Archives of Bone and Joint Surgery
Volume:11 Issue: 4, Apr 2023

ChatGPT a fluent chatbot developed by San Francisco- based Open artificial intelligence (AI);  has made a storm that swept the world since its launch in November 2022. It is enabled people to communicate with a machine in almost any topic. ChatGPT passed 100 million users at the beginning of February 2023 which making it as the fastest expanding consumer application.

Health literacy is defined as the degree to which an individual obtains and processes basic health information and services so as to make appropriate and informed health decisions. Limited health literacy (LHL), as assessed by various validated instruments, remains prevalent amongst older adult patients, non-Caucasian ethnicities, and those of lower socioeconomic backgrounds. Of concern, LHL has been associated with decreased medical knowledge, disuse of preventative medical services, worse chronic disease control and increased use of emergency services. Within orthopedics specifically, LHL has been associated with lower expectations regarding outcomes and ambulation following total hip and knee surgery and fewer questions asked regarding diagnosis and treatment in the outpatient care setting. In some cases, LHL has been independently correlated with worse patient -reported outcome measures (PROMs), though this finding may be due in part to the reading level required of the PROMs. There is growing evidence that active intervention by the orthopedic provider and demonstration of empathy improves patient comprehension of the nature of their musculoskeletal complaints, aids informed decision-making and, ultimately, maximizes patient satisfaction. Recognition of the associated factors for LHL will ensure improved physician-patient communication through the implementation of health literate interventions focused on those most at-risk. Level of evidence: III

Latissimus dorsi tendon transfer is a treatment option in patients with irreparable rotator cuff tears. This study aimed to compare the effectiveness and safety of anterior and posterior transfer of latissimus dorsi tendon for anterosuperior or posterosuperior massive irr eparable rotator cuff tears. In this prospective clinical trial, 27 patients with irreparable rotator cuff tears were treated with latissimus dorsi transfer. The transfers in 14 and 13 patients were from the anterior for anterosuperior cuff deficiency (group A) and from the posterior for posterosuperior cuff deficiency (group B), respectively. Pain, shoulder range of motion in forward elevation, abduction, external rotation, and functional scores were evaluated 12 months after the surgery. Two and one patients were excluded from the study due to not referring in time for follow-up and infection, respectively. Therefore, 13 patients remained in group A and 11 patients in group B. Visual analog scale scores decreased from 6.5 to 3.0 in group A (P=0.016) and from 5.909 to 2.818 in group B (P=0.028). The constant scores improved from 41 to 50.2 (P=0.010) in group A and from 30.2 to 42.5 (P=0.001) in group B. There was a significant improvement in the abduction and forward elevation in both groups which was more significant in group B. The posterior transfer made significant improvement in external rotation; however, the anterior transfer did not change external rotation. No radial or axillary nerve injury was observed in any of the two groups. Latissimus dorsi transfer in patients with irreparable rotator cuff tears has a significant effect on recovery. It improves shoulder function and range of motion and reduces pain. Improvement of shoulder elevation and abduction is more significant in posterior transfer. The anterior transfer is as safe as the posterior transfer for nerve injury. Level of evidence: II

Accurate estimation of post-operative clinical parameters in scoliosis correction surgery is crucial. Different studies have been carried out to investigate scoliosis surgery results, which were costly, time-consuming, and with limited application. This study aims to estimate post-operative main thoracic cobb and thoracic kyphosis angles in adolescent idiopathic scoliosis patients using an adaptive neuro-fuzzy interface system.  Distinct pre-operative clinical indices of fifty-five patients (e.g., thoracic cobb, kyphosis, lordosis, and pelvic incidence) were taken as the inputs of the adaptive neuro-fuzzy interface system in four categorized groups, and post-operative thoracic cobb and kyphosis angles were taken as the outputs. To evaluate the robustness of this adaptive system, the predicted values of post-operative angles were compared with the measured indices after the surgery by calculating the root mean square errors and clinical corrective deviation indices, including the relative deviation of post-operative angle prediction from the actual angle after the surgery. The group with inputs for main thoracic cobb, pelvic incidence, thoracic kyphosis, and T1 spinopelvic inclination angles had the lowest root mean square error among the four groups. The error values were 3.0° and 6.3° for the post-operative cobb and thoracic kyphosis angles, respectively. Moreover, the values of clinical corrective deviation indices were calculated for four sample cases, including 0.0086 and 0.0641 for the cobb angles of two cases and 0.0534 and 0.2879 for thoracic kyphosis of the other two cases. In all scoliotic cases, the post-operative cobb angles were lesser than the pre-operative ones; however, the post-operative thoracic kyphosis might be lesser or higher than the pre-operative ones. Therefore, the cobb angle correction is in a more regular pattern and is more straightforward to predict cobb angles. Consequently, their root-mean-squared errors become lesser values than thoracic kyphosis. Level of evidence: IV

Lumbar multifidus muscle provides stability to the spine. The present study aimed to evaluate the reliability of ultrasound findings in patients with lumbar multifidus myofascial pain syndrome (MPS). A total of 24 cases (7 females, 17 males, mean age: 40.13± 5.69, BMI: 26.48±4.96) with multifidus MPS were assessed. The variables were muscle thickness in rest and contraction, thickness changes, and cross-sectional area (CSA) in rest and contraction. Two examiners performed the test and retest sessions. The active trigger points of lumbar multifidus on the right and left side of the cases were 45.8 % and 54.2%, respectively. The intraclass correlation coefficient (ICC) values for muscle thickness and thickness changes showed moderate to very high reliability for both within and between intra-examiner measurements. (ICC, 1st examiner: 0.78-0.96; ICC, 2nd examiner: 0.86-0.95). In addition, the ICC values of within and between-session intra-examiner for CSA were high. (ICC, 1st examiner: 0.83-0.88; ICC, 2nd examiner: 0.84-0.89). The ICC and standard error of measurement (SEM) of inter-examiner reliability ranged between 0.75 to 0.93 and 0.19 to 0.88 for multifidus muscle thickness and thickness changes. The ICC and SEM of inter-examiner reliability ranged between 0.78 to 0.88 and 0.33 to 0.90 for CSA of the multifidus muscle.  The within and between-session reliability of multifidus thickness, thickness changes, and CSA was moderate to very high in patients with lumbar MPS when taken by two examiners. Furthermore, the inter-examiner reliability of these sonographic findings was high. Level of evidence: III

The primary aim of this study was to assess the reliability of the ten -segment classification system proposed (TSC) by Krause et al. and see how it compares with the traditionally used Schatzker classification, AO classification system, and Luo’s “Three columns” classification (ThCC) system. The second aim of this study was to assess the inter-observer reliability of the above classifications based on professional experience by comparing the entry level of residents (1 year into postgraduation), senior residents (1 year after postgraduation completion), and faculty (>10 years after postgraduation completion). 50 TPFs were classified by a 10-segment classification system, and its intra-observer (at 1-month interval) and inter-observer reproducibility was checked using k values by three different groups with varying levels of experience (Group I, II, and III comprised of 2 juniors residents, senior residents and consultants each), and the same was compared for three other common classification systems (Schatzker, AO and 3 –column). 10-segment classification showed least k for both inter-observer (0.08) and intra-observer (0.03) reliability. Highest individual inter-observer (k= 0.52) and intra-observer reliability (k= 0.31) was for Schatzker classification in Group I. Lowest individual inter-observer and intra-observer reliability was seen for 10-segment classification (k= 0.07) and AO classification system (k= -0.03) respectively. 10-segment classification showed the lowest k for both inter-observer and intra-observer reliability. The inter-observer reliability for the Schatzker, AO, and 3- column classifications reduced with increasing experience of the observer (JR>SR>Consultant). A possible reason could be a more critical evaluation of the fractures with increasing seniority. Level of evidence: I

In the local and cultural setting of high trauma rates and a reserved outlook on sexual function, this study examines the incidence and underlying factors of sexual dysfunction (SD) following pelvic fractures. A Multi-center retrospective cohort analysis performed in two general hospitals and one tertiary orthopedic center with collection between 2017 and 2019. Consecutive patients with pelvic fractures between January 2017 and February 2019 were followed up at 18-24 months to screen for new-onset SD using the International Index of Erectile Function-5 (IIEF-5) and Female-Sexual-Function-Index-6 (FSFI-6). Additional variables include age, sex, Young-Burgess classification, urogenital injury, injury severity score, persisting pain, sacroiliac disruption, intervention and if sexual health was discussed or patient referred for sexual healthcare. One-hundred and sixty-five patients (n = 165) were included, (83%) male, (16%) female with a mean age of 35.1 years (Range 18-55). Fracture patterns included lateral compression (LC) (51.5%), anteroposterior compression (APC) (27.7%), and vertical shear (VS) (20.6%). The urogenital injury occurred in 10.3%. The mean IIEF-5 and FSFI-6 scores were 20.8 and 24.7 in males and females, respectively. A total of 40 males (29%) scored below the 21 cut-off scores for SD, while only one female (3.7%) scored below the corresponding score of 19. Of all participants reporting sexual dysfunction, 56% discussed sexual health with their providers, while 46% of these patients were referred for further management. Significant predictive factors for SD using a multivariate logistic regression model include increasing age (OR-1.093, p = 0.006), APC III (OR 88.887, p = 0.006), VS (OR-15.607, p = 0.020), persisting pain (OR 3.600, p = 0.021) and increasing injury severity score (OR 1.184, p <0.001). SD is common among pelvic fractures, and risk factors include APC or VS type fractures, increasing age, increasing injury severity score, and persisting pain. Providers should ensure patients are screened for SD and referred appropriately as patients may not willingly disclose underlying symptoms. Level of evidence: III

While operative fixation is the current recommendation for treating significantly displaced tibial plateau fractures (DTPFs) in elderly patients, our research suggests that non -operative management may also be a viable option as the primary treatment for these individuals. Our study aimed to evaluate the clinical outcomes of patients with complex DTPFs who received non-operative management as their primary management. Our study involved a retrospective analysis of non-operatively treated DTPFs during the period of 2019 to 2020. We included all patients for the evaluation of fracture healing and range of motion (ROM). Additionally, we conducted functional outcome assessments on all patients, utilizing the Oxford Knee Score (OKS) both before their injury and at the 10-month mark after their injury. The study included 10 patients, comprising two males and eight females, with a mean age of 62.9 years (range: 46-74). Among them, four patients had Schatzker Type III DTPFs, two had Type V, and four had Type VI. Non-operative management was administered using hinged-knee braces, and patients progressed to weightbearing gradually, with a minimum follow-up period of 10 months. The average time to bone union was 4.3 months (range: 2-7). The mean Oxford Knee Score (OKS) after the injury was 38.8 (range: 23-45), with an average reduction of 16.9% (p = 0.003). The average fracture depression was 11.41 mm (range: 4.2-29), and the average fracture split was 14.03 mm (range: 5.5-44). Based on our study, it appears that elderly patients with significantly displaced tibial plateau fractures (DTPFs) can be treated non-operatively as their primary management, despite the current consensus suggesting otherwise. Level of evidence: IV

The primary aim was to assess the association between bone resection and the resultant flexion and extension gaps in the medial and lateral compartments of the knee when performing robotic -arm assisted total knee arthroplasty (rTKA). The secondary aims were to compare medial and lateral bone resections and the influence on limb alignment, and whether the amount of bone resection that resulted in equal gaps was predictable. A prospective study of 22 consecutive patients with a mean age of 66 years undergoing rTKA was conducted. The femoral component was mechanically aligned, and the alignment of the tibial component was adjusted (+/-3degrees of the mechanical axis) to obtain equal extension and flexion gaps. All knees underwent soft tissue balancing using sensor-guided technology. The final compartmental bone resection, gaps, and implant alignment were obtained from the robot data archive. There was a correlation between bone resection and the resultant gap in the medial (r=0.433, p=0.044) and lateral (r=0.724, p<0.001) compartments of the knee. There were no differences in bone resection from the distal femur and posterior condyles in the medial (p=0.941) or lateral compartments (p=0.604) or for the resultant gaps (p=0.341 and p=0.542, respectively). There was more bone removed from the medial compartment compared to the lateral aspect: 0.9mm (p=0.005) in extension and 1.2mm (p=0.026) flexion. The differential bone resection changed the knee alignment by one degree of varus. There were no significant differences between the actual and predicted medial (difference 0.05, p=0.893) or lateral (difference 0.00, p=0.992) tibial bone resection.  There was a direct association between bone resection and resultant compartment joint gap when using rTKA, which was predictable. Gap balancing was achieved when less bone was resected from the lateral compartment which resulted in an estimated one-degree varus alignment of the knee.  Level of evidence: II

Increasing bicycle ridership is accompanied by ongoing bicycle-related accidents in many urban cities. There is a need for improved understanding of patterns and risks of urban bicycle usage. We describe the injuries and outcomes of bicycle-related trauma in Boston, Massachusetts, and determine accident-related factors and behaviors associated with injury severity. We conducted a retrospective review via chart review of 313 bicycle-related injuries presenting to a Level 1 trauma center in Boston, Massachusetts. These patients were also surveyed regarding accident-related factors, personal safety practices, and road and environmental conditions during the accident. Over half of all cyclists biked for commuting and recreational purposes (54%), used a road without a bike lane (58%), and a majority wore a helmet (91%). The most common injury pattern involved the extremities (42%) followed by head injuries (13%). Bicycling for commuting rather than recreation, cycling on a road with a dedicated bicycle lane, the absence of gravel or sand, and use of bicycle lights were all factors associated with decreased injury severity (p<0.05). After any bicycle injury, the number of miles cycled decreased significantly regardless of cycling purpose. Our results suggest that physical separation of cyclists from motor vehicles via bicycle lanes, regular cleaning of these lanes, and usage of bicycle lights are modifiable factors protective against injury and injury severity.Safe bicycling practices and understanding of factors involved in bicycle-related trauma can reduce injury severity and guide effective public health initiatives and urban planning. Level of evidence: IV

Burnout is a well-known consequence of chronic stress. Orthopedic surgery is among the mostdesired specialty among Iranian medical students. The nature of the job, the income, and the ability to deal withstress can all be stressful factors for orthopedic surgeons. Nonetheless, little is known about how these medicaldoctors work and live in Iran. The present study aimed to assess job satisfaction, engagement, and burnout amongIranian orthopedists. A nationwide online survey was conducted in Iran. Job satisfaction, engagement, and burnout wereevaluated using the job description index (JDI), Utrecht Work Engagement Scale, and Maslach Burnout Scale. Theywere also asked some additional questions related to career choice. A total of 456 questionnaires (41% response rate) were retrieved. Overall, 56.8% of the participantsexperienced burnout. The burnout levels significantly differed based on age, years from graduation, working in publichospitals, operating more than 10 patients in a week, monthly income, having less than two children, and beingsingle (P<0.05). They scored higher on work questions on the present job and jobs in general but lower scores onpay and opportunities for promotion. In a national study of orthopedic surgeons, their primary concern in JDI was “pay and promotion.”Burnout was substantially associated with respondents’ characteristics, such as younger age and having fewerchildren. This will lead to impaired performance, increased patient complaints, and the tendency to immigrate.Level of evidence: V

Atlantoaxial rotatory fixation (AARF) is a rare type of adult cervical spine injury. The classic symptoms are painful torticollis and limited neck range of motion. To avoid catastrophic consequences, early diagnosis is necessary. The present study presents the successful treatment of a scarce case of adult AARF with a Hangman fracture and a comprehensive literature review. A 25 -year-old man presented to the trauma bay with left-sided torticollis after a motor vehicle accident. Cervical computed tomography scans revealed type I AARF. Torticollis resolved after cervical traction with partial reduction, and posterior C1-C2 fusion was performed as part of the therapy. Recognition of AARF after trauma requires a high index of suspicion, and early diagnosis is critical for the achievement of the best possible patient outcomes. Since the combination of a Hangman fracture and C1-C2 rotatory fixation is complex and unique, it must be tailored to the associated injuries. Level of evidence: IV