Revision Total Joint Arthroplasty Places a Disproportionate Burden on Surgeons: A Comparison Using the National Aeronautics and Space Administration Task Load Index (NASA TLX).

BACKGROUND: Perceived surgeon workload of performing primary and revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) is challenging to quantify. The National Aeronautics and Space Administration Task Load Index (NASA TLX) survey was developed to quantify experiences following aviation and has been applied to healthcare fields. Our purposes were to 1) quantify the workload endured by surgeons who are performing primary and revision TKA and THA and 2) compare these values to their Center for Medicare & Medicaid Services (CMS) reimbursement. METHODS: A prospective cohort of 5 fellowship-trained adult reconstruction surgeons completed NASA TLX surveys following primary and revision TKA/THA cases. A total of 122 surveys consisting of 70 TKA (48 primaries and 22 revisions) and 55 THA surveys (38 primaries and 17 revisions) were completed. Patient demographics and surgical variables were recorded. Final NASA TLX workloads were compared to 2021 CMS work relative value units. RESULTS: Compared to primary TKA, revision TKA had 176% increased intraoperative workload (P < .001), 233% increased mental burden (P < .001), and 150% increased physical burden (P < .001). Compared to primary THA, revision THA had 106% increased intraoperative workload (P < .001), 96% increased mental burden (P < .001), and 91% increased physical burden (P < .001). Operative time was higher in revision versus primary TKA (118 versus 84.5 minutes, P = .05) and THA (150 versus 115 minutes, P = .001). Based upon 2021 CMS data, revision TKA and THA would need to be compensated by an additional 36% and 12.3%, respectively, to parallel intraoperative efforts. CONCLUSIONS: Revision hip and knee arthroplasty places a major mental and physical workload upon surgeons and is disproportionately compensated by CMS.

Can Artificial Intelligence Pass the American Board of Orthopaedic Surgery Examination? Orthopaedic Residents Versus ChatGPT.

BACKGROUND: Advances in neural networks, deep learning, and artificial intelligence (AI) have progressed recently. Previous deep learning AI has been structured around domain-specific areas that are trained on dataset-specific areas of interest that yield high accuracy and precision. A new AI model using large language models (LLM) and nonspecific domain areas, ChatGPT (OpenAI), has gained attention. Although AI has demonstrated proficiency in managing vast amounts of data, implementation of that knowledge remains a challenge. QUESTIONS/PURPOSES: (1) What percentage of Orthopaedic In-Training Examination questions can a generative, pretrained transformer chatbot (ChatGPT) answer correctly? (2) How does that percentage compare with results achieved by orthopaedic residents of different levels, and if scoring lower than the 10th percentile relative to 5th-year residents is likely to correspond to a failing American Board of Orthopaedic Surgery score, is this LLM likely to pass the orthopaedic surgery written boards? (3) Does increasing question taxonomy affect the LLM's ability to select the correct answer choices? METHODS: This study randomly selected 400 of 3840 publicly available questions based on the Orthopaedic In-Training Examination and compared the mean score with that of residents who took the test over a 5-year period. Questions with figures, diagrams, or charts were excluded, including five questions the LLM could not provide an answer for, resulting in 207 questions administered with raw score recorded. The LLM's answer results were compared with the Orthopaedic In-Training Examination ranking of orthopaedic surgery residents. Based on the findings of an earlier study, a pass-fail cutoff was set at the 10th percentile. Questions answered were then categorized based on the Buckwalter taxonomy of recall, which deals with increasingly complex levels of interpretation and application of knowledge; comparison was made of the LLM's performance across taxonomic levels and was analyzed using a chi-square test. RESULTS: ChatGPT selected the correct answer 47% (97 of 207) of the time, and 53% (110 of 207) of the time it answered incorrectly. Based on prior Orthopaedic In-Training Examination testing, the LLM scored in the 40th percentile for postgraduate year (PGY) 1s, the eighth percentile for PGY2s, and the first percentile for PGY3s, PGY4s, and PGY5s; based on the latter finding (and using a predefined cutoff of the 10th percentile of PGY5s as the threshold for a passing score), it seems unlikely that the LLM would pass the written board examination. The LLM's performance decreased as question taxonomy level increased (it answered 54% [54 of 101] of Tax 1 questions correctly, 51% [18 of 35] of Tax 2 questions correctly, and 34% [24 of 71] of Tax 3 questions correctly; p = 0.034). CONCLUSION: Although this general-domain LLM has a low likelihood of passing the orthopaedic surgery board examination, testing performance and knowledge are comparable to that of a first-year orthopaedic surgery resident. The LLM's ability to provide accurate answers declines with increasing question taxonomy and complexity, indicating a deficiency in implementing knowledge. CLINICAL RELEVANCE: Current AI appears to perform better at knowledge and interpretation-based inquires, and based on this study and other areas of opportunity, it may become an additional tool for orthopaedic learning and education.

Infection and Mortality Rate in Hepatitis C and Cirrhotic Patients Undergoing Hip and Knee Replacement.

Liver disease carries significant risk in total joint arthroplasty (TJA). The authors sought to investigate the complications in hepatitis C virus (HCV) and cirrhosis patients after TJA. PRISMA guidelines extracted ten studies and meta-analytic analysis was performed. Five hundred and twenty-seven patients with liver disease underwent TJA. The complication rate was 38.9%, with 8% infection at 57 months. Cirrhotic patients had higher complication and infection rates compared to HCV patients (p < 0.001, p < 0.039, respectively). Mortality in cirrhosis patients was 17.8% at 36 months. Studies suggested Child Pugh Class A patients had significantly lower complications than Class B or C. One study revealed lower MELD (Model for End-Stage Liver Disease) scores < 10 carry a low mortality risk of 9.8% compared with 32% mortality if MELD score 10 or above. Cirrhosis has significant infection and mortality risk in total hip and knee arthroplasty. Surgeons can risk stratify these patients by MELD score and Child Pugh Class. (Journal of Surgical Orthopaedic Advances 31(1):001-006, 2022).

Mortality During Total Hip Periprosthetic Joint Infection.

BACKGROUND: We sought to understand the mortality rate of periprosthetic joint infection (PJI) of the hip undergoing 2-stage revision for infection. METHODS: Database search, yielding 23 relevant studies, totaled 19,169 patients who underwent revision for total hip PJI. RESULTS: One-year weighted mortality rate was 4.22% after total hip PJI. Five-year mortality was 21.12%. Average age was 65 years. When comparing the national age-adjusted risk of mortality and the reported 1-year mortality risk in this systematic review, the risk of death after total hip PJI is significantly increased (odds ratio 3.58, P < .001). CONCLUSION: The mortality rate during total hip revision for infection is high. When counseling a patient regarding complications of this disease, death should be discussed.

The Current Knowledge on Spinopelvic Mobility.

Recent studies may suggest that our conventional knowledge of risk factors for dislocation may need rethinking. Previous studies have demonstrated a large majority of total hip arthroplasty instability with acetabular cups implanted in safe zones. Recently discovered spinopelvic motion is a coordinated biomechanical relationship among acetabular anteversion, pelvic tilt, and lumbar lordosis. Classification includes normal, hypermobile, stiff, stuck standing, stuck sitting, and fused. Normal spinopelvic motion from standing to sitting occurs with hip flexion, posterior sacral tilt, and decreased lumbar lordosis to accommodate a flexed femur and prevent impingement and dislocation. Acetabular cup implantation ideally is adapted based on spinopelvic interactions. This may lower the rate of impingement and subsequent dislocation. These new biomechanical interactions may provide a better understanding of the safe zones of anteversion and inclination.

Mortality During Total Knee Periprosthetic Joint Infection.

BACKGROUND: Periprosthetic joint infections (PJIs) are fraught with multiple complications including poor patient-reported outcomes, disability, reinfection, disarticulation, and even death. We sought to perform a systematic review asking the question: (1) What is the mortality rate of a PJI of the knee undergoing 2-stage revision for infection? (2) Has this rate improved over time? (3) How does this compare to a normal cohort of individuals? METHODS: We performed a database search in MEDLINE/EMBASE, PubMed, and all relevant reference studies using the following keywords: "periprosthetic joint infection," "mortality rates," "total knee arthroplasty," and "outcomes after two stage revision." Two hundred forty-two relevant studies and citations were identified, and 14 studies were extracted and included in the review. RESULTS: A total of 20,719 patients underwent 2-stage revision for total knee PJI. Average age was 66 years. Mean mortality percentage reported was 14.4% (1.7%-34.0%) with average follow-up 3.8 years (0.25-9 years). One-year mortality rate was 4.33% (3.14%-5.51%) after total knee PJI with an increase of 3.13% per year mortality thereafter (r = 0.76 [0.49, 0.90], P < .001). Five-year mortality was 21.64%. When comparing the national age-adjusted mortality (Actuarial Life Table) and the reported 1-year mortality risk in this meta-analysis, the risk of death after total knee PJI is significantly increased, with an odds ratio of 3.05 (95% confidence interval, 2.69-3.44; P < .001). CONCLUSION: The mortality rate after 2-stage total knee revision for infection is very high. When counseling a patient regarding complications of this disease, death should be discussed.

Does Local Soft Tissue Infiltration With a Liposomal Bupivacaine Cocktail Have a Synergistic Effect When Combined With Single-Shot Adductor Canal Peripheral Nerve Block in Knee Arthroplasty?

The purpose of this study was to determine if periarticular injection (PAI) with liposomal bupivacaine cocktail has a synergistic effect on pain relief with a single-injection adductor canal block in knee arthroplasty. Three hundred thirty-three knee arthroplasties were divided into three groups. Group 1 received general anesthesia (GA) and liposomal bupivacaine PAI. Group 2 received GA, peripheral nerve block (PNB), and liposomal bupivacaine PAI. Group 3 received GA, PNB, and ``plain'' ropivacaine PAI. Remaining perioperative multimodal medications and therapies were identical. There were no statistically significant differences in average narcotic use between any groups on the day of surgery, postoperative day 1, or postoperative day 2. Group 3 had the lowest postoperative nausea. Group 2 had the least pruritis. The current study failed to demonstrate a decrease in narcotic consumption with the combination of liposomal bupivacaine PAI and PNB. This study supports previous studies demonstrating that liposomal bupivacaine PAI provides similar outcomes to PNB.

The Impact of Bundled Payment Initiatives in Orthopedic Surgery Access to Care: Cherry Picking and Lemon Dropping.

This editorial explores the impact of bundled payment initiatives, specifically in the context of orthopedic surgery, on access to care. We examine the phenomenon of "cherry picking" healthier patients and "lemon dropping" higher-risk patients, potentially leading to disparities in access and healthcare outcomes. We discuss recent studies investigating these concerns and highlight the need for more in-depth research to better understand the groups these policies may marginalize. Policymakers are urged to consider measures to protect disadvantaged patients and ensure equitable access to care, aligning with the principles of equality and diversity in healthcare.

Outcomes of platelet rich plasma injections in the adhesive capsulitis of the shoulder.

Background: Platelet rich plasma (PRP) injections have been utilized in an attempt to provide improved pain and functional outcomes to patients with a variety of orthopaedic ailments. Adhesive capsulitis, also known as frozen shoulder is a common debilitating condition that carries significant morbidity due to the painful and prolonged course. Various studies have investigated intra-articular PRP administration with different methodologies and outcomes. Hypothesis/purpose: We sought to perform a meta-analysis on outcomes of adhesive capsulitis after PRP injection, determine effectiveness compared to corticosteroid, and compare adverse events. Study design: Meta analysis. Methods: EMBASE, EBSCO, Pubmed and Google Scholar were used to extract titles and abstracts using keywords "adhesive capsulitis", "frozen shoulder", "PRP", "platelet rich plasma". 41 articles were found and after duplicates removed and full-text review, 7 studies investigating 385 patients undergoing PRP or corticosteroid injections were found. Age, gender, body mass index (BMI), and ASA scores were obtained. Patient reported outcomes (PROs) were obtained and all reported range of motion (ROM) were recorded and compared after PRP and steroid injections using random effects meta-regression pre-injection and post-injection. Results: Both intra-articular PRP and steroid injections resulted in improved outcomes for treatment of adhesive capsulitis at 3 months. PRP injections had significantly better range of motion in passive forward flexion (151° vs 144.1°, p = 0.024) and had improved Shoulder Pain and Disability Index (SPADI) scores (14.6° vs 18.6°, p = 0.009) compared to steroid, however these may not reach minimum clinical thresholds. PRP had significantly better active (60° vs 43. 5°, p = 0.038) and passive internal rotation (69.6° vs 52.7°, p = 0.017) compared to steroid which did reach minimum clinical thresholds. There were no differences detected between VAS pain, active forward flexion, extension, abduction, external rotation nor difference in adverse events. Discussion: Both injections decreased pain and improved range of motion in patients. Intra-articular PRP injections may result in improved internal rotation compared to corticosteroid. Improvement in SPADI and passive forward flexion may be statistically significantly but may not be clinically relevant. Level of evidence: 3, Therapeutic.

Lesser Trochanter Apophyseal Avulsion Fracture: A Case Report and Review of the Literature.

Pediatric and adolescent apophyseal avulsion injuries are rare but important to recognize. This case report presents a 15-year-old male sprinter with a lesser trochanter apophyseal avulsion fracture who was treated nonoperatively. After 12 months of follow-up, conservative management resulted in significant healing and consolidation, with no pain or functional limitations at final follow-up. Conservative management of apophyseal avulsion injuries leads to positive outcomes in adolescents, while surgical intervention may be necessary for certain cases. Precise diagnosis and management are essential for successful outcomes, and in adults, a more extensive workup is recommended to rule out underlying malignancy.

Trends in Orthopaedic Surgery Workforce Diversity: Analyzing Changes Over Time.

INTRODUCTION: There are many reasons why orthopaedic surgeons move or change careers. We asked the questions: (1) What is the geographic distribution of orthopaedic surgeons with respect to age, sex, and race and ethnicity? (2) How has our workforce changed over time with regard to these factors? (3) Are there any patterns or trends detected regarding policy or regulatory events that coincide with these differences? METHODS: The American Academy of Orthopaedic Surgeons surveys over 30,000 members, collecting data on demographics, age, race sex, and practice statistics. We calculated geographic distributions and evaluated these differences over time-potential influences from malpractice suits or tort reform were investigated. RESULTS: Overall surgeon density increased over time. The largest negative changes were noted in District of Columbia, Wyoming, and North Dakota and positive changes in Colorado, South Dakota, and West Virginia. Age across all states increased (mean 1.7 years). Number of female surgeons increased in most states (4.6% to 5.7%). Number of African Americans increased from 1.6% to 1.8%, Hispanic/LatinX from 1.8% to 2.2%, Asian from 5.5% to 6.7%, and multiracial from 0.8% to 1.2%. No change was noted in the percentage of Native American surgeons. DISCUSSION: Surgeon density increased from 2012 to 2018; the cause for this change was not evident. Small increases in surgeon population, female surgeons, and in some underrepresented minorities were seen.

Natural History of Opioid Use in Naive and Tolerant Patients in Revision Total Hip Arthroplasty.

BACKGROUND: Opioid use after revision total hip arthroplasty (rTHA) has not been well characterized. The purpose of this study was to characterize preoperative, perioperative, and postoperative opioid use during rTHA. METHODS: Patients undergoing revision THA from 2010 to 2018 were screened for opioid use 3 months before revision surgery and tracked 24 months postoperatively. Patients were categorized as naïve or tolerant. Opioid prescriptions and average morphine milligram equivalents (MME) were compared between the two groups. RESULTS: One hundred twenty-four of 247 patients (50%) in the tolerant group averaged a preoperative MME of 23.7 mg/day. Postoperatively, tolerant patients received significantly higher daily MME at all time points, including at 3 months 31.4 versus 18.1 mg/day (P < 0.001), 6 months 19.9 versus 2.95 mg/day (P < 0.001), 12 months 14.3 versus 3.5 mg/day (P < 0.001), and 24 months 10.7 versus 2.17 mg/day (P < 0.001). Tolerant patients were more likely to have a prescription at 6 months (44% versus 22%), 12 months (41.4% versus 24%), and 24 months (38% versus 19.3%) (P < 0.001, P = 0.002, P < 0.001, respectively). DISCUSSION: Opioid-tolerant patients had higher postoperative MME requirements for longer recovery duration. Both groups reduced opioid use at 3 months and plateaued at 6 months. These findings can help the revision surgeon counsel patients and expectations.

Generative Artificial Intelligence Performs at a Second-Year Orthopedic Resident Level.

Introduction Artificial intelligence (AI) models using large language models (LLMs) and non-specific domains have gained attention for their innovative information processing. As AI advances, it's essential to regularly evaluate these tools' competency to maintain high standards, prevent errors or biases, and avoid flawed reasoning or misinformation that could harm patients or spread inaccuracies. Our study aimed to determine the performance of Chat Generative Pre-trained Transformer (ChatGPT) by OpenAI and Google BARD (BARD) in orthopedic surgery, assess performance based on question types, contrast performance between different AIs and compare AI performance to orthopedic residents. Methods We administered ChatGPT and BARD 757 Orthopedic In-Training Examination (OITE) questions. After excluding image-related questions, the AIs answered 390 multiple choice questions, all categorized within 10 sub-specialties (basic science, trauma, sports medicine, spine, hip and knee, pediatrics, oncology, shoulder and elbow, hand, and food and ankle) and three taxonomy classes (recall, interpretation, and application of knowledge). Statistical analysis was performed to analyze the number of questions answered correctly by each AI model, the performance returned by each AI model within the categorized question sub-specialty designation, and the performance of each AI model in comparison to the results returned by orthopedic residents classified by their respective post-graduate year (PGY) level. Results BARD answered more overall questions correctly (58% vs 54%, p<0.001). ChatGPT performed better in sports medicine and basic science and worse in hand surgery, while BARD performed better in basic science (p<0.05). The AIs performed better in recall questions compared to the application of knowledge (p<0.05). Based on previous data, it ranked in the 42nd-96th percentile for post-graduate year ones (PGY1s), 27th-58th for PGY2s, 3rd-29th for PGY3s, 1st-21st for PGY4s, and 1st-17th for PGY5s. Discussion ChatGPT excelled in sports medicine but fell short in hand surgery, while both AIs performed well in the basic science sub-specialty but performed poorly in the application of knowledge-based taxonomy questions. BARD performed better than ChatGPT overall. Although the AI reached the second-year PGY orthopedic resident level, it fell short of passing the American Board of Orthopedic Surgery (ABOS). Its strengths in recall-based inquiries highlight its potential as an orthopedic learning and educational tool.

Utility of D-dimer in total joint arthroplasty.

As the number of patients receiving total joint replacements continues to rise, considerable attention has been directed towards the early detection and prevention of postoperative complications. While D-dimer has long been studied as a diagnostic tool in venous thromboembolism (VTE), this assay has recently received considerable attention in the diagnosis of periprosthetic joint infection (PJI). D-dimer values are substantially elevated in the acute postoperative period after total joint arthroplasty, with levels often exceeding the standard institutional cutoff for VTE (500 µg/L). The utility of D-dimer in detecting VTE after total joint replacement is currently limited, and more research to assess its value in the setting of contemporary prophylaxis protocols is warranted. Recent literature supports D-dimer as a good to excellent biomarker for the diagnosis of chronic PJI, especially when using serum sample technique. Providers should exercise caution when interpreting D-dimer levels in patients with inflammatory and hypercoagulability disorders, as the diagnostic value is decreased. The updated 2018 Musculoskeletal Infection Society criteria, which includes D-dimer levels > 860 µg/L as a minor criterion, may be the most accurate for diagnosing chronic PJI to date. Larger prospective trials with transparent lab testing protocols are needed to establish best assay practices and optimal cutoff values for D-dimer in the diagnosis of PJI. This review summarizes the most current literature on the value of D-dimer in total joint arthroplasty and elucidates areas for future progress.

Intravenous Dexmedetomidine Use in Total Hip Arthroplasty May Lead to Elevated Rates of Hypotension.

Purpose Enhanced recovery protocols for total hip arthroplasty (THA), using opioid-sparing techniques have become widely used. Reports of novel additions to multimodal pain control regimens have been published, however, a paucity of literature exists on the use of intravenous dexmedetomidine. In this study, we analyzed our experience with intravenous dexmedetomidine and hypothesized that it would reduce postoperative opioid use. Secondary outcomes were also examined, including post-operative hypotension, hemoglobin, length of stay, and discharge disposition. Methods All patients who underwent primary THA at a single tertiary-level center between January 1, 2016, and September 1, 2019, underwent investigation. Diagnosis, surgical approach, anesthetic type, body mass index (BMI), and American Society of Anesthesiologists (ASA) score were recorded. Postoperative clinical measures were analyzed, adjusting for patient and surgical characteristics. Results Of the 599 patients included in the study, 218 patients received intravenous (IV) dexmedetomidine, at a mean dose of 44.9 mg during their operative event. Using a multivariate model, patients in the IV dexmedetomidine group were estimated to have received 24% elevated morphine milligram equivalent at postoperative day zero compared to those in the control group (p = 0.05). In addition, patients in the IV dexmedetomidine group who underwent spinal anesthesia had increased odds of hypotension 3.47 times that of the control [odds ratio (OR) 1.43-8.43, p=0.006]. Conclusions Surprisingly, we found no opioid-sparing effects with the use of IV dexmedetomidine. IV dexmedetomidine may be used cautiously as an anesthesia adjunct with spinal anesthesia in the setting of primary THA, as the experience at our institution illustrated increased odds of postoperative hypotension. Level of evidence This retrospective case-control study has a level of evidence III.

Tantalum Cementless Versus Cemented Total Knee Arthroplasty: A Meta-analysis of Level 1 Studies.

INTRODUCTION: Controversy exists on the ideal type of fixation in total knee arthroplasty (TKA). Noncemented fixation has been theorized to improve patient outcomes and longevity of implantation without increased risk of aseptic loosening or radiolucent lines. We sought to compare (1) patient-reported outcomes, (2) survivorship, and (3) revision rates for all-cause and aseptic loosening in a noncemented tantalum total knee with its cemented counterpart. METHODS: Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines were searched using a combination of keywords "trabecular metal," "tantalum knee," "total knee arthroplasty," and "cementless trabecular." Patient demographics such as age, sex, and body mass index were collected. Outcomes such as Knee Society Scores (KSSs), revisions, and radiolucent lines were recorded for analysis. RESULTS: Four randomized controlled trials involving 507 patients with an average 5-year follow-up were eligible for meta-analysis. No differences were observed in any demographics such as age, sex, body mass index, nor preoperative KSS. Patients in the cemented cohort improved from preoperative KSS 46.4 to postoperative KSS 90.4 while the tantalum cohort improved from 46.4 to 89.3. No statistical difference was observed in postoperative KSS mean difference between groups. Six patients from the tantalum group underwent revision with one patient for aseptic loosening. Twelve patients from the cemented group underwent revision with four patients for aseptic loosening. No statistical difference was observed between rates of revision, aseptic loosening, or radiolucent line development. DISCUSSION: Patient-reported outcomes improved postoperatively in both groups. No differences were detected between the cemented and noncemented TKAs in patient-reported outcomes, revision rates, or radiolucent line development. Noncemented tantalum fixation seems equivalent to cemented TKA survivorship. Longer term follow-up of these randomized controlled trials may provide a clearer understanding whether a difference exists.