ChatGPT performance on the American Shoulder and Elbow Surgeons maintenance of certification exam.

BACKGROUND: While multiple studies have tested the ability of large language models (LLMs), such as ChatGPT, to pass standardized medical exams at different levels of training, LLMs have never been tested on surgical sub-specialty examinations, such as the American Shoulder and Elbow Surgeons (ASES) Maintenance of Certification (MOC). The purpose of this study was to compare results of ChatGPT 3.5, GPT-4, and fellowship-trained surgeons on the 2023 ASES MOC self-assessment exam. METHODS: ChatGPT 3.5 and GPT-4 were subjected to the same set of text-only questions from the ASES MOC exam, and GPT-4 was additionally subjected to image-based MOC exam questions. Question responses from both models were compared against the correct answers. Performance of both models was compared to corresponding average human performance on the same question subsets. One sided proportional z-test were utilized to analyze data. RESULTS: Humans performed significantly better than Chat GPT 3.5 on exclusively text-based questions (76.4% vs. 60.8%, P = .044). Humans also performed significantly better than GPT 4 on image-based questions (73.9% vs. 53.2%, P = .019). There was no significant difference between humans and GPT 4 in text-based questions (76.4% vs. 66.7%, P = .136). Accounting for all questions, humans significantly outperformed GPT-4 (75.3% vs. 60.2%, P = .012). GPT-4 did not perform statistically significantly betterer than ChatGPT 3.5 on text-only questions (66.7% vs. 60.8%, P = .268). DISCUSSION: Although human performance was overall superior, ChatGPT demonstrated the capacity to analyze orthopedic information and answer specialty-specific questions on the ASES MOC exam for both text and image-based questions. With continued advancements in deep learning, LLMs may someday rival exam performance of fellowship-trained surgeons.

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses.

CONTEXT: Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health. OBJECTIVE: To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes. DATA SOURCES: PubMed and Scopus databases were searched on April 8, 2022. STUDY SELECTION: Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis. STUDY DESIGN: Umbrella review of SRs and MAs. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted. RESULTS: A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance. CONCLUSION: In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

Spanish-Speaking Patients Have Limited Access Scheduling Outpatient Orthopaedic Appointments Compared With English-Speaking Patients Across the United States.

Purpose: To evaluate whether Spanish-speaking patients can obtain appointments to outpatient orthopaedic surgery clinics across the United States at a similar rate as English-speaking patients and to examine the language interpretation services available at those clinics. Methods: Orthopaedic offices nationwide were called by a bilingual investigator to request an appointment with a pre-established script. The investigators called in English asking for an appointment for an English-speaking patient (English-English), called in English requesting an appointment for a Spanish-speaking patient (English-Spanish), and called in Spanish asking for an appointment for a Spanish-speaking patient (Spanish-Spanish) in a random order. During each call whether an appointment was given, the number of days to the offered appointment, the mechanism of interpretation available in clinic, and whether the patient's citizenship or insurance information was requested was collected. Results: A total of 78 clinics included in the analysis. There was a statistically significant decrease in access to scheduling an orthopaedic appointment in the Spanish-Spanish group (26.3%) compared with English-English (61.3%) or English-Spanish (58.8%) groups (P < .001). There was no significant difference in access to appointment between rural and urban areas. Patients in the Spanish-Spanish group who made an appointment were offered in-person interpretation 55% of the time. There was no statistically significant difference in time from call to offered appointment or the request for citizenship status between the 3 groups. Conclusions: This study detected a considerable disparity regarding access to orthopaedic clinics nationwide in the individuals who called to establish an appointment in Spanish. Patients in the Spanish-Spanish group were able to make an appointment less often but had in-person interpreters available for interpretation services. Clinical Relevance: With a large Spanish-speaking population in the United States, it is important to understand how lack of proficiency with the English language may affect access to orthopaedic care. This study uncovers variables associated with difficulties scheduling appointments for Spanish-speaking patients.

Meniscal Extrusion Measurements After Posterior Medial Meniscus Root Tears: A Systematic Review and Meta-analysis.

BACKGROUND: Meniscal extrusion has become increasingly utilized when evaluating meniscus root abnormalities. However, no consensus definition or approach exists on how to measure extrusion. PURPOSE/HYPOTHESIS: The purpose of this study was to evaluate the extent of heterogeneity in meniscal extrusion measurement techniques and reported extrusion values in knees with posterior medial meniscus root tears (PMMRTs). We hypothesized that meniscal extrusion measurement techniques would vary considerably throughout reported studies, with resultant wide-ranging published extrusion values. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. The inclusion criteria consisted of all clinical and cadaveric studies reporting on meniscal extrusion after PMMRTs, excluding studies lacking data in full extension, those presenting only semiquantitative analyses, articles reporting only differences in meniscal extrusion, and review articles. RESULTS: A total of 45 studies were included. Imaging modality types included magnetic resonance imaging (89%), 3-dimensional reconstruction with computed tomography (7%), linear displacement transducers (2%), and a combination of magnetic resonance imaging and ultrasound (2%). The 3 most commonly used landmarks to acquire coronal images for meniscal extrusion measurements were the medial collateral ligament (38%), the midpoint of the anterior-posterior length of the medial meniscus (23%), and the middle of the medial femoral condyle (19%). The pooled mean extrusion values according to the measurement location were 3.5 ± 0.7 mm, 3.9 ± 0.8 mm, and 4.5 ± 2.1 mm, respectively, with no significant differences noted between the modality types (P = .23). The pooled mean meniscal extrusion from all included studies was 3.2 ± 2.0 mm. CONCLUSION: Substantial variation exists in measurement techniques for meniscal extrusion, particularly as it relates to the coronal cross-sectional reference location. Further studies should aim to provide clear descriptions of the measurement method and have uniform measurement methodology to allow comparisons and pooling between studies.

Arthroscopic biceps tenodesis using the knotless lasso technique.

Long head biceps tendinopathy can be a significant pain generator, often presenting with pain localised to the anterior shoulder. Biceps tenodesis, both open and arthroscopic, is a well-established treatment for long head biceps pathology. In this presentation, we describe a novel arthroscopic onlay technique for long head biceps tenodesis using a lasso configuration with two knotless suture anchors that provide an efficient, low-profile construct to limit scarring and adhesions while providing circumferential fixation. We use this technique for the following surgical indications: severe tendinosis refractory to non-operative management, unable superior labral anterior to posterior (SLAP) tears, biceps instability and partial or complete tearing. The procedure is performed using standard shoulder arthroscopy portals with the addition of an anterolateral biceps working portal approximately 2 cm inferior and 2 cm lateral to the anterior rotator interval portal. Novel advantages of this technique include a low-profile knotless construct, efficient suture passage and circumferential two-point fixation while maintaining anatomic biceps tensioning. Technical pearls including visualisation, release of the biceps tendon from the groove and location of two point tenodesis fixation are all critical to a good outcome.

Radiographic and Clinical Outcomes After Tibial Tubercle Osteotomy for the Treatment of Patella Alta: A Systematic Review and Meta-analysis.

BACKGROUND: Patella alta is a known risk factor for patellar instability and, in the setting of recurrent patellar instability with significant patella alta, correction of patellar height with a tibial tubercle osteotomy (TTO) may help decrease the failure of soft tissue-based stabilization. PURPOSE: To perform a systematic review and meta-analysis of radiographic and clinical outcomes after TTO for patella alta. STUDY DESIGN: Systematic review and meta-analysis; Level of evidence, 4. METHODS: PubMed, OVID/Medline, and Cochrane databases were queried in June 2020 for studies reporting outcomes of TTO for patella alta. Data pertaining to study characteristics and design, radiographic and clinical outcome values, and incidence of complications and reoperations were extracted. DerSimonian-Laird continuous and binary random-effects models were constructed to (1) perform subgroup-based analysis of mean changes in radiographic indices after TTO and (2) quantify the pooled incidence of complications and reoperations. RESULTS: Eight studies including 340 patients (420 knees) with a mean age of 24.7 ± 8.4 years were included. The mean follow-up was 53.1 months (range, 3-120 months), with 1 study reporting a mean follow-up of less than 2 years. The pooled mean anterior transfer was 5.6 mm; the mean medial transfer was 8.7 ± 1.3 mm; and the pooled mean distalization of the tibial tubercle was 12.2 ± 4.5 mm. Continuous random-effects meta-analysis determined that significant reductions in the mean Insall-Salvati ratio (1.40 vs 0.98, P < .001), Caton-Deschamps index (1.26 vs 0.97, P < .001), and tibial tubercle to trochlear groove ratio (18.27 vs 10.69, P < .001) were observed after TTO. The overall incidence of complications was 7.6% (95% CI, 4.8%-10.5%), while the overall incidence of reoperations was 14.3% (95% CI 6.2%-22.4%). CONCLUSION: TTO for patellar instability in the setting of patella alta results in a significant decrease in patellar height with varying degrees of medialization depending on the utilized technique. A mean postoperative complication rate of 7.6% was reported with a reoperation incidence of 14.3%, related primarily to hardware removal.

Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review.

BACKGROUND: Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. PURPOSE: The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. RESULTS: After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. CONCLUSION: Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

Atraumatic Fracture of the Medial Femoral Condyle of a Total Knee Arthroplasty.

The fracture of the femoral component is a rare complication of a total knee arthroplasty (TKA). This article presents a case in which a 70-year-old man underwent a left press-fit Advance Medial-Pivot Knee System TKA (MicroPort Orthopedics, Arlington, TN) in 2000. Twenty years later, he experienced a nontraumatic onset of knee pain after standing up from a lunge position. Radiographs and CT scans revealed a complete fracture of the medial condyle of the femoral component. Revision surgery was performed confirming the broken component. A cemented Triathlon Total Stabilizer (Stryker Orthopedics, Kalamazoo, MI) prosthesis was used for the revision. The authors recommend that surgeons maintain a high level of suspicion of component fracture when patients present with persistent severe knee pain and instability after a TKA.

Hip Instability in the Athlete: Anatomy, Etiology, and Management.

In this review, the recent literature evaluating the anatomic considerations, etiology, and management options for athletes with hip instability are investigated. Studies on the osseous, chondrolabral capsuloligamentous, and dynamic muscular contributions to hip stability are highlighted. Microinstability, iatrogenic instability, and femoroacetabular impingement-induced instability are discussed with a focus on demographic and outcomes research in athletes. Surgical techniques including both open and arthroscopic approaches are additionally evaluated.

Tularemia in a Prosthetic Joint Infection.

Periprosthetic infections occur in approximately 0.8% to 1.9% of all total knee arthroplasties (TKAs). Even with these low rates, it is rare to find a zoonotic bacterium causing a periprosthetic infection. In this case report, the authors identify the second documented case of a total joint infection with Francisella tularensis in the world and the first in the United States. A 58-year-old man underwent a left TKA in 1994 and a right TKA in 1997 for severe primary bilateral knee osteoarthrosis. In 2015, he underwent polyethylene exchange for polyethylene wear. Subsequently, he developed repeated effusion without fever or constitutional signs of infection. One aspiration was sent for culture and grew F tularensis. He was treated with doxycycline for chronic suppression and currently has no signs of infection. Total joint implantation rates are expected to rise, with 3.5 million procedures projected to be performed annually by the year 2030 vs 450,000 procedures performed in 2005. With the increased number of operations, it is likely that zoonotic infections will increase as well. Thus, rare zoonotic bacterial infections as well as chronic outdoor exposure in the presence of persistent joint swelling should be considered when obtaining a patient history. [Orthopedics. 2020; 43(1):e54-e56.].

Step time asymmetry increases metabolic energy expenditure during running.

To improve locomotor performance, coaches and clinicians encourage individuals with unilateral physical impairments to minimize biomechanical asymmetries. Yet, it is unknown if biomechanical asymmetries per se, affect metabolic energy expenditure in individuals with or without unilateral impairments during running. Thus, inter-leg biomechanical asymmetries may or may not influence distance-running performance. PURPOSE: We sought to determine whether running with asymmetric step times affects metabolic rate in unimpaired individuals. METHODS: Ten unimpaired individuals were instructed to run on a force-measuring treadmill at 2.8 m/s and contact the ground simultaneously to the beat of an audible metronome. The metronome either played at time intervals equal to the respective participant's preferred step times (0% asymmetry), or at time intervals that elicited asymmetric step times between legs (7, 14, and 21% step time asymmetry); stride time remained constant across all trials. We measured ground reaction forces and metabolic rates during each trial. RESULTS: Every 10% increase in step time and stance average vertical ground reaction force asymmetry increased net metabolic power by 3.5%. Every 10% increase in ground contact time asymmetry increased net metabolic power by 7.8%. More asymmetric peak braking and peak propulsive ground reaction forces, leg stiffness, as well as positive and negative external mechanical work, but not peak vertical ground reaction force, increased net metabolic power during running. Step time asymmetry increases the net metabolic power of unimpaired individuals during running. Therefore, unimpaired individuals likely optimize distance-running performance by using symmetric step times and overall symmetric biomechanics.