CSIs) and postoperative infection risk has been frequently studied in the literature to date. The period within four weeks after knee arthroscopy has been identified as a particularly high-risk time to receive a CSI, and caution has been recommended as a result of the increased risk for infection that patients who receive a CSI during this time experience. CSIs given within four weeks prior to knee arthroscopy and at the time of knee arthroscopy have been shown to increase postoperative infection risk as well. As surgeons seek to better understand this association to be able to counsel patients about an appropriate interval between surgery and injection - as CSIs have been proven to accelerate postoperative recovery and reduce prolonged inflammation - questions remain, nonetheless. For example, while superficial infections may be localized and treated with a short course of oral antibiotics, deep infections can involve hospitalizations, intravenous antibiotics, and reoperation in the form of procedures like irrigation and debridement (I&D). Thus, the severity of infections associated with CSIs administered around the time of knee arthroscopy remains unclear. One explanation for these unanswered questions is the relative low frequency with which these complications occur and the fact that many studies that seek to address them rely on large commercial claims databases to do so. These databases frequently lack granularity, but due to the large sample size they offer, frequently provide the best available option to address such questions. Nevertheless, their limitations should be understood to avoid overstating clinical significance in the context of statistical significance and ensure conclusions are interpreted in their proper context.

Treatment options for large and massive rotator cuff tears, in the setting of failed conservative treatment, include debridement, isolated biceps tenotomy or tenodesis, primary repair, partial repair, subacromial spacer, superior capsular reconstruction, biologic tuberoplasty, bridging reconstruction, tendon transfers, reverse shoulder arthroplasty, and others. Each performs well under optimal indications. Bridging reconstruction performs best in the setting of an irreparable tear of the superior-posterior rotator cuff, with an intact or reparable subscapularis, particularly if the patient has reasonably preserved function/range of motion preoperatively. Advantages of bridging reconstruction include lower-tension repair, which may be superior to partial primary repair with incomplete footprint coverage in the case of irreparable tears.

Purpose: To assess the accuracy of answers provided by ChatGPT 4.0 (an advanced language model developed by OpenAI) regarding 25 common patient questions about hip arthroscopy.

Methods: ChatGPT 4.0 was presented with 25 common patient questions regarding hip arthroscopy with no follow-up questions and repetition. Each response was evaluated by two board-certified orthopaedic sports medicine surgeons, independently. Responses were rated as scores 1, 2, 3 and 4 corresponded to "excellent response not requiring clarification", "satisfactory requiring minimal clarification", "satisfactory requiring moderate clarification", and "unsatisfactory requiring substantial clarification", respectively.

Results: Twenty responses were rated "excellent" and 2 responses were rated "satisfactory requiring minimal clarification" by both of reviewers. Responses to questions "What kind of anesthesia is used for hip arthroscopy" and "What is the average age for hip arthroscopy?" were the two that both reviewers rated as "satisfactory requiring minimal clarification". None of the responses were rated as "satisfactory requiring moderate clarification" or "unsatisfactory" by either of the reviewers.

Conclusions: ChatGPT 4.0 provides at least satisfactory responses to patient questions regarding hip arthroscopy. Under the supervision of an orthopaedic sports medicine surgeon it could be used as a supplementary tool for patient education.

Clinical relevance: This study compared the answers of ChatGPT to patients' questions regarding hip arthroscopy with the current literature. As ChatGPT have gained popularity among patients, the study aimed to find if the responses patients get from this chatbot is compatible with the up-to-date literature.

Purpose: The purpose of this systematic review was to evaluate the use of shoulder arthroscopic simulation in Orthopaedic surgery trainees.

Methods: A literature search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, using PubMed, Medline (Ovid), and EMBASE library databases. Inclusion criteria were experimental studies reporting pre- and post-test results of shoulder arthroscopic simulation in orthopaedic trainees (studies reporting results of comparison between groups not within the groups were excluded). Participant demographics, type of simulator training, simulator tasks assessed and performance outcome measures were systematically reviewed. Each performance outcome measure was graphically represented in a Forest plot with point estimates of the incidence of performance outcomes with corresponding 95% confidence intervals and I².

Results: Fifteen studies met inclusion criteria with a total of 353 participants. The most common procedures simulated were diagnostic shoulder arthroscopy (n=9 [60%]), arthroscopic Bankart repairs (n=3 [20%]), and rotator cuff repairs (n =2 [13%]). Simulations primarily utilized virtual reality (60%) and bench top models (40%). The primary outcomes measured were time to task completion and Arthroscopic Surgical Skill Evaluation Tool (ASSET) scores. Time to task completion improved significantly with training (range 13-439 seconds pre-test to 8-253.29 seconds post-test), with substantial heterogeneity across studies (I²=87%). ASSET scores improved in 60% of the studies (ranging from 14-20.9 pre-test to 17.9-28.5 post-test), with low heterogeneity (I²=20%). Additionally, both camera and probe distances decreased after simulation use, while the 14-point anatomic checklist showed no pre to post-test differences.

Conclusion: Arthroscopic simulation training benefits technical skills in shoulder arthroscopy, but the quality, assessment, and validity of these protocols vary. The translation of simulation training into the operating room has yet to be conclusively demonstrated.

Purpose: To assess the patient-reported outcomes measures (PROMs), functional knee measures, and incidence of complications in patients aged 50 and older undergoing anterior cruciate ligament reconstruction (ACLR).

Methods: A literature search was conducted across PubMed, Embase, and Scopus databases, spanning from their inception to November 2023, in accordance with the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. Inclusion criteria consisted of clinical studies reporting PROMs, measures of knee stability, and complication rates, following ACLR in patients aged ≥ 50 with minimum 2 year follow-up. The Methodological Index for Non-Randomized Studies (MINORS) criteria was used to assess study quality. Primary outcome measures consisted of changes PROMs and complication rates following ACLR.

Results: A total of 17 studies, consisting of 1,163 patients undergoing ACLR were identified. Autografts were utilized in 90.3% of patients, compared to 9.7% of patients treated using allografts. At minimum 24-month follow-up, the mean International Knee Documentation Score (IKDC) ranged from 67.4 to 92.96, while mean Lysholm scores ranged from 84.4 to 94.8, and mean Tegner scores ranged from 0.3 to 5.4. The mean side to side difference at final follow-up ranged from 1.2 to 2.4mm while the rates of recurrent instability ranged from 0 to 18%. Complications and revisions ranged from 0% to 40.4% and 0% to 37.5% of cases, with the highest rates observed in studies noting a high incidence of intraoperative cartilage lesions.

Conclusion: Anterior cruciate ligament reconstruction in patients above the age of 50 results in favorable IKDC, Lysholm and Tegner activity scores and improvements in functional knee measures. However, a wide range of reoperation and complications are reported, attributed to varying levels of chondral injury and osteoarthritis which warrant consideration when discussing expectations in patients 50 and above undergoing ACLR.

Level of evidence: IV, Systematic Review of Level II-IV studies.

Massive irreparable rotator cuff tears (MIRCTs) represent a vexing problem, particularly in the physiologically young patient with no glenohumeral arthritis and high functional expectations. Not even the last line of defense, the reverse shoulder arthroplasty can help all of our patients with MIRCTs and resultant pseudoparalysis, and in younger patients, joint preservation could be a preferable first line intervention. Superior capsular reconstruction (SCR) shares the joint preservation arena with an evolving multitude of options, including arthroscopic debridement, partial rotator cuff repair, biologic tuberoplasty, interposition balloon spacer, and lower trapezius tendon transfer. SCR shows promising biomechanical and clinical outcomes, including restoration of native glenohumeral biomechanics and contact pressures, achievement of humeral head depression, reduction of pain, and improved patient reported outcome measures (PROMs) and range of motion (ROM), despite a high rate of graft re-tear or discontinuity. Yet, comparable results may be achieved via simpler procedures including debridement, partial repair, tuberoplasty, and/or spacer. Ultimately, the true value of SCR, or any other technique, would be proven improvement in strength or survivorship from subsequent surgery, particularly reverse arthroplasty. Optimizing indications for these constantly evolving techniques is a moving target and essential for selecting the highest value procedures for patients based on their individual needs.

Forcing ChatGPT and other large language models to perform roles reserved for physicians and other healthcare professionals - namely evaluation, management, and triage - poses a threat from regulatory, risk management, and professional perspectives. The clinical practice of medicine would benefit tremendously from automated administrative support with systems-based transparency and fluidity - not substitution for clinical diagnostics and decision-making. ChatGPT and other large language models are not intended or authorized for clinical use, let alone to be tested or rubber stamped for this application. The best clinical use cases of artificial intelligence require physician partnership to enable personal care, minimize administrative burden, maximize efficiency, and minimize risk - without substitution of core physician tasks.