ChatGPT-3.5 Responses Require Advanced Readability for the General Population and May Not Effectively Supplement Patient-Related Information Provided by the Treating Surgeon Regarding Common Questions About Rotator Cuff Repair.

PURPOSE: To investigate the accuracy of ChatGPT's responses to frequently asked questions prior to rotator cuff repair surgery. METHODS: The 10 most common frequently asked questions related to rotator cuff repair were compiled from 4 institution websites. Questions were then input into ChatGPT-3.5 in 1 session. The provided ChatGPT-3.5 responses were analyzed by 2 orthopaedic surgeons for reliability, quality, and readability using the Journal of the American Medical Association Benchmark criteria, the DISCERN score, and the Flesch-Kincaid Grade Level. RESULTS: The Journal of the American Medical Association Benchmark criteria score was 0, indicating the absence of reliable source material citations. The mean Flesch-Kincaid Grade Level was 13.4 (range, 11.2-15.0). The mean DISCERN score was 43.4 (range, 36-51), indicating that the quality of the responses overall was considered fair. All responses cited making final decision-making to be made with the treating physician. CONCLUSIONS: ChatGPT-3.5 provided substandard patient-related information in alignment with recommendations from the treating surgeon regarding common questions around rotator cuff repair surgery. Additionally, the responses lacked reliable source material citations, and the readability of the responses was relatively advanced with a complex language style. CLINICAL RELEVANCE: The findings of this study suggest that ChatGPT-3.5 may not effectively supplement patient-related information in the context of recommendations provided by the treating surgeon prior to rotator cuff repair surgery.

Meniscal ramp lesion classification systems: A systematic review.

PURPOSE: To describe the proposed classification systems for meniscal ramp lesions (RLs) in the literature and evaluate their accuracy and reliability. METHODS: A systematic search was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-analyses guidelines utilising PubMed, Embase and Cochrane Library databases. Level I-IV studies referencing RLs along with either an arthroscopic- or magnetic resonance imaging (MRI)-based classification system used to describe RL subtypes were included. RESULTS: In total, 21 clinical studies were included. Twenty-seven (79%) of the included studies were published in 2020 or later. There were four main classification systems proposed within the literature (two arthroscopic-, two MRI-based), describing tear patterns, mediolateral extent, associated ligament disruption and stability of the lesion. The first classification was proposed in 2015 by Thaunat et al. and is referenced in 22 (64.7%) of the included studies. The application of the Thaunat et al. criteria to MRI showed variable sensitivity (31.70%-93.8%) and interobserver agreement (k = 0.55-0.80). The Greif et al. modification to the Thaunat et al. system was referenced in 32.4% of the included studies and had a substantial interobserver agreement (k = 0.8). Stability to probing and specific tear location were each used to classify RLs in 28.6% and 23.8% of the included clinical studies, respectively. CONCLUSION: Although there has been a recent increase in the recognition and treatment of meniscal RLs, there is limited consistency in descriptive classifications used for this pathology. Current RL classification systems based on preoperative MRI have variable reliability, and arthroscopic examination remains the gold standard for diagnosis and classification. LEVEL OF EVIDENCE: Level IV.

Ulnar Collateral Ligament Reconstruction Is Commonly Performed Using a Palmaris Graft and Provides Favorable Patient Outcomes With Variable Return-to-Play and Postoperative Complication Rates: A Systematic Review.

PURPOSE: To systematically review the literature to provide an updated evaluation of postoperative clinical outcomes, return to play (RTP), and postoperative complications after primary ulnar collateral ligament reconstruction (UCLR) in throwing and nonthrowing athletes at minimum 2-year follow-up. METHODS: A literature search was performed on November 25, 2023, by querying the Embase, PubMed, and Scopus online databases using the 2020 Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines. The inclusion criteria consisted of Level I to IV human clinical studies reporting postoperative outcomes and/or complications after primary UCLR with minimum 2-year follow-up. The exclusion criteria consisted of non-English-language studies; biomechanical, animal, and cadaveric studies; review articles; letters to the editor; and studies not reporting postoperative outcomes or complications. Study quality was evaluated using the Methodological Index for Non-Randomized Studies criteria. The incidence of reported complications among the included studies was extracted. Clinical outcome scores included the Kerlan-Jobe Orthopaedic Clinic Shoulder & Elbow (KJOC) score, Andrews-Timmerman (AT) score, and satisfaction score. RTP data were also extracted. RESULTS: A total of 21 studies published from 2006 to 2023, consisting of 2,452 patients (2,420 male patients) with a mean age of 21.7 years (mean range, 12-65 years) and mean follow-up period of 50.5 months (mean range, 24-151.2 months), were included. The mean Methodological Index for Non-Randomized Studies score was 16 (range, 13-20). A total of 46% of patients (1,138 of 2,452) underwent concomitant ulnar nerve transposition. Palmaris graft was the most frequently used method (66.6%; n = 1,799), followed by hamstring graft (26.0%, n = 703). At the final follow-up, mean postoperative KJOC scores ranged from 72.0 to 88.0; mean AT scores, from 83.6 to 98.3; and mean satisfaction scores, from 86.1 to 98.3. The overall RTP rate ranged from 62.5% to 100% at a mean range of 9.5 to 18.5 months. The total incidence of complications ranged from 0% to 31.8%, with 0% to 7.4% of patients undergoing revision surgery. CONCLUSIONS: UCLR was commonly performed using a palmaris graft, with concomitant ulnar nerve transposition reported in 46% of patients. At a mean follow-up of 50.5 months, mean postoperative KJOC scores ranged from 72 to 98.3, AT scores ranged from 83.6 to 98.3, and satisfaction scores ranged from 86.1 to 98.3, with variable RTP rates. LEVEL OF EVIDENCE: Level IV, systematic review of Level II to IV studies.

Analysis of patient-directed search content and online resource quality for ulnar collateral ligament injury and surgery.

Background: Patients use the Internet to learn information about injuries, yet online content remains largely unstudied. This study analyzed patient questions posed online regarding ulnar collateral ligament (UCL) tears or UCL surgical management. Methods: Three separate search strings about UCL tear and UCL surgery were queried on the Google search engine. The 300 most commonly asked questions were compiled for each topic and associated webpage information was collected from the "People also ask" section. Questions were categorized using the Rothwell classification and webpages by Journal of the American Medical Association (JAMA) benchmark criteria. Results: The most frequent UCL tear questions were "how long does it take to heal a torn UCL?" and "what is nonsurgical treatment for the UCL?" The most frequent UCL surgery question was "can you retear your UCL after surgery?" The Rothwell classification of questions for UCL tear/UCL surgery was 55%/32% policy, 38%/57% fact, and 7%/11% value with highest subcategories being indications/management (46%/25%) and technical details (24%/25%). The most common webpages were academic (39%/29%) and medical practice (24%/26%). Mean JAMA score for all 600 webpages was low (1.2), with journals (mean = 3.4) having the highest score. Medical practice (mean = 0.5) and legal websites (mean = 0.0) had the lowest JAMA scores. Only 30% of webpages provided UCL-specific information. Conclusion: Online UCL patient questions commonly pertain to technical details and injury management. Webpages suggested by search engines contain information specific to UCL tears and surgery only one-third of the time. The quality of most webpages provided to patients is poor, with minimal source transparency.

All-Inside and Inside-Out Repair Techniques for Bucket-Handle Meniscus Tears Both Result in Improved Patient Outcomes and a Broad Range of Failure Rates: A Systematic Review.

PURPOSE: To compare patient-reported outcomes, failure rates, risk factors for failure, and complications in patients with bucket-handle meniscus tears (BHMTs) undergoing repair with inside-out (IO) versus all-inside (AI) techniques. METHODS: A literature search was performed using the PubMed, Embase, and Scopus databases from database inception to August 2023 according to the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. The inclusion criteria consisted of Level I to IV clinical studies published in the past 10 years with greater than 2 years of follow-up that evaluated patient-reported outcome scores and/or the incidence of failure after IO or AI repairs for BHMTs. Clinical studies not reporting outcomes or failure rates, older studies using outdated implants, animal studies, reviews, letters to the editor, case reports, cadaveric studies, and articles not written in the English language or with English-language translation were excluded. Study quality was assessed using the Methodological Index for Non-randomized Studies (MINORS) criteria. Outcomes were reported as ranges and qualitatively compared. RESULTS: A total of 16 studies published from 2013 to 2023, consisting of 1,062 patients with BHMTs, were identified. Thirteen studies (14 cohorts, 649 patients) reported on AI repair (mean age range, 23.7-32 years) and 7 studies (7 cohorts, 413 patients) reported on IO repair (mean age range, 16.7-34.6 years). Both groups had improved postoperative Lysholm and Tegner scores. Decreased range of motion was the most commonly reported complication in the AI group (range, 2.6%-4%), whereas adhesions for arthrofibrosis were the most commonly reported complication in the IO group (n = 12; range, 6%-7.9%). The overall reported failure rate ranged from 6.9% to 20.5% within the AI group and from 0% to 20% within the IO group. CONCLUSIONS: AI and IO repair techniques for BHMTs both result in improved Lysholm and Tegner scores. However, broad ranges of failure are reported in the literature, with overall failure rates ranging from 6.9% to 20.5% after AI repair and from 0% to 20% after IO repair. Younger age and isolated medial BHMT repair are the most frequently reported risk factors for the AI technique, whereas postoperative stiffness is the most frequently reported complication after both repair techniques. LEVEL OF EVIDENCE: Level IV, systematic review of Level I to IV studies.

Increased Posterior Tibial Slope Is Associated With Increased Risk of Meniscal Root Tears: A Systematic Review.

BACKGROUND: While increased posterior tibial slope (PTS) is an established risk factor for anterior cruciate ligament tears, the association between tibial slope and meniscal posterior root tears is not well-defined. PURPOSE: To summarize the available literature evaluating the association between PTS and meniscus root injuries compared with patients without root tears. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A literature search was performed using the Scopus, PubMed, and Embase databases. Human clinical studies evaluating the associations between the medial tibial slope (MTS), lateral tibial slope (LTS), lateral-to-medial (L-to-M) slope asymmetry, and the risk of meniscus root tears were included. Patients with medial meniscus posterior root tears (MMPRTs) and lateral meniscus posterior root tears (LMPRTs) were compared with a control group without root injury. Study quality was assessed using the methodological index for non-randomized studies criteria. RESULTS: Ten studies with 1313 patients were included (884 patients with root tears; 429 controls). The LMPRT subgroup (n = 284) had a significantly greater LTS (mean ± SD, 7.3°± 1.5° vs 5.7°± 3.91°; P < .001), MTS (5.26°± 1.2° vs 4.8°± 1.25°; P < .001), and increased L-to-M asymmetry (2.3°± 1.3° vs 0.65°± 0.5°; P < .001) compared with controls. The MMPRT group (n = 600) had significantly increased MTS relative to controls (8.1°± 2.5° vs 4.3°± 0.7°; P < .001). Furthermore, there was a higher incidence of noncontact injuries (79.3%) and concomitant ramp lesions (56%) reported in patients with LMPRT. CONCLUSION: Increased MTS, LTS, and L-to-M slope asymmetry are associated with an increased risk of LMPRTs, while increased MTS is associated with MMPRTs. Surgeons should consider how proximal tibial anatomy increases the risk of meniscus root injury.

Increased Alpha Angles and Younger Age Increase the Risk of Contralateral Femoral Acetabular Impingement Syndrome Symptom Development and Surgical Intervention: A Systematic Review.

PURPOSE: To identify the preoperative risk factors associated with contralateral symptom development and surgical intervention for patients presenting with unilateral femoral acetabular impingement (FAI) syndrome. METHODS: A literature search was performed using PubMed and Scopus computerized databases according to the 2020 Preferred Reporting Items for Systematic Meta-Analyses guidelines. Studies evaluating preoperative risk factors associated with the contralateral progression of FAI were included. Quality assessment was completed using the Methodological Index for Non-Randomized Studies criteria. RESULTS: A total of 5 studies (n = 1,011 patients; mean age, 29.9 years) published from 2013 to 2022 met the inclusion/exclusion criteria. Mean follow-up ranged from 12 to 132 months. The overall rate of contralateral progression of symptomatic FAI ranged from 32.4% to 81%. Increased alpha angle was frequently reported factor associated with contralateral symptom progression, followed by decreased total arc of rotation, decreased internal rotation, reduced neck-shaft angle, and head-neck offset. The incidence rate of progression to contralateral surgery ranged from 15.7% to 24% of patients. Younger age was frequently reported factor associated with contralateral surgical intervention, followed by male sex, increased level of activity, and increased alpha angle. CONCLUSIONS: Increased alpha angle and younger age were commonly reported risk factors associated with an increased risk of symptom development and surgical progression of contralateral FAI, respectively. The overall rate of contralateral progression of symptomatic FAI and the rate of progression to surgical intervention ranged up to 81% and 24%, respectively. This information may help both patients and surgeons to establish expectations regarding development of contralateral hip symptoms and possible need for surgery. LEVEL OF EVIDENCE: Level III; systematic review of Level II-III studies.

Patient-Directed Online Education for Carpal Tunnel Syndrome and Release: Analysis of What Patients Ask and Quality of Resources.

Purpose: This study classifies common questions searched by patients from the Google search engine and categorizes the types and quality of online education resources used by patients regarding carpal tunnel syndrome (CTS) and carpal tunnel release (CTR). Methods: Google's results were extracted and compiled using the "People also ask" function for frequent questions and associated web pages for CTS and CTR. Questions were categorized using Rothwell's classification with further topic subcategorization. Web pages were evaluated by using Journal of the American Medical Association Benchmark Criteria for source quality. Results: Of the 600 questions evaluated, "How do I know if I have carpal tunnel or tendonitis?" and "What causes carpal tunnel to flare up?" were the most commonly investigated questions for CTS. For CTR, frequent questions investigated included "How long after hand surgery can I drive" and "How do you wipe after carpal tunnel surgery." The most common questions for CTS by Rothwell classification were policy (51%), fact (41%), and value (8%) with the highest subcategories being indications/management (46%) and technical details (27%). For CTR, the most common questions entailed fact (54%), policy (34%), and value (11%) with the highest subcategories as technical details (31%) and indications/management (26%). The most common web pages were academic and medical practice. The mean Journal of the American Medical Association score for all 600 web pages was 1.43, with journals (mean = 3.91) having the highest score and legal (mean = 0.52) and single surgeon practice websites (mean = 0.28) having the lowest scores. Conclusions: Patients frequently inquire online about etiology, precipitating factors, diagnostic criteria, and activity restrictions regarding CTS/CTR. Overall, the quality of online resources for this topic was poor, especially from single surgeon practices and legal websites. Clinical relevance: Understanding the type and quality of information patients are accessing assists physicians in tailoring counseling to patient concerns and facilitates informed decision-making regarding CTS/CTR as well as guiding patients to high-quality online searches.

Higher Rates of Residual Postoperative Instability after Anterior Cruciate Ligament Reconstruction in Female Patients: A Systematic Review of Level II Studies.

Purpose: To compare revision rates and residual postoperative instability after anterior cruciate ligament (ACL) reconstruction based on biological sex. Methods: A systematic review was conducted according to the 2020 PRISMA guidelines. PubMed, Embase, MEDLINE, and Cochrane library databases were queried from database inception through October 2022. Level I and II prospectively-enrolling human clinical studies that compared revision rates and physical examination of postoperative stability after ACL reconstruction between male and female patients were included. Outcomes were stratified by patient sex and quantitatively compared using a χ2 test. Study quality was assessed using the MINORS criteria. Results: Four studies consisting of 406 patients (50% males) with a mean age of 25 years (range, 13.9-62 years) were identified. Mean follow-up time was 34.4 months (range, 22-60 months). Hamstring tendon autografts were used in 62% of ACL reconstructions in males and in 65% of ACL reconstructions in females, whereas bone-patellar tendon-bone autografts were used in 38% and 35% of procedures in males and females, respectively. A residual positive Lachman test result was more frequently reported among females compared to males (5.8% vs 0.6%; P = 0.03). No significant difference in revision rates or residual pivot-shift on examination was observed between males and females (P = 0.38 and P = 0.08, respectively). Conclusion: Female patients undergoing ACL reconstruction have higher reported rates of residual anterior instability with Lachman than male patients. However, no sex-based differences were identified with residual pivot-shift on examination or rate of revision ACL surgery. Level of Evidence: II; Systematic Review of level II studies.

Radiofrequency-Based Chondroplasty Creates a Precise Area of Targeted Chondrocyte Death With Minimal Necrosis Outside the Target Zone: A Systematic Review.

Purpose: To systematically examine the effects of radiofrequency (RF) ablation or coblation (controlled ablation) on chondrocyte viability following knee chondroplasty in preclinical literature to determine the effectiveness and safety of RF-based techniques. Methods: A literature search was performed in September 2022 using PubMed and Scopus using the following search terms combined with Boolean operators: "chondroplasty," "radiofrequency," "thermal," "knee," "chondral defect," "articular cartilage," and "cartilage." The inclusion criteria consisted of preclinical studies examining the effect of RF ablation or coblation on chondrocytes during knee chondroplasty. Exclusion criteria consisted of studies reporting chondroplasty in joints other than the knee, clinical studies, in vitro studies using animal models, case reports, non-full-text articles, letters to editors, surveys, review articles, and abstracts. The following data were extracted from the included articles: author, year of publication, chondral defect location within the knee and chondral characteristics, RF probe characteristics, cartilage macroscopic description, microscopic chondrocyte description, and extracellular matrix characteristics. Results: A total of 17 articles, consisting of 811 cartilage specimens, were identified. The mean specimen age was 63.4 ± 6.0 (range, 37-89) years. Five studies used monopolar RF devices, 7 studies used bipolar RF devices, whereas 4 studies used both monopolar and bipolar RF devices. Time until cell death during ablation at any power was reported in 5 studies (n = 351 specimens), with a mean time to cell death of 54.4 seconds (mean range, 23.1-64) for bipolar RF and 56.3 seconds (mean range, 12.5-64) for monopolar RF devices. Chondrocyte cell death increased with increased wattage, while treatment time was positively correlated with deeper cell death. Conclusions: In this systematic review, histologic analysis demonstrated that RF-based chondroplasty creates a precise area of targeted chondrocyte death, with minimal evidence of necrosis outside the target zone. Caution must be exercised when performing RF-based chondroplasty due to the risk of cell death with increased application time and wattage. Clinical Relevance: Although RF ablation has demonstrated favorable results in preliminary trials, including smoother cartilage and less damage to the surrounding healthy tissue, the risks versus benefits of the procedure are largely unknown. Caution must be exercised when performing RF-based chondroplasty in the clinical setting due to the risk of cell death with increased application time and wattage.

Medial Collateral Ligament Reconstruction and Repair Show Similar Improvement in Outcome Scores, But Repair Shows Higher Rates of Knee Stiffness and Failure: A Systematic Review.

PURPOSE: To compare patient-reported outcomes and complications in patients with medial collateral ligament (MCL) injuries undergoing repair versus reconstruction with a minimum 2-year follow-up. METHODS: A literature search was conducted using the PubMed, Scopus, and Embase-computerized databases from database inception to November 2022, according to the 2020 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies evaluating clinical outcomes and complications at a minimum of 2 years following MCL repair versus reconstruction were included. Study quality was assessed using the MINORS criteria. RESULTS: A total of 18 studies published from 1997 to 2022, consisting of 503 patients were identified. Twelve studies (n = 308 patients; mean age: 32.6 years) reported outcomes following MCL reconstruction, and 8 studies (n = 195 patients; mean age: 28.5 years) reported results following MCL repair. Postoperative International Knee Documentation Committee, Lysholm, and Tegner scores ranged from 67.6 to 91, 75.8 to 94.8, and 4.4 to 8, respectively, in the MCL reconstruction group, compared to 73 to 91, 75.1 to 98.5, and 5.2 to 10, respectively, in the MCL repair group. Knee stiffness was the most commonly reported complication following MCL repair (range: 0% - 50%) and reconstruction (range: 0% - 26.7%). Failures occurred in 0% to 14.6% of patients following reconstruction versus 0% to 35.1% of patients undergoing MCL repair. Manipulation under anesthesia (MUA) for postoperative arthrofibrosis (range: 0% - 12.2%) and surgical debridement for arthrofibrosis (range: 0% - 20%) were the most commonly reported reoperations in the MCL reconstruction and repair groups, respectively. CONCLUSIONS: MCL reconstruction versus repair both demonstrate improved International Knee Documentation Committee, Lysholm, and Tegner scores. MCL repair demonstrates higher rates of postoperative knee stiffness and failure at a minimum 2-year follow-up. LEVEL OF EVIDENCE: Level IV, systematic review of Level III and IV studies.

Keratin 13 deficiency causes white sponge nevus in mice.

White sponge nevus (WSN) is a benign autosomal dominant disorder characterized by the formation of white spongy plaques in the oral mucosa. Keratin (KRT) 13 is highly expressed in the mucosa, and mutations in this gene have been commonly associated with WSN patients. However, it remains unknown whether there is a causal relationship between KRT13 mutations and WSN and what the underlying mechanisms might be. Here, we use mouse genetic models to demonstrate that Krt13 is crucial for the maintenance of epithelial integrity. Krt13 knockout mice show a WSN-like phenotype in several tissues, including the tongue, buccal mucosa, and esophagus. Transcriptome analyses uncover that Krt13 regulates a cohort of gene networks in tongue epithelial cells, including epithelial differentiation, immune responses, stress-activated kinase signaling, and metabolic processes. We also provide evidence that epithelial cells without Krt13 are susceptible to mechanical stresses experienced during postnatal life, resulting in unbalanced cell proliferation and differentiation. These data demonstrate that Krt13 is essential for maintaining epithelial homeostasis and loss of Krt13 causes the WSN-like phenotype in mice.