ChatGPT Performance on the American Shoulder and Elbow Surgeons Maintenance of Certification Exam.

BACKGROUND: While multiple studies have tested the ability of large language models (LLM), such as ChatGPT, to pass standardized medical exams at different levels of training, LLMs have never been tested on surgical sub-specialty examinations, such as the American Shoulder and Elbow Surgeons (ASES) Maintenance of Certification (MOC). The purpose of this study was to compare results of ChatGPT 3.5, GPT-4, and fellowship-trained surgeons on the 2023 American Shoulder and Elbow Surgeons (ASES) Maintenance of Certification (MOC) self-assessment exam. METHODS: ChatGPT 3.5 and GPT-4 were subjected to the same set of text-only questions from the ASES MOC exam, and GPT-4 was additionally subjected to image-based MOC exam questions. Question responses from both models were compared against the correct answers. Performance of both models was compared to corresponding average human performance on the same question subsets. One sided proportional z-test were utilized to analyze data. RESULTS: Humans performed significantly better than Chat GPT 3.5 on exclusively text-based questions (76.4% vs. 60.8%, p= .044). Humans also performed significantly better than GPT 4 on image-based questions (73.9% vs. 53.2%, p= .019). There was no significant difference between humans and GPT 4 in text-based questions (76.4% vs. 66.7%, p=0.136). Accounting for all questions, humans significantly outperformed GPT-4 (75.3% vs. 60.2%, p= .012). GPT-4 did not perform statistically significantly betterer than ChatGPT 3.5 on text-only questions (66.7% vs. 60.8%, p= .268). DISCUSSION: Although human performance was overall superior, ChatGPT demonstrated the capacity to analyze orthopedic information and answer specialty-specific questions on the ASES MOC exam for both text and image-based questions. With continued advancements in deep learning, large language models may someday rival exam performance of fellowship-trained surgeons.

Performance-Enhancing Drugs in Healthy Athletes: An Umbrella Review of Systematic Reviews and Meta-analyses.

CONTEXT: Many clinicians, trainers, and athletes do not have a true understanding of the effects of commonly used performance-enhancing drugs (PEDs) on performance and health. OBJECTIVE: To provide an evidence-based review of 7 commonly used pharmacological interventions for performance enhancement in athletes. DATA SOURCES: PubMed and Scopus databases were searched on April 8, 2022. STUDY SELECTION: Systematic reviews (SRs) and meta-analyses (MAs) assessing the performance-enhancing effects of the following interventions were included: androgenic anabolic steroids (AAS), growth hormone (GH), selective androgen receptor modulators (SARMs), creatine, angiotensin-converting enzyme (ACE)-inhibitors, recombinant human erythropoietin (rHuEPO), and cannabis. STUDY DESIGN: Umbrella review of SRs and MAs. LEVEL OF EVIDENCE: Level 4. DATA EXTRACTION: Primary outcomes collected were (1) body mass, (2) muscle strength, (3) performance, and (4) recovery. Adverse effects were also noted. RESULTS: A total of 27 papers evaluating 5 pharmacological interventions met inclusion criteria. No studies evaluating SARMs or ACE-inhibitors were included. AAS lead to a 5% to 52% increase in strength and a 0.62 standard mean difference in lean body mass with subsequent lipid derangements. GH alters body composition, without providing a strength or performance benefit, but potential risks include soft tissue edema, fatigue, arthralgias, and carpel tunnel syndrome. Creatine use during resistance training can safely increase total and lean body mass, strength, and performance in high-intensity, short-duration, repetitive tasks. Limited evidence supports rHuEPO benefit on performance despite increases in both VO2max and maximal power output, and severe cardiovascular risks are documented. Cannabis provides no performance benefit and may even impair athletic performance. CONCLUSION: In young healthy persons and athletes, creatine can safely provide a performance-enhancing benefit when taken in controlled doses. AAS, GH, and rHuEPO are associated with severe adverse events and do not support a performance benefit, despite showing the ability to change bodily composition, strength, and/or physiologic measures. Cannabis may have an ergolytic, instead of ergogenic, effect.

Inconsistencies in Controlling for Risk Factors for Recurrent Shoulder Instability After Primary Arthroscopic Bankart Repair: A Systematic Review.

BACKGROUND: Failure rates after arthroscopic shoulder stabilization are highly variable in the current orthopaedic literature. Predictive factors for risk of failure have been studied to improve patient selection, refine surgical techniques, and define the role of bony procedures. However, significant heterogeneity in the analysis and controlling of risk factors makes evidence-based management decisions challenging. PURPOSE: The goals of this systematic review were (1) to critically assess the consistency of reported risk factors for recurrent instability after arthroscopic Bankart repair, (2) to identify the existing studies with the most comprehensive inclusion of confounding factors in their analyses, and (3) to give recommendations for which factors should be reported consistently in future clinical studies. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: A systematic review of the literature was performed in accordance with the PRISMA guidelines. An initial search yielded 1754 titles, from which 56 full-text articles were screened for inclusion. A total of 29 full-text articles met the following inclusion criteria: (1) clinical studies regarding recurrent anterior shoulder instability; (2) surgical procedures performed including arthroscopic anterior labral repair; (3) reported clinical outcome data including failure rate; and (4) assessment of risk factors for surgical failure. Further subanalyses were performed for 15 studies that included a multivariate analysis, 17 studies that included glenoid bone loss, and 8 studies that analyzed the Instability Severity Index Score. RESULTS: After full-text review, 12 of the most commonly studied risk factors were identified and included in this review. The risk factors that were most consistently significant in multivariate analyses were off-track lesions (100%), glenoid bone loss (78%), Instability Severity Index Score (75%), level of sports participation (67%), number of anchors (67%), and younger age (63%). In studies of bone loss, statistical significance was more likely to be found using advanced imaging, with critical bone loss thresholds of 10% to 15%. Several studies found predictive thresholds of 2 to 4 for Instability Severity Index Score by receiver operating characteristic or multivariate analysis. CONCLUSION: Studies reporting risk factors for failure of arthroscopic Bankart repair often fail to control for known confounding variables. The factors with the most common statistical significance among 15 multivariate analyses are off-track lesions, glenoid bone loss, Instability Severity Index Score, level of sports participation, number of anchors, and younger age. Studies found significance more commonly with advanced imaging measurements or arthroscopic assessment of glenoid bone loss and with lower thresholds for the Instability Severity Index Score (2-4). Future studies should attempt to control for all relevant factors, use advanced imaging for glenoid bone loss measurements, and consider a lower predictive threshold for the Instability Severity Index Score.

Tularemia in a Prosthetic Joint Infection.

Periprosthetic infections occur in approximately 0.8% to 1.9% of all total knee arthroplasties (TKAs). Even with these low rates, it is rare to find a zoonotic bacterium causing a periprosthetic infection. In this case report, the authors identify the second documented case of a total joint infection with Francisella tularensis in the world and the first in the United States. A 58-year-old man underwent a left TKA in 1994 and a right TKA in 1997 for severe primary bilateral knee osteoarthrosis. In 2015, he underwent polyethylene exchange for polyethylene wear. Subsequently, he developed repeated effusion without fever or constitutional signs of infection. One aspiration was sent for culture and grew F tularensis. He was treated with doxycycline for chronic suppression and currently has no signs of infection. Total joint implantation rates are expected to rise, with 3.5 million procedures projected to be performed annually by the year 2030 vs 450,000 procedures performed in 2005. With the increased number of operations, it is likely that zoonotic infections will increase as well. Thus, rare zoonotic bacterial infections as well as chronic outdoor exposure in the presence of persistent joint swelling should be considered when obtaining a patient history. [Orthopedics. 2020; 43(1):e54-e56.].

Step time asymmetry increases metabolic energy expenditure during running.

To improve locomotor performance, coaches and clinicians encourage individuals with unilateral physical impairments to minimize biomechanical asymmetries. Yet, it is unknown if biomechanical asymmetries per se, affect metabolic energy expenditure in individuals with or without unilateral impairments during running. Thus, inter-leg biomechanical asymmetries may or may not influence distance-running performance. PURPOSE: We sought to determine whether running with asymmetric step times affects metabolic rate in unimpaired individuals. METHODS: Ten unimpaired individuals were instructed to run on a force-measuring treadmill at 2.8 m/s and contact the ground simultaneously to the beat of an audible metronome. The metronome either played at time intervals equal to the respective participant's preferred step times (0% asymmetry), or at time intervals that elicited asymmetric step times between legs (7, 14, and 21% step time asymmetry); stride time remained constant across all trials. We measured ground reaction forces and metabolic rates during each trial. RESULTS: Every 10% increase in step time and stance average vertical ground reaction force asymmetry increased net metabolic power by 3.5%. Every 10% increase in ground contact time asymmetry increased net metabolic power by 7.8%. More asymmetric peak braking and peak propulsive ground reaction forces, leg stiffness, as well as positive and negative external mechanical work, but not peak vertical ground reaction force, increased net metabolic power during running. Step time asymmetry increases the net metabolic power of unimpaired individuals during running. Therefore, unimpaired individuals likely optimize distance-running performance by using symmetric step times and overall symmetric biomechanics.