Hallucination Rates and Reference Accuracy of ChatGPT and Bard for Systematic Reviews: Comparative Analysis.

BACKGROUND: Large language models (LLMs) have raised both interest and concern in the academic community. They offer the potential for automating literature search and synthesis for systematic reviews but raise concerns regarding their reliability, as the tendency to generate unsupported (hallucinated) content persist. OBJECTIVE: The aim of the study is to assess the performance of LLMs such as ChatGPT and Bard (subsequently rebranded Gemini) to produce references in the context of scientific writing. METHODS: The performance of ChatGPT and Bard in replicating the results of human-conducted systematic reviews was assessed. Using systematic reviews pertaining to shoulder rotator cuff pathology, these LLMs were tested by providing the same inclusion criteria and comparing the results with original systematic review references, serving as gold standards. The study used 3 key performance metrics: recall, precision, and F1-score, alongside the hallucination rate. Papers were considered "hallucinated" if any 2 of the following information were wrong: title, first author, or year of publication. RESULTS: In total, 11 systematic reviews across 4 fields yielded 33 prompts to LLMs (3 LLMs×11 reviews), with 471 references analyzed. Precision rates for GPT-3.5, GPT-4, and Bard were 9.4% (13/139), 13.4% (16/119), and 0% (0/104) respectively (P<.001). Recall rates were 11.9% (13/109) for GPT-3.5 and 13.7% (15/109) for GPT-4, with Bard failing to retrieve any relevant papers (P<.001). Hallucination rates stood at 39.6% (55/139) for GPT-3.5, 28.6% (34/119) for GPT-4, and 91.4% (95/104) for Bard (P<.001). Further analysis of nonhallucinated papers retrieved by GPT models revealed significant differences in identifying various criteria, such as randomized studies, participant criteria, and intervention criteria. The study also noted the geographical and open-access biases in the papers retrieved by the LLMs. CONCLUSIONS: Given their current performance, it is not recommended for LLMs to be deployed as the primary or exclusive tool for conducting systematic reviews. Any references generated by such models warrant thorough validation by researchers. The high occurrence of hallucinations in LLMs highlights the necessity for refining their training and functionality before confidently using them for rigorous academic purposes.

Postoperative Shoulder Function Assessment: Proposing the Concept of "Forgotten Shoulder" Over "Normal Shoulder" as the New Standard in Single Assessment Numerical Evaluation.

A major limitation of Patient-Reported Outcomes Measures (PROMs) postoperatively is the ceiling effect, where patients report the maximum score, making it difficult to differentiate between different conditions. Our findings regarding the SSV-Sport reveal a significant ceiling effect post-surgery, indicating the need for improvements in PROMs, including the Single Assessment Numerical Evaluation (SANE). One of the problems with SANE is scoring a 'normal' joint as the maximum. Patients might tolerate some subtle imperfections in their recovery and still consider their joint 'normal'. Proposing the concept of a 'forgotten' joint into the SANE could be a more accurate assessment tool and c which could diminish the ceiling effect. We suggest a shift from 'normal joint' to 'forgotten joint' as a standard for evaluating postoperative recovery and function in SANE.

Subjective Shoulder Value for Sport Is a Simple, Reliable, and Valid Score to Assess Shoulder Function in Athletes.

PURPOSE: To validate the subjective shoulder value for sport (SSV-Sport) by measuring its correlation with existing patient-reported outcome measures (PROMs) and defining its psychometric properties. METHODS: Between May 2021 and May 2022, we established 2 patient groups. Group 1 included those (1) aged 18 years or older, who were (2) consulting for the first time for any shoulder condition, (3) regularly participated in sports, and were capable of accessing a questionnaire independently. There were asked to rate their SSV and SSV-Sport at admission and 2 weeks later; they also were asked to answer a questionnaire including other PROMS. Group 2 comprised patients who had (1) undergone shoulder stabilization surgery and had (2) a minimum follow-up period of 6 months. RESULTS: For the shoulder disability patients (group 1, n = 62), there was a strong and significant correlation between SSV-Sport and other PROMs: Quick Disabilities of the Arm, Shoulder and Hand Sport (r = 0.84), Walch-Duplay (r = 0.65), Rowe (r = 0.74), Western Ontario Shoulder Instability (r = 0.78), and SSV (r = 0.75) (P = .0001). The SSV-Sport was reliable at baseline and 2 weeks after (0.91, 95% confidence interval 0.85-0.94), and was responsive to change (P < .001). For the anterior instability patients (group 2, n = 83), SSV was on average 50 points greater than SSV-Sport (29.2 vs 79.4, P < .001) for preoperative values. In both groups, the values of SSV were constantly and significantly higher than the values of SSV-Sport (81.9 ± 21.3 vs 54.8 ± 30.9; P < .001). CONCLUSIONS: The SSV-Sport is an easily administered, reliable, responsive, and valid measure of shoulder function in athletes that is highly correlated with other PROMs. SSV-Sport is better adapted than SSV to quantify pre- and postoperative shoulder deficiency in athletes. LEVEL OF EVIDENCE: Level III, cohort study (diagnosis).

Can we separately measure glenoid vs. humeral lateralization and distalization in reverse shoulder arthroplasty?

BACKGROUND: Lateralization and distalization in reverse shoulder arthroplasty (RSA) can be measured on anteroposterior (AP) radiographs using 2 previously described angles: lateralization shoulder angle (LSA) and distalization shoulder angle (DSA). However, these 2 angles measure global lateralization and distalization but do not allow to differentiate how much lateralization or distalization are attributable to the glenoid and the humerus. We hypothesized that new angles could allow us to separately measure glenoid vs. humeral lateralization and distalization. A more precise understanding of independent glenoid and humeral contributions to lateralization and distalization may be beneficial in subsequent clinical research. METHOD: Retrospective analysis of postoperative AP radiographs of 100 patients who underwent primary RSA for cuff-tear arthropathy, massive cuff tear, or glenohumeral osteoarthritis were analyzed. The new angles that we proposed use well-known bony landmarks (the acromion, glenoid, and humerus) and the most lateral point of the glenosphere, which we termed the "glenoid pivot point" (GPP). For lateralization, we used the GPP to split LSA into 2 new angles: glenoid lateralization angle (GLA) and humeral lateralization angle (HLA). For distalization, we introduced the modified distalization shoulder angle (mDSA) that can also be split into 2 new angles: glenoid distalization angle (GDA) and humeral distalization angle (HDA). Three orthopedic surgeons measured the new angles, using the online tool Tyche. Mean values with overall and individual standard deviations as well as intraclass correlation coefficients (ICCs) were calculated. RESULTS: Because the angles form a triangle, the following equations can be made: LSA = GLA + HLA, and mDSA = GDA + HDA. All angles showed excellent inter- and intraobserver reliability (ICC = 0.92-0.97) with low means of individual standard deviations that indicate a precision of 2° for each angle. CONCLUSION: Use of the most lateral part of the glenosphere (termed glenoid pivot point) allows us to separately measure glenoid vs. humeral lateralization and distalization. The 4 new angles (HLA, GLA, GDA, HDA) described in the present study can be used on true AP radiographs, routinely obtained after shoulder replacement, and the measured angles may be used with all types of reverse prostheses available.

Long-term results of revision rotator cuff repair for failed cuff repair: a minimum 10-year follow-up study.

HYPOTHESIS: Rotator cuff repair remains associated with high retear rates, which range from 13% to 79%. The objective of this study was to evaluate the long-term clinical and structural results after revision rotator cuff repair at a minimum 10-year follow-up. METHODS: We retrospectively studied the records of all patients who underwent revision rotator cuff repair in 3 different institutions between July 2001 and December 2007 with a minimum 10-year follow-up. A total of 54 patients (61% males, mean age 52 ± 6 years old) met the inclusion criteria. Outcome measures included pain (visual analog scale [VAS]), range of motion (ROM), Subjective Shoulder Value (SSV), and the Constant score. Superior migration, osteoarthritis, and acromiohumeral interval (AHI) were assessed on standard radiographs. Fatty infiltration and structural integrity of the repaired tendon were evaluated on magnetic resonance imaging or computed tomographic arthrogram. RESULTS: At a mean 14.1 years (10.4-20.5), range of motion did not progress significantly in elevation and internal rotation between pre- and postoperation (158° [range, 100°-180°] to 164° [range, 60°-180°], P = .33, and L3 [range, sacrum-T12] to T12 [range, buttocks-T7], P = .34, respectively) and decreased in active external rotation from 45° (range, 10°-80°) to 39° (range, 10°-80°) (P = .02). However, VAS, SSV, and Constant score were all significantly improved at last follow-up (P < .001). AHI decreased significantly (P = .002) from 10 mm (7-14 mm) to 8 mm (0-12 mm). Two percent of the supraspinatus/infraspinatus tendons were Sugaya 1, 24% were Sugaya 2, 35% were Sugaya 3, 12% were Sugaya 4, and 27% were Sugaya 5. Goutallier score progressed for all muscles, but this did not reach significance and mean Goutallier remained <2 for all 4 muscles at last follow-up. Hamada score progressed from 0% >grade 2 preoperatively to 6% >grade 2 at last follow-up. CONCLUSION: Revision rotator cuff repair provides significant pain relief and improvement in functional scores at long-term follow-up. The mild progression of fatty infiltration, AHI, and Hamada score suggests that despite high retear rates (39% of stage 4 and 5 in the Sugaya classification), revision repair could possibly have a protective role on the evolution toward cuff tear arthropathy.

Intramedullary nailing of humeral shaft fractures: percutaneous nailing in the lateral position through the Neviaser approach is a reliable technique.

BACKGROUND: Displaced humeral shaft fractures are frequently treated by osteosynthesis in the active patient. We aimed to evaluate the results of intramedullary nailing (IMN) in the lateral position with the Neviaser approach and to compare them with those from IMN nailing in the standard position and conventional approach. METHODS: In the retrospectively evaluated, single-center study, we compared 20 cases of long IMN for fractures of the proximal or middle third of the humerus shaft (Multilock; Synthes Laboratory) in the lateral position with the percutaneous Neviaser approach with 52 cases of IMN in the standard position. The mean age of patients was 62 ± 21 years. Clinical outcomes were analyzed: Constant score, subjective shoulder evaluation score and range of motion. Radiographically, entry point at the proximal part of the humerus, the healing rate and the possible association between the critical shoulder angle (CSA) and the correct positioning of the nail were assessed. RESULTS: With a mean follow-up of 26 ± 2 months, the healing rate was 89% (64/72) in the overall series, (eight patients in non-union), with no difference between the two groups. The overall mean active anterior elevation (AAE) was 125 ± 22°, mean external rotation (ER1) was 35 ± 17°, and mean internal rotation (IR) was at L3. The mean Constant score was 58 ± 23 and subjective shoulder evaluation score 73 ± 12%. ranges of motion were better in the lateral than standard position group (AAE 133 ± 17 vs. 122 ± 23, P = .03; ER1 47 ± 13 vs. 30 ± 16, P < .001; IR T12 vs. L5, P = .02). The nail was less often protruding in the lateral than standard position group (1/20 [5%] vs. 20/52 [38.5%], P = .002). The nail was better positioned from the anteroposterior view (nail centered: 16/20 [75%] vs. 26/52 [50%], P = .047) and lateral view (nail centered: 18/20 [90%] vs. 34/52 [65.4%], P = .02) in the lateral than standard position group. We found no association between nail position, type of approach and CSA. CONCLUSIONS: In the short-term follow-up, osteosynthesis of humeral shaft fractures by using long IMN in the lateral position with the Neviaser approach is a reliable technique. The positioning of the nail, in particular its entry point, and the clinical results were better with the lateral position and Neviaser approach than with the standard position and conventional approach. Further studies with a larger number of patients, assessment of the learning curve, and analysis of the impact of this technique on comorbidities (unchanged cerebral perfusion) are needed to fully validate this technique.

Is preoperative 3D planning reliable for predicting postoperative clinical differences in range of motion between two stem designs in reverse shoulder arthroplasty.

BACKGROUND: We aim to predict a clinical difference in the postoperative range of motion (RoM) between 2 reverse shoulder arthroplasty (RSA) stem designs (Inlay-155° and Onlay-145°) using preoperative planning software. We hypothesized that preoperative 3D planning could anticipate the differences in postoperative clinical RoM between 2 humeral stem designs and by keeping the same glenoid implant. METHODS: Thirty-seven patients (14 men and 23 women, 76 ± 7 years) underwent a BIO-RSA (bony increased offset-RSA) with the use of preoperative planning and an intraoperative 3-dimensional-printed patient-specific guide for glenoid component implantation between January 2014 and September 2019 with a minimum follow-up of 2 years. Two types of humeral implants were used: Inlay with a 155° inclination (Inlay-155°) and Onlay with a 145°inclination (Onlay-145°). Glenoid implants remained unchanged. The postoperative RSA angle (inclination of the area in which the glenoid component of the RSA is implanted) and the lateralization shoulder angle were measured to confirm the good positioning of the glenoid implant and the global lateralization on postoperative X-rays. A correlation between simulated and clinical RoM was studied. Simulated and last follow-up active forward flexion (AFE), abduction, and external rotation (ER) were compared between the 2 types of implants. RESULTS: No significant difference in RSA and lateralization shoulder angle was found between planned and postoperative radiological implants' position. Clinical RoM at the last follow-up was always significantly different from simulated preoperative RoM. A low-to-moderate but significant correlation existed for AFE, abduction, and ER (r = 0.45, r = 0.47, and r = 0.57, respectively; P < .01). AFE and abduction were systematically underestimated (126° ± 16° and 95° ± 13° simulated vs. 150° ± 24° and 114° ± 13° postoperatively; P < .001), whereas ER was systematically overestimated (50° ± 19° simulated vs. 36° ± 19° postoperatively; P < .001). Simulated abduction and ER highlighted a significant difference between Inlay-155° and Onlay-145° (12° ± 2°, P = .01, and 23° ± 3°, P < .001), and this was also retrieved clinically at the last follow-up (23° ± 2°, P = .02, and 22° ± 2°, P < .001). CONCLUSIONS: This study is the first to evaluate the clinical relevance of predicted RoM for RSA preoperative planning. Motion that involves the scapulothoracic joint (AFE and abduction) is underestimated, while ER is overestimated. However, preoperative planning provides clinically relevant RoM prediction with a significant correlation between both and brings reliable data when comparing 2 different types of humeral implants (Inlay-155° and Onlay-145°) for abduction and ER. Thus, RoM simulation is a valuable tool to optimize implant selection and choose RSA implants to reach the optimal RoM.

Total shoulder arthroplasty for primary glenohumeral osteoarthritis: does posterior humeral subluxation persist after correction of the glenoid version at 5 years minimum?

BACKGROUND: Primary glenohumeral osteoarthritis is associated with both excessive posterior humeral subluxation (PHS) and excessive glenoid retroversion in 40% of cases. These morphometric abnormalities are a particular issue because they may be responsible for a deterioration in long-term clinical and radiologic outcomes. The aim of this study was to perform a computed tomographic (CT) analysis of patients who underwent total shoulder arthroplasty (TSA) for primary osteoarthritis (OA) with B2-, B3-, or C-type glenoids in whom an attempt was made to correct for excessive glenoid retroversion and excessive posterior humeral subluxation intraoperatively. MATERIAL: We performed a retrospective, single-center study including 62 TSA patients with a preoperative PHS of the glenohumeral joint (31 men, 31 women, 70 ± 9 years) between January 2000 and January 2014. Glenoids were classified as B2 (32 cases), B3 (13 cases), or C (17 cases). Glenoid retroversion was corrected by anterior asymmetric reaming. Patients were reviewed for clinical and CT scan assessment with a mean follow-up of 8.3 years (minimum 5 years). At final follow-up, the CT images were reconstructed in the scapular plane. A PHS index >65% defined persistence. RESULTS: The revision-free rate was estimated at 93%. Correlation between PHS and retroversion was moderate preoperatively (ρ = 0.58) and strong at final follow-up (ρ = 0.73). Postoperative CT scans on average showed a surgical correction of PHS compared to preoperatively (79% vs. 65% respectively, P < .05) and retroversion (20° vs. 10° respectively, P < .05). At final follow-up, 25 of 62 patients had a persistence in the 2-dimensional (2D) model and 41 of 62 in the corrected 2D model. Persistence of PHS had no influence on clinical outcomes but did demonstrate a significantly higher glenoid loosening rate (20% vs. 59%, P < .05). CONCLUSION: Correlation between PHS and retroversion was moderate preoperatively and strengthened at long-term follow-up. Anterior asymmetric reaming allowed for a surgical improvement of both PHS and retroversion, but it was not sufficient to maintain a correction over time. Glenoid loosening was more frequent in case of PHS persistence but seemingly without clinical relevance.

Glenoid lateralization and subscapularis repair are independent predictive factors of improved internal rotation after reverse shoulder arthroplasty.

PURPOSE: Reverse shoulder arthroplasty (RSA) has shown improvement in clinical outcomes for various conditions, although some authors expressed concern about the restoration of active internal rotation (AIR). The current study assesses preoperative and intraoperative predictive factors of AIR in patients having a Grammont-style RSA with a minimum five year follow-up. METHODS: We conducted a retrospective multicentric study, including patients operated on with a 155° Grammont-style RSA for cuff-related pathology or primary osteoarthritis with posterior subluxation or an associated cuff tear. Patients were clinically evaluated at a minimum of five year follow-up. Patients with previous surgery or those who had a tendon transfer with the RSA were excluded. Demographic parameters, BMI, preoperative notes, and operative reports were obtained from medical records. AIR was graded according to the constant score system from 0 to 10. RESULTS: A total of 280 shoulders in 269 patients (mean age at surgery, 74.9 ± 5.9 years) met the inclusion criteria and were analyzed. The average follow-up was 8.1 years (range, 5-16 years). Overall, AIR increased from 4.2 (SD 2.5, range 0 to 10) preoperatively to 5.9 (SD 2.6, range 0 to 10) at final follow-up. At the last follow-up, AIR increased in 56% of cases, was unchanged in 26% and decreased in 18%. In 188 shoulders (67%), internal rotation was functional and allowed patients to reach the level of L3 or higher. Multivariable linear regression found the following preoperative clinical factors predictive of worse AIR after RSA: male gender (ß = -1.25 [-2.10; -0.40]; p = 0.0042) and higher values of BMI (ß = -0.085 [-0.17; -0.0065]; p = 0.048). Two surgical factors were associated with better AIR after RSA: glenoid lateralization with BIO-RSA technique (ß = 0.80 [0.043; 1.56]; p = 0.039) and subscapularis repair (ß = 1.16 [0.29; 2.02]; p = 0.0092). CONCLUSIONS: With a mean of eight year follow-up (5 to 16 years), internal rotation was functional (≥ L3 level) in 67% of operated shoulders after Grammont-style RSA; however, two patients out of ten had decreased AIR after surgery. Male patients and those with higher BMIs had worse AIR, with glenoid lateralization (using the BIO-RSA technique) and subscapularis repair, as they are predictive of increased AIR after RSA. LEVEL OF EVIDENCE: Case series, Level IV.

Early morbidity and mortality after one-stage bilateral shoulder arthroplasty.

PURPOSE: One-stage bilateral shoulder arthroplasty has the advantage of requiring a single hospital stay and a single anaesthesia. The topic has been little reported, unlike one stage bilateral hip and knee arthroplasty, which have demonstrated their interest. The aim of the present study was to determine peri- and early post-operative morbidity and mortality after this procedure. The study hypothesis was that peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty is low in selected patients and that satisfaction is high. METHODS: A single-centre retrospective study assessed peri- and early post-operative morbidity and mortality in one stage bilateral shoulder arthroplasty. Twenty-one patients, aged < 80 years, with ASA score ≤ 3, were consecutively operated on between 1999 and 2020. Indications comprised primary osteoarthritis, aseptic osteonecrosis, inflammatory arthritis, massive rotator cuff tear, and dislocation fracture, involving both shoulders. RESULTS: There were no early deaths. The complication rate was 10% (4/21 cases). No prosthesis dislocation or sepsis was reported. Mean blood loss was 145 ± 40 cc, mean surgery time 164 ± 63 min, and mean hospital stay five ± four days. Only one patient required postoperative transfusion. Functional results at six months showed significantly improved range of motion and good patient satisfaction. CONCLUSIONS: One-stage bilateral shoulder arthroplasty was feasible in selected patients. Mortality was zero, and morbidity was low. Surgery time was reasonable and required no repositioning. Postoperative home help is indispensable for patient satisfaction during rehabilitation.

Neonatal outcomes for women at risk of preterm delivery given half dose versus full dose of antenatal betamethasone: a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial.

BACKGROUND: Antenatal betamethasone is recommended before preterm delivery to accelerate fetal lung maturation. However, reports of growth and neurodevelopmental dose-related side-effects suggest that the current dose (12 mg plus 12 mg, 24 h apart) might be too high. We therefore investigated whether a half dose would be non-inferior to the current full dose for preventing respiratory distress syndrome. METHODS: We designed a randomised, multicentre, double-blind, placebo-controlled, non-inferiority trial in 37 level 3 referral perinatal centres in France. Eligible participants were pregnant women aged 18 years or older with a singleton fetus at risk of preterm delivery and already treated with the first injection of antenatal betamethasone (11·4 mg) before 32 weeks' gestation. We used a computer-generated code producing permuted blocks of varying sizes to randomly assign (1:1) women to receive either a placebo (half-dose group) or a second 11·4 mg betamethasone injection (full-dose group) 24 h later. Randomisation was stratified by gestational age (before or after 28 weeks). Participants, clinicians, and study staff were masked to the treatment allocation. The primary outcome was the need for exogenous intratracheal surfactant within 48 h after birth. Non-inferiority would be shown if the higher limit of the 95% CI for the between-group difference between the half-dose and full-dose groups in the primary endpoint was less than 4 percentage points (corresponding to a maximum relative risk of 1·20). Four interim analyses monitoring the primary and the secondary safety outcomes were done during the study period, using a sequential data analysis method that provided futility and non-inferiority stopping rules and checked for type I and II errors. Interim analyses were done in the intention-to-treat population. This trial was registered with ClinicalTrials.gov, NCT02897076. FINDINGS: Between Jan 2, 2017, and Oct 9, 2019, 3244 women were randomly assigned to the half-dose (n=1620 [49·9%]) or the full-dose group (n=1624 [50·1%]); 48 women withdrew consent, 30 fetuses were stillborn, 16 neonates were lost to follow-up, and 9 neonates died before evaluation, so that 3141 neonates remained for analysis. In the intention-to-treat analysis, the primary outcome occurred in 313 (20·0%) of 1567 neonates in the half-dose group and 276 (17·5%) of 1574 neonates in the full-dose group (risk difference 2·4%, 95% CI -0·3 to 5·2); thus non-inferiority was not shown. The per-protocol analysis also did not show non-inferiority (risk difference 2·2%, 95% CI -0·6 to 5·1). No between-group differences appeared in the rates of neonatal death, grade 3-4 intraventricular haemorrhage, stage ≥2 necrotising enterocolitis, severe retinopathy of prematurity, or bronchopulmonary dysplasia. INTERPRETATION: Because non-inferiority of the half-dose compared with the full-dose regimen was not shown, our results do not support practice changes towards antenatal betamethasone dose reduction. FUNDING: French Ministry of Health.

Early elevated alkaline phosphatase as a surrogate biomarker of ongoing metabolic bone disease of prematurity.

Very low birth weight (VLBW) neonates present a high risk of metabolic bone disease (MBD). Our main objective was to determine the easiest way to make an early diagnosis of this disease by identifying surrogate biomarkers before any radiological signs occurred. We conducted in our NICU a 6-month observational prospective study, with inclusion of all singleton VLBW neonates. We collected clinical and biological data, and nutritional intakes during hospitalization. We defined biological MBD (bMBD) as alkaline phosphatase (ALP) levels superior to 600 UI/L at day of life 30 (DOL30) and performed a case-control analysis. Nine out of 30 patients (30%) exhibited bMBD. All have extremely low birth weight and were significantly younger in gestational age (GA) and smaller at birth. There was no statistically significant difference in nutritional intake between bMBD and control groups. In the bMBD group, phosphatemia was lower since DOL3. ALP was already significantly higher at DOL15, and way beyond normal range. CONCLUSIONS: Our results showed that even the strict respect of nutritional guidelines cannot completely prevent bMBD in high-risk patients and suggest that an early screening from DOL15, with ALP levels greater than 500 UI/L, could be sufficient for detection of upcoming MBD. WHAT IS KNOWN: • Metabolic bone disease of prematurity (MBD) definition is not consensual, but biological changes appear earlier than radiological signs of rickets. • MBD management relies on biological evidence. Treatment is based on phosphate and/or calcium and calcitriol supplementation. WHAT IS NEW: • Studying phosphocalcic biological assessment in very low birth weight neonates, we showed respect of nutritional guidelines could not protect from biological MBD. • Increase in alkaline phosphatase (ALP), about 500 UI/l at day of life 15, could be a biomarker of MBD with no need of X-ray evaluation and sufficient to begin a treatment to prevent osteopenia.

Circumstances, causes and timing of death in extremely preterm infants admitted to NICU: The EPIPAGE-2 study.

AIM: To describe the circumstances, causes and timing of death in extremely preterm infants. METHODS: We included from the EPIPAGE-2 study infants born at 24-26 weeks in 2011 admitted to neonatal intensive care units (NICU). Vital status and circumstances of death were used to define three groups of infants: alive at discharge, death with or without withholding or withdrawing life-sustaining treatment (WWLST). The main cause of death was classified as respiratory disease, necrotizing enterocolitis, infection, central nervous system (CNS) injury, other or unknown. RESULTS: Among 768 infants admitted to NICU, 224 died among which 89 died without WWLST and 135 with WWLST. The main causes of death were respiratory disease (38%), CNS injury (30%) and infection (12%). Among the infants who died with WWLST, CNS injury was the main cause of death (47%), whereas respiratory disease (56%) and infection (20%) were the main causes in case of death without WWLST. Half (51%) of all deaths occurred within the first 7 days of life, and 35% occurred within 8 and 28 days. CONCLUSION: The death of extremely preterm infants in NICU is a complex phenomenon in which the circumstances and causes of death are intertwined.

The Arthroscopic Trillat Procedure Is a Valuable Treatment Option for Recurrent Anterior Instability in Young Athletes With Shoulder Hyperlaxity.

PURPOSE: The purpose of this study is to report the outcomes of the all-arthroscopic Trillat procedure, combined with capsular plication, for the treatment of recurrent anterior instability in young athletes with shoulder hyperlaxity (external rotation >90°). METHODS: We performed a retrospective evaluation of patients with recurrent anterior instability and shoulder hyperlaxity who underwent an arthroscopic Trillat between 2009 and 2019. Patients with concomitant rotator cuff lesions or voluntary or multidirectional instability were excluded. The osteotomized coracoid was fixed above the subscapularis with a cannulated screw or a suture button; a capsular plication was systematically associated. We followed patients with x-rays, computed tomography scans, and Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. Mean follow-up was 56 months (24-145). RESULTS: Twenty-eight consecutive patients (30 shoulders) with a mean age of 25 years were identified, and all met criteria. The main finding under arthroscopy was a "loose shoulder" with anteroinferior capsular redundancy and no or few (10%) labrum tears, glenoid erosion (13%), or Hill-Sachs lesions (10%). At last follow-up, 90% of the shoulders (27/30) were stable, and 79% (19/24) of the patients practicing sports returned to their preinjury activity level. The Walch-Duplay and Rowe scores improved from 54 (38-68) to 81 (4-100) and 55 (30-71) to 84 (45-100), respectively, P < .001. CONCLUSIONS: The arthroscopic Trillat is an effective procedure for the treatment of recurrent anterior instability in young athletes with shoulder hyperlaxity but no substantial humeral or glenoid bone loss, allowing return to overhead/contact sports. LEVEL OF EVIDENCE: Level IV, retrospective study.

The Arthroscopic Trillat Procedure Is a Valuable and Durable Treatment Option for Recurrent Anterior Instability Associated With Massive Irreparable Cuff Tears.

PURPOSE: The purpose of the present study is to report the mid- and long-term clinical and radiologic outcomes of the arthroscopic Trillat for the treatment of recurrent anterior instability in patients with chronic massive irreparable rotator cuff tears (MIRCTs) and maintained active shoulder motion where reverse shoulder arthroplasty (RSA) is not indicated. METHODS: Twenty-one consecutive patients (mean age 61 years) were identified and retrospectively reviewed. All patients had recurrent anterior dislocations and conserved active forward elevation and active external rotation. The MIRCTs included a retracted (stage 3) supraspinatus tear in 14%, a supra- and infraspinatus tear in 76.5%, and a 3-tendon tear in 14%. A closed-wedge osteotomy of the coracoid was performed, and the coracoid was fixed above the subscapularis with a cannulated screw (10 cases) or suture buttons (11 cases). We followed patients with x-rays and computed tomography scan at 6 months, along with Subjective Shoulder Value, visual analog scale, Walch, Constant, and Rowe scores. The mean clinical and radiographic follow-up was 58 months (24-145 months). RESULTS: Overall, 96% (20/21) of the patients had a stable and functional shoulder and were satisfied with the procedure; no patient lost active shoulder motion. The Subjective Shoulder Value increased from 44% (10%-75%) to 94% (80%-100%), P < .001. The Constant and Rowe scores improved from 60 (25-81) to 81 (66-96) and from 54 (35 to 65) to 92 (70-100), respectively (P < .001). Among the 13 patients practicing sports before surgery, 10 (77%) went back to sports. At last follow-up, only 1 patient was revised to RSA. CONCLUSIONS: The arthroscopic Trillat procedure is a valuable and durable option for the treatment of recurrent anterior dislocations in older patients with chronic MIRCTs and conserved active shoulder motion. LEVEL OF EVIDENCE: Level IV, therapeutic case series.

Early Antibiotic Exposure and Adverse Outcomes in Very Preterm Infants at Low Risk of Early-Onset Sepsis: The EPIPAGE-2 Cohort Study.

OBJECTIVE: To assess the association between early empirical antibiotics and neonatal adverse outcomes in very preterm infants without risk factors for early-onset sepsis (EOS). STUDY DESIGN: This is a secondary analysis of the EPIPAGE-2 study, a prospective national population-based cohort that included all liveborn infants at 22-31 completed weeks of gestation in France in 2011. Infants at high risk of EOS (ie, born after preterm labor or preterm premature rupture of membranes or from a mother who had clinical chorioamnionitis or had received antibiotics during the last 72 hours) were excluded. Early antibiotic exposure was defined as antibiotic therapy started at day 0 or day 1 of life, irrespective of the duration and type of antibiotics. We compared treated and untreated patients using inverse probability of treatment weighting based on estimated propensity scores. RESULTS: Among 648 very preterm infants at low risk of EOS, 173 (26.2%) had received early antibiotic treatment. Early antibiotic exposure was not associated with death or late-onset sepsis or necrotizing enterocolitis (OR, 1.04; 95% CI, 0.72-1.50); however, it was associated with higher odds of severe cerebral lesions (OR, 2.71; 95% CI, 1.25-5.86) and moderate-severe bronchopulmonary dysplasia (BPD) (OR, 2.30; 95% CI, 1.21-4.38). CONCLUSIONS: Early empirical antibiotic therapy administrated in very preterm infants at low risk of EOS was associated with a higher risk of severe cerebral lesions and moderate-severe BPD.

Antibiotic prophylaxis in preterm premature rupture of membranes at 24-31 weeks' gestation: Perinatal and 2-year outcomes in the EPIPAGE-2 cohort.

OBJECTIVE: To compare different antibiotic prophylaxis administered after preterm premature rupture of membranes to determine whether any were associated with differences in obstetric and/or neonatal outcomes and/or neurodevelopmental outcomes at 2 years of corrected age. DESIGN: Prospective, nationwide, population-based EPIPAGE-2 cohort study of preterm infants. SETTING: France, 2011. SAMPLE: We included 492 women with a singleton pregnancy and a diagnosis of preterm premature rupture of membranes at 24-31 weeks. Exclusion criteria were contraindication to expectant management or indication for antibiotic therapy other than preterm premature rupture of membranes. Antibiotic prophylaxis was categorised as amoxicillin (n = 345), macrolide (n = 30), third-generation cephalosporin (n = 45) or any combinations covering Streptococcus agalactiae and >90% of Escherichia coli (n = 72), initiated within 24 hours after preterm premature rupture of membranes. METHODS: Population-averaged robust Poisson models. MAIN OUTCOME MEASURES: Survival at discharge without severe neonatal morbidity, 2-year neurodevelopment. RESULTS: With amoxicillin, macrolide, third-generation cephalosporin and combinations, 78.5%, 83.9%, 93.6% and 86.0% of neonates were discharged alive without severe morbidity. The administration of third-generation cephalosporin or any E. coli-targeting combinations was associated with improved survival without severe morbidity (adjusted risk ratio 1.25 [95% confidence interval 1.08-1.45] and 1.10 [95 % confidence interval 1.01-1.20], respectively) compared with amoxicillin. We evidenced no increase in neonatal sepsis related to third-generation cephalosporin-resistant pathogen. CONCLUSION: In preterm premature rupture of membranes at 24-31 weeks, antibiotic prophylaxis based on third-generation cephalosporin may be associated with improved survival without severe neonatal morbidity when compared with amoxicillin, with no evidence of increase in neonatal sepsis related to third-generation cephalosporin-resistant pathogen. TWEETABLE ABSTRACT: Antibiotic prophylaxis after PPROM at 24-31 weeks: 3rd-generation cephalosporins associated with improved neonatal outcomes.

Arthroscopic Lateral Patellar Facetectomy and Lateral Release Can Be Recommended for Isolated Patellofemoral Osteoarthritis.

PURPOSE: To analyze the clinical outcomes and survival curve of arthroscopic lateral patellar facetectomy and lateral release for isolated patellofemoral osteoarthritis (PFOA). METHODS: All patients undergoing arthroscopic lateral patellar facetectomy and lateral release between January 2008 and January 2018 were evaluated retrospectively. The inclusion criteria were 1) diagnosis of isolated symptomatic lateral PFOA, 2) PFOA with kissing lesions (defined as a lesion on both the patella and trochlea, which were in direct contact, 3) arthroscopic lateral patellar facetectomy and lateral release, and 4) two-year minimum follow-up. Evaluation included preoperative and postoperative subjective International Knee Documentation Committee (IKDC), Knee Injury and Osteoarthritis Outcome Score (KOOS) scores, and visual analogue pain scale (VAS). The primary end point determining the survival curve was revision of lateral facetectomy. RESULTS: A retrospective analysis was conducted of 61 consecutive arthroscopic lateral patellar facetectomy and lateral release procedures, performed in 55 patients for a diagnosis of isolated PFOA. Five patients were lost to follow-up, leaving 56 knees (50 patients) available at a mean follow up of 7.5 years (range: 2-10). The cohort included 37 women and 13 men with a mean age of 59 years (range: 34-87). Nine patients (18%) underwent revision surgery: six total knee replacements (TKR), two high tibial osteotomies, and one revision arthroscopic lateral patellar facetectomy. The mean time from arthroscopic facetectomy to TKR was 51 months (range: 10-114). The survival curve rate was 86% at 7.5 years. Both KOOS and IKDC scores improved significantly. These results are confirmed by an analysis of MCID. The mean VAS decreased from 6.98 ± 1.2 preoperatively to 2.06 ± 1.6 at the last follow-up (ΔCI95% = [-5.6; -4.4]; P = .0001). CONCLUSION: Arthroscopic lateral patellar facetectomy and lateral release for isolated PFOA demonstrates sustained significant improvement in knee clinical outcome scores and pain with a low rate of complications and revision surgery at mid-term follow-up. This operation can be recommended in cases of symptomatic isolated PFOA. LEVEL OF EVIDENCE: IV, case series.

Tensioning device increases coracoid bone block healing rates in arthroscopic Latarjet procedure with suture-button fixation.

BACKGROUND: There is growing interest in using suture buttons for coracoid fixation to avoid the complications associated with screws during the Latarjet procedure. However, achieving bone block healing is critical for successful shoulder stabilization and return to sport. The purpose of this study was to assess and compare the healing rates and positioning of the coracoid bone block fixed with cortical suture buttons that were either manually tensioned (using a knot pusher) or mechanically tensioned (using a tensioning device) during arthroscopic Latarjet procedures. METHODS: This prospective, nonrandomized, comparative study enrolled 69 consecutive patients (mean age, 27 years) who underwent an arthroscopic guided Latarjet procedure with suture-button fixation. Hand tensioning was performed in the first 34 shoulders, whereas the next 35 shoulders underwent mechanical tensioning. Twelve patients (17%) had a history of failed Bankart stabilization. The characteristics of the patients in each group in terms of age, sex, type of sport, bone loss, number of previous failed surgical procedures, smoking, and length of follow-up were comparable. Intraoperatively, the tensioning device was set at 100 N successively 3 times until complete immobilization of the bone block was confirmed, as assessed with a probe. The primary outcome measure was coracoid bone block union and position on computed tomography scan images at 6 months' follow-up. Secondary outcome measures included functional outcome scores, shoulder stability, return to sports, and complications at last follow-up. RESULTS: Overall, the rate of bone block healing was 74% (25 of 34 patients) in the hand-tensioning group and 94% (33 of 35 patients) in the mechanical tensioning group (P = .043). Smoking was an independent risk factor associated with nonunion (P < .001) in each group. Patient age, size of the preoperative glenoid bone defect (<20% or >20%), and a history of surgery were not found to have any influence. The tensioning modality did not affect the bone block position, which was subequatorial in 92% of the cases and flush with the glenoid rim in 92%. At a mean of 34 months of follow-up (range, 24-62 months), 96% of the patients (65 of 69) had a stable shoulder and 87% returned to sports. At final follow-up, no significant difference in clinical scores was noted between the groups; no neurologic or hardware complications were observed. CONCLUSION: Mechanical tensioning achieves significantly higher healing rates than hand tensioning during the arthroscopic Latarjet procedure with suture-button fixation. The use of a suture-tensioning device is a key step to the suture-button fixation technique during arthroscopic Latarjet procedures. By making the suture-button construct rigid, the tensioning device transforms the initially flexible suture into a "rigid fixation", similar to a bolt (or a rivet).

Arthroscopic revision cuff repair: do tendons have a second chance to heal?

BACKGROUND: Few studies have investigated postoperative tendon integrity after reoperation for failed rotator cuff repair. The purpose of this study was to evaluate the anatomic and clinical outcomes of arthroscopic revision rotator cuff repair (AR-RCR) and identify the risk factors related to re-retear. METHODS: Sixty-nine consecutive patients (mean age, 55 years) with primary failed open (38%) or arthroscopic (62%) cuff repairs underwent AR-RCR and were reviewed regarding clinical examination findings and imaging studies. Patients with massive cuff tears and upward humeral migration (acromiohumeral distance < 6 mm) or glenohumeral osteoarthritis were excluded. Revision repair was performed by a single, experienced shoulder surgeon. Complete footprint coverage was achieved in all cases using a single-row (70%), double-row (19%), or side-to-side (11%) technique. The primary outcome measure was tendon healing assessed with magnetic resonance imaging (57 cases) or computed tomography arthrogram (12 cases) performed at minimum 1-year follow-up. Secondary outcome measures included functional outcome scores, subjective results, and complications. The mean follow-up period was 43 months (range, 12-136 months). RESULTS: The cuff tendons did not heal to the tuberosity in 36% of the shoulders (25 of 69) following revision cuff surgery. Absence of tendon healing was associated with poorer shoulder function (average Constant score, 69 ± 20 vs. 54 ± 18; P = .003) and a decreased Subjective Shoulder Value (72% vs. 54%, P = .002). Factors that were negatively associated with tendon healing were age ≥ 55 years (odds ratio [OR], 4.5 [95% confidence interval, 1.6-12.5]; P = .02), tendon retraction of stage 2 or higher (OR, 4.4 [95% confidence interval, 1.4-14.3]; P = .01), and fatty infiltration index > 2 (OR, 10.2; P < .0001). No differences in retear rates were found between single-row and double-row cases. In 36 shoulders, tissue samples were harvested and submitted for bacteriologic culture analysis; 13 (36%) showed positive findings for infection (Cutibacterium acnes in 12 of 13) and associated antibiotic treatment was given. Overall, 25% of patients had unsatisfactory clinical results and 22% were disappointed or dissatisfied. At last follow-up, 4 patients (5.7%) underwent reoperations, with a second AR-RCR in 1 and conversion to reverse shoulder arthroplasty in 3. CONCLUSION: Despite careful patient selection and intraoperative complete footprint coverage, in this study the tendons did not heal to bone in 36% of cases after revision cuff surgery. The absence of tendon healing is associated with poorer clinical and subjective results. Patients aged ≥ 55 years and patients with larger tears (stage 2 or higher) and/or muscle fatty infiltration (fatty infiltration index > 2) have significantly lower rates of healing. Surgeons should be aware that structurally failed cuff repair may also be associated with low-grade infection.