Google Bard and ChatGPT in Orthopedics: Which Is the Better Doctor in Sports Medicine and Pediatric Orthopedics? The Role of AI in Patient Education.

BACKGROUND: This study evaluates the potential of ChatGPT and Google Bard as educational tools for patients in orthopedics, focusing on sports medicine and pediatric orthopedics. The aim is to compare the quality of responses provided by these natural language processing (NLP) models, addressing concerns about the potential dissemination of incorrect medical information. METHODS: Ten ACL- and flat foot-related questions from a Google search were presented to ChatGPT-3.5 and Google Bard. Expert orthopedic surgeons rated the responses using the Global Quality Score (GQS). The study minimized bias by clearing chat history before each question, maintaining respondent anonymity and employing statistical analysis to compare response quality. RESULTS: ChatGPT-3.5 and Google Bard yielded good-quality responses, with average scores of 4.1 ± 0.7 and 4 ± 0.78, respectively, for sports medicine. For pediatric orthopedics, Google Bard scored 3.5 ± 1, while the average score for responses generated by ChatGPT was 3.8 ± 0.83. In both cases, no statistically significant difference was found between the platforms (p = 0.6787, p = 0.3092). Despite ChatGPT's responses being considered more readable, both platforms showed promise for AI-driven patient education, with no reported misinformation. CONCLUSIONS: ChatGPT and Google Bard demonstrate significant potential as supplementary patient education resources in orthopedics. However, improvements are needed for increased reliability. The study underscores the evolving role of AI in orthopedics and calls for continued research to ensure a conscientious integration of AI in healthcare education.

Low-density cultured cartilage cells expanded in platelet lysate present distinct features to develop an innovative clinical treatment for diffuse cartilage lesions.

PURPOSE: Chondrocyte-based cell therapies are effective for the treatment of chondral lesions, but remain poorly indicated for diffuse lesions in the context of early osteoarthritis (OA). The aim of this study was to develop a protocol to obtain chondroprogenitor cells suitable for the treatment of diffuse chondral lesions within early OA. METHODS: Cartilage cells were expanded at low density in human platelet lysate (hPL). A test was performed to exclude senescence. The expression of surface cluster of differentiation 146, cluster of differentiation 166, major histocompatibility complex (MHC)-I and MHC-II and of genes of interest were evaluated, as well as the trophic potential of these cells, by the assessment of lubricin and matrix production. The immunomodulatory potential was assessed through their co-culture with macrophages. RESULTS: Cartilage cells expanded at low density in hPL showed higher proliferation rate than standard-density cells, no replicative senescence, low immunogenicity and expression of lubricin. Moreover, they presented an increased expression of chondrogenic and antihypertrophic markers, as well as a superior matrix deposition if compared to cells cultured at standard density. Cartilage cells induced on macrophages an upregulation of CD206, although a higher increase of CD163 expression was observed in the presence of low-density cells. CONCLUSIONS: These findings lay the grounds to explore the clinical usefulness of low-density cultured cartilage cells to treat diffuse lesions in early OA joints for both autologous and allogenic use. LEVEL OF EVIDENCE: Not applicable.

Management of Medial Femorotibial Knee Osteoarthritis in Conjunction with Anterior Cruciate Ligament Deficiency: Technical Note and Literature Review.

In recent years, there has been increased interest in the management of medial femorotibial knee osteoarthritis (OA) in conjunction with anterior cruciate ligament (ACL) deficiency. Traditional treatment modalities included conservative therapy, high tibial osteotomy with or without ACL reconstruction, and total knee replacement. Since younger patients with higher physical demands are more likely to suffer from this pathological condition, reduced invasiveness, faster recovery time, and improved knee kinematics are preferred to allow for satisfying clinical and functional outcomes. Thus, a new surgical strategy combining medial unicompartmental knee replacement (UKR) and ACL reconstruction has been proposed to allow bone stock preservation, to reduce surgical morbidity and recovery time, and ultimately to improve joint kinematics and clinical outcomes. Based on the data present in the literature, in the setting of unicompartmental OA in association with ACL deficiency, UKR combined with ACL reconstruction provided encouraging early results. Studies evaluating the outcomes of combined ACL reconstruction and UKR demonstrate promising results in select patient populations. Improved knee stability, pain relief, functional recovery, and patient satisfaction improved after surgery. Moreover, the combined approach offered advantages such as reduced surgical trauma, faster rehabilitation, and preservation of native knee anatomy compared with traditional treatment strategies. However, still, high-level studies on this topic are lacking; therefore, more comparative studies reporting long-term outcomes are needed to support the potential of this combined procedure to become mainstream. In this paper, we discuss the relevant features and rationale behind the indications and technique of this combined surgical procedure, to help surgeons choose the correct therapeutic approach for a patient with concomitant medial OA and ACL insufficiency. Continued advancements in surgical techniques, patient selection criteria, and rehabilitation strategies will further enhance the success of this combined approach, offering hope to individuals with concomitant ACL injuries and unicompartmental knee OA.

Microbiology of Prosthetic Joint Infections: A Retrospective Study of an Italian Orthopaedic Hospital.

The most frequent cause of periprosthetic infections (PJIs) is intraoperative contamination; hence, antibiotic prophylaxis plays a crucial role in prevention. Modifications to standard prophylaxis can be considered if there is a high incidence of microorganisms resistant to current protocols. To date, very few studies regarding microbial etiology have been published in Italy. In this single-center, retrospective study conducted at IRCCS Ospedale Galeazzi-Sant'Ambrogio in Milan, we analyzed hip, knee, and shoulder PJIs in patients undergoing first implantation between 1 January 17 and 31 December 2021. The primary aim was to derive a local microbiological case history. The secondary aim was to evaluate the adequacy of preoperative antibiotic prophylaxis in relation to the identified bacteria. A total of 57 PJIs and 65 pathogens were identified: 16 S. aureus, 15 S. epidermidis, and 10 other coagulase-negative staphylococci (CoNS), which accounted for 63% of the isolations. A total of 86.7% of S. epidermidis were methicillin-resistant (MRSE). In line with other case reports, we found a predominance of staphylococcal infections, with a lower percentage of MRSA than the Italian average, while we found a high percentage of MRSE. We estimated that 44.6% of the bacteria isolated were resistant to cefazolin, our standard prophylaxis. These PJIs could be prevented by using glycopeptide alone or in combination with cefazolin, but the literature reports conflicting results regarding the adequacy of such prophylaxis. In conclusion, our study showed that in our local hospital, our standard antibiotic prophylaxis is ineffective for almost half of the cases, highlighting the importance of defining specific antibiotic guidelines based on the local bacterial prevalence of each institution.

Orthobiologics in delayed union and non-union of adult long bones fractures: A systematic review.

Background: Fracture healing poses a significant challenge in orthopedics. Successful regeneration of bone is provided by mechanical stability and a favorable biological microenvironment. This systematic review aims to explore the clinical application of orthobiologics in treating aseptic delayed union and non-union of long bones in adults. Methods: A systematic review was conducted following the Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines. Three databases were explored, with no date restrictions, using keywords related to orthobiologics and delayed union and non-union. Eligible studies included human clinical studies in English, with available full texts, examining orthobiologics such as platelet-rich plasma (PRP), mesenchymal stem cells (MSCs), and bone morphogenetic protein (BMPs) for treating aseptic delayed unions and non-unions in adults. Animal studies, in vitro research, and studies on non-unions due to congenital defects, tumors or infections were excluded. Results: The initial search identified 9417 studies, with 20 ultimately included in the review. These studies involved 493 patients affected by non-union and 256 patients affected by delayed union, with an average age respectively of 40.62 years and 41.7 years. The mean follow-up period was 15.55 months for non-unions and 8.07 months for delayed unions. PRP was the most used orthobiologic, and outcomes were evaluated through time to union, functional scores, and clinical examinations. The results indicated that orthobiologics, especially PRP, tended to yield better outcomes compared to surgical procedures without biological factors. Conclusion: This systematic review suggests that orthobiologics, such as PRP, BMPs, and MSCs, can be effective and safe in the management of delayed union and non-union fractures. These biological treatments have the potential to improve union rates, reduce healing times, and enhance functional outcomes in patients with non-union fractures. Further research is essential to refine treatment protocols and determine the most suitable orthobiologic for specific patient populations and fracture types.

High incidence of RAMP lesions and a nonnegligible incidence of anterolateral ligament and posterior oblique ligament rupture in acute ACL injury.

PURPOSE: The purpose of this study was to assess the frequency of medial collateral ligament (MCL), posterior oblique ligament (POL) and anterolateral ligament (ALL) tears and different types of RAMP lesions of patients with verified acute anterior cruciate ligament (ACL) tears by magnetic resonance imaging (MRI). METHODS: MRI was performed on patients with a clinical diagnosis of acute ACL injury. Patients were eligible for inclusion if they had an initially clinically noted ACL tear confirmed on MRI within 30 days of trauma. RESULTS: A total of 146 patients were included in the study, 42 (28.8%) females and 104 (71.2%) males. The mean age at MRI was 27.2 ± 9.4 years, and the mean time from injury to MRI was 15.7 ± 7.8 days. Thirty-four (23.3%) patients had a complete MCL lesion, 32 (21.9%) had a complete POL lesion and 28 (19.2%) had a complete ALL lesion. One hundred and fourteen patients (78.1%) presented with RAMP lesions, while 20 (13.7%) patients reported other meniscal lesions. The mean medial and lateral tibial slopes were 4.0° ± 2.7° and 4.0° ± 3.1°, respectively. Only 10 (6.8%) patients reported no lesions associated with ACL rupture. The most common injuries were isolated RAMP type 3 (18-12.3%) and isolated RAMP type 1 (17-11.6%). Thirteen (8.9%) patients had a combination of MCL, POL and ALL rupture. CONCLUSIONS: Isolated lesions of the ACL are extremely rare. In most cases, a single RAMP lesion should be investigated. In the presence of MCL injury, POL injury should always be suspected as well, while nearly 20% of patients present a rupture of the ALL. About one in 10 patients had three lesions (MCL, ALL and POL), and most of them had a combined RAMP lesion. LEVEL OF EVIDENCE: Level IV.

Italian research on anterior cruciate ligament: a bibliometric analysis.

INTRODUCTION: This study analysed the trend of publications on anterior cruciate ligament (ACL) in Italy. It was hypothesised that publications on this topic have quickly increased in recent years due to increased knowledge of both clinical and radiological pathology. METHODS: PubMed and Scopus were accessed on 29/11/2023. This retrieved 838 articles from PubMed and 1050 from Scopus. We analysed the top 10 authors, and journals in publication numbers, citation numbers, and citations per year. We have also looked at the top 10 institutions publishing on anterior cruciate ligament from Scopus as PubMed does not give this information in the output. Data mining was performed using the Orange software, Mac version 3.32.0 ( https://orangedatamining.com/ ) from the titles of all articles. A word cloud analysis of titles, authors, journals and universities was performed. RESULTS: The peak of citations was in 2017 with 1529, whilst the peak of publications was in 2019 with 59 articles published. Analysing the number of publications and citations for the journal, the most impacted journal is Knee Surgery, Sports Traumatology, Arthroscopy with 5472 citations and 183 articles, followed by The American Journal of Sports Medicine, with 2722 citations and 56 articles and Arthroscopy with 1990 citations and 62 articles. Considering also international collaborations, the most cited author is Della Villa F. in 2020 with 43.67 citations per year. The Italian author with the major number of publications is Zaffagnini S. with 39 articles, whilst the author with the higher number of citations is Aglietti P. with 1612 citations. CONCLUSIONS: ACL reconstruction has gained growing interest amongst the scientific community. Publications and citations presented a rising trend, the majority of the highly cited papers were contributed by few centres, and clinical trials were the most cited study designs. The long-term outcomes of ACL lesions have attracted interest. The authors hypothesised that shortly there will be an increase in articles analysing the results of ACL revisions, the use of lateral extra-articular tenodesis, and meniscus transplants. LEVEL OF EVIDENCE IV: Cross-Sectional Study.

Men and women undergoing total hip arthroplasty have different clinical presentations before surgery and different outcomes at 1-year follow-up.

PURPOSE: The purpose of this study was to investigate the influence of sex on patients undergoing total hip arthroplasty (THA) for hip osteoarthritis (HOA), aiming to assess the clinical and functional outcomes using patient-reported outcome measures (PROMs). METHODS: A retrospective analysis of patients undergoing THA at Ospedale Galeazzi-Sant'Ambrogio between 2016 and 2022 was conducted. Inclusion criteria encompassed Kellgren-Lawrence grade III or IV HOA, with preoperative and 12-month postoperative PROMs. Enroled patients have been selected from a larger cohort without matching design for confounders. The analyses were performed using R software v4.0.3 (R Core Team) and data distributions were assessed using the Shapiro-Wilk normality test. RESULTS: One hundred ninety patients (72 male and 118 female) who had both preoperative and postoperative PROMs have been analysed from our institutional prosthesis registry (Datareg). Baseline and 12-month post-THA PROMs showed significant improvements overall. VAS score dropped notably from baseline to 3 months postsurgery (7.1 ± 2.1 vs. 0.9 ± 1.7). Functional and mental PROMs, including Harris Hip Score-functional (HHS-F), Harris Hip Score-total (HHS-t), SF-12PS and SF-12MS, exhibited substantial improvements post-THA. Stratifying by sex, males had lower baseline VAS, higher HHS-F, SF-12MS and hip disability and osteoarthritis outcome score-physical function short form (HOOS-PS). At 12 months, males displayed significantly better VAS, HHS-F, SF-12PS and HOOS-PS scores. Complication rates were minimal (1.5%), with stable rates across genders, mostly involving dislocation and periprosthetic fractures. Implant survival at 12 months reached an impressive 99%. CONCLUSION: THA remains an effective treatment for severe HOA. However, females presented with worse baseline conditions and showed relatively less improvement at 1-year postsurgery compared to males. This difference could be attributed to physiological and psychosocial factors associated with sex, including hormonal changes, muscle mass decline and perception of pain. Longer follow-ups and prospective studies are necessary to validate these findings and facilitate personalised approaches in HOA treatment, emphasising the need for careful consideration of sex-related variables in clinical decision-making for THA patients. LEVEL OF EVIDENCE: Level III.

Enhanced molecular release from elderly bone samples using collagenase I: insights into fatty acid metabolism alterations.

BACKGROUND: Bone is a metabolically active tissue containing different cell types acting as endocrine targets and effectors. Further, bone is a dynamic depot for calcium, phosphorous and other essential minerals. The tissue matrix is subjected to a constant turnover in response to mechanical/endocrine stimuli. Bone turnover demands high energy levels, making fatty acids a crucial source for the bone cells. However, the current understanding of bone cell metabolism is poor. This is partly due to bone matrix complexity and difficulty in small molecules extraction from bone samples. This study aimed to evaluate the effect of metabolite sequestering from a protein-dominated matrix to increase the quality and amount of metabolomics data in discovering small molecule patterns in pathological conditions. METHODS: Human bone samples were collected from 65 to 85 years old (the elderly age span) patients who underwent hip replacement surgery. Separated cortical and trabecular bone powders were treated with decalcifying, enzymatic (collagenase I and proteinase K) and solvent-based metabolite extraction protocols. The extracted mixtures were analyzed with the high-resolution mass spectrometry (HRMS). Data analysis was performed with XCMS and MetaboAnalystR packages. RESULTS: Fast enzymatic treatment of bone samples before solvent addition led to a significantly higher yield of metabolite extraction. Collagenase I and proteinase K rapid digestion showed more effectiveness in cortical and trabecular bone samples, with a significantly higher rate (2.2 folds) for collagenase I. Further analysis showed significant enrichment in pathways like de novo fatty acid biosynthesis, glycosphingolipid metabolism and fatty acid oxidation-peroxisome. CONCLUSION: This work presents a novel approach for bone sample preparation for HRMS metabolomics. The disruption of bone matrix conformation at the molecular level helps the molecular release into the extracting solvent and, therefore, can lead to higher quality results and trustable biomarker discovery. Our results showed ß-oxidation alteration in the aged bone sample. Future work covering more patients is worthy to identify the effective therapeutics to achieve healthy aging.

A high level of scientific evidence is available to guide treatment of primary shoulder stiffness: The SIAGASCOT consensus.

PURPOSE: Shoulder stiffness (SS) is a condition characterised by active and passive restricted glenohumeral range of motion, which can occur spontaneously in an idiopathic manner or be associated with a known underlying aetiology. Several treatment options are available and currently no consensus has been obtained on which treatment algorithm represents the best choice for the patient. Herein we present the results of a national consensus on the treatment of primary SS. METHODS: The project followed the modified Delphi consensus process, involving a steering, a rating and a peer-review group. Sixteen questions were generated and subsequently answered by the steering group after a thorough literature search. A rating group composed by professionals specialised in the diagnosis and treatment of shoulder pathologies rated the question-answer sets according to the scientific evidence and their clinical experience. RESULTS: Recommendations were rated with an average of 8.4 points out of maximum 9 points. None of the 16 answers received a rating of less than 8 and all the answers were considered as appropriate. The majority of responses were assessed as Grade A, signifying a substantial availability of scientific evidence to guide treatment and support recommendations encompassing diagnostics, physiotherapy, electrophysical agents, oral and injective medical therapies, as well as surgical interventions for primary SS. CONCLUSIONS: A consensus regarding the conservative and surgical treatment of primary SS could be achieved at a national level. This consensus sets basis for evidence-based clinical practice in the management of primary SS and can serve as a model for similar initiatives and adaptable guidelines in other European countries and potentially on a global scale. LEVEL OF EVIDENCE: Level I.

Clinical and Functional Outcomes of Kinematic Aligned Total Knee Arthroplasty with a Medial Pivot Design: Two-Year Follow-Up.

BACKGROUND: Kinematic alignment (KA) restores native limb alignment following total knee arthroplasty (TKA). The association of this technique with a medial pivot implant design attempts to re-establish the physiological kinematics of the knee. This study aims to analyze the clinical and radiological outcomes of patients undergoing MP-TKA with kinematic alignment and to assess the effect of limb alignment on the clinical outcomes. METHODS: We retrospectively analyzed 55 patients who underwent kinematic aligned medial pivot TKA from September 2018 to January 2020. Patient-related outcomes (PROMs) were collected at baseline, 3, 12, and 24 months after surgery. Long-standing weight-bearing radiographs were performed three months after surgery. RESULTS: We demonstrated a significant improvement in clinical outcomes from 3 months after surgery up to 24 months of follow-up. This clinical improvement was independent of limb alignment. The radiological analysis showed that the patient's native limb alignment was restored and that their joint line orientation was parallel to the floor. CONCLUSION: The association of kinematic alignment and a medial pivot TKA implant allows for a fast recovery, with good clinical and functional outcomes up to a minimum of 2 years of follow-up, independent of the final limb alignment.

How Do Older Patients with End-Stage Osteoarthritis of the Hip Eat Prior to Hip Replacement? A Preliminary Snapshot That Highlights a Poor Diet.

Diet quantity and quality in older adults is critical for the proper functioning of the musculoskeletal system. In view of hip surgery, old patients should consume 1.2-1.5 g of proteins and 27-30 kcal per kilo of body weight daily, and adhere to healthy eating habits. In this analytical study, we studied diet quantity and quality in relation to the clinical chemistry and functional status of 57 older adults undergoing elective hip replacement. Nine in ten patients did not meet suggested protein and energy intakes and only one in ten patients exhibited high adherence to the Mediterranean diet. Legume consumption adjusted for sex, age, body mass index, and health status successfully forecasted haemoglobin levels (p < 0.05), and patients regularly consuming olive oil reported minor hip disability compared to those using it less frequently (p < 0.05). Patients who reported daily ingestion of <1 serving of meat versus those consuming >1.5 servings had greater cumulative comorbidity (p < 0.05), with meat consumption independently predicting walking ability, mobility, and balance in the fully adjusted model (p < 0.01). In conclusion, our patients seem to eat poorly. There is room for improvement in pre-operative pathways to make older adults eat better, but there is a need to plan an interventional study to fully understand the cause-effect of a dietary pattern or specific food in enhancing recovery after surgery.

No difference in Oxford Knee Score between medial and lateral unicompartmental knee arthroplasty after two years of follow-up: a clinical trial.

PURPOSE: In patients with monocompartmental knee osteoarthritis, unicompartmental knee arthroplasty (UKA) can be performed. This study compared the medial versus lateral UKA in patients with monocompartimental knee arthroplasty. It was hypothesised that both implants achieve a similar outcome in OKS. METHODS: The UKAs were fixed-bearing medial PPK (Zimmer-Biomet, Warsaw, Indiana, USA) and fixed-bearing lateral Zuk (Lima Corporate, Udine, Italy). An intraarticular drain was placed and removed on the first postoperative day. Enoxaparin sodium 4000 units subcutaneously daily for 45 days was used as thromboembolic prophylaxis. The Italian version of the OKS was used for the clinical assessment. The following complications were also recorded: anterior knee pain, infection and revision surgeries. RESULTS: Data from 203 patients were collected. The mean age of the patients was 68.9 ± 6.7 years and the mean BMI was 28.1 ± 4.1 kg/m2. The mean OKS on admission was 22.1 ± 4.5 points. On admission, women, patients older than 70 years, and those with a BMI lower than 28 kg/m2 who underwent lateral UKA evidenced lower OKS. At the last follow-up, 26.7 and 26.9 months for the lateral and medial UKA, respectively, no between groups difference in OKS was evidenced. No patients experienced complications. CONCLUSION: Medial and lateral UKA achieve similar outcomes in OKS at a minimum of two years of follow-up.

Results and complications of bilateral limb lengthening in achondroplasia: a retrospective analysis.

Background: Achondroplasia is one of the main causes of disharmonic dwarfism. Patients with achondroplasia might have physical and psychological limitations due to their disproportionate stature. Surgical limb lengthening is the only practical option available to achieve a stature comparable to normal population range. The purpose of this study is to analyze results and complications of our lengthening protocol. Methods: A retrospective analysis was performed on 33 patients with achondroplasia (21 females and 12 males) undergoing simultaneous bilateral tibia or femur lengthening in four surgical stages from 2017 to 2021 (46 lengthening procedures, with a total of 56 tibias and 36 femurs). For each patient, patients' characteristics and antero-posterior and lateral radiographs were obtained. The following parameters were analyzed: duration of lengthening with external fixator, amount of lengthening, complications or events that influenced outcomes and the healing index (HI). Results: The average tibial and femoral gain was 7.9 cm and 6.9 cm, respectively. The tibiae achieved better results than the femurs (p = 0.005). Nineteen complications were reported for 92 segments (20.7%), and the variables influencing complications were: step (p = 0.002) and fixation duration (p = 0.061). Conclusions: Bilateral parallel lower limb lengthening in four surgical steps may be a viable technique in patients with achondroplasia.

Investigation into the effect of epidermal growth factor and hyaluronic acid on fracture healing in a rat femoral fracture model.

OBJECTIVE: This study aimed to investigate the role of an exogenous Epidermal Growth Factor and a hyaluronic acid-based scaffold on fracture healing in a rat femoral fracture model Methods: Forty-eight male Wistar-Albino rats, each weighing a mean 392 grams (range= 350-450 grams) and aged 8.2 months (6-9 months), were used for this experimental study. All surgical procedures were performed on the left femur by a single surgeon. An open femoral fracture was created in all rats. The animals were randomly divided into one of the four groups: Control (12), EGF (12), HA (12) and Combined (12). In the 4th and sixth weeks, samples were processed and analyzed using biomechanical and histological methods. RESULTS: Fracture healing was significantly improved in the Combined group compared to the control one, EGF and HA groups in all parameters at both experimental time points. At the fourth and sixth weeks after surgery, fracture healing in the EGF and HA groups was significantly increased at histological evaluation compared to controls. In addition, compared with EGF, HA and Control groups, a significant difference in callus tissue was detected in the Combined group at 4 and 6-week time points in biomechanical features. CONCLUSION: This study has shown that combining local EGF and HA scaffold accelerates bone healing and strengthens the bony callus histologically and biomechanically. Using EGF-HA combined scaffolds may represent a possible future strategy in trauma surgery. LEVEL OF EVIDENCE: N/A.

Huntington procedure for the treatment of tibial nonunion in a 17-years old male: A case report.

INTRODUCTION: Bone is considered a tissue with good healing properties, and many bone defects can heal spontaneously under appropriate conditions. Extreme bone loss can hinder remodeling and regenerative processes, leading to bone nonunion. This condition negatively impacts the patient's quality of life with a severe socioeconomic burden. Many treatment options have been proposed, but none can be defined as a gold standard, mainly due to the variety of clinical presentation, bone loss, and quality. PRESENTATION OF CASE: We present a 15-year-old case of tibial nonunion following multiple traumas. The patient was treated non-surgically at the beginning, but the external fixator positioning was required due to a delay in the healing process. Following further trauma, the patient showed progressive anterolateral angulation, severe lateral procurvation, and a progressive worsening of the pseudoarthrosis. The severe bone loss and poor quality of the bone surrounding the defect required a special technique called Huntington procedure that consists in a vascularized bone autograft from the ipsilateral fibula to achieve mechanical and biological healing of the pseudoarthrosis. The patient recovered well and returned to full weight bearing without a mobility aid. DISCUSSION: We report this case of complex tibial nonunion and malalignment, developed after subsequent traumas. Due to the multiple complications, and the poor biology a Huntington procedure was required to provide mechanical stability and a biological boost to the bone defect. CONCLUSION: This case report shows a complicated case requiring several surgeries and treatment options and confirms the potential benefit of the Huntington procedure for treating a tibial severe bone loss.

ChatGPT in orthopedics: a narrative review exploring the potential of artificial intelligence in orthopedic practice.

The field of orthopedics faces complex challenges requiring quick and intricate decisions, with patient education and compliance playing crucial roles in treatment outcomes. Technological advancements in artificial intelligence (AI) can potentially enhance orthopedic care. ChatGPT, a natural language processing technology developed by OpenAI, has shown promise in various sectors, including healthcare. ChatGPT can facilitate patient information exchange in orthopedics, provide clinical decision support, and improve patient communication and education. It can assist in differential diagnosis, suggest appropriate imaging modalities, and optimize treatment plans based on evidence-based guidelines. However, ChatGPT has limitations, such as insufficient expertise in specialized domains and a lack of contextual understanding. The application of ChatGPT in orthopedics is still evolving, with studies exploring its potential in clinical decision-making, patient education, workflow optimization, and scientific literature. The results indicate both the benefits and limitations of ChatGPT, emphasizing the need for caution, ethical considerations, and human oversight. Addressing training data quality, biases, data privacy, and accountability challenges is crucial for responsible implementation. While ChatGPT has the potential to transform orthopedic healthcare, further research and development are necessary to ensure its reliability, accuracy, and ethical use in patient care.

Effects of tele-prehabilitation on clinical and muscular recovery in patients awaiting knee replacement: protocol of a randomised controlled trial.

BACKGROUND: The increasing prevalence of knee osteoarthritis and total knee arthroplasty (TKA) impose a significant socioeconomic burden in developed and developing countries. Prehabilitation (rehabilitation in the weeks immediately before surgery) may be crucial to prepare patients for surgery improving outcomes and reducing assistance costs. Moreover, considering the progress of telemedicine, candidates for TKA could potentially benefit from a tele-prehabilitation programme. We aim to evaluate the effects of a home-based tele-prehabilitation program for patients waiting for total knee replacement. METHODS AND ANALYSIS: Forty-eight male patients, aged 65-80, on a waiting list for TKA will be recruited and randomly assigned to the tele-prehabilitation intervention or control groups. Both groups will undergo the same 6-week exercise program (five sessions/week) and the same educational session (one per week). The tele-prehabilitation group will perform asynchronous sessions using a tablet, two accelerometers and a balance board (Khymeia, Padova, Italy), while the control group will use a booklet. The Western Ontario and McMaster Universities Osteoarthritis Index Questionnaire, at the end of the prehabilitation, will be the primary outcome. Secondary outcomes will include self-reported outcomes, performance tests and change in expressions of blood and muscle biomarkers. Ten healthy subjects, aged 18-30, will be also recruited for muscle and blood samples collection. They will not undergo any intervention and their data will be used as benchmarks for the intervention and control groups' analyses. ETHICS AND DISSEMINATION: This randomised controlled trial will be conducted in accordance with the ethical principles of the Declaration of Helsinki. This study has been approved by the Ethics Committee of Vita-Salute San Raffaele University (Milan, Italy. No. 50/INT/2022). The research results will be published in peer-reviewed publications. TRIAL REGISTRATION NUMBER: NCT05668312.

Framing Patellar Instability: From Diagnosis to the Treatment of the First Episode.

The patellofemoral joint (PFJ) is a complex articulation between the patella and the femur which is involved in the extensor mechanism of the knee. Patellofemoral disorders can be classified into objective patellar instability, potential patellar instability, and patellofemoral pain syndrome. Anatomical factors such as trochlear dysplasia, patella alta, and the tibial tuberosity-trochlear groove (TT-TG) distance contribute to instability. Patellofemoral instability can result in various types of dislocations, and the frequency of dislocation can be categorized as recurrent, habitual, or permanent. Primary patellar dislocation requires diagnostic framing, including physical examination and imaging. Magnetic resonance imaging (MRI) is essential for assessing the extent of damage, such as bone bruises, osteochondral fractures, and medial patellofemoral ligament (MPFL) rupture. Treatment options for primary dislocation include urgent surgery for osteochondral fragments or conservative treatment for cases without lesions. Follow-up after treatment involves imaging screening and assessing principal and secondary factors of instability. Detecting and addressing these factors is crucial for preventing recurrent dislocations and optimizing patient outcomes.