Are Generative Pretrained Transformer 4 Responses to Developmental Dysplasia of the Hip Clinical Scenarios Universal? An International Review.

OBJECTIVE: There is increasing interest in applying artificial intelligence chatbots like generative pretrained transformer 4 (GPT-4) in the medical field. This study aimed to explore the universality of GPT-4 responses to simulated clinical scenarios of developmental dysplasia of the hip (DDH) across diverse global settings. METHODS: Seventeen international experts with more than 15 years of experience in pediatric orthopaedics were selected for the evaluation panel. Eight simulated DDH clinical scenarios were created, covering 4 key areas: (1) initial evaluation and diagnosis, (2) initial examination and treatment, (3) nursing care and follow-up, and (4) prognosis and rehabilitation planning. Each scenario was completed independently in a new GPT-4 session. Interrater reliability was assessed using Fleiss kappa, and the quality, relevance, and applicability of GPT-4 responses were analyzed using median scores and interquartile ranges. Following scoring, experts met in ZOOM sessions to generate Regional Consensus Assessment Scores, which were intended to represent a consistent regional assessment of the use of the GPT-4 in pediatric orthopaedic care. RESULTS: GPT-4's responses to the 8 clinical DDH scenarios received performance scores ranging from 44.3% to 98.9% of the 88-point maximum. The Fleiss kappa statistic of 0.113 ( P = 0.001) indicated low agreement among experts in their ratings. When assessing the responses' quality, relevance, and applicability, the median scores were 3, with interquartile ranges of 3 to 4, 3 to 4, and 2 to 3, respectively. Significant differences were noted in the prognosis and rehabilitation domain scores ( P < 0.05 for all). Regional consensus scores were 75 for Africa, 74 for Asia, 73 for India, 80 for Europe, and 65 for North America, with the Kruskal-Wallis test highlighting significant disparities between these regions ( P = 0.034). CONCLUSIONS: This study demonstrates the promise of GPT-4 in pediatric orthopaedic care, particularly in supporting preliminary DDH assessments and guiding treatment strategies for specialist care. However, effective integration of GPT-4 into clinical practice will require adaptation to specific regional health care contexts, highlighting the importance of a nuanced approach to health technology adaptation. LEVEL OF EVIDENCE: Level IV.

An Adolescent With Intermittent Claudication.

ABSTRACT: Intermittent claudication is very uncommon in children and adolescents. We describe the case of a 14-year-old adolescent girl experiencing left calf pain for a year that occurs during running and becomes unbearable after around 2 km. She was ultimately diagnosed with extrinsic compression of the popliteal artery caused by an osteocartilaginous exostosis (osteochondroma) originating from the fibula.

Osteochondral flap fracture of the coronoid in pediatric elbow dislocation: a case report and literature review.

Osteochondral flap fractures of the coronoid are rare occult fractures, often diagnosed in delay, in pediatric patients who underwent elbow dislocations. Only 11 pediatric cases of osteochondral flap fractures of the coronoid are described in the literature. We describe a pediatric case treated in our institution for an elbow dislocation accompanied by a triad of elbow fractures, including the osteochondral flap fracture of the coronoid, and review available literature on the osteochondral flap fracture of the coronoid in pediatric patients.

Treatment of paediatric unstable displaced distal radius fractures using Kapandji technique: a case series.

BACKGROUND: The technique of intra-focal pinning described by Kapandji is seldom used in paediatric patients. We present our series of paediatric patients treated with Kapandji technique for unstable displaced distal radius fractures. METHODS: We retrospectively reviewed medical records and radiographs of a consecutive series of 56 paediatric patients who underwent closed reduction and fixation with Kapandji technique for unstable displaced metaphyseal and Salter Harris 2 distal radius fractures, from 2008 to March 2018. One or two percutaneous K-wires were inserted intra-focally without crossing the physis to lever out, reduce and stabilize the distal fragment. The arm was immobilized with an above-elbow cast, and radiographic controls were scheduled at 1, 4, 8 weeks, at least. RESULTS: The mean age at the time of the trauma was 10.5 years. The K-wires were removed at a mean of 6.4 post-operative weeks. An above-elbow cast was used for the first 4 weeks, afterwards a below-elbow cast for 2 weeks and a short-arm brace until the full recovery of motion. The mean follow-up was 18 months (range 1.5-108 months). No pin-related complications were found. All fractures showed good healing, and the full function of the wrist was achieved in every case. CONCLUSION: Kapandji pinning is a reliable technique in paediatric patients with unstable displaced distal radius fractures. It shows a lower complication rate compared to other techniques. For these reasons, we suggest implementing its use in clinical practice.

A simple, precocious, and reliable way to assess future clinical outcome in children with Perthes disease and mild femoral head involvement: correlation between MRI with diffusion-weighted and dynamic gadolinium-enhanced subtraction and Catterall and Herring classifications.

BACKGROUND: In children older than 5 years with a mild form of Legg-Calvé-Perthes disease, the outcome is difficult to predict. In this study, we retrospectively correlated gadolinium-enhanced subtracted (DGS) and diffusion (DWI) MRI findings to the radiographic assessment according to the Catterall and Herring et al. classifications and to the final score according to Stulberg et al.: the aim was to identify a precocious, simple, and objective criterion to differentiate between forms evolving favourably and forms requiring an early surgical treatment in order to avoid femoral head deformity and subsequent osteoarthritis. METHODS: Twelve boys with unilateral mild femoral head involvement (Catterall grade 2 or grade 3) underwent DSG and DWI MR during the early phase of the disease. The absence of enhancement of the external pillar on DSG MRI and the presence of metaphyseal hyperintensity on DWI were considered to be the signs of poor outcome. These findings were correlated with the Catterall and Herring et al. classifications at the initial sclerotic stage and early fragmentation phase and with the Stulberg et al. classifications at least 5 years after the onset of the disease. RESULTS: DSG MRI findings correctly discriminated three out of four patients with a good outcome but underestimated two out of eight patients with a poor outcome. DWI findings correlated with the Catterall and Herring et al. classifications in 12 out of 12 cases. In only one case, DWI findings did not correlate with the Stulberg et al. classification. CONCLUSION: DWI MR provides an objective and accurate prognostic criterion that is relatively easy to recognise. DGS MR findings are less accurate, thus underestimating the gravity of the disease in one-fourth of the patients with a poor outcome.

Outcome of Displaced Fractures of the Distal Metaphyseal-Diaphyseal Junction of the Humerus in Children Treated With Elastic Stable Intramedullary Nails.

BACKGROUND: The main objective of this study was to retrospectively evaluate the clinical and radiographic outcomes of displaced distal humeral metaphyseal-diaphyseal junction fractures in children treated by elastic stable intramedullary nailing (ESIN). METHODS: During the study period, 14 consecutive children with fractures of the distal humeral metaphyseal-diaphyseal junction were surgically treated by ESIN. All patients underwent full-length preoperative and postoperative anteroposterior and lateral radiographs of the injured humerus. One year after the index surgery, patients were asked to answer the short version of the Disabilities of the Arm, Shoulder and Hand outcome questionnaire (Quick DASH). RESULTS: During the study period, fractures of the distal metaphyseal-diaphyseal humeral junction represented 1.5% (16/1100) of all humeral fractures. Fourteen patients underwent surgery and met the inclusion criteria. The male to female ratio was 1:1. The average patient age at the time of injury was 9.7 years (range, 3.6 to 13.7 y). The left and right sides were equally affected. The mean follow-up was 28.1 months (range, 20 to 38 mo).Radiologically, no secondary displacement, nail migration, loss of fixation, consolidation delay, nonunion, or refracture was noted. None of the patients showed signs of growth arrest on either radiologic or clinical assessment.All patients returned to their previous daily and sport activities without discomfort or difficulty, and they were free of pain at their last follow-up visits. The injured elbow range of motion was comparable with that of the contralateral side at the last follow-up visit in all patients. The mean Quick DASH score was 0.81 (range, 0 to 6.8). CONCLUSIONS: We recommend surgery for displaced fractures of the distal humeral metaphyseal-diaphyseal junction. ESIN results in stable reduction, good rotational control, and faster mobilization. LEVEL OF EVIDENCE: Level IV.

Outcome of displaced distal tibial metaphyseal fractures in children between 6 and 15 years of age treated by elastic stable intramedullary nails.

UNLABELLED: From June 1995 to August 2012, 18 children were treated surgically using elastic stable intramedullary nails for displaced closed fractures of the distal metaphysis of the tibia. The patients were followed radiographically and clinically on a regular basis until union was clinically and radiographically achieved. Thirteen boys and five girls with a mean age at trauma of 11 ± 2.9 years (range 6-15) were included in the study. Radiographically, all fractures healed without evidence of delayed union, re-fracture, hardware migration. All patients were pain free at last follow-up and all regained full, normal activities including sports. LEVEL OF EVIDENCE: IV.

Simultaneous Bilateral Avulsion of Tibial Anterior Tubercle in Adolescent: Two Case Reports and Narrative Review of the Literature.

Fractures of the anterior tibial tuberosity are uncommon, ranging from 0.4% to 2.7% of all epiphyseal lesions reported. Bilateral sequential fractures are even rarer, with less than twenty-eight cases described to date and, as such, there is very little consensus data on their treatment as a whole. We report the first two documented cases of bilateral tibial tuberosity avulsions of the anterior tubercle in Switzerland, treated by open reduction and internal fixation. Both cases were 14-year-old healthy males with no previous medical history, who both suffered extra-articular fractures after falling from a height. The first case was treated in 2012 with a four-year long clinical follow-up and full recovery. The second, treated in 2019, was clinically followed for one year with a complete recovery and has returned to sporting activity at a pre-injury level. Due to the rarity of the condition, a lack of consensus on the optimal therapy, we believe the documentation of these two cases treated by the same team may be of clinical relevance.

Cervical spine sagittal alignment variations following posterior spinal fusion and instrumentation for adolescent idiopathic scoliosis.

The aim of this study is to quantify the changes in the sagittal alignment of the cervical spine in patients with adolescent idiopathic scoliosis following posterior spinal fusion. Patients eligible for study inclusion included those with a diagnosis of mainly thoracic adolescent idiopathic scoliosis treated by means of posterior multisegmented hook and screw instrumentation. Pre and post-operative anterior-posterior and lateral radiographs of the entire spine were reviewed to assess the changes of cervical sagittal alignment. Thirty-two patients (3 boys, 29 girls) met the inclusion criteria for the study. The average pre-operative cervical sagittal alignment (CSA) was 4.0° ± 12.3° (range -30° to 40°) of lordosis. Postoperatively, the average CSA was 1.7° ± 11.4° (range -24° to 30°). After surgery, it was less than 20° in 27 patients (84.4%) and between 20° and 40° in 5 patients (15.6%). The results of the present study suggest that even if rod precontouring is performed and postoperative thoracic sagittal alignment is restored, improved or remains unchanged after significant correction of the deformity on the frontal plane, the inherent rigidity of the cervical spine limits changes in the CSA as the cervical spine becomes rigid over time.

[A case of percutaneous coronary intervention after transfemoral implantation of a medtronic CoreValve System]. / Un caso di angioplastica percutanea dopo impianto transfemorale di protesi Medtronic CoreValve System.

The association between aortic valve disease and coronary atherosclerosis is common. In the recent era of transcatheter aortic valve implantation there is little experience with coronary artery intervention after valve implantation. We report a case of a 80-year-old male who underwent successful coronary artery intervention few months after a Medtronic CoreValve System percutaneous implantation for severe aortic valve stenosis. Verification of the position of the used wires (crossing from inside the self expanding frame) is of utmost importance before proceeding to coronary intervention. In this case, crossing the aortic valve, coronary angiography and percutaneous coronary intervention were successfully performed. In conclusion, percutaneous coronary intervention in patients with previous Medtronic CoreValve System implantation is feasible and safe.

Regulatory T cell frequency in patients with melanoma with different disease stage and course, and modulating effects of high-dose interferon-alpha 2b treatment.

BACKGROUND: High-dose interferon-alpha 2b (IFN-alpha 2b) is the only approved systemic therapy in the United States for the adjuvant treatment of melanoma. The study objective was to explore the immunomodulatory mechanism of action for IFN-alpha 2b by measuring serum regulatory T cell (Treg), serum transforming growth factor-beta (TGF-beta), interleukin (IL)-10, and autoantibody levels in patients with melanoma treated with the induction phase of the high-dose IFN-alpha 2b regimen. METHODS: Patients with melanoma received IFN-alpha 2b administered intravenously (20 MU/m2 each day from day 1 to day 5 for 4 consecutive weeks). Serum Treg levels were measured as whole lymphocytes in CD4+ cells using flow cytometry while TGF-beta, IL-10, and autoantibody levels were measured using enzyme-linked immunosorbent assays. RESULTS: Twenty-two patients with melanoma received IFN-alpha 2b treatment and were evaluated for Treg levels. Before treatment, Treg levels were significantly higher in patients with melanoma when compared with data from 20 healthy subjects (P = 0.001; Mann-Whitney test). Although a trend for reduction of Treg levels following IFN-α 2b treatment was observed (average decrease 0.29% per week), statistical significance was not achieved. Subgroup analyses indicated higher baseline Treg levels for stage III versus IV disease (P = 0.082), early recurrence versus no recurrence (P = 0.017), deceased versus surviving patients (P = 0.021), and preoperative neoadjuvant versus postoperative adjuvant treatment groups (not significant). No significant effects were observed on the levels of TGF-beta, IL-10, and autoantibodies in patients with melanoma treated with IFN-alpha 2b. CONCLUSIONS: Patients with melanoma in this study showed increased basal levels of Treg that may be relevant to their disease and its progression. Treg levels shifted in patients with melanoma treated with IFN-alpha 2b, although no firm conclusions regarding the role of Tregs as a marker of treatment response or outcome can be made at present.

Diffusion-weighted imaging findings in Perthes disease with dynamic gadolinium-enhanced subtracted (DGS) MR correlation: a preliminary study.

BACKGROUND: Legg-Calvé-Perthes disease (LCP) is necrosis of the proximal femoral epiphysis of vascular origin. Clinical course and outcome in LCP disease varies considerably between different patients. Earlier prognostic criteria than those offered by conventional radiography are necessary to identify children who require prompt surgical treatment. OBJECTIVE: To assess the significance of signal alteration on diffusion-weighted MR imaging (DWI MR) in LCP. MATERIALS AND METHODS: Twelve boys with unilateral LCP disease (Catterall grade 2 and 3), at the initial sclerotic stage and early fragmentation phase, underwent dynamic gadolinium-enhanced subtracted (DGS) and DWI MR. For DGS MR, the lateral pillar enhancement was recorded. For DWI imaging, we measured ADC values in the diseased and the unaffected epiphyses and metaphyses. Receiver operating characteristic curves were performed to analyze the performance of DWI in establishing agreement with the results of DGS MR, which is the gold standard for prognosis. RESULTS: Femoral epiphysis increased diffusivity was observed in the affected hip in all cases. Increased metaphysis diffusivity in the affected side was observed in all cases with absent lateral pillar enhancement at DGS MR. CONCLUSION: DWI seems to be a noninvasive means of distinguishing between Perthes disease with favourable and unfavourable prognosis.

Percutaneous cyst aspiration with injection of two different bioresorbable bone cements in treatment of simple bone cyst.

INTRODUCTION: Simple bone cysts (SBCs) are common in children and adolescents. The risk of refracture and the probability of spontaneous healing in SBCs are mainly dependent on the activity of the cyst and can be quantified with the Cyst-Index. Avoiding pathological fractures is the primary goal. Our study presents a comparison of two different bioresorbable bone graft substitutes (BGSs) in the minimally-invasive treatment of SBC in the active stage by percutaneous cyst aspiration and injection. METHODS: Between 2006 and 2017, 38 patients (aged two to 37 years; mean age 12.4 (sd 5.6)) were treated with percutaneous cyst aspiration and refilled with bioresorbable BGSs in three hospitals. The cysts of 21 patients (11 humerus, five femur, four calcaneus, one fibula) were refilled with porous beta-tricalcium phosphate (PB-TP group) (ChronOS Inject) and of 17 patients (nine humerus, six femur, one calcaneus, one fibula) with hydroxyapatite/calcium sulphate (H/CS group) (CERAMENT|BONE VOID FILLER). There were 13 (62%) preceding fractures in the PB-TP group and eight (47%) in the H/CS group. The follow-up of all patients was at least two years. During follow-up, radiological healing (modified Neer classification), activity level, refracture rates, recurrence rates, resorption period and complications were analyzed. RESULTS: In all, 21 patients treated with PB-TP group experienced 27 operations (one refracture, three recurrences and one persistent cyst). A total of 17 patients treated with H/CS experienced 20 operations (one refracture and one recurrence). After six weeks, 95% in the PB-TP group returned to unrestricted activity with one refracture in the femur due to insufficient biomechanical stability and all returned to unrestricted activity in the H/CS group. Partial or complete radiological response was observed in 81% after 13 months (sd 3.4). Three recurrences (14%) occurred in the PB-TP group and one recurrence (6%) occurred in the H/CS group. The refracture rates were similar in both groups; one (5%) in the PB-TP group and one (6%) in the H/CS group. All H/CS treated cysts showed completed resorption after two years, whilst in PB-TP treated cysts no resorption occurred in five cases (25%) (p = 0.031). Two (10%) wound infections occurred in the PB-TP group and no infections occurred in the H/CS group. CONCLUSION: Both PB-TP and H/CS can provide stability and prevent refracture in patients with single bone cysts at the upper extremity or the foot. For the proximal femur, additional stabilization is necessary, due to the weight-bearing and associated high refracture rate. The H/CS bone graft substitute has a better resorption rate than the PB-TP graft. LEVEL OF EVIDENCE: III.

Posttraumatic Pseudoarthrosis of a Clavicle Fracture in an 11-Year-Old Girl: A Case Report and Analysis.

Clavicular fractures are some of the most common bone injuries in the paediatric population, yet the rates of nonunion are very low under 18 years. To the best of our knowledge, posttraumatic nonunion of the clavicle in a paediatric population is rarely reported. We report the case of an 11-year-old girl who presented with a nondislocated fracture of the midshaft to the proximal third of the right clavicle. Initial conservative treatment by sling immobilization demonstrated radiologically confirmed healing at 3 months. However, at 1-year follow-up, she presented with painful nonunion. Diagnostic MRI and CT exams confirmed a pseudoarthrosis, requiring elective open reduction and internal fixation with the aid of an ipsilateral iliac crest bone graft.

Tobramycin-impregnated calcium sulfate pellets for the treatment of chronic osteomyelitis in children and adolescents.

The aim of this work was to evaluate the outcome and efficacy of treatment in a homogeneous group of skeletally immature patients with chronic osteomyelitis of the long bones managed by a combination of radical debridement and insertion of tobramycin-impregnated calcium sulfate pellets to fill the bone defect in a single-stage procedure. Between 2011 and 2016, 12 skeletally immature patients were treated surgically by the reported technique. Single-stage surgery using tobramycin-impregnated calcium sulfate pellets in association with systemic antibiotic therapy yields satisfactory outcomes in skeletally immature children presenting chronic osteomyelitis by reducing the risk of occurrence of comorbidities, hospital stays, and healthcare costs.

Spindle cell neuroendocrine carcinoma of the lung: report of a case with fine needle aspiration cytology and differential diagnostic considerations.

BACKGROUND: Spindle cell neuroendocrine carcinomas of the lung may be frequently observed on fine needle cytology (FNC) samples and often pose stimulating differential diagnostic problems. CASE: The cytopathologic findings from FNC performed on a long-standing coin lesion of the lung in a 54-year-old woman were analyzed in view of the data and long clinical history. CONCLUSION: A final diagnosis of low grade spindle cell neuroendocrine carcinoma was reached by combining cytopathologic and immunocytochemical information. The main lesions considered in the differential diagnosis were intrapulmonary inflammatory myofibroblastic tumor (fibrohistiocytic variant) and spindle cell thymoma.

Pediatric Posterior Cruciate Ligament Avulsion Fracture of the Tibial Insertion: Case Report and Review of the Literature.

Background Posterior cruciate ligament (PCL) avulsion fracture of the tibial insertion is a very rare injury in children. In addition to performing an attentive clinical examination, radiologic studies are fundamental for its correct diagnosis and treatment. Its management may be either conservative or operative. So far, only a few cases treated conservatively have been reported in the pediatric population, with controversial results. Methods We prospectively collected and reviewed clinical and radiographic data of an 11-year-old boy with avulsion fracture of the tibial insertion of the PCL. In addition, we performed a systematic review of the literature available to date. Results We decided to treat the avulsion fracture in a conservative way. The patient has been followed with accurate clinical and radiological follow-up controls until complete recovery. Conclusion Posterior cruciate avulsion fracture is a very rare finding in children, and no definitive indications for its appropriate management exist. With this report, we demonstrate that these fractures can be treated conservatively in selected cases with good results, avoiding potential surgical-related complications. Study Design This is a case report (level of evidence V).

Pegylated arginine deiminase treatment of patients with metastatic melanoma: results from phase I and II studies.

PURPOSE: Individuals with metastatic melanoma have a poor prognosis. Many human melanomas are auxotrophic for arginine, and arginine is not an essential amino acid in humans. We hypothesized that this auxotrophy may be therapeutically exploited. A novel amino acid-degrading enzyme (arginine deiminase) conjugated to polyethylene glycol (ADI-SS PEG 20,000 mw) was used to lower plasma arginine in individuals with metastatic melanoma. PATIENTS AND METHODS: Two cohort dose-escalation studies were performed. A phase I study in the United States enrolled 15 patients, and a phase I to II study in Italy enrolled 24 patients. The Italian patients also received two subsequent cycles of treatment, each consisting of four once-weekly injections of 160 U/m2. The goals of these studies were to determine pharmacokinetics (PK), pharmacodynamics (PD), safety, and the antitumor activity of ADI-SS PEG 20,000 mw. RESULTS: PK and PD studies indicated that a dose of 160 U/m2 lowered plasma arginine from a resting level of approximately 130 micromol/L to less than 2 micromol/L for at least 7 days; nitric oxide levels also were lowered. There were no grade 3 or 4 toxicities directly attributable to the drug. Six of 24 phase I to II patients responded to treatment (five partial responses and one complete response; 25% response rate) and also had prolonged survival. CONCLUSION Elimination of all detectable plasma arginine in patients with metastatic melanoma was well tolerated and may be effective in the treatment of this cancer. Further testing of ADI-SS PEG 20,000 mw in a larger population of individuals with metastatic melanoma is warranted.

New emerging drugs in soft tissue sarcoma.

Doxorubicin and ifosfamide are the two most active drugs in the treatment of patients with advanced, soft tissue sarcoma (STS) of most histologic subtypes, aside from gastrointestinal stromal tumor (GIST). However, after failure of these drugs, alone or in combination, patients with advanced STS have few therapeutic options and the search for new active drugs is well worth pursuing. ET-743, a DNA minor groove binder, which blocks cell cycle progression in G2/M phase through a p53-independent apoptotic process, represents the most promising among novel compounds in STS, since recently completed phase II trials have consistently shown high survival, in spite of the relatively low incidence of major objective responses. The potential for combination with other active compounds further increases the appeal of ET-743. Imatinib mesylate is being tested also in STS other than GIST, which can overexpress one or more of the tyrosine kinases inhibited by imatinib; however, negative data have recently been presented. Clinical studies with a number of other compounds are ongoing or planned. However, investigators involved in the management of patients with advanced STS are to be increasingly aware of the emergence of new molecular targets and genetic profiles in different histologic subtypes, according to which treatment strategies should be adapted.

Primary gastrointestinal stromal tumor of the liver with lung metastases successfully treated with STI-571 (imatinib mesylate).

We report a case of a primary malignant GIST of the liver metastatic to the lung in a 37 years-old man. The liver tumor showed histological feature of a GIST and expressed vimentin, and diffusely exhibited CD117. One year after the resection of the liver mass, the patient developed multiple small lung metastases which completely disappeared with STI-571 (imatinib mesylate--Gleevec) therapy. C.T. or PET did not show any mass in the abdomen. These findings suggest that the liver mass was a primary rather than a metastatic tumour. They also support the hypothesis that GIST could originate from undifferentiated mesenchymal cells capable to differentiate toward a pacemaker cell phenotype, which are present in sites other than the G.I. tract.