Current Concepts Review: Large Language Models in Orthopaedics: Definitions, Uses, and Limitations.

➤ Large language models are a subset of artificial intelligence. Large language models are powerful tools that excel in natural language text processing and generation.➤ There are many potential clinical, research, and educational applications of large language models in orthopaedics, but the development of these applications needs to be focused on patient safety and the maintenance of high standards.➤ There are numerous methodological, ethical, and regulatory concerns with regard to the use of large language models. Orthopaedic surgeons need to be aware of the controversies and advocate for an alignment of these models with patient and caregiver priorities.

Sleep disturbances in rotator cuff pathology: insights into mechanisms and clinical implications.

Rotator cuff disease is highly prevalent and can have a detrimental effect on the quality of life of affected patients. One of the most common complaints from rotator cuff disease is sleep disturbance due to shoulder pain. Numerous studies have attempted to explore the relationship between rotator cuff disease and sleep disturbance, but results are inconsistent and limited. In this setting, the Pittsburgh Sleep Quality Index (PSQI) plays an important role in preoperative assessment and evaluation of sleep in rotator cuff patients. However, despite the current efforts, the literature presents conflicting results regarding the relationships between magnetic resonance imaging characteristics of rotator cuff tear and PSQI score, signifying a gap in understanding. That being said, it has been shown that rotator cuff repair surgery can alleviate sleep disturbances witnessed preoperatively in and can restore quality of life.

The addition of mammalian cell culture medium impacts nanoparticle toxicity in zebrafish.

Engineered nanomaterials (ENMs) are ubiquitous in contemporary applications, yet their environmental and human health impacts remain inadequately understood. This study addresses the challenge of identifying potential risks associated with ENM exposure by highlighting the significant variability in existing research methodologies. Without a systematic collection of toxicological data that encompasses standardized materials, relevant platforms, and assays, the task of identifying potential risks linked to ENM exposure becomes an intricate challenge. In vitro assessments often use media rich in ionic species, such as RPMI and fetal bovine serum (FBS). Zebrafish embryos, known to develop normally in low-ionic environments, were exposed to Cerium Oxide, Zinc Oxide, and Graphene Oxides in different media at varying concentrations. Here, we discovered that zebrafish embryos tolerated a mix of 80 % RPMI, 2 % FBS, and 1 % antibiotic cocktail. The results revealed that adverse effects observed in zebrafish with certain nanomaterials in Ultra-Pure (UP) water were mitigated in cell culture medium, emphasizing the importance of revisiting previously considered non-toxic materials in vitro. The zebrafish results underscore the importance of utilizing a multidimensional in vivo platform to gauge the biological activity of nanomaterials accurately.

Is Arthroscopic Latarjet a Cost-Effective Procedure? A Decision Analysis.

Objectives: Arthroscopic Latarjet for glenohumeral stabilization has emerged as an alternative to the open approach; however, the evidence to date has questioned if this technique delivers improved outcomes. This analysis provides an assessment of the cost and utility associated with arthroscopic versus open Latarjet. Methods: The cost-effectiveness of Latarjet stabilization was modeled over a ten-year period. Institutional cases were reviewed for equipment utilization. Cost data from ambulatory surgical centers was obtained for each piece of equipment used intraoperatively. Based upon prior analyses, the operating room cost was assigned a value of $36.14 per minute. To determine effectiveness, a utility score was derived based upon prior analysis of shoulder stabilization using the EuroQol (EQ) 5D. For reoperations, a utility score of 0.01 was assigned for a single year for revision surgeries for instability and 0.5 for minor procedures. Probability of surgical outcomes and operative time for arthroscopic and open Latarjet were taken from prior studies comparing outcomes of these procedures. Decision-tree analysis utilizing these values was performed. Results: Based upon equipment and operating room costs, arthroscopic Latarjet was found to cost $2,796.87 more than the equivalent open procedure. Analysis of the utility of these procedures were 1.330 and 1.338 quality adjusted life years obtained over the modeled period for arthroscopic versus open Latarjet, respectively. For arthroscopic Latarjet to be cost-equivalent to open Latarjet, surgical time would need to be reduced to 41.5 minutes or the surgical equipment would need to be provided at no expense, while maintaining the same success rates. Conclusion: With nearly identical utility scores favoring open surgery, the added cost associated with arthroscopic Latarjet cannot be supported with available cost and utility data. To provide value, additional benefits such as decreased post-operative narcotic utilization, decreased blood loss, or lower complications of the arthroscopic approach must be demonstrated.

Beyond the joint: Exploring the interplay between mental health and shoulder arthroplasty outcomes.

Considering the fact that mental health illnesses increase with age, and that shoulder arthroplasty procedures are often indicated in the older population, exploring the relationship between mental health and shoulder arthroplasty outcomes can have pivotal implications for shoulder surgeons and patients worldwide. The literature has shown that patients with poor mental health report lower patient-reported outcomes, higher peri-operative complications (such as anemia, infection, delirium, and others), lengthier hospital stays, and higher readmission rates than the normal patient. Employing a holistic approach when managing shoulder arthroplasty patients is necessary for optimizing outcomes and setting up recovery expectations.

Similar return to sport between double cortical button and docking techniques for ulnar collateral ligament reconstruction in baseball players.

BACKGROUND AND HYPOTHESIS: A double cortical button technique for ulnar collateral ligament reconstruction (UCLR) has advantages including significant control over graft tensioning, less concern about graft length, and minimized risk of bone tunnel fracture compared with traditional UCLR techniques. This double cortical button technique was recently found to be noninferior in mechanical performance to the traditional docking technique regarding joint strength, joint stiffness, and graft strain. However, clinical outcomes have not been compared between these UCLR techniques. Therefore, the purpose of this study was to determine whether baseball players who underwent UCLR with a double cortical button (double button) technique have similar return-to-sport (RTS) outcomes to baseball players who underwent UCLR with the traditional docking (docking) technique. MATERIALS AND METHODS: Baseball players who underwent primary UCLR from 2011 to 2020 across 2 institutions were identified. Included patients were contacted to complete a follow-up survey evaluating reoperations, RTS, and functional outcome scores. Functional outcome surveys include the Kerlan-Jobe Orthopaedic Clinic score, the Conway-Jobe score, the Andrews-Timmerman elbow score, and the Single Assessment Numeric Evaluation score. RESULTS: Overall, 78 male baseball players (age: 18.9 ± 2.4 years) with an average follow-up of 3.1 ± 2.4 years were evaluated, with 73 of the players being baseball pitchers. Players in the double button group more frequently received palmaris longus autografts (78% vs. 30%) and less frequently received gracilis autografts (22% vs. 58%) compared with players in the docking group (P = .001); however, all other demographic factors were similar between the groups. All players in the double button group were able to RTS in 11.1 ± 2.6 months, whereas 96% of players in the docking group were able to RTS in 13.5 ± 3.4 months (P > .05). All postoperative outcomes and patient-reported outcomes were statistically similar between the groups and remained similar after isolating pitchers only and after separating partial-thickness from full-thickness UCL tears (all P > .05). CONCLUSION: RTS and other postoperative outcomes may be similar between baseball players who underwent UCLR with the double button technique and the docking technique. Although future research may be necessary to strengthen clinical recommendations, these findings provide the first clinical outcomes in light of a recent cadaveric study finding similar elbow strength, joint stiffness, and graft strain compared with the docking technique.

Anatomic factors associated with degeneration and fraying of the coracoacromial ligament.

BACKGROUND: The coracoacromial ligament (CAL) is frequently observed to be damaged during arthroscopy and it is unclear how demographic, anatomic, and radiographic factors are related to CAL degeneration in full-thickness rotator cuff tears. METHODS: A prospective study was conducted of patients at a single institution undergoing shoulder arthroscopy for first-time, full-thickness rotator cuff tears. We evaluated preoperative anteroposterior radiographs to obtain critical shoulder angle, glenoid inclination, acromial index, acromiohumeral distance, lateral acromial angle, and acromial morphology. We documented CAL quality, rotator cuff tear size and pattern during arthroscopy. Multiple logistic regression was used to identify predictive factors for encountering severe CAL fraying during arthroscopy. RESULTS: Shoulders had mild CAL degeneration in 58.1% of cases, whereas severe CAL degeneration was present in 41.9% of shoulders. Patients with severe CAL attrition were significantly older (62.0 years vs. 58.0 years, P=0.042). Shoulders with severe CAL attrition had large rotator cuff tears in 54.1% of cases (P<0.001), and tears involving the infraspinatus (63.2% vs. 29.6%, P=0.003). The severe degeneration group was more likely to have a larger critical shoulder angle measurement on preoperative radiographs than those in the mild attrition group (36.1°±3.6° [range, 30°-45°] vs. 34.1°±3.8° [range, 26°-45°], P=0.037). CONCLUSIONS: While the clinical impact of CAL degeneration remains uncertain, increased severity of CAL degeneration is associated with older age, larger rotator cuff tear size, presence of infraspinatus tearing, and increased preoperative critical shoulder angle. Level of evidence: III.

Comparison of total elbow arthroplasty complications between various surgical indications at 90-day and 1-year follow-up in 1600 elbows.

BACKGROUND: Total elbow arthroplasty (TEA) was traditionally a mainstay of treatment for patients with severe inflammatory arthritis. Recently, the indications for TEA have expanded, and TEA has grown into a versatile procedure that can be used to treat several pathologies of the elbow. The objective of this study was to compare complication rates between TEAs performed for rheumatoid arthritis (RA), fracture (FX), or osteoarthritis (degenerative joint disease [DJD]). METHODS: A retrospective analysis of the MUExtr data set of the PearlDiver national database was performed. International Classification of Diseases, Tenth Revision codes were used to identify patients who underwent TEA from 2010-2020 and to separate them into RA, FX, and DJD cohorts. Demographic characteristics, comorbidities, and hospital data were identified and compared using analysis of variance. Systemic complications at 90 days and surgical complications at both 90 days and 1 year were compared using multivariable logistic regression. Surgical complications included wound dehiscence, hematoma, deep infection, periprosthetic FX, stiffness, instability, triceps injury, nerve injury, and need for revision. RESULTS: We identified 1600 patients (DJD, 38.9%; FX, 48.8%; and RA, 12.3%). The majority of patients in all 3 cohorts were female patients, with the RA group having a significantly higher percentage of female patients than the FX and DJD groups (87.3% vs. 81.4% and 76.9%, respectively; P = .003). No significant differences in systemic complications and surgical complications were noted between all 3 groups at 90 days postoperatively. After controlling for patient factors, FX patients were more likely to have elbow stiffness (odds ratio, 1.53; P = .006) and less likely to have a triceps injury (odds ratio, 0.26; P < .001) at 1 year than were RA or DJD patients. CONCLUSION: The indications for TEA have expanded over the past 10 years, with nearly half of all cases being performed for FX. At 1 year postoperatively, TEAs performed for FX have a significantly lower rate of triceps injury and higher rate of elbow stiffness than TEAs performed for other indications. This finding is important to consider when preoperatively planning, as well as when discussing expected outcomes with patients prior to surgery, especially with the expanded incidence of TEA for FX being performed over the past decade.

Size- and Oxidation-Dependent Toxicity of Graphene Oxide Nanomaterials in Embryonic Zebrafish.

Graphene oxides (GOs) are a popular graphene alternative. The goal of this study was to compare the biocompatibility of a diversity of well-characterized GOs. Our previous work advanced developmental zebrafish as a model to interrogate the interactions and biological responses following exposures to engineered nanomaterials (ENMs). Here, we investigated GO 250 nm × 250 nm (sGO), 400 nm × 400 nm (mGO), and 1 µm × 1 µm (lGO), partially reduced GO (prGO) 400 nm × 400 nm, and reduced GO (rGO) 400 nm × 400 nm and 2 µm × 2 µm, which first underwent extensive characterization under the support of the Nanomaterials Health Implications Research (NHIR) Consortium. GOs were stabilized in water (GOs), while prGO and rGOs were dispersed in sodium cholate. Zebrafish were statically exposed to up to 50 µg/mL of each material from 6 h post-fertilization (hpf) until 120 hpf. Toxicity was dependent on GO properties. mGO was the most toxic material; its effects manifested in the yolk syncytial layer (YSL). Additionally, sodium cholate stabilization significantly increased GO toxicity. The observed effects were size- and oxidation-state-dependent, revealing the importance of identifying the structure-specific toxicity of GOs.

Correction: The expanding spectrum of diketopiperazine natural product biosynthetic pathways containing cyclodipeptide synthases.

Correction for 'The expanding spectrum of diketopiperazine natural product biosynthetic pathways containing cyclodipeptide synthases' by Paul Borgman et al., Org. Biomol. Chem., 2019, DOI: 10.1039/c8ob03063d.

The expanding spectrum of diketopiperazine natural product biosynthetic pathways containing cyclodipeptide synthases.

Microorganisms are remarkable chemists, with enzymes as their tools for executing multi-step syntheses to yield myriad natural products. Microbial synthetic aptitudes are illustrated by the structurally diverse 2,5-diketopiperazine (DKP) family of bioactive nonribosomal peptide natural products. Nonribosomal peptide synthetases (NRPSs) have long been recognized as catalysts for formation of DKP scaffolds from two amino acid substrates. Cyclodipeptide synthases (CDPSs) are more recently recognized catalysts of DKP assembly, employing two aminoacyl-tRNAs (aa-tRNAs) as substrates. CDPS-encoding genes are typically found in genomic neighbourhoods with genes encoding additional biosynthetic enzymes. These include oxidoreductases, cytochrome P450s, prenyltransferases, methyltransferases, and cyclases, which equip the DKP scaffold with groups that diversify chemical structures and confer biological activity. These tailoring enzymes have been characterized from nine CDPS-containing biosynthetic pathways to date, including four during the last year. In this review, we highlight these nine DKP pathways, emphasizing recently characterized tailoring reactions and connecting new developments to earlier findings. Featured pathways encompass a broad spectrum of chemistry, including the formation of challenging C-C and C-O bonds, regioselective methylation, a unique indole alkaloid DKP prenylation strategy, and unprecedented peptide-nucleobase bond formation. These CDPS-containing pathways also provide intriguing models of metabolic pathway evolution across related and divergent microorganisms, and open doors to synthetic biology approaches for generation of DKP combinatorial libraries. Further, bioinformatics analyses support that much unique genetically encoded DKP tailoring potential remains unexplored, suggesting opportunities for further expansion of Nature's biosynthetic spectrum. Together, recent studies of DKP pathways demonstrate the chemical ingenuity of microorganisms, highlight the wealth of unique enzymology provided by bacterial biosynthetic pathways, and suggest an abundance of untapped biosynthetic potential for future exploration.

Surface modifications for enhanced enzyme immobilization and improved electron transfer of PQQ-dependent glucose dehydrogenase anodes.

Pyrroloquinoline quinone dependent soluble glucose dehydrogenase (PQQ-sGDH) enzymatic MWCNT electrodes were p roduced using 1-pyrenecarboxylic acid (PCA) activated through carbodiimide functionalization and 1-Pyrenebutyric acid N-hydroxysuccinimide ester (PBSE) as tethering agents. At 600 mV potential, the current density generated by the activated-PCA tethered PQQ-sGDH anode was significantly greater than the current density generated by the untethered PQQ-sGDH and PBSE tethered anodes, and performance was nearly identical to the performance of a covalently bound PQQ-sGDH anode. A technique for covalently bonding heme-b (hemin), a natural quinohemoprotein porphyrin redox cofactor, to carbon nanotubes modified with arylamine groups is reported. The resulting performance of the covalently bound hemin PQQ-sGDH anode is considerably higher than that of any other PQQ-sGDH anodes tested.

Towards a hybrid anaerobic digester-microbial fuel cell integrated energy recovery system: an overview of the development of an electrogenic biofilm.

An electrogenic biofilm was developed on a macroporous chitosan-carbon nanotube (CHIT-CNT) electrode under constant poised potential (-0.25V versus Ag/AgCl reference electrode) and flow through conditions utilizing the effluent of an anaerobic digester as both the inoculant and substrate for the electrogenic biofilm. After 125 days of inoculation the bioelectrode demonstrated an open circuit potential of -0.62V and a current density of 9.43µAcm(-3) (at -0.25V). Scanning electron microscopy images indicate thorough surface coverage of the biofilm with a high density of bacterial nanowires physically connecting bacteria to bacteria and bacteria to carbon nanotube (electrode surface) suggesting the nanowires are electrically conductive. DGGE was used to identify the major bacterial and archaeal populations.