Patient experiences and perspectives of health service access for carpal tunnel syndrome in Aotearoa New Zealand: a normalisation process theory-informed qualitative study.

BACKGROUND: Early access to care for carpal tunnel syndrome (CTS) can avoid higher rates of surgery and permanent harm yet is often delayed, particularly for populations more likely to underutilise care. OBJECTIVE: We sought to explore patient experiences and perspectives of health service access for CTS to inform an equity-focussed co-design of a health service for improving early care access. METHODS: In this Normalisation Process Theory (NPT)-informed qualitative study we conducted semistructured in-depth interviews with 19 adults with experience of CTS. Recruitment prioritised New Zealand Maori, Pasifika, low-income, and rural populations. Data were analysed using deductive then inductive thematic analysis. RESULTS: We identified five major themes: (1) the 'Significant Impact of CTS' of the sense-making and relational work to understand the condition, deciding when to get care, compelling clinicians to provide care, and garnering help from others; (2) 'Waiting and Paying for Care'- the enacting, relational, and appraising work to avoid long wait times unless paying privately, particularly where quality of care was low, employment relations poor, or injury compensation processes faltered; (3) circumstances of 'Occupation and CTS Onset' whereby the burden of proof to relate onset of CT symptoms to occupation created excessive relational and enacting work; (4) the 'Information Scarcity' of good information about CTS and the high relational and appraising work associated with using online resources; (5) 'Negotiating Telehealth Perspectives' where telehealth was valued if it meant earlier access for all despite the challenges it held for many. CONCLUSION: Quality, culturally and linguistically responsive information and communication from clinicians and health services will improve equitable early access to CTS care including realising the potential of telehealth modes of care. Policy changes that reduce individual burden of proof in injury compensation claims processes, enable time off work to attend health appointments, and increase public funding for surgical resources would improve early access to CTS care particularly for Maori and Pacific populations and those in small and rural workplaces. NPT is valuable for understanding where opportunities lie to reduce inequitable delays to accessing care including the impact of racism, particularly for populations more likely to underutilise care.

Comparison of early clinical outcome in carpal tunnel release - mini-open technique with palmar incision vs. endoscopic technique with wrist crease incision.

BACKGROUND: The purpose of this study was to examine two techniques for Carpal Tunnel Syndrome, mini-Open Carpal Tunnel Release (mini-OCTR) and Endoscopic Carpal Tunnel Release (ECTR), to compare their therapeutic efficacy. METHODS: Sixteen patients who underwent mini-OCTR in palmar incision and 17 patients who underwent ECTR in the wrist crease incision were included in the study. All patients presented preoperatively and at 1, 3, and 6 months postoperatively and were assessed with the Visual Analogue Scale (VAS) and the Disabilities of Arm, Shoulder and Hand Score (DASH). We also assessed the pain and cosmetic VAS of the entire affected hand or surgical wound, and the patient's satisfaction with the surgery. RESULTS: In the objective evaluation, both surgical techniques showed improvement at 6 months postoperatively. The DASH score was significantly lower in the ECTR group (average = 3 months: 13.6, 6 months: 11.9) than in the mini-OCTR group (average = 3 months: 27.3, 6 months: 20.6) at 3 and 6 months postoperatively. Also, the pain VAS score was significantly lower in the ECTR group (average = 17.1) than in the mini-OCTR group (average = 36.6) at 3 months postoperatively. The cosmetic VAS was significantly lower in the ECTR group (average = 1 month: 15.3, 3 months: 12.2, 6 months: 5.41) than in the mini-OCTR group (average = 1 month: 33.3, 3 months: 31.2, 6 months: 24.8) at all time points postoperatively. Patient satisfaction scores tended to be higher in the ECTR group (average = 3.3) compared to the mini-OCTR group (average = 2.7). CONCLUSIONS: ECTR in wrist increase incision resulted in better pain and cosmetic recovery in an early postoperative phase compared with mini-OCTR in palmar incision. Our findings suggest that ECTR is an effective technique for patient satisfaction.

Perineural 5% dextrose versus corticosteroid injection in non-surgical carpal tunnel syndrom treatment.

Background and purpose:

We aimed to investigate the difference of clinical and electrophysiological improvement between perineural corticosteroid injection therapy (PCIT) and perineural 5% dextrose injection therapy (5%PDIT) in carpal tunnel syndrome (CTS).

Total of 92 wrists that were diagnosed as mild-to-moderate idiopathic CTS and completed their follow-up were included in our study. The severity of pain, symptom severity and functional status were asses­sed by visual analog scale (VAS) and the Boston Carpal Tunnel Syndrome Questionnaire (BCTQ) scores for treatment effectiveness. Randomized wrists were administered PCIT or 5%PDIT accompanied by ultrasound guidance. VAS, BCTQ scores and the electro­physiological study repeated before and after treatment at the 1st and 6th months after perineural injection therapies (PITs) were recorded.

Compared with baseline data, within groups there was significant improvement in VAS, BCTQ severity and function scores at 1st and 6th months follow-up (all p < 0.001). Considerable advance were detected in the median sensory nerve conduction velocity (SNCV) when pretreatment values were compared with posttreatment first month in both groups (p = 0.01; p < 0.001, respectively). No significant change occurred in median distal motor latency (DML) values between the 1st and 6th months in the groups (p = 0.095; p = 0.113, respectively). No significant difference was observed bet­ween 5%PDIT and PCIT groups.

Clinical and electrophysiologic improvement in CTS began from 1st month after PCIT and 5%PDIT. At the 6th month follow-up of the patients, 5%PDIT and PCIT had similar therapeutic effects. As a result, we can consider the replacement of PCIT with 5%PDIT in mild-to-moderate CTS patients especially in those who are hesitant because of the corticosteroid’s adverse effects.

Health-related quality of life in patients with conditions affecting the hand: meta-analysis.

BACKGROUND: Health state utility values provide the quality component of quality-adjusted life years and are essential for health economic analyses, such as the National Institute for Health and Care Excellence Technology Appraisal. The aims of this systematic review were to: catalogue utility values for health states experienced by patients with hand conditions; provide pooled utility estimates for common hand conditions; and determine how utilities have been estimated. METHODS: A PRISMA-compliant systematic review and meta-analysis was conducted (registered in PROSPERO, the international prospective register of systematic reviews (CRD42021226098)). Five databases were searched from inception until April 2023 (Embase, MEDLINE, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), and the Cochrane Central Register of Controlled Trials (CENTRAL)). All studies that reported primary utility values for hand health states in adult patients were eligible for inclusion. Pooled utility estimates were determined across conditions and intervention status using random-effects meta-analysis. RESULTS: A total of 10 254 articles were identified; 57 studies met the full inclusion criteria and reported 363 distinct health state utility values. Health state utility values were estimated using a range of methods; the most common measure was the EQ-5D. Pooled utility estimates for carpal tunnel syndrome and hand osteoarthritis before surgical intervention were 0.69 (95% c.i. 0.66 to 0.73) and 0.63 (95% c.i. 0.60 to 0.67) respectively. CONCLUSION: Pooled utility estimates for patients with untreated carpal tunnel syndrome and hand osteoarthritis are 11% and 18% lower than age-matched population norms respectively. Hand conditions have a significant detrimental impact on health-related quality of life and this study provides catalogued utility values for use in future economic analyses to support the delivery of value-based hand surgery.

Association of carpal tunnel syndrome risk factors with treatment modality selection focusing on corticosteroid injection and surgery: A nationwide population-based study.

Several studies have revealed the risk factors for carpal tunnel syndrome (CTS). However, no studies have evaluated the influence of these risk factors on the selection of treatment modalities for CTS. This study aimed to determine the influence of CTS risk factors on the selection of CTS treatment modalities with a focus on corticosteroid injection (CI) and surgery. We conducted a retrospective cohort study of patients aged ≥20 years with newly diagnosed CTS in the Korean health insurance review and assessment service between 2010 and 2019. We evaluated the demographic information, the existence of CTS risk factors, and the applied treatment modalities for CTS, including CI and operation. The CTS risk factors include age, sex, diabetes mellitus, osteoarthritis of the hand or wrist, rheumatoid arthritis, hypothyroidism, gout, chronic kidney disease (CKD) on dialysis, antiestrogen or aromatase inhibitor medication, and a history of distal radius fracture (DRF). Multivariable logistic regression analyses were conducted. Age over 80 years was the most significantly associated factor for the selection of CI in CTS (odd ratio [OR], 2.149; 95% confidence interval [CI], 2.092 to 2.209; P < .001). Among underlying diseases or medications, CKD on dialysis (OR, 4.001; 95% CI, 3.819-4.193; P < .001) was the most significant associated factor for the selection of operation for CTS, followed by a history of DRF (OR, 1.803; 95% CI, 1.749-1.860; P < .001). Old age was the most significantly related factor for selecting CI. Among underlying diseases or medications, CKD on dialysis and the history of DRF were the most significantly related factors for selecting operative treatment. For these patients, clinicians should proactively consider an operation to reduce the long-term discomfort and economic burdens.

Carpal tunnel syndrome prediction with machine learning algorithms using anthropometric and strength-based measurement.

OBJECTIVES: Carpal tunnel syndrome (CTS) stands as the most prevalent upper extremity entrapment neuropathy, with a multifaceted etiology encompassing various risk factors. This study aimed to investigate whether anthropometric measurements of the hand, grip strength, and pinch strength could serve as predictive indicators for CTS through machine learning techniques. METHODS: Enrollment encompassed patients exhibiting CTS symptoms (n = 56) and asymptomatic healthy controls (n = 56), with confirmation via electrophysiological assessments. Anthropometric measurements of the hand were obtained using a digital caliper, grip strength was gauged via a digital handgrip dynamometer, and pinch strengths were assessed using a pinchmeter. A comprehensive analysis was conducted employing four most common and effective machine learning algorithms, integrating thorough parameter tuning and cross-validation procedures. Additionally, the outcomes of variable importance were presented. RESULTS: Among the diverse algorithms, Random Forests (accuracy of 89.474%, F1-score of 0.905, and kappa value of 0.789) and XGBoost (accuracy of 86.842%, F1-score of 0.878, and kappa value of 0.736) emerged as the top-performing choices based on distinct classification metrics. In addition, using variable importance calculations specific to these models, the most important variables were found to be wrist circumference, hand width, hand grip strength, tip pinch, key pinch, and middle finger length. CONCLUSION: The findings of this study demonstrated that wrist circumference, hand width, hand grip strength, tip pinch, key pinch, and middle finger length can be utilized as reliable indicators of CTS. Also, the model developed herein, along with the identified crucial variables, could serve as an informative guide for healthcare professionals, enhancing precision and efficacy in CTS prediction.

Skin closUre in carPal tunnEl Release (SUPER): protocol for a blinded randomised controlled trial comparing absorbable and non-absorbable sutures in carpal tunnel release.

INTRODUCTION: Carpal tunnel syndrome is a common disorder affecting a substantial portion of the general population. Surgical intervention is often deemed necessary, with the median nerve release being one of the most frequent operations. Optimising all the aspects of this procedure can enhance patient satisfaction with the treatment. METHODS AND ANALYSIS: We aim to determine the differences in the aesthetic outcome of the scar as well as the pain experienced during the healing process between the use of absorbable and non-absorbable sutures. The primary outcome measure will be the patients' subjective satisfaction with the aesthetic appearance of the scar 1 year after the operation. Secondary outcomes will include a similar evaluation of the aesthetics performed by a blinded outcome assessor, as well as pain experienced by the patients during the 2 weeks postoperatively. The severity and improvement of the patients' symptoms will also be measured by a Finnish version of the Boston Carpal Tunnel Questionnaire. Costs will be evaluated for both groups. Safety of the wound closure will be followed and reported. ETHICS AND DISSEMINATION: This protocol was approved by the Research Ethics Committee of the Northern Savo Hospital District (2319/2021). The trial will be conducted in accordance with the principles of Good Clinical Practice and the Declaration of Helsinki. The results will be disseminated through publication in peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT05503719.

Thrombosed Persistent Median Artery with Coexisting Bifid Median Nerve in a Robotic Arthroplasty Surgeon: A Case Report.

CASE: A 47-year-old orthopaedic surgeon presented with acute volar left wrist pain. He performed over 250 robot-assisted knee arthroplasties each year. Color Doppler evaluation revealed bilateral persistent median arteries and bifid median nerves, with focal occlusive thrombosis of the left median artery. He was advised rest and oral aspirin. He could return to his professional activities after 1 month. He had no recurrence of symptoms at 1 year of follow-up. CONCLUSION: Orthopaedic surgeons use vibrating hand tools on a daily basis. The possibility of hand-arm vibration syndrome must be considered in the differential diagnosis of wrist pain among orthopaedic surgeons.

Investigating the association between diabetes and carpal tunnel syndrome: A systematic review and meta-analysis approach.

INTRODUCTION: In recent years, several studies have reported on the relationship between diabetes and carpal tunnel syndrome (CTS). However, due to their contradictory results, a systematic review and meta-analysis were conducted to investigate this subject. METHODS: This study is a systematic review and meta-analysis of studies published in ISI Web of Science, Scopus, PubMed, Cochrane, Google Scholar, and Embase databases. Heterogeneity in the studies included in the meta-analysis was evaluated using statistical tests such as the Chi-square test, I2, and forest plots. Publication bias was assessed using Begg's and Egger's tests. RESULTS: This investigation analyzed data from 42 studies conducted between 1985 and 2022, with a total of 3,377,816 participants. The meta-analysis demonstrated that the odds ratio (OR) of CTS in participants with a history of diabetes compared to those without was 1.90 (95% CI: 1.64-2.21; P-value < 0.001). Given that publication bias was observed in this study (Begg's test P-value = 0.01), the modified OR was calculated with consideration of missed studies, which was 1.68 (95% CI: 1.45-1.94; P-value < 0.001). CONCLUSION: The results of this study suggest that diabetic patients have 90% higher odds of developing CTS compared to non-diabetic individuals, which is statistically significant.

Relationship between Gravidity, Parity, and Neurophysiological Features in Carpal Tunnel Syndrome (CTS) Patients with a History of Pregnancy.

BACKGROUND: It is not yet clear if gravidity and parity have any relationships with the electrodiagnostic parameters of carpal tunnel syndrome (CTS). OBJECTIVE: To determine whether there is a relationship between electrodiagnostic findings, gravidity, and parity number in CTS. MATERIALS AND METHODS: Female patients over 18 years of age with CTS were included in this retrospective cohort study. The gravidity/parity number, median nerve compound muscle action potential (CMAP), and compound nerve action potential (CNAP) of the patients were analyzed. The two subgroups of the Boston carpal tunnel syndrome questionnaire (BCTSQ): The Symptom Severity Scale (SSS) and Functional Severity Scale (FSS) were applied to the patients. CTS patients were divided into two groups aged at first pregnancy ≤20 years and >20 years. RESULTS: One hundred and eight CTS extremities (seven right-sided CTS, three left-sided CTS, 49 bilateral CTS) of 59 patients were included. The median (interquartile range: 25%-75%) number of gravidity, parity, and abortion were 3 (2-5), 3 (2-4), and 0 (0-0), respectively. Right-sided CTS patients at the age of first pregnancy ≤20 years had higher BCTSQ-SSS/FSS scores and median nerve CMAP latency compared to patients at the age of first pregnancy >20 years (P = 0.029 for SSS; P = 0.042 for FSS; and P = 0.041 for CMAP latency). A negative correlation was found between the gravidity/parity numbers and median nerve CNAP/CMAP amplitudes (P = 0.028/0.031, r = -0.293/-0.289 for CNAP amplitude; and P = 0.006/0.035, r = -0.363/-0.283 for CMAP amplitude). CONCLUSION: Neurophysiological findings worsen as the number of gravidity and parity increase. Electrodiagnostic and clinical features of CTS may be worsening in females below 20 years at first pregnancy.

[Rare nerve compression neuropathies] / Seltene Nervenkompressionssyndrome.

UNCOMMON NERVE COMPRESSION SYNDROMES: In regard to the complex anatomical relationship of peripheral nerves and muscles, tendons, fasciae as well as their long course within those anatomical structures and additional close contact to bony structures, they are prone to suffer from local compression syndromes. Hence creating a vast majority of entrapment syndromes - well described in literature for almost every single nerve. The purpose of this article is to give an overview of symptoms, signs, diagnostic studies and treatment options, addressing especially the less known syndromes. Compression syndromes of the upper arm and shoulder region include the suprascapular nerve syndrome the compression of the axillary nerve within the spatium quadrilaterale and the compression of the long thoracic nerve at the chest wall. The upper extremity offers a variety of infrequent entrapment syndromes, as the pronator teres syndrome and anterior interosseus syndrome, both resulting from pressure to the median nerve in the forearm. Compression neuropathy in the course of the radial nerve in the distal upper extremity is also known as supinator syndrome. Guyon's canal syndrome is the ulnar side equivalent to the well-known carpal tunnel syndrome. In the case of a Cheiralgia paresthetica, a compression of a sensory branch of the superficial radial nerve can be seen. In the lower extremities, a variety of nerves especially in the groin and thigh area can be compressed as they pass through the narrow spaces between the abdominal muscles or underneath the inguinal ligament. Compression of the lateral femoral cutaneous nerve is the most common syndrome. Compression syndromes of the femoral and obturator nerves are most often iatrogenic. Pain around the knee, especially the lateral part and following orthopedic procedures of the knee, can arise from a compression or a lesion of a small infrapatellar branch of the saphenous nerve. Another probably underdiagnosed syndrome is piriformis syndrome, resulting from an entrapment of the sciatic nerve as it passes through certain muscular structures. In the distal lower extremity, the peroneal and tibial nerves can be compressed at multple sites, clinically known as peroneal nerve paralysis resulting from nerve compression around the fibular head, the anterior and posterior tarsal tunnel syndrome, and Morton's metatarsalgia.

Carpal Tunnel Syndrome Caused by a Juxta-articular Myxoma: A Case Report.

Juxta-articular myxoma (JAM) is a rare soft tissue tumour predominantly composed of mucinous tissue and usually found around large joints. We report a 73-year-old woman with a 5-year history of a soft tissue mass in the thenar eminence of the right wrist who presented to our department. An initial diagnosis of a ganglion cyst was made using magnetic resonance imaging (MRI) and the jellied content of the mass by aspiration. Two years after presentation, surgical treatment with tumour resection and carpal tunnel release via the radial approach was performed because the symptoms of carpal tunnel syndrome worsened, and the tumour invaded the carpal tunnel. Histopathological examination revealed a JAM. At the 1-year follow-up, the symptoms of carpal tunnel syndrome had resolved, and no recurrence was confirmed by MRI. Level of Evidence: Level V (Therapeutic).

Prevalence of transthyretin cardiac amyloidosis in patients with high-degree AV block.

OBJECTIVE: Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative cardiac disorder caused by deposition of wild type or mutated transthyretin. As ATTR-CM is associated with conduction disease, we sought to determine its prevalence in patients with idiopathic high-degree atrioventricular (AV) block requiring permanent pacemaker (PPM) implantation. METHODS: Consecutive patients aged 70-85 years undergoing PPM implantation for idiopathic high-degree AV block between November 2019 and November 2021 were offered a 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scan. Demographics, comorbidities, electrocardiographic and imaging data from the time of device implantation were retrospectively collected. RESULTS: 39 patients (79.5% male, mean (SD) age at device implantation 76.2 (2.9) years) had a DPD scan. 3/39 (7.7%, all male) had a result consistent with ATTR-CM (Perugini grade 2 or 3). Mean (SD) maximum wall thickness of those with a positive DPD scan was 19.0 mm (3.6 mm) vs 11.4 mm (2.7 mm) in those with a negative scan (p=0.06). All patients diagnosed with ATTR-CM had spinal canal stenosis and two had carpal tunnel syndrome. CONCLUSIONS: ATTR-CM should be considered in older patients requiring permanent pacing for high-degree AV block, particularly in the presence of left ventricular hypertrophy, carpal tunnel syndrome or spinal canal stenosis.

Low-Income, Poor Physical Health, Poor Mental Health, and Other Social Risk Factors Are Associated With Decreased Access to Care in Patients With Carpal Tunnel Syndrome.

BACKGROUND: Carpal Tunnel Syndrome (CTS) is associated with a significant personal and societal burden. Evaluating access to care can identify barriers, limitations, and disparities in the delivery of healthcare services in this population. The purpose of this study was to evaluate access to overall healthcare and healthcare utilization among patients with CTS. METHODS: This is a retrospective cohort study conducted with the All of Us database. Patients diagnosed with CTS that completed the access to care survey were included and matched to a control group. The primary outcomes were access to care across 4 domains: (1) delayed care, (2) could not afford care, (3) skipped medications, and (4) over 1 year since seeing provider. Secondary analysis was then performed to identify patient-specific factors associated with reduced access to care. RESULTS: In total, 7649 patients with CTS were included and control matched to 7649 patients without CTS. In the CTS group, 33.7% (n = 2577) had delayed care, 30.4% (n = 2323) could not afford care, 15.4% (n = 1180) skipped medications, and 1.6% (n = 123) had not seen a provider in more than 1 year. Within the CTS cohort, low-income, worse physical health, and worse mental health were associated with poor access to care. CONCLUSION: Patients experience notable challenges with delayed care, affordability of care, and medication adherence regardless of having a diagnosis of CTS. Targeted interventions on modifiable risk factors such as low income, poor mental health, and poor physical health are important opportunities to improve access to care in this population.

Análisis de los parámetros ecográficos descritos en el estudio del síndrome del túnel del carpo. Una revisión sistemática / Analysis of the echographic parameters described in the study of carpal tunnel syndrome: A systematic review

El síndrome del túnel del carpo (STC) es la mononeuropatía por atrapamiento más frecuente; el diagnóstico se establece mediante pruebas electrodiagnósticas con un número sustancial de falsos positivos/negativos. Presentamos la siguiente revisión sistemática, cuyo objetivo es analizar la literatura más reciente en relación con los parámetros ecográficos descritos para estudiar el STC. Seleccionamos estudios que evaluasen parámetros ecográficos en pacientes con sospecha clínica, siguiendo las recomendaciones del manual Cochrane; incluimos revisiones sistemáticas, metaanálisis, estudios caso-control y de pruebas diagnósticas, valorando estudios retrospectivos y revisiones bibliográficas con buena calidad metodológica. La revisión se hizo de artículos publicados entre 2005-2019. Incluimos 8 artículos (2 revisiones sistemáticas/metaanálisis, 2 estudios caso-control, un estudio de pruebas diagnósticas, 2 revisiones literarias y un estudio retrospectivo). Los parámetros analizados fueron el área de sección transversa del nervio mediano, el índice muñeca-antebrazo, el índice entrada-salida, el rango de adelgazamiento del nervio mediano, el abombamiento del retináculo flexor y la vascularización/movilidad. La evidencia actual permite afirmar que la ecografía tiene utilidad en el cribado del STC.(AU)

Carpal tunnel syndrome (CTS) is the most common entrapment mononeuropathy; the diagnosis is established by electrodiagnostic tests with until 34% of false positives/negatives. We present the following systematic review which objective is to analyze the most recent literature related to the ultrasound parameters described to study CTS. We selected studies that evaluated ultrasound parameters in patients with clinical suspicion following the Cochrane manual's recommendations. We include systematic reviews, meta-analyses, case–control studies and diagnostic tests, evaluating retrospective studies and bibliographic reviews with proper methodological quality. Articles published between 2005 and 2019. We included eight articles (two systematic reviews/meta-analyses, two case–control studies, one diagnostic test study, two literature reviews, and one retrospective). The parameters analyzed were cross-sectional area, wrist–forearm index, entry–exit index, thinning range, palmar bowing of the flexor retinaculum, and vascularity/mobility. Current evidence allows us to affirm that ultrasound is useful in screening for CTS.(AU)

How Does ChatGPT Use Source Information Compared With Google? A Text Network Analysis of Online Health Information.

BACKGROUND: The lay public is increasingly using ChatGPT (a large language model) as a source of medical information. Traditional search engines such as Google provide several distinct responses to each search query and indicate the source for each response, but ChatGPT provides responses in paragraph form in prose without providing the sources used, which makes it difficult or impossible to ascertain whether those sources are reliable. One practical method to infer the sources used by ChatGPT is text network analysis. By understanding how ChatGPT uses source information in relation to traditional search engines, physicians and physician organizations can better counsel patients on the use of this new tool. QUESTIONS/PURPOSES: (1) In terms of key content words, how similar are ChatGPT and Google Search responses for queries related to topics in orthopaedic surgery? (2) Does the source distribution (academic, governmental, commercial, or form of a scientific manuscript) differ for Google Search responses based on the topic's level of medical consensus, and how is this reflected in the text similarity between ChatGPT and Google Search responses? (3) Do these results vary between different versions of ChatGPT? METHODS: We evaluated three search queries relating to orthopaedic conditions: "What is the cause of carpal tunnel syndrome?," "What is the cause of tennis elbow?," and "Platelet-rich plasma for thumb arthritis?" These were selected because of their relatively high, medium, and low consensus in the medical evidence, respectively. Each question was posed to ChatGPT version 3.5 and version 4.0 20 times for a total of 120 responses. Text network analysis using term frequency-inverse document frequency (TF-IDF) was used to compare text similarity between responses from ChatGPT and Google Search. In the field of information retrieval, TF-IDF is a weighted statistical measure of the importance of a key word to a document in a collection of documents. Higher TF-IDF scores indicate greater similarity between two sources. TF-IDF scores are most often used to compare and rank the text similarity of documents. Using this type of text network analysis, text similarity between ChatGPT and Google Search can be determined by calculating and summing the TF-IDF for all keywords in a ChatGPT response and comparing it with each Google search result to assess their text similarity to each other. In this way, text similarity can be used to infer relative content similarity. To answer our first question, we characterized the text similarity between ChatGPT and Google Search responses by finding the TF-IDF scores of the ChatGPT response and each of the 20 Google Search results for each question. Using these scores, we could compare the similarity of each ChatGPT response to the Google Search results. To provide a reference point for interpreting TF-IDF values, we generated randomized text samples with the same term distribution as the Google Search results. By comparing ChatGPT TF-IDF to the random text sample, we could assess whether TF-IDF values were statistically significant from TF-IDF values obtained by random chance, and it allowed us to test whether text similarity was an appropriate quantitative statistical measure of relative content similarity. To answer our second question, we classified the Google Search results to better understand sourcing. Google Search provides 20 or more distinct sources of information, but ChatGPT gives only a single prose paragraph in response to each query. So, to answer this question, we used TF-IDF to ascertain whether the ChatGPT response was principally driven by one of four source categories: academic, government, commercial, or material that took the form of a scientific manuscript but was not peer-reviewed or indexed on a government site (such as PubMed). We then compared the TF-IDF similarity between ChatGPT responses and the source category. To answer our third research question, we repeated both analyses and compared the results when using ChatGPT 3.5 versus ChatGPT 4.0. RESULTS: The ChatGPT response was dominated by the top Google Search result. For example, for carpal tunnel syndrome, the top result was an academic website with a mean TF-IDF of 7.2. A similar result was observed for the other search topics. To provide a reference point for interpreting TF-IDF values, a randomly generated sample of text compared with Google Search would have a mean TF-IDF of 2.7 ± 1.9, controlling for text length and keyword distribution. The observed TF-IDF distribution was higher for ChatGPT responses than for random text samples, supporting the claim that keyword text similarity is a measure of relative content similarity. When comparing source distribution, the ChatGPT response was most similar to the most common source category from Google Search. For the subject where there was strong consensus (carpal tunnel syndrome), the ChatGPT response was most similar to high-quality academic sources rather than lower-quality commercial sources (TF-IDF 8.6 versus 2.2). For topics with low consensus, the ChatGPT response paralleled lower-quality commercial websites compared with higher-quality academic websites (TF-IDF 14.6 versus 0.2). ChatGPT 4.0 had higher text similarity to Google Search results than ChatGPT 3.5 (mean increase in TF-IDF similarity of 0.80 to 0.91; p < 0.001). The ChatGPT 4.0 response was still dominated by the top Google Search result and reflected the most common search category for all search topics. CONCLUSION: ChatGPT responses are similar to individual Google Search results for queries related to orthopaedic surgery, but the distribution of source information can vary substantially based on the relative level of consensus on a topic. For example, for carpal tunnel syndrome, where there is widely accepted medical consensus, ChatGPT responses had higher similarity to academic sources and therefore used those sources more. When fewer academic or government sources are available, especially in our search related to platelet-rich plasma, ChatGPT appears to have relied more heavily on a small number of nonacademic sources. These findings persisted even as ChatGPT was updated from version 3.5 to version 4.0. CLINICAL RELEVANCE: Physicians should be aware that ChatGPT and Google likely use the same sources for a specific question. The main difference is that ChatGPT can draw upon multiple sources to create one aggregate response, while Google maintains its distinctness by providing multiple results. For topics with a low consensus and therefore a low number of quality sources, there is a much higher chance that ChatGPT will use less-reliable sources, in which case physicians should take the time to educate patients on the topic or provide resources that give more reliable information. Physician organizations should make it clear when the evidence is limited so that ChatGPT can reflect the lack of quality information or evidence.