Prophylactic Antibiotic Choice and Deep Infection in Lower Extremity Endoprosthetic Reconstruction: Comparison of Cefazolin, Cefazolin-Vancomycin, and Alternative Regimens.

INTRODUCTION: Infection is a common mode of failure in lower extremity endoprostheses. The Prophylactic Antibiotic Regimens in Tumor Surgery trial reported that 5 days of cefazolin had no difference in surgical site infection compared with 24 hours of cefazolin. Our purpose was to evaluate infection rates of patients receiving perioperative cefazolin monotherapy, cefazolin-vancomycin dual therapy, or alternative antibiotic regimens. METHODS: A single-center retrospective review was conducted on patients who received lower extremity endoprostheses from 2008 to 2021 with minimum 1-year follow-up. Three prophylactic antibiotic regimen groups were compared: cefazolin monotherapy, cefazolin-vancomycin dual therapy, and alternative regimens. The primary outcome was deep infection, defined by a sinus tract, positive culture, or clinical diagnosis. Secondary outcomes were revision surgery, microorganisms isolated, and superficial wound issues. RESULTS: The overall deep infection rate was 10% (30/294) at the median final follow-up of 3.0 years (IQR 1.7 to 5.4). The deep infection rates in the cefazolin, cefazolin-vancomycin, and alternative regimen groups were 8% (6/72), 10% (18/179), and 14% (6/43), respectively (P = 0.625). Patients not receiving cefazolin had an 18% deep infection rate (6/34) and 21% revision surgery rate (7/34) compared with a 9% deep infection rate (24/260) (P = 0.13) and 12% revision surgery rate (31/260) (P = 0.17) in patients receiving cefazolin. In those not receiving cefazolin, 88% (30/34) were due to a documented penicillin allergy, only two being anaphylaxis. All six patients in the alternative regimen group who developed deep infections did not receive cefazolin secondary to nonanaphylactic penicillin allergy. CONCLUSION: The addition of perioperative vancomycin to cefazolin in lower extremity endoprosthetic reconstructions was not associated with a lower deep infection rate. Patients who did not receive cefazolin trended toward higher rates of deep infection and revision surgery, although not statistically significant. The most common reason for not receiving cefazolin was a nonanaphylactic penicillin allergy, highlighting the continued practice of foregoing cefazolin unnecessarily.

Evaluating ChatGPT's Ability to Answer Common Patient Questions Regarding Hip Fracture.

INTRODUCTION: ChatGPT is an artificial intelligence chatbot software programmed for conversational applications using reinforcement learning techniques. With its growing popularity and overall versatility, it is likely that ChatGPT's applications will expand into health care especially because it relates to patients researching their injuries. The purpose of this study was to investigate ChatGPT's ability to accurately answer frequently asked questions regarding hip fractures. METHODS: Eleven frequently asked questions regarding hip fractures were posed to ChatGPT, and the responses were recorded in full. Five of these questions were determined to be high-yield based on the likelihood that a patient would ask the question to a chatbot software. The chatbot's responses were analyzed by five fellowship-trained orthopaedic trauma surgeons for their quality and accuracy using an evidence-based approach. The chatbot's answers were rated as "Excellent response requiring no clarification", "Satisfactory response requiring minimal clarification", "Satisfactory response requiring moderate clarification", or "Unsatisfactory response requiring significant clarification." RESULTS: Of the five high-yield questions posed to the chatbot, no question was determined to be unsatisfactory requiring significant clarification by the authors. The remaining responses were either satisfactory requiring minimal clarification (n = 3) or satisfactory requiring moderate clarification (n = 2). DISCUSSION: The chatbot was generally found to provide unbiased and evidence-based answers that would be clearly understood by most orthopaedic patients. These findings suggest that ChatGPT has the potential to be an effective patient education tool especially because it continues to grow and improve as a chatbot application. LEVEL OF EVIDENCE: Level IV study.

Can ChatGPT Answer Patient Questions Regarding Total Knee Arthroplasty?

The internet has introduced many resources frequently accessed by patients prior to orthopaedic visits. Recently, Chat Generative Pre-Trained Transformer, an artificial intelligence-based chat application, has become publicly and freely available. The interface uses deep learning technology to mimic human interaction and provide convincing answers to questions posed by users. With its rapidly expanding usership, it is reasonable to assume that patients will soon use this technology for preoperative education. Therefore, we sought to determine the accuracy of answers to frequently asked questions (FAQs) pertaining to total knee arthroplasty (TKA).Ten FAQs were posed to the chatbot during a single online interaction with no follow-up questions or repetition. All 10 FAQs were analyzed for accuracy using an evidence-based approach. Answers were then rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."Of the 10 answers given by the chatbot, none received an "unsatisfactory" rating with the majority either requiring minimal (5) or moderate (4) clarification. While many answers required nuanced clarification, overall, answers tended to be unbiased and evidence-based, even when presented with controversial subjects.The chatbot does an excellent job of providing basic, evidence-based answers to patient FAQs prior to TKA. These data were presented in a manner that will be easily comprehendible by most patients and may serve as a useful clinical adjunct in the future.

Glucagon-like Peptide-1 Agonists: What the Orthopaedic Surgeon Needs to Know.

¼ Orthopaedic surgeons are increasingly likely to encounter patients with obesity and/or type 2 diabetes taking glucagon-like peptide-1 (GLP-1) agonists for weight loss.¼ GLP-1 agonists are an effective treatment for weight loss with semaglutide and tirzepatide being the most effective agents. Randomized controlled trials using these agents have reported weight loss up to 21 kg (46 lb).¼ The use of GLP-1 agonists preoperatively can improve glycemic control, which can potentially reduce the risk of postoperative complications. However, multiple cases of intraoperative aspiration/regurgitation have been reported, potentially related to the effect of GLP-1 agonists on gastric emptying.¼ While efficacious, GLP-1 agonists may not produce sufficient weight loss to achieve body mass index cutoffs for total joint arthroplasty depending on individual patient factors, including starting bodyweight. Multifactorial approaches to weight loss with focus on lifestyle modification in addition to GLP-1 agonists should be considered in such patients.¼ Although GLP-1 agonists are efficacious agents for weight loss, they may not be accessible or affordable for all patients. Each patient's unique circumstances should be considered when creating an ideal weight loss plan during optimization efforts.

Assessing ChatGPT Responses to Common Patient Questions Regarding Total Hip Arthroplasty.

BACKGROUND: The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA). METHODS: Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification." RESULTS: Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics. CONCLUSIONS: The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.

The Impact of the COVID-19 Pandemic on the Presentation of Patients With Spinal Metastases.

STUDY DESIGN: Retrospective review. OBJECTIVE: The aim was to determine if preoperative spinal instability neoplastic scores (SINSs) and Tokuhashi prognostication scores differed in patients receiving surgical care before and during the coronavirus disease-2019 (COVID-19) pandemic. SUMMARY OF BACKGROUND DATA: The COVID-19 pandemic has caused delays in scheduling nonemergent surgeries. Delay in presentation and/or surgical treatment for oncology patients with metastatic spinal disease could result in progression of the disease, which can complicate surgical care and worsen patient outcomes. MATERIALS AND METHODS: Retrospective review of electronic medical records between March 1, 2019 and March 1, 2021 at a tertiary medical center was performed to identify patients who underwent surgery for metastatic spine disease. Primary spinal tumors were excluded. Patients were separated into two groups base on their surgery date: before the COVID-19 pandemic (March 1, 2019-February 29, 2020) and during the COVID-19 pandemic (March 1, 2020-March 1, 2021). Primary outcomes included SINS and Tokuhashi scores. A variety of statistical tests were performed to compare the groups. RESULTS: Fifty-two patients who underwent surgery before the COVID-19 pandemic were compared to 41 patients who underwent surgery during the COVID-19 pandemic. There was a significant difference between the before and during groups with respect to SINS (9.31±2.39 vs . 11.00±2.74, P =0.002) and Tokuhashi scores (9.27±2.35 vs . 7.88±2.85, P =0.012). Linear regression demonstrated time of surgery (before or during COVID-19 restrictions) was a significant predictor of SINS (ß=1.55, 95% CI: 0.42-2.62, P =0.005) and Tokuhashi scores (ß=-1.41, 95% CI: -2.49 to -0.34, P =0.010). CONCLUSIONS: Patients with metastatic spinal disease who underwent surgery during the COVID-19 pandemic had higher SINS, lower Tokuhashi scores and similar Skeletal Oncology Research Group scores compared to patients who underwent surgery before the pandemic. This suggests the pandemic has impacted the instability of disease at presentation in patients with spinal metastases, but has not impacted surgical prognosis, as there were no differences in Skeletal Oncology Research Group scores and the difference in Tokuhashi scores is most likely not clinically significant.

Conditional pulmonary over-expression of Claudin 6 during embryogenesis delays lung morphogenesis.

Claudin 6 (Cldn6) is a tetraspanin protein expressed by barrier epithelial cells. In order to assess the effects of persistent tight junctions involving Cldn6 during lung development, a doxycycline (dox)-inducible conditional transgenic mouse was generated that up-regulates Cldn6 in the distal lung. Pups had unlimited access to dox from conception until sacrifice date at embryonic day (E) 18.5. Quantitative PCR, immunoblotting, and immunohistochemistry revealed significantly elevated Cldn6 expression in transgenic mice compared to non-transgenic controls. There were no differences in terms of lung size, lung weight, or whole body weight at the time of necropsy. Histological evaluations led to the discovery that E18.5 Cldn6 transgenic pups appeared to be in the early canalicular stage of development coincident with fewer, thickened respiratory airspaces. In contrast, controls appeared to have entered the saccular stage characterized by thin airspace walls and spherical architecture. Immunostaining for transcriptional regulators including TTF-1 and FoxA2 was conducted to assess cell differentiation and specific cell types were identified via staining for pro-surfactant protein C (alveolar type II epithelial cells) or Clara Cell Secretory Protein (cub or Clara cells). Lastly, cell turnover was qualitatively measured via staining for cell proliferation or apoptosis. These data suggest that Cldn6 is an important junctional protein potentially involved in the programming of epithelial cells during lung development. Furthermore, genetic down-regulation of Cldn6 as development proceeds may influence differentiation observed in the transition from the canalicular to the saccular lung.