Evaluation of Patient Education Materials From Large-Language Artificial Intelligence Models on Carpal Tunnel Release.

BACKGROUND: ChatGPT, an artificial intelligence technology, has the potential to be a useful patient aid, though the accuracy and appropriateness of its responses and recommendations on common hand surgical pathologies and procedures must be understood. Comparing the sources referenced and characteristics of responses from ChatGPT and an established search engine (Google) on carpal tunnel surgery will allow for an understanding of the utility of ChatGPT for patient education. METHODS: A Google search of "carpal tunnel release surgery" was performed and "frequently asked questions (FAQs)" were recorded with their answer and source. ChatGPT was then asked to provide answers to the Google FAQs. The FAQs were compared, and answer content was compared using word count, readability analyses, and content source. RESULTS: There was 40% concordance among questions asked by the programs. Google answered each question with one source per answer, whereas ChatGPT's answers were created from two sources per answer. ChatGPT's answers were significantly longer than Google's and multiple readability analysis algorithms found ChatGPT responses to be statistically significantly more difficult to read and at a higher grade level than Google's. ChatGPT always recommended "contacting your surgeon." CONCLUSION: A comparison of ChatGPT's responses to Google's FAQ responses revealed that ChatGPT's answers were more in-depth, from multiple sources, and from a higher proportion of academic Web sites. However, ChatGPT answers were found to be more difficult to understand. Further study is needed to understand if the differences in the responses between programs correlate to a difference in patient comprehension.

Silver Carboxylate-Eluting Titanium-Dioxide Polydimethylsiloxane Coating Inhibits Multi-Drug-Resistant Acinetobacterium baumannii and Vancomycin-Resistant Enterococcus faecalis Adherence and Proliferation on Orthopedic Trauma Fixation and Spinal Fusion Materials.

Background: Vancomycin-resistant Enterococcus faecalis and multi-drug-resistant (MDR) Acinetobacter baumannii are rising contributors to spinal fusion and fracture-associated infections (FAI), respectively. These MDR bacteria can form protective biofilms, complicating traditional antibiotic treatment. This study explores the effects of the antibiotic-independent antimicrobial silver carboxylate (AgCar)-doped coating on the adherence sand proliferation of these pathogens on orthopedic implant materials utilized in spinal fusion and orthopedic trauma fixation. Methods: Multi-drug-resistant Acinetobacter baumannii and vancomycin-resistant Enterococcus faecalis were inoculated on five common implant materials: cobalt chromium, titanium, titanium alloy, polyether ether ketone, and stainless steel. Dose response curves were generated to assess antimicrobial potency. Scanning electron microscopy and confocal laser scanning microscopy were utilized to characterize and quantify growth and adherence on each material. Results: The optimal AgCar concentration was a 95% titanium dioxide (TiO2)-5% polydimethylsiloxane (PDMS) matrix combined with 10 × silver carboxylate, which inhibited bacterial proliferation by 89.40% (p = 0.001) for MDR Acinetobacter baumannii and 84.02% (p = 0.001) for vancomycin-resistant Enterococcus faecalis compared with uncoated implants. A 95% TiO2-5% PDMS matrix combined with 10 × AgCar was equally effective at inhibiting bacterial proliferation across all implant materials for MDR Acinetobacter baumannii (p = 0.19) and vancomycin-resistant Enterococcus faecalis (p = 0.07). A 95% TiO2-5% PDMS matrix with 10 × AgCar is effective at decreasing bacterial adherence of both MDR Acinetobacter baumannii and vancomycin-resistant Enterococcus faecalis on implant materials. Conclusions: Application of this antibiotic-independent coating for surgery in which these implant materials might be used may prevent adherence, biofilm formation, spinal infections, and FAI by MDR Acinetobacter baumannii and vancomycin-resistant Enterococcus faecalis.

Antibiotic Cement Utilization for the Prophylaxis and Treatment of Infections in Spine Surgery: Basic Science Principles and Rationale for Clinical Use.

Antibiotic bone cement (ABC) is an effective tool for the prophylaxis and treatment of osteomyelitis due to the controlled, sustained release of local antibiotics. ABC has been proven to be effective in the orthopedic fields of arthroplasty and extremity trauma, but the adoption of ABC in spine surgery is limited. The characteristics of ABC make it an optimal solution for treating vertebral osteomyelitis (VO), a serious complication following spine surgery, typically caused by bacterial and sometimes fungal and parasitic pathogens. VO can be devastating, as infection can result in pathogenic biofilms on instrumentation that is dangerous to remove. New techniques, such as kyphoplasty and novel vertebroplasty methods, could amplify the potential of ABC in spine surgery. However, caution should be exercised when using ABC as there is some evidence of toxicity to patients and surgeons, antibiotic allergies, bone cement structural impairment, and possible development of antibiotic resistance. The purpose of this article is to describe the basic science of antibiotic cement utilization and review its usage in spine surgery.

Indolent Infection After Lumbar Interbody Fusion: An Under-recognized Cause of Pseudarthrosis, Which Can Be Successfully Treated With Anterior Revision Fusion.

INTRODUCTION: Bacterial infection is a common etiology for pseudarthrosis after transforaminal lumbar interbody fusion, although it is often difficult to identify because of a delayed presentation and normal laboratory values. The primary goal of this study was to present a series of cases demonstrating patients with infection-related pseudarthrosis successfully managed with anterior revision. METHODS: We retrospectively reviewed patients presenting to a single academic spine center who were found to have evidence of Cutibacterium acnes or coagulase-negative Staphylococcus infection on routine culturing of lumbar interbody fusion revisions from July 2019 to January 2021. All patients underwent salvage of a transforaminal lumbar interbody fusion pseudarthrosis through an anterior lumbar approach. RESULTS: A total of six patients managed for pseudarthrosis secondary to suspected infection were eligible for this study (mean age 64.8 years, range 54-70 years; mean body mass index, range 24.5-39.1). Persistent radiculopathy was the primary presenting symptom in all patients with a mean time to revision of 17 months. Coagulase-negative Staphylococcus was the primary pathogen, identified from intraoperative samples in 50% of the cases. All patients demonstrated a resolution of symptoms after placement of an anterior lumbar interbody cage, without intraoperative complications, and a subsequent antibiotic regimen. DISCUSSION: Indolent infection is an under-recognized cause of pseudarthrosis of the lumbar spine. Revision surgery through an anterior lumbar approach, which promotes ease of cage removal and optimized alignment and surface area available for revision fusion, is sufficient to manage pseudarthrosis due to infection.

Synergistic Effects of Silver Carboxylate and Chlorhexidine Gluconate for Wound Care and Prevention of Surgical Site Infections by Cutibacterium acnes and Methicillin-Resistant Staphylococcus aureus.

Background: This study presents the effectiveness of a combined silver carboxylate (AgCar) and chlorohexidine gluconate (AgCar:CHG) chemistry assessed against two commonly encountered nosocomial pathogens, Methicillin-resistant Staphylococcus aureus (MRSA) and Cutibacterium acnes, within the context of surgical antisepsis and wound care. Methods: Through an Institutional Review Board- and Institutional Animal Care and Use Committee (IACUC)-approved protocol, AgCar:CHG was applied to live Yucatan porcine skin and visualized by fast red and green staining to assess level of skin penetration. Dose response curves for Cutibacterium acnes and MRSA were generated to determine the optimal therapeutic ratio of AgCar to CHG. Coatings were applied to two different clinically available sutures and antimicrobial efficacy was evaluated at 24-hour intervals using Kirby-Bauer (KB) assays. Graphite furnace atomic absorption spectroscopy was used to measure AgCar elution from sutures over time. Results: Synergistic application of AgCar:CHG demonstrated deep pilosebaceous gland penetration on Yucatan pig skin. The therapeutic concentration range of AgCar was determined to be between 120 × -150 × and 30 × -60 × dopage for MRSA and Cutibacterium acnes, respectively. A 1:1 therapeutic ratio of AgCar to CHG was found to have 100% bactericidal activity against both pathogens. Sutures coated with AgCar:CHG showed sustained antimicrobial activity against MRSA and Cutibacterium acnes, and were significantly more efficacious than antimicrobial sutures over the three- to four-day period (p < 0.01). Conclusions: This AgCar:CHG chemistry demonstrates deep skin penetration, extended elution, and broad-spectrum antimicrobial activity compared with commercially available options. This chemistry shows promise as an additional tool for the prophylaxis of surgical site infections.

Silver carboxylate-doped titanium dioxide-polydimethylsiloxane coating decreases Cutibacterium acnes adherence and biofilm formation on polyether ether ketone.

BACKGROUND CONTEXT: Cutibacterium acnes (C. acnes) is a gram-positive facultative anaerobe found in the deep sebaceous follicles of the skin on the shoulder and back. C. acnes has been increasingly recognized as a pathogen in spinal surgical site infection (SSI) especially in the presence of instrumentation. PURPOSE: This study assesses whether a silver carboxylate-doped titanium dioxide-polydimethylsiloxane (TiO2-PDMS) coating can decrease C. acnes adherence and biofilm formation on PEEK and four other commonly used spinal implant materials, stainless steel, cobalt chromium, titanium, and titanium alloy. STUDY DESIGN: We compared the adherence of C. acnes over 24 hours between uncoated, 95:5 TiO2 to PDMS ratio with 10× silver carboxylate coating and a 100% silver carboxylate coating on each implant material, which were uniformly saw cut and sterilized. Implants were then subjected to scanning electron microscopy (SEM) and confocal scanning laser microscopy (CSLM). METHODS: Samples were coated using 95:5 TiO2-PDMS 10× silver carboxylate, 100% silver carboxylate, or left uncoated. C. acnes was applied onto the samples and allowed to adhere for periods of 4, 8, 12, 16, or 20 hours. Nonadherent bacteria were then washed from the samples. These samples were then allowed to continue incubating for a total of 24 hours. SEM and confocal laser scanning microscope were used to visualize all samples for the presence of biofilm and quantification of C. acnes adherence at each time point. RESULTS: The 95:5 TiO2-PDMS 10× silver carboxylate coating was able to significantly decrease C. acnes adherence on PEEK after 8, 12, 16, and 20 hours of adherence. No statistical difference was found between the 95:5 TiO2-PDMS 10× silver carboxylate coating and the 100% silver carboxylate positive control. We previously observed extensive C. acnes biofilm formation on uncoated PEEK, but none on PEEK coated with either the 95:5 TiO2-PDMS 10× silver carboxylate or 100% Ag coating . Furthermore, no biofilm formation was observed on stainless steel, cobalt chromium, titanium, and titanium alloy coated with 95:5 TiO2-PDMS 10× silver carboxylate or 100% Ag coating. CONCLUSION: A 95:5 TiO2-PDMS 10× silver carboxylate coating decreases C. acnes adhesion and prevents biofilm formation on PEEK and other common orthopedic implant materials. CLINICAL SIGNIFICANCE: A 95:5 TiO2-PDMS 10× silver carboxylate coating may help decrease spinal SSI due to C. acnes, especially in procedures with instrumentation.

In vitro visualization and quantitative characterization of Pseudomonas aeruginosa biofilm growth dynamics on polyether ether ketone.

Prevention and treatment of orthopedic device-related infection (ODRI) is complicated by the formation of bacterial biofilms. Biofilm formation involves dynamic production of macromolecules that contribute to the structure of the biofilm over time. Limitations to clinically relevant and translational biofilm visualization and measurement hamper advances in this area of research. In this paper, we present a multimodal methodology for improved characterization of Pseudomonas aeruginosa grown on polyether ether ketone (PEEK) as a model for ODRI. PEEK discs were inoculated with P. aeruginosa, incubated for 4-48 h time intervals, and fixed with 10% neutral-buffered formalin. Samples were stained with fluorescent dyes to measure biofilm components, imaged with confocal laser scanning microscopy (CLSM) and scanning electron microscopy (SEM), and quantified. We were able to visualize and quantify P. aeruginosa biofilm growth on PEEK implants over 48 h. Based on imaging data, we propose a generalized growth cycle that can inform orthopedic diagnostic and treatment for this pathogen on PEEK. These results demonstrate the potential of using a combined CLSM and SEM approach for determining biofilm structure, composition, post-adherence development on orthopedic materials. This model may be used for quantitative biofilm analysis for other pathogens and other materials of orthopedic relevance for translational study of ODRI.

Analysis of Patients' Online Reviews of Orthopaedic Surgeons.

INTRODUCTION: Physician rating websites (PRWs) are an increasingly popular interface between patient and surgeon. Despite the growing popularity of PRWs, little guidance exists for orthopaedic surgeons regarding online reviews. We analyzed online ratings and comments to provide a better understanding of patients' values and expectations so that surgeons can tailor their practice accordingly to enhance their clinical care and online reputation. METHODS: Three common PRWs (Vitals, HealthGrades, and RateMDs) were queried from January 1, 2006, to May 18, 2020. Publicly available ratings, both quantitative (1 to 5 stars) and qualitative (free text comments), were collected. Comments were qualitatively tabulated as having positive or negative assessments for categories including outcome, personality, staff, surgical skill, visit time, bedside manner, wait time, diagnosis, knowledge, treatment, and advanced practice providers and analyzed using chi square goodness of fit. Quantitative comparisons of star ratings were made across surgeon years in practice, sex, practice setting, and PRW and compared using chi square independence testing. RESULTS: In total, 81% of patient comments were found to have a positive assessment. Comments regarding outcome (P < 0.001), staff (P = 0.001), surgical skill (P < 0.001), or knowledge (P = 0.001) were more likely to be positive. Reviews regarding bedside manner (P < 0.001), wait time (P < 0.001), diagnosis (P < 0.001), treatment (P < 0.001), or advanced practice providers (P < 0.001) were more likely to be negative. Surgeon sex was not associated with a difference in quantitative ratings (P = 0.131), unlike practice setting (P < 0.001) and PRW (P < 0.001). DISCUSSION: PRWs are a growing interface between surgeon and patient with a considerable effect on surgeon marketability. This study reveals a statistical association between certain patient-centered medical practices and positive patient reviews. This emphasizes the importance of ensuring that high standards are maintained throughout a physician's practice of maintaining a constant awareness of the fundamentals for effective patient care and of taking care to curate a physician's online presence.

Review of Pre-Operative Skin Preparation Options Based on Surgical Site in Orthopedic Surgery.

Background: Surgical site infections (SSIs) are a primary contributor to surgical morbidity and mortality, causing a substantial financial burden on the healthcare system. Specifically, Cutibacterium acnes contributes greatly to infections in the shoulder and spine regions. Prevention of infection is crucial to improve patient outcomes and reduce costs. This article reviews current surgical skin preparation solutions, the unique distribution of organisms at common orthopedic surgical sites, and recommends solutions based on surgical location. Methods: A search of electronic databases (PubMed, MEDLINE, and Embase) was conducted for relevant literature until December 2020. Sources were compiled based on title and abstract, then full texts were read for possible inclusion. This review summarizes the most recent publications in the field of SSIs and preparation solutions. Results: The mechanism and efficacy of alcohol-, iodine-, and chlorhexidine-based preparations were reviewed, along with experimental preparations. This article identifies common colonization patterns for the shoulder, elbow, hip, knee, spine, foot, and ankle, and discusses recommendations for preparations based on current evidence. Recommendations: For shoulder and elbow operations, we recommend ChloraPrep™ (CareFusion, BD, El Paso, TX), DuraPrep™ (3M Health Care, St. Paul, MN), or Betadine® applied with 4 × 4 gauze sponge, three-day pre-operative benzyl peroxide, and application of 3% hydrogen peroxide before skin preparation. For the hip and knee, we recommend application of 2% chlorhexidine gluconate (CHG) cloth the night before and morning of surgery and either DuraPrep or iodine-alcohol skin prep prior to surgery. For spine surgeries, we recommended ChloraPrep. For foot and ankle, our recommendations are: ChloraPrep or DuraPrep, submersion of foot in 70% ethanol/10% isopropyl alcohol for five minutes prior to procedure, application with a bristled brush, and a second vigorous scrub with 4 × 4 soaked gauze. Conclusions: The current surgical skin preparations have both benefits and drawbacks. We recommend that orthopedic surgeons choose a skin preparation based on surgical site and prevalence of unique skin flora there.

Silver carboxylate and titanium dioxide-polydimethylsiloxane coating decreases adherence of multi-drug resistant Serratia marcescens on spinal implant materials.

PURPOSE: The opportunistic multi-drug resistant nosocomial gram negative bacilli Serratia marcescens (S. marcescens) is a rising contributor to spinal implant infections (Iguchi et al., Genome Biol Evol 6:2096-2110, 2014; Teresa et al., J Clin Microbiol 55:2334-2347; Dante et al., J Clin Microbiol 54:120-126). This study investigates the most effective matrix ratio of an antibiotic-independent, silver carboxylate-doped titanium dioxide (TiO2)-polydimethylsiloxane (PDMS) coating in preventing adherence of multidrug resistant pathogen S. marcescens to spinal implant materials. METHODS: This project examined an antibiotic-independent, silver carboxylate-doped titanium dioxide (TiO2)-polydimethylsiloxane (PDMS) coating on three common spinal implant materials, polyetheretherketone (PEEK), stainless steel (SS), and titanium (Ti), which previously were found to be prone to bacterial adhesion (Garcia et al., Spine Deform 8:351-359). After generation of dose response curves to find the optimal silver carboxylate concentration, 95% TiO2-5% PDMS was combined with 10× silver carboxylate and compared to 100% silver carboxylate and uncoated implants. Implants were imaged using scanning electron microscopy and confocal laser scanning microscopy to detect adherent S. marcescens. RESULTS: Ninety-five percent TiO2-5% PDMS and 10× silver carboxylate coating decreased adherence of S. marcescens on PEEK by 99.61% (p = 0.001), on titanium by 98.77% (p = 0.001), and on stainless steel by 88.10% (p = 0.001) after 24 h. The average decrease in bacterial adherence was 95.49% compared to uncoated implants. CONCLUSION: A coating composition comprised of 95% TiO2-5% PDMS matrix and 10× silver carboxylate most effectively decreases adherence of S. marcescens on spinal implants. These results suggest that the application of a non-antibiotic, bactericidal coating prior to spinal surgery may prevent the adherence and proliferation of MDR S. marcescens and decrease the incidence of spinal SSI.

Applicant Ranking Criteria in Adult Reconstruction Fellowship: Your Interview Counts When Applying for Fellowship.

Background The criteria for successful ranking in the fellowship match remains unclear. Although some data are available regarding the qualities sought after in medical students for the residency match, little information is available regarding the fellowship match. In this study, for arthroplasty applications to our institution, the interview was hypothesized to be the most important factor for ranking, with little impact from other commonly assessed variables. Methodology All 40 applicants who applied for fellowship were selected to interview for the 2017 Brown University Comprehensive Adult Reconstruction Fellowship and were evaluated on the interview, United States Medical Licensing Examination (USMLE) scores, letters of recommendation, personal statement, extracurricular activities, research, and caliber of undergraduate institution, medical school, and residency program. The interview score was based on a combined score of individual components of personality, program fit, and research. Results Of the 40 applicants who were interviewed, eight did not match. The interview score was the only statistically significant variable and had the highest correlation with ranking (r = 0.92). Moreover, extracurricular activities correlated with a higher ranking whereas USMLE Step 1/Step 2 scores had a relatively low correlation (r = 0.32 and 0.29, respectively). Recommendation letters and caliber of medical school, undergraduate education, and residency demonstrated low correlations. The personal statement and research components had the lowest correlations. Conclusions The combined interview score, in particular the personality and program fit components, was the most important determinant of successful ranking at our institution. Because all 40 applicants who applied for an arthroplasty fellowship at our institution were selected for an interview, there was no pre-interview selection bias that would confound these results. However, the ranking does not correlate with an applicant's success in fellowship, and further research is required to determine the qualifications of a successful surgeon.

Fluorescent-conjugated antibodies as rapid ex vivo markers for bacterial presence on orthopedic surgical explants and synovium: A pilot study.

Surgical infection is one of the most pressing problems in the field of orthopedic surgery; however, current detection methods are plagued by high costs and long wait times. This study seeks to demonstrate the ability of a novel assay using fluorescently conjugated antibodies and confocal laser scanning microscopy (CLSM) to accurately detect bacterial presence on orthopedic surgical explants, tissue, and synovial fluid in 30 min. Explanted hardware, tissue, and synovial fluid samples suspected to be infected were collected from human subjects with institutional review board consent. Samples were prepared using a 30-min protocol, consisting of rinsing, nonspecific blocking and staining steps, and imaged using CLSM. Images were analyzed using ImageJ (National Institute of Health) to determine the percent area of Gram positive and Gram negative bacteria. Results of the assay were compared to the hospital's microbiological laboratory and Gram staining results. Ninety three samples were collected and tested using the 30-min testing protocol; 75 samples were synovial fluid and 18 were tissue and explants. Seventy four of 75 (98.6%) synovial fluid samples correlated with the hospital laboratory's microbiological findings. Of the 18 explant and tissue samples, our assay found bacterial presence in 14 of 18 samples, while the hospital microbiology laboratory found bacterial presence in 13 of 18 samples. This assay reliably stained and rapidly identified the presence of Gram negative and Gram positive bacteria on surgical explants, tissue and synovial fluid in 30 min. This methodology may serve as a point of service tool for the determination of bacterial presence during surgical procedures.

Wound Irrigation in Orthopedic Open Fractures: A Review.

Background: Management of open fractures remains a major clinical challenge because of the higher energy involved in the injury, the greater local trauma, tissue necrosis, and extensive contamination. Even though early surgical debridement was thought to be critical, limited available operative techniques have minimized surgery in favor of early antibiotic administration. No clear agreement on the surgical approach, debridement, or irrigation technique exists. Surgeons continue to argue about the use of various fluids, the appropriate pressure of irrigation, antiseptics, and other factors. The current work reviews the available data and summarizes the capabilities of modern orthopedic irrigation solutions. Methods: To delineate available research on the topic, the PubMed database was queried for the most common techniques, fluid variables, and chemical adjuvants utilized in current open fracture and wound irrigation methodologies. Modes of delivery, volume, pressure, temperature, timing, solution type, and additives are evaluated in the context of known outcomes to determine which solutions may be preferable. Results: Various methods have been described with their own advantages as well as limitations. Particular solutions may apply to specific clinical scenarios, presence of implants, and degree of tissue contamination. Desired irrigation solutions are isotonic, non-toxic, non-hemolytic, transparent, sterilizable, efficient in removing debris and pathogens, as well as affordable; however, no current irrigant achieves all these desired characteristics. Conclusions: Despite being crucial for the healing of open fractures, there is no clear gold standard for irrigation. Although there are some novel irrigation solutions, there has been a paucity of research on finding new, safer, and more effective irrigation solutions that will promote wound healing and reduce infection.

Current Clinical Methods for Detection of Peri-Prosthetic Joint Infection.

Background: Currently, one of the most pressing problems in the field of orthopedic surgery is peri-prosthetic joint infection [PJI]. While there are numerous ways to detect PJI, current clinical detection methods differ across institutions and have varying criteria and protocols. Some of these methods include the Modified Musculoskeletal Infection Society system, culturing, polymerase chain reaction, the determination of the presence of certain biomarkers, testing for the presence of alpha defensin peptides, and leukocyte level testing. Methods: This review summarizes the most recent publications in the field of PJI detection to highlight current strengths as well as provide future directions to find the system for the quickest, cost-effective, and most accurate way to diagnose these types of infections. Results: The results of this literature review suggest that, while each method of diagnosis has its advantages, each has various drawbacks as well. Current methods can be expensive, take days to weeks to complete, be prone to contamination, and can produce ambiguous results. Conclusions: The findings in this review emphasize the need for a more comprehensive and accurate system for diagnosing PJI. In addition, the specific comparison of advantages and drawbacks can be useful for researchers and clinicians with goals of creating new diagnostic tests for PJIs, as well as in clinical scenarios to determine the correct treatment for patients.