Use of an Artificial Intelligence Conversational Agent (Chatbot) for Hip Arthroscopy Patients Following Surgery.

Purpose: The purpose of this study was to evaluate the use of an AI conversational agent during the postoperative recovery of patients undergoing elective hip arthroscopy. Methods: Patients undergoing hip arthroscopy were enrolled in a prospective cohort for their first 6 weeks following surgery. Patients used standard SMS text messaging to interact with an artificial intelligence (AI) chatbot ("Felix") used to initiate automated conversations regarding elements of postoperative recovery. Patient satisfaction was measured at 6 weeks after surgery using a Likert scale survey. Accuracy was determined by measuring the appropriateness of chatbot responses, topic recognition, and examples of confusion. Safety was measured by evaluating the chatbot's responses to any questions with potential medical urgency. Results: Twenty-six patients were enrolled with a mean age of 36 years, and 58% (n = 15) were male. Overall, 80% of patients (n = 20) rated the helpfulness of Felix as good or excellent. In the postoperative period, 12/25 (48%) patients reported being worried about a complication but were reassured by Felix and, thus, did not seek medical attention. Of a total of 128 independent patient questions, Felix handled 101/128 questions appropriately (79%), either by addressing them independently, or facilitating contact with the care team. Felix was able to adequately answer the patient question independently 31% of the time (n = 40/128). Of 10 patient questions that were thought to potentially represent patient complications, in 3 cases Felix did not adequately address or recognize the health concern-none of these situations resulted in patient harm. Conclusion: The results of this study demonstrate that the use of a chatbot or conversational agent can enhance the postoperative experience for hip arthroscopy patients, as demonstrated by high levels of patient satisfaction. Levels of Evidence: Level IV, therapeutic case series.

Is anterior knee pain following anterior cruciate ligament reconstruction a consideration for graft choice, and the influence of COVID: a qualitative analysis in recreational athletes.

BACKGROUND: We set out to investigate whether anterior knee pain following anterior cruciate ligament reconstruction has a significant effect on patients, and whether it should influence graft choice. METHODS: This was a qualitative analysis of a set of recreational athletes treated at a university hospital at about 1 year following anterior cruciate ligament reconstruction surgery. Participants were interviewed by an orthopaedic fellow and resident using structured, open-ended questions. Inductive theme analysis was used to code the data. RESULTS: There were 4 major themes: (1) Our hypothesis was that patients would be given adequate information to make an appropriate graft choice. This hypothesis was rejected. Discussion took place, but with little details or rationale for the graft choice. The predominant theme was that the surgeon made the decision, and there was a lack of reliable information for the patient to make a choice. (2) The overall theme was that most patients had no anterior knee pain, and it did not interfere with activities of daily living. (3) One theme was that patients were able to resume all sports without restriction, but in some, the anterior knee pain interfered with the more demanding activities such as impact, cutting, and pivoting. A separate theme was that fear was a major impediment to return to sports and was not related to the anterior knee pain. (4) The overriding theme was that the generalized closures associated with the COVID-19 pandemic slowed the rehabilitation process. Although virtual care was available in general, it was not particularly satisfactory. Patients indicated that they had not been able to return to the gym or to their sporting activities as a result. CONCLUSIONS: Amongst non-competitive athletes, anterior knee pain post-anterior cruciate ligament reconstruction surgery does not significantly affect activities of daily living. Although there is a minor effect on sporting activities, the inability to return to sports is related to factors such as the COVID-19 pandemic, fear, or insufficient rehabilitation, rather than anterior knee pain. Overall, anterior knee pain is not a significant factor that plays a role in determining graft choice.

RoboHapalytics: A Robot Assisted Haptic Controller for Immersive Analytics.

Immersive environments offer new possibilities for exploring three-dimensional volumetric or abstract data. However, typical mid-air interaction offers little guidance to the user in interacting with the resulting visuals. Previous work has explored the use of haptic controls to give users tangible affordances for interacting with the data, but these controls have either: been limited in their range and resolution; were spatially fixed; or required users to manually align them with the data space. We explore the use of a robot arm with hand tracking to align tangible controls under the user's fingers as they reach out to interact with data affordances. We begin with a study evaluating the effectiveness of a robot-extended slider control compared to a large fixed physical slider and a purely virtual mid-air slider. We find that the robot slider has similar accuracy to the physical slider but is significantly more accurate than mid-air interaction. Further, the robot slider can be arbitrarily reoriented, opening up many new possibilities for tangible haptic interaction with immersive visualisations. We demonstrate these possibilities through three use-cases: selection in a time-series chart; interactive slicing of CT scans; and finally exploration of a scatter plot depicting time-varying socio-economic data.

Wie wichtig sind psychologische Maßnahmen, um die Bereitschaft zur Rückkehr zum Sport nach der Rekonstruktion des vorderen Kreuzbandes zu bestimmen? Ergebnisse einer Online-Umfrage.

BACKGROUND: Recent studies have suggested that psychological factors are important components of a successful return to sports (RTS) after anterior cruciate ligament reconstruction (ACLR). The purpose of this study was to survey physicians with respect to their criteria used to determine readiness to RTS after ACLR and to understand the significance of psychological factors on RTS. METHODS: A survey was designed to understand the practices of clinicians managing rehabilitation after ACLR, consisting of 25 questions divided into 3 different sections, including one section about psychological scores and factors affecting RTS. The survey was delivered to three North American organizations for orthopedic sports medicine. RESULTS: The total number of respondents was 113. Of the respondents, 95% considered psychological tests at least "somewhat important" (33% "important", 23% selected "very important"). Routine use of psychological tests in practice was only reported by 35% of respondents. The ACL-Return to Sport after Injury Scale was the most frequently used psychological test (23%). Fear of reinjury was considered the most common patient-cited psychological factor affecting RTS. Psychological factors ranked 8th out of 9 outcomes measures in determining readiness to RTS. CONCLUSION: This study demonstrates a discrepancy between the importance of psychological tests and the frequency of use in practice. Additional education on this topic, web-based applications, and a multidisciplinary approach may increase the usage of psychological tests to determine RTS after ACLR.

Six Percent Incidence of Graft-Tunnel Mismatch in Anatomic Anterior Cruciate Ligament Reconstruction Using Bone-Patella Tendon-Bone Autograft and Anteromedial Portal Drilling.

Purpose: The purpose of this study was to determine the incidence of graft-tunnel mismatch (GTM) when performing anatomic anterior cruciate ligament reconstruction (ACLR) using bone-patella tendon-bone (BPTB) grafts and anteromedial portal drilling. Methods: Beginning in November 2018, 100 consecutive patients who underwent ACLR by two sports fellowship-trained, orthopedic surgeons using BPTB autograft and anteromedial portal drilling were prospectively identified. The BPTB graft dimensions and the femoral tunnel distance, tibial tunnel distance, intra-articular distance, and total distance were measured. Surgeons determined the depth and angle of tunnels based on the patella tendon graft length dimensions in each case. After passage of the graft, the distance from the distal graft tip to the tibial cortex aperture was measured. GTM was defined as the need for additional measures to obtain satisfactory tibial graft fixation (<15-20 mm of bone fixation). Results: The incidence of mismatch was 6/100 (6%). Five cases involved the graft being too long, with the tibial bone plug protruding excessively from the tibial tunnel-4/5 had a patella tendon length ≥ 50 mm. Three cases were managed with femoral tunnel recession, and two were treated with a free bone plug technique. One patient with a patella tendon length of 35 mm had a graft that was too short, with the tibial bone plug recessed in the tibial tunnel. Of patients whose tibial tunnel distance was within 5 mm of the patella tendon length, only 1/46 (2%) patients had mismatch, whereas 5/54 (9%) of patients who had >5 mm difference had mismatch. Conclusions: The incidence of graft-tunnel mismatch after anatomic ACLR using BTPB and anteromedial portal drilling in this study is 6%. To limit the occurrence of GTM where the graft is too long, surgeons should drill tibial tunnel distances within 5 mm of the patella tendon length. Clinical Relevance: The results of this study provide surgeons with a technique of limiting graft tunnel mismatch when performing ACLR using BPTB and anteromedial portal drilling.

Investigating Cognitive Load in Energy Network Control Rooms: Recommendations for Future Designs.

This study analyzed and explored the cognitive load of Australian energy market operators managing one of the longest inter-connected electrical networks in the world. Each operator uses a workstation with seven screens in an active control room environment, with a large coordination screen to show information and enable collaboration between different control centers. Cognitive load was assessed during both training scenarios and regular control room operations via the integration of subjective and physiological measures. Eye-tracking glasses were also used to analyze the operators gaze behavior. Our results indicate that different events (normal or unexpected), different participants for the same session, and different periods of one session all have varying degrees of cognitive load. The system design was observed to be inefficient in some situations and to have an adverse affect on cognitive load. In critical situations for instance, operator collaboration was high and the coordination screen was used heavily when collaborating between two control centers, yet integration with the system could be improved. Eye tracking data analysis showed that the layout of applications across the seven screens was not optimal for many tasks. Improved layout strategies, potential combination of applications, redesigning of certain applications, and linked views are all recommended for further exploration in addition to improved integration of procedures and linking alarms to visual cues.

A Survey of Treatment Trends for Acute Quadriceps Tendon Ruptures Among North American Surgeons.

Background: To date, little clinical evidence exists to support a specific surgical technique or postoperative rehabilitation protocol for quadriceps tendon ruptures. With a lack of evidence-based superiority, assessment of clinical practices and surgeon preferences is pertinent. Purpose: To describe the current surgical technique and rehabilitation preferences among members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine pertaining to acute quadriceps tendon rupture. Study Design: Cross-sectional study. Methods: Orthopaedic staff members of the Canadian Orthopaedic Association and American Orthopaedic Society for Sports Medicine were invited to complete an internet-based survey composed of 26 questions assessing current trends in the management and rehabilitation of acute quadriceps tendon rupture. Survey questions were developed after a thorough review of current literature. Survey responses were analyzed and reported using descriptive statistics (absolute values, frequencies, and percentages) where appropriate. Statistical comparisons and contrasts between Canadian and American surgeons were made using chi-square analyses and Student t tests. Results: A total of 264 surgeons participated in the survey (136 Canadians; 128 Americans). Canadian surgeons were more likely to obtain a preoperative ultrasound as compared with Americans (43.0% vs 6.7%; P < .00001), while American respondents were more likely to obtain magnetic resonance imaging scans (65.8% vs 10.2%; P < .00001). The transosseous drill hole technique was the most commonly utilized (70.2%); the suture anchor technique was used 20.6% of the time. Canadian respondents trended toward a higher use of transosseous tunnels; however, this was not statistically significant (75.8% vs 64.2%; P = .068). American respondents were more likely to utilize suture anchors (27.5% vs 14.1%; P = .0096). Most respondents advanced range of motion goals stepwise in 2-week intervals of 30° (Canadians, 54.0% vs Americans, 58.5%; P = .3091); timing of range of motion initiation varied. Conclusion: Among North American surgeons who responded to this study, the transosseous technique was the most commonly used, and range of motion was generally advanced in a 2-week stepwise fashion. We found several differences in practice between Canadian and American respondents, including the type of preoperative imaging and the frequency of using the suture anchor technique.

Rotate or Wrap? Interactive Visualisations of Cyclical Data on Cylindrical or Toroidal Topologies.

In this paper, we report on a study of visual representations for cyclical data and the effect of interactively wrapping a bar chart 'around its boundaries'. Compared to linear bar chart, polar (or radial) visualisations have the advantage that cyclical data can be presented continuously without mentally bridging the visual 'cut' across the left-and-right boundaries. To investigate this hypothesis and to assess the effect the cut has on analysis performance, this paper presents results from a crowdsourced, controlled experiment with 72 participants comparing new continuous panning technique to linear bar charts (interactive wrapping). Our results show that bar charts with interactive wrapping lead to less errors compared to standard bar charts or polar charts. Inspired by these results, we generalise the concept of interactive wrapping to other visualisations for cyclical or relational data. We describe a design space based on the concept of one-dimensional wrapping and two-dimensional wrapping, linked to two common 3D topologies; cylinder and torus that can be used to metaphorically explain one- and two-dimensional wrapping. This design space suggests that interactive wrapping is widely applicable to many different data types.

Anterior Cruciate Ligament Patellar Tendon Autograft Fixation at 0° Versus 30° Results in Improved Activity Scores and a Greater Proportion of Patients Achieving the Minimal Clinical Important Difference For Knee Injury and Osteoarthritis Outcome Score Pain: A Randomized Controlled Trial.

PURPOSE: The aim of the current study was to determine the effect of the knee flexion angle (KFA) during tibial anterior cruciate ligament (ACL) graft fixation on patient-reported outcomes, graft stability, extension loss, and reoperation after anatomic single-bundle ACL reconstruction. METHODS: All 169 included patients (mean age 28.5 years, 65% male) were treated with anatomic single-bundle ACL reconstruction using patellar tendon autograft and were randomized to tibial fixation of the ACL graft at either 0° (n = 85) or 30° (n = 84). The primary outcome was the Knee Injury and Osteoarthritis Outcome Score (KOOS) 2 years after surgery. Secondary outcomes were the Marx Activity Scale (MAS), the rate of reoperation, and physical examination findings at 1 year, including KT-1000 and side-to-side differences in knee extension. RESULTS: The follow-up rate was 82% (n = 139) for the primary outcome. Graft failure rate at 2 years was 1% (n = 2, 1 per group). ACL tibial graft fixation at 0° or 30° did not have a significant effect on KOOS scores at 2 years after ACLR. Patients whose graft was fixed at a knee flexion angle of 0° had greater scores on the MAS (mean 9.6 95% confidence interval [CI] 8.5 to 10.6, versus 8.0, 95% CI 6.9 to 9.1; P = .04), and a greater proportion achieved the minimal clinical important difference (MCID) for the KOOS pain subdomain (94% versus 81%; P = .04). There was no significant difference in knee extension loss, KT-1000 measurements, or reoperation between the 2 groups. CONCLUSION: In the setting of anatomic single-bundle ACLR using patellar tendon autograft and anteromedial portal femoral drilling, there was no difference in KOOS scores between patients fixed at 0° and 30°. Patient fixed in full extension did demonstrate higher activity scores at 2 years after surgery and a greater likelihood of achieving the MCID for KOOS pain. LEVEL OF EVIDENCE: II, prospective randomized trial.

Injection of Bone Marrow Aspirate for Glenohumeral Joint Osteoarthritis: A Pilot Randomized Control Trial.

PURPOSE: To compare the efficacy of a single, intra-articular, nonconcentrated bone marrow aspirate (BMA) injection in comparison to cortisone for the treatment of glenohumeral joint osteoarthritis (GHJ OA). METHODS: Inclusion criteria were patients between the ages of 18 and 75 with a diagnosis of GHJ OA on radiograph. Patients were randomized to receive an ultrasound-guided, intra-articular cortisone injection or BMA injection (without concentration). The primary outcome measure was the Western Ontario Osteoarthritis of the Shoulder (WOOS) index at 12 months. Secondary outcome measures were the QuickDASH, EuroQOL 5-dimensions 5-level questionnaire (EQ-5D-5L) and visual analogue scale. RESULTS: The study included 25 shoulders of 22 patients who completed baseline and 12 months' patient-reported outcome measures (12 shoulders received cortisone, 13 shoulders received BMA) after the study was terminated early by changes in Health Canada regulations. Baseline characteristics demonstrated a significant difference in the ages of the 2 groups, with the BMA group being older (61.6 vs 53.8 mean years, P = 0.021). For the BMA group, a significant improvement was seen in the WOOS index (P = 0.002), the QuickDASH (P < 0.001), and the EQ-5D-5L pain dimension (P = 0.004) between baseline and 12 months. No significant difference was seen for any outcome in the cortisone group between baseline and 12 months. No significant difference was demonstrated between changes in the WOOS scores from baseline to 12 months when compared between groups (P = 0.07). However, a significant difference in changes in scores was seen in the QuickDASH (P = 0.006) and the EQ-5D-5L pain scores (P = 0.003) and the EQ-5D-5L health scores (P = 0.032) in favor of BMA. CONCLUSIONS: The results of this study demonstrate that patients with GHJ OA treated with BMA have superior changes in the QuickDASH and EQ-5D-5L pain and health scores but not in the WOOS outcomes measures at 12 months post injection when compared to patients treated with cortisone. However, because of the limited number of patients as a result of the early termination of the study, larger randomized studies are required to confirm these findings. LEVEL OF EVIDENCE: Level II, randomized controlled trial.

Editorial Commentary: Patients Who Achieve a Minimal Clinically Important Difference (Feel Better) Early After Hip Arthroscopy Have the Highest Rates of Long-Term Satisfaction.

Analyzing patient-reported outcomes using the lens of the minimal clinical important difference (MCID) and patient acceptable symptomatic state allows surgeons to assess patient recovery at the individual level and make necessary changes to management if necessary. When patients with femoroacetabular impingement achieve MCID 6 months after arthroscopic treatment, they achieve patient acceptable symptomatic state 2 years postoperatively 88% of the time. The findings highlight the importance of the postoperative recovery trajectory and illustrate a quantitative way to study the progress of individual patients along their care journey.

Regional anesthesia and acute compartment syndrome: principles for practice.

Acute compartment syndrome (ACS) is a potentially reversible orthopedic surgical emergency leading to tissue ischemia and ultimately cell death. Diagnosis of ACS can be challenging, as neither clinical symptoms nor signs are sufficiently sensitive. The cardinal symptom associated with ACS is pain reported in excess of what would otherwise be expected for the underlying injury, and not reasonably managed by opioid-based analgesia. Regional anesthesia (RA) techniques are traditionally discouraged in clinical settings where the development of ACS is a concern as sensory and motor nerve blockade may mask symptoms and signs of ACS. This Education article addresses the most common trauma and elective orthopedic surgical procedures in adults with a view towards assessing their respective risk of ACS and offering suggestions regarding the suitability of RA for each type of surgery.

Entrustable Professional Activities in Orthopaedics.

BACKGROUND: An entrustable professional activity (EPA) is defined as a core task of a specialty that is entrusted to a trainee once sufficient competence has been reached. A group of EPAs reflects the activities that clinicians commonly do on a day-to-day basis. Lists of EPAs have been created for most medical subspecialties, but not orthopaedic surgery. The aim of this study was to create a peer-reviewed list of essential EPAs that a resident must perform independently before completing orthopaedic residency training. METHODS: A focus group of 7 orthopaedic surgeons from the University of Toronto developed a comprehensive list of 285 EPAs. For each subspecialty group, the opinions of at least 15 academic and nonacademic surgeons, as well as subspecialty-trained and non-subspecialty-trained surgeons, were used. The modified Delphi method was used to rank EPAs on a five-point scale from not important to mandatory for a resident to competent before exiting training. Two Delphi rounds were used, using a threshold of >50% of surgeons considering the EPA as mandatory before being considered for the next round. A final list of EPAs was ratified using the focus group of academic surgeons involved in the study. RESULTS: Seventy-five (75) of 107 (70%) surgeons invited responded to the survey. Nearly half (129) of the 285 EPAs were discarded after the first round of Delphi. A further 118 EPAs were discarded after the second Delphi round, leaving 49 final EPAs, across 9 subspecialties in orthopaedic surgery. CONCLUSIONS: Expert consensus was used to create a list of EPAs considered mandatory for completion of resident training in orthopaedics in our province. The final 49 peer-reviewed EPAs will be a valuable benchmark in curriculum design and assessment in orthopaedic surgery in the competency-based era for other programs.

Preoperative Magnetic Resonance Imaging Accurately Detects the Arthroscopic Comma Sign in Subscapularis Tears.

PURPOSE: To assess the accuracy and reliability of routine preoperative magnetic resonance imaging (MRI) in the detection of the comma sign compared with the gold standard of arthroscopic findings. METHODS AND MATERIALS: Preoperative MRI exams in consecutive patients undergoing arthroscopic subscapularis tendon repair, over a 5-year time frame, were retrospectively reviewed for full-thickness tears of the subscapularis and supraspinatus tendons, fatty atrophy of the subscapularis and supraspinatus muscles, and status of the long head of the biceps tendon. Each case was also evaluated for presence or absence of a comma sign on MRI. Surgical findings served as the diagnostic standard of reference in determination of a comma sign. RESULTS: The study cohort included 45 male and 10 female patients (mean age, 56; range, 32-80 years). A comma sign was present at arthroscopy in 19 patients (34.5%). Interclass and intrarater correlation showed 100% agreement in preoperative assessment of a comma sign on MRI. MRI showed an overall accuracy of 83.6% in diagnosis of a comma sign (sensitivity, 63.2%; specificity, 94.4%; positive predictive value, 85.7%; negative predictive value, 82.9%; positive likelihood ratio, 11.37; negative likelihood ratio, 0.39). No statistically significant association was observed between an arthroscopic comma sign and patient demographics or MRI findings of full-thickness rotator cuff tears, muscle fatty atrophy, or long head of the biceps tendon pathology. CONCLUSIONS: MR imaging illustrates excellent reliability and good specificity and accuracy in detection of the arthroscopic comma sign in the setting of subscapularis tendon tearing. Detection of a comma sign on MRI may be important preoperative planning information in the arthroscopic management of patients with subscapularis tendon tears. LEVEL OF EVIDENCE: Level IV, retrospective diagnostic study.

Editorial Commentary: Injections for Knee Osteoarthritis: Doc, You Gotta Help Me!

Injections for the pain caused by knee osteoarthritis have been the focus of significant research for the last few decades. Systematic reviews and meta-analyses suggest that platelet-rich plasma (PRP) can provide up to 12 months of pain relief in these patients, superior to both cortisone and hyaluronic acid. There is also some evidence for a synergistic effect when combining both PRP and hyaluronic acid. Bone marrow aspirate concentrate (BMAC) has significantly greater levels of interleukin-1ra than PRP, as well as a small concentration of mesenchymal stromal cells. However, BMAC is yet unproven in its efficacy, and obtaining BMAC is not as simple as taking blood. Research into the use of expanded autologous and allogenic mesenchymal stem cells continues and shows future promise. For today, PRP remains the gold standard for the treatment of pain associated with knee osteoarthritis.

The Next Billion Users of Visualization.

We argue that visualization research has overwhelmingly focused on users from the economically developed world. However, billions of people around the world are rapidly emerging as new users of information technology. Most of the next billion users of visualization technologies will come from parts of the world that are extremely populous but historically ignored by the visualization research community. Their needs may be different to the types of users that researchers have targeted in the past, but, at the same time, they may have even more to gain in terms of access to data potentially affecting their quality of life. We propose a call to action for the visualization community to identify opportunities and use cases where users can benefit from visualization; develop universal design principles; extend evaluations by including the general population; and engage with a wider global population.

Limiting the Risk of Osteoarthritis After Anterior Cruciate Ligament Injury: Are Health Care Providers Missing the Opportunity to Intervene?

OBJECTIVE: To understand what sports orthopedic surgeons (OS), primary care physicians (PCPs) with sports medicine training, and physical therapists (PTs) managing nonelite athletes with anterior cruciate ligament (ACL) injury tell their patients about their osteoarthritis (OA) risk. METHODS: An electronic survey was distributed by the Canadian Academy of Sport and Exercise Medicine (PCPs, OS), the Sports and Orthopedic Divisions of the Canadian Physiotherapy Association (PTs), and to OS identified through the Royal College of Physicians and Surgeons and the Canadian Orthopaedic Association. The survey included 4 sections: demographics, factors discussed, timing of discussions, and discussion of risk factors and their management. Proportions or means with 95% confidence intervals were calculated. RESULTS: A total of 501 health care professionals (HCPs) responded (98 PCPs, 263 PTs, and 140 OS). Of those responding, 70-77% of physicians reported always discussing OA risk, but only 35% of PTs did. All HCPs reported that patient activities perceived as detrimental to knee health, ACL reinjury, and simultaneous injury to other structures in the knee were most often the reason for discussing OA risk. OA risk was discussed at initial management post-injury (65-94%), with few discussing risk subsequently. Eighty percent of physicians and 99% of PTs indicated that PTs were suited to provide OA risk and management information. CONCLUSION: HCPs routinely managing people with ACL injury do not consistently discuss OA risk post-injury with them. Educational strategies for HCPs are urgently needed to develop care pathways inclusive of support for OA risk management following ACL injury.