Cubital tunnel syndrome: anatomy, pathology, and imaging.

Cubital tunnel syndrome (CuTS) is the second most common peripheral neuropathy in the upper limb. It occurs due to ulnar nerve compression within the fibro-osseous cubital tunnel at the elbow joint. Although CuTS is typically diagnosed clinically and with electrodiagnostic studies, the importance of imaging in evaluating the condition is growing. Knowing the typical imaging findings of ulnar nerve entrapment is necessary for precise diagnosis and proper treatment. In this article, we focus on the clinical features, workup and complex imaging of the "anatomic" cubital tunnel and relevant pathological entities.

Journal metrics of the top-ranked Orthopaedic, Medical, and Surgical journals - A cross-sectional, comparative study.

PURPOSE: In academic publishing, research metrics play a crucial role in assessing the scientific impact and performance of the published literature, as well as of the journals in which they are published. Several journal-level metrics (JLM) such as the h-index of the analysed journals, total citations, total documents, citable documents, references and external citations per document are considered crucial indicators of the importance and reputation of the journals. We hypothesize that journals in the field of Medicine receive more citations than those in Surgical journals like Orthopaedic surgery, and hence have better JLM. This study aims to to assess and compare the JLM of Medical and Surgical journals between two time zones 2017-2019 vs. 2020-2022, i.e., pre and post-COVID-19 pandemic period. METHODS: A cross-sectional bibliometric analysis of the top-ranked Orthopaedic, Medical, and Surgical journals was undertaken based on traditional JLM, using the SCImago database from 2017 to 2022. Our analysis focused on identifying trends in the h-index of the analysed journals, total citations, total documents, citable documents, references and external citations per document. RESULTS: Overall Medical journals were found to have higher JLM than the Surgical and Orthopaedic journals. The h-index of Surgical journals, Medical journals and Orthopaedic journals were comparable between the two periods (pre and -post-COVID-19 pandemic); Total Cites (3 years), total documents (2017), total documents (3 years), total references, and citable documents (3 years) of Surgical journals, Medical journals and Orthopaedic journals were significantly higher in the period 2020-2022. CONCLUSION: There has been a steady increase in the number of publications from post COVID-19 period. Medical journals have higher JLM than Surgical and Orthopaedic journals. Journal of Bone and Joint Surgery (Am), Annals of Surgery and Diabetes Care were the most published journals in Orthopaedics, General Surgery and Medicine-related topics respectively.

Total hip arthroplasty in active and advanced tubercular arthritis: a systematic review of the current evidence.

STUDY DESIGN: Systematic review. INTRODUCTION: Total hip arthroplasty (THA) is a well-acknowledged surgical intervention to restore a painless and mobile joint in patients with osteoarticular tubercular arthritis of the hip joint. However, there is still substantial uncertainty about the ideal management, clinical and functional outcomes following THA undertaken in patients with acute Mycobacterium tuberculosis (TB) hip infections. AIM OF THE STUDY: To undertake a systematic review and evaluate existing literature on patients undergoing THA for acute mycobacterium tuberculosis arthritis of the hip. METHODS: A systematic review of electronic databases of PubMed, EMBASE, Scopus, Web of Science and Cochrane Library was performed on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The search focused on "arthroplasty in cases with tuberculosis of hip joint" since inception of databases until July 2023. Data on patient demographics, clinical characteristics, treatment administered, surgical interventions and outcome, as reported in the included studies, were recorded. Median (range) and mean (standard deviation) were used to summarise the data for continuous variables (as reported in the original studies); and frequency/percentage was employed for categorical variables. Available data on Harris hip scores and complications were statistically pooled using random-effects meta-analysis or fixed-effect meta-analysis, as appropriate RESULTS: Among a total of 1695 articles, 15 papers were selected for qualitative summarisation and 12 reporting relevant data were included for proportional meta-analysis. A total of 303 patients (mean age: 34 to 52 years; mean follow-up: 2.5 to 10.5 years) were included in our systematic review. In a majority of included studies, postero-lateral approach and non-cemented prosthesis were employed. Fourteen studies described a single-staged procedure in the absence of sinus, abscess and tubercular infection syndrome (TIS). All surgeries were performed under cover of prolonged course of multi-drug anti-tubercular regimen. The mean Harris hip score (HHS) at final follow-up was 91.36 [95% confidence interval (CI): 89.56-93.16; I2:90.44%; p<0.001]. There were 30 complications amongst 174 (9.9%) patients (95% CI: 0.06-0.13; p=0.14; I2=0%). CONCLUSION: THA is a safe and effective surgical intervention in patients with active and advanced TB arthritis of hip. It is recommended that the surgery be performed under cover of multi-drug anti-tubercular regimen. In patients with active sinus tracts, abscesses and TIS, surgery may be accomplished in a multi-staged manner. The clinical (range of motion, deformity correction, walking ability and pain scores), radiological (evidence of radiological reactivation and implant incorporation) and function outcome (as assessed by HHS) significantly improve after THA in these patients.

Effectiveness of AI-powered Chatbots in responding to orthopaedic postgraduate exam questions-an observational study.

PURPOSE: This study analyses the performance and proficiency of the three Artificial Intelligence (AI) generative chatbots (ChatGPT-3.5, ChatGPT-4.0, Bard Google AI®) and in answering the Multiple Choice Questions (MCQs) of postgraduate (PG) level orthopaedic qualifying examinations. METHODS: A series of 120 mock Single Best Answer' (SBA) MCQs with four possible options named A, B, C and D as answers on various musculoskeletal (MSK) conditions covering Trauma and Orthopaedic curricula were compiled. A standardised text prompt was used to generate and feed ChatGPT (both 3.5 and 4.0 versions) and Google Bard programs, which were then statistically analysed. RESULTS: Significant differences were found between responses from Chat GPT 3.5 with Chat GPT 4.0 (Chi square = 27.2, P < 0.001) and on comparing both Chat GPT 3.5 (Chi square = 63.852, P < 0.001) with Chat GPT 4.0 (Chi square = 44.246, P < 0.001) with. Bard Google AI® had 100% efficiency and was significantly more efficient than both Chat GPT 3.5 with Chat GPT 4.0 (p < 0.0001). CONCLUSION: The results demonstrate the variable potential of the different AI generative chatbots (Chat GPT 3.5, Chat GPT 4.0 and Bard Google) in their ability to answer the MCQ of PG-level orthopaedic qualifying examinations. Bard Google AI® has shown superior performance than both ChatGPT versions, underlining the potential of such large language processing models in processing and applying orthopaedic subspecialty knowledge at a PG level.

Angle of BRINK - a new way to measure Haglund's deformity.

INTRODUCTION: Haglund's deformity, an abnormality of the postero-superior corner of the calcaneum, is a common, critically debated cause of posterior heel pain. Several radiological indices such as Fowler-Philip angle, Ruch pitch, Chauveaux-Liet angle, calcaneal pitch angle, parallel pitch lines, and X-Y ratio have been described to measure this deformity. However, most of these lack specificity and have variable intra- and inter-observer reliability. PURPOSE: The study aims to describe a new radiological "angle of BRINK" (Botchu-Reilly-Iyengar-Nischal-Kakarala) to measure Haglund's deformity. PATIENT AND METHODS: We performed a retrospective cohort analysis, assessing 20 weight-bearing lateral ankle radiographs of patients with Haglund's deformity (Haglund's cohort) and 100 radiographs without the deformity (normal cohort). Demographic details and angle of BRINK to measure Haglund's deformity were measured for each patient. Statistical analysis was performed using t-test and inter-observer reliability was calculated using kappa coefficient. RESULTS: The mean angle of BRINK to measure Haglund's deformity in the normal cohort was 20.04° (SD 4.88), and in the Haglund's cohort was 25.1° (SD 3.3). This was statistically significant with a p-value of less than 0.0001. There was excellent intra- and inter-observer reliability with kappa value of 0.8. CONCLUSION: Our proposed radiological angle of BRINK to measure Haglund's deformity is simple and easy to calculate on standard weight-bearing radiographs. Contrary to the traditional measurements used to estimate the deformity, it has shown a good intra- and inter-observer reliability and can support surgical decision-making process for management of patients with symptomatic Haglund's deformity.

A comparison of ChatGPT-generated articles with human-written articles.

OBJECTIVE: ChatGPT (Generative Pre-trained Transformer) is an artificial intelligence language tool developed by OpenAI that utilises machine learning algorithms to generate text that closely mimics human language. It has recently taken the internet by storm. There have been several concerns regarding the accuracy of documents it generates. This study compares the accuracy and quality of several ChatGPT-generated academic articles with those written by human authors. MATERIAL AND METHODS: We performed a study to assess the accuracy of ChatGPT-generated radiology articles by comparing them with the published or written, and under review articles. These were independently analysed by two fellowship-trained musculoskeletal radiologists and graded from 1 to 5 (1 being bad and inaccurate to 5 being excellent and accurate). RESULTS: In total, 4 of the 5 articles written by ChatGPT were significantly inaccurate with fictitious references. One of the papers was well written, with a good introduction and discussion; however, all references were fictitious. CONCLUSION: ChatGPT is able to generate coherent research articles, which on initial review may closely resemble authentic articles published by academic researchers. However, all of the articles we assessed were factually inaccurate and had fictitious references. It is worth noting, however, that the articles generated may appear authentic to an untrained reader.

Assessing ChatGPT's ability to pass the FRCS orthopaedic part A exam: A critical analysis.

AI technology has made significant advancements in recent years, with the notable development of ChatGPT in November 2022. Users have observed evidence of deductive reasoning, logical thinking, and coherent thought in ChatGPT's responses. This study aimed to determine if ChatGPT has the capability to pass the Orthopaedic Fellow of the Royal College of Surgeons (FRCS Orth) Part A exam. METHODS: To assess ChatGPT4's ability to pass the Orthopaedic FRCS Orth Part A exam, a study was conducted using 240 mock FRCS Orth Part A questions. The study evaluated the accuracy of ChatGPT's answers and the response time for each question. Descriptive statistics were employed to analyse the chatbot's performance. RESULTS: The evaluation revealed that ChatGPT4 achieved an overall score of 67.5% on Part A of the exam. However, ChatGPT4 did not meet the overall pass mark required for the FRCS Orth Part A exam. CONCLUSION: This study demonstrates that ChatGPT was unable to pass the FRCS Orthopaedic examination. Several factors contributed to this outcome, including the lack of critical or high-order thinking abilities, limited clinical expertise, and the inability to meet the rigorous requirements of the exam.

Validation of the supinator fat pad sign in radial head and neck fractures.

OBJECTIVE: To assess the displacement of the supinator fat pad in radial head and neck fractures and to validate its significance. MATERIAL AND METHODS: One hundred two adult patients from the Royal Orthopaedic Hospital, Birmingham, United Kingdom and Sultan Qaboos University Hospital, Muscat, Oman with confirmed radial head and/or neck fractures were included. Fractures were classified using the Mason-Johnston classification. The displacement of the supinator fat pad from the radius was measured on anterior-posterior (AP) and lateral radiographs and correlated to fracture classification. RESULTS: The supinator fat pad was on average displaced by 10.6 mm and 13.8 mm from the radius on AP and lateral radiographs, respectively. The displacement of the fat pad progressively increased between non-displaced (Mason I) and severely comminuted (Mason III) fractures on both the AP (10.25 to 14.25 mm) and lateral (12.70 to 16.00 mm) projections. The progression of displacement on AP (p = 0.016) and on lateral (p = 0.007) projections was statistically significant. Fracture dislocation was not associated with increased fat pad displacement. CONCLUSION: The supinator fat pad sign is a useful adjunct in the assessment of radial head and neck fractures.

Does intraoperative patellar eversion affect clinical and functional outcomes in patients undergoing primary total knee arthroplasty? An evidence-based meta-analysis.

PURPOSE: This meta-analysis aims to compare the early postoperative recovery, complications encountered, length of hospital stay, and initial functional scores between patellar eversion and non-eversion manoeuvres in patients undergoing during primary total knee arthroplasty (TKA) based on clinical studies available in the literature. METHODS: A systematic literature search was conducted using PubMed, Embase, Web of Science, and the Cochrane Library databases between January 1, 2000 and August 12, 2022. Prospective trials comparing clinical, radiological, and functional outcomes in patients undergoing TKA with and without patellar eversion manoeuvre were included. The meta-analysis was performed using Rev-Man version 5.41 (Cochrane Collaboration). Pooled-odds ratios (for categorical data) and mean differences with 95% confidence intervals (for continuous data) were calculated (p < 0.05 was regarded as statistically significant). RESULTS: Ten (out of the 298 publications identified in this subject) were included for the meta-analysis. The patellar eversion group (PEG) had a significantly shorter tourniquet time [mean difference (MD) - 8.91 min; p = 0.002], although the overall intraoperative blood loss was higher (IOBL; MD 93.02 ml; p = 0.0003). The patellar retraction group (PRG), on the other hand, revealed statistically better early clinical outcomes in terms of shorter time necessary to perform active straight leg raising (MD 0.66, p = 0.0001), shorter time to achieve 90° knee-flexion (MD 0.29, p = 0.03), higher degree of knee flexion achieved at 90 days (MD - 1.90, p = 0.03), and reduced length of hospital stay (MD 0.65, p = 0.03). There was no statistically significant difference in the early complication rates, 36-item short-form health survey (1 year), visual analogue scores (1 year), and Insall-Salvati index at follow-up between the groups. CONCLUSION: The implications from the evaluated studies suggest that in comparison with patellar eversion, patellar retraction manoeuvre during surgery provides significantly faster recovery of quadriceps function, earlier attainment of functional knee range of motion (ROM), and shorter length of hospital stay in patients undergoing TKA.

Nanotechnology applications in rheumatology.

Nanomedicine (NM) is the medical use of nanotechnology (NT). NT is the study and control of nanoscale structures (between approximately 1 and 100 nm). Nanomaterials are created by manipulating atoms and molecules at the nanoscale, resulting in novel physical and chemical properties. With its targeted tissue delivery capabilities, NT has enabled molecular modulation of the immune response and underlying inflammatory responses in individuals with rheumatic diseases (RD). NM has enabled targeted drug delivery, reduced adverse effects on non-target organs, raised drug concentration in synovial tissue, and slowed the progression of immune-mediated RD such as rheumatoid arthritis (RA) and systemic lupus erythematosus (SLE). Thus, NM has evolved in rheumatology prevention, diagnosis, and therapy. Animal models have proven superior outcomes to conventional techniques of treating specific illnesses. Nanodiamond (ND) immunomodulatory applications have been proposed as an alternative to traditional nanoparticles in the diagnosis and treatment of RA due to their small size and ability to be removed from the body without causing harm to the patient's organs, such as the liver. However, human clinical NM needs more research. We conducted a literature review to assess the present role of NM in clinical rheumatology, describing its current and future applications in the diagnosis and treatment of rheumatic diseases.

Virtual risk assessment pathway for deep venous thrombosis: a preliminary model.

BACKGROUND: COVID-19 has necessitated the reduction in conventional face-to-face patient consultation to reduce the risk of novel coronavirus SARS-CoV-2 transmission. Traditional pathways to risk assess for deep venous thrombosis (DVT) would involve face-to-face assessment to formulate an appropriate management plan following an initial presentation usually in secondary care or in-hospital settings. Appropriate antithrombotic measures can prevent complication of DVT such as pulmonary embolism with prompt early diagnosis and treatment. METHODS: This observational, pilot study evaluates the possibility of combining telemedicine technology and a virtual examination pathway for remote triage and assessment of patients with suspected DVT. RESULTS: Piloting and development of a virtual risk assessment pathway for DVT involves various challenges and multidisciplinary co-ordination. CONCLUSION: Advances in telecommunication technology can enable clinicians, specialist nurses and hospital departments to develop a virtual examination pathway for remote triage and assessment of patients with suspected DVT. This pathway is not a replacement for conventional 'face-to-face' evaluation, but we believe the template can be explored and refined to act as a blueprint for future applications even when the pandemic has stabilised.

Bone stress injuries in the presence of tarsal coalition as a cause of hindfoot pain in adolescents: case series of 6 patients with literature review.

OBJECTIVE: To highlight causal relationship between stress fracture in the presence of tarsal coalition and hindfoot pain in adolescents on magnetic resonance imaging (MRI). MATERIAL AND METHODS: A retrospective review was performed of the clinical and MRI imaging findings of 6 adolescents referred for MRI to evaluate symptoms of hindfoot pain with possible tarsal coalition. MRI studies were systematically assessed for cause of hindfoot pain, types of tarsal coalition, patterns of stress fractures, bone marrow oedema and any other associated features. RESULTS: All the 6 patients (4 male: 2 female) aged between 12 and 19 years developed insidious onset of hindfoot or midfoot pain over a period of weeks to months. On MRI, all 6 cases had features of fibrous tarsal coalition predominantly in the calcaneonavicular articulation (5 out of 6 patients). Associated stress fractures/response were in the posterior facet/body of the calcaneus (3), talar head (2), cuboid (1) and third metatarsal bone in one patient. CONCLUSION: Stress fractures/response adjacent to tarsal coalition could be because of altered biomechanics and can be an unusual cause of hindfoot pain in adolescents. A high index of suspicion and complementary MRI findings is crucial to interpret this condition to direct appropriate patient management.

Virtual postgraduate orthopaedic practical examination: a pilot model.

COVID-19 pandemic has had a profound impact on the delivery of medical education, training and examination schedule across the world both at undergraduate and at postgraduate (PG) levels. The novel coronavirus SARS-CoV-2 outbreak has resulted in the cancellation of traditional in-person meetings and clinical examination assessments, learning and education activities because of concern of viral transmission. Various medical universities, Royal Medical and Surgical Colleges in the UK have suspended delivery of qualifying examinations until they can be resumed safely with updated social distancing guidelines. This article evaluates the role and the possibility of virtual PG practical examination template based on authors' own recent experience of conducting successful virtual practical PG orthopaedic qualifying examinations during the COVID-19 pandemic in New Delhi, India. Advances in telecommunication technology can enable academic institution and orthopaedic educators to develop such a model and act as a blueprint for the future.

Total Hip Arthroplasty in Patients With Postpolio Residual Paralysis: A Systematic Review.

BACKGROUND: Patients with postpolio residual paralysis can develop disabling hip arthritis in paralytic as well as a nonparalytic limb, warranting total hip arthroplasty (THA). Limited literature is available on the results of THA among these patients in the form of small series or case reports. We have undertaken a systematic review to evaluate the clinical outcome of THA in patients with poliomyelitis with hip pathologies. METHODS: A systematic search of electronic databases of PubMed, Scopus, and Web of Science pertaining to English literature was undertaken from 1945 to August 2020 to assess the results of THA in patients with poliomyelitis. Information was gathered about demographics, indication, clinical course, complications, functional outcome, survival, and need for any revision surgery in these patients. RESULTS: The literature search revealed 81 articles. Finally, after deduplication and manual selection, 16 relevant articles (128 hips) were included for evaluation. There is a paucity of literature evaluating THA in patients with poliomyelitis over the last 2 decades. The principal reason for arthroplasty was osteoarthritis of the hip in the ipsilateral (paralyzed) limb. A combination of cemented, uncemented, and hybrid implant fixation system was found to be used by surgeons. Addressing instability and perioperative management of limb length discrepancy were found to be challenging propositions. CONCLUSION: THA remains an effective intervention to relieve pain and improve quality of life in patients of poliomyelitis afflicted with either primary or secondary arthritis of the hip. The use of uncemented nonconstrained hip implant designs appears to demonstrate better results than constrained implants.

Clinical Characteristics and Learning Outcomes of Managing Orthopaedic Trauma Patients during the First Wave of Covid- 19 Pandemic: A Retrospective Cohort Analysis.

BACKGROUND: Management of trauma and emergency orthopaedic conditions during the pandemic was reorganised across the United Kingdom including our hospital following the COVID-19 British Orthopaedic Association and National Health Service England guidelines. AIMS: This retrospective, observational cohort study analyses the impact of the first wave of COVID-19 pandemic on trauma and emergency patient care at a district general hospital. A comparative analysis to assess patient characteristics and clinical outcomes during the initial phase of COVID-19 outbreak with a cohort of patients treated during a similar period in 2019 was undertaken. METHODS: Patients who underwent trauma and emergency surgeries between 01 April to 31 May 2020 at a Northwest Mersey NHS Trust were studied and compared to a similar period in 2019. The outcome measures assessed were 30- and 60-day mortality, Time to Surgery, length of stay after surgery, systemic and orthopaedic complications including the subsequent need for surgery. RESULTS: Overall, there was a decrease in the number of patients who underwent trauma or emergency surgery from 184 in 2019 to 116 in 2020. 30- and 60-day mortality slightly increased by 2.05% and 2.68%, respectively. Time to surgery and hospital length of stay were comparable between both cohorts. CONCLUSION: Continuity of services to patients with obligatory injuries was managed using enhanced personal protective equipment and infection control strategies including segregation of patients based on COVID-19 status. Lessons learnt during this period such as COVID-19 testing regime and care pathways have prepared us for the near future. LEVEL OF STUDY: Retrospective Cohort study; Level III.

CONTEXTE: La gestion des traumatismes et des urgences orthopédiques pendant la pandémie a été réorganisée dans tout le Royaume-Uni, y compris dans notre hôpital, conformément aux directives COVID-19 de la British Orthopaedic Association et du National Health Service England. OBJECTIFS: Cette étude de cohorte rétrospective et observationnelle analyse l'impact de la première vague de la pandémie COVID-19 sur les soins aux patients en traumatologie et en urgence dans un hôpital général de district. Une analyse comparative visant à évaluer les caractéristiques des patients et les résultats cliniques pendant la phase initiale de l'épidémie de COVID-19 avec une cohorte de patients traités pendant une période similaire en 2019 a été entreprise. MÉTHODES: Les patients qui ont subi des traumatismes et des chirurgies d'urgence entre le 01 avril et le 31 mai 2020 dans un Northwest Mersey NHS Trust ont été étudiés et comparés à une période similaire en 2019. Les mesures de résultats évaluées étaient la mortalité à 30 et 60 jours, le délai d'intervention chirurgicale, la durée du séjour après la chirurgie, les complications systémiques et orthopédiques, y compris le besoin ultérieur de chirurgie. RÉSULTATS: Dans l'ensemble, le nombre de patients ayant subi une chirurgie traumatique ou d'urgence a diminué, passant de 184 en 2019 à 116 en 2020. La mortalité à 30 et 60 jours a légèrement augmenté de 2,05 % et 2,68 %, respectivement. Le délai d'intervention chirurgicale et la durée de séjour à l'hôpital étaient comparables entre les deux cohortes. CONCLUSION: La continuité des services aux patients présentant des blessures obligatoires a été gérée en utilisant des équipements de protection individuelle améliorés et des stratégies de contrôle des infections, y compris la ségrégation des patients en fonction de leur statut COVID-19. Les leçons apprises au cours de cette période, telles que le régime de test COVID-19 et les parcours de soins, nous ont préparés pour l'avenir proche. NIVEAU DE L'ÉTUDE: Étude rétrospective de cohorte ; Niveau III. MOTS-CLÉS: COVID-19; Coronavirus; pandémie; traumatisme; orthopédie ; mortalité; test COVID-19; évaluation des résultats; soins de santé.

COVID-19 reinfection - An enigmatic public health threat.

To the Editor The COVID-19 pandemic has been consistently on the rise across the globe. The recovered patients getting long-term sequelae, especially lung fibrosis and residual neurological deficits, is an area of concern. Another extremely important conundrum is the risk of re-infection. It has been recently documented from Hong Kong  and puts an unpleasant question mark on long term immunity, sampling technique standardization, viral mutation and efficacy of herd immunity. There are definitions for COVID -19 infection and its severity, but unfortunately none for re-infection.