Faculty Bibliography

INTRODUCTION/BACKGROUND:Artificial intelligence (AI) in the field of orthopaedics has been a topic of increasing interest and opportunity in recent years. Its applications are widespread both for physicians and patients, including use in clinical decision-making, in the operating room, and in research. In this study, we aimed to assess the quality of ChatGPT answers when asked questions related to total knee arthroplasty (TKA). METHODS:ChatGPT prompts were created by turning 15 of the American Academy of Orthopaedic Surgeons (AAOS) Clinical Practice Guidelines into questions. An online survey was created, which included screenshots of each prompt and answers to the 15 questions. Surgeons were asked to grade ChatGPT answers from 1 to 5 based on their characteristics: 1) Relevance; 2) Accuracy; 3) Clarity; 4) Completeness; 5) Evidence-based; and 6) Consistency. There were eleven Adult Joint Reconstruction fellowship-trained surgeons who completed the survey. Questions were subclassified based on the subject of the prompt: 1) risk factors, 2) implant/Intraoperative, and 3) pain/functional outcomes. The average and standard deviation for all answers, as well as for each subgroup, were calculated. Inter-rater reliability (IRR) was also calculated. RESULTS:All answer characteristics were graded as being above average (i.e., a score > 3). Relevance demonstrated the highest scores (4.43±0.77) by surgeons surveyed, and consistency demonstrated the lowest scores (3.54±1.10). ChatGPT prompts in the Risk Factors group demonstrated the best responses, while those in the Pain/Functional Outcome group demonstrated the lowest. The overall IRR was found to be 0.33 (poor reliability), with the highest IRR for relevance (0.43) and the lowest for evidence-based (0.28). CONCLUSION/CONCLUSIONS:ChatGPT can answer questions regarding well-established clinical guidelines in TKA with above-average accuracy but demonstrates variable reliability. This investigation is the first step in understanding large language model (LLM) AIs like ChatGPT and how well they perform in the field of arthroplasty.

BACKGROUND:The lower morbidity and mortality rate associated with increased surgeon and hospital volume may also correlate with improved patient-reported outcome measures. The goal of this study was to determine the relationship between surgeon and hospital volume and patient-reported outcome measures after total knee arthroplasty (TKA) using American Joint Replacement Registry data. METHODS:Using American Joint Replacement Registry data from 2012 to 2020, 8,193 primary, elective TKAs with both preoperative and 1-year postoperative The Knee Injury and Osteoarthritis Outcome Score, Joint Replacement (KOOS-JR) scores were analyzed. This study was powered to detect the minimally clinical important difference (MCID). The main exposure variables were median annual surgeon and hospital volume. Tertiles were formed based on the median annual number of TKAs performed: low-volume surgeons (1 to 52), medium-volume (53 to 114), and high-volume (≥115); low-volume hospitals (1 to 283), medium-volume (284 to 602), and high-volume (≥603). The mean preoperative and 1-year postoperative KOOS-JR were compared. Multivariable logistic regression models were used to determine the effect of surgeon and hospital volume and demographics on achieving the MCID for KOOS-JR. RESULTS:The mean preoperative and 1-year postoperative KOOS-JR score for low-volume surgeons was 47.78 ± 13.50 and 77.75 ± 16.65, respectively, and 47.32 ± 13.73 and 76.86 ± 16.38 for low-volume hospitals. The mean preoperative and 1-year postoperative KOOS-JR score for medium-volume surgeons was 47.20 ± 13.46 and 76.70 ± 16.98, and 48.93 ± 12.50 and 77.15 ± 16.36 for medium-volume hospitals. The mean preoperative and 1-year postoperative KOOS-JR scores for high-volume surgeons were 49.08 ± 13.04 and 78.23 ± 16.72, and 48.11 ± 13.47 and 78.23 ± 17.22 for high-volume hospitals. No notable difference was observed in reaching MCID for KOOS-JR after adjustment for potential confounders. CONCLUSION/CONCLUSIONS:An increased number of TKA cases performed by a given surgeon or at a given hospital did not have an effect on achieving MCID for KOOS-JR outcomes.

BACKGROUND:Supervised machine learning techniques have been increasingly applied to predict patient outcomes after hip and knee arthroplasty procedures. The purpose of this study was to systematically review the applications of supervised machine learning techniques to predict patient outcomes after primary total hip and knee arthroplasty. METHODS:A comprehensive literature search using the electronic databases MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Cochrane Database of Systematic Reviews was conducted in July of 2021. The inclusion criteria were studies that utilized supervised machine learning techniques to predict patient outcomes after primary total hip or knee arthroplasty. RESULTS:Search criteria yielded n = 30 relevant studies. Topics of study included patient complications (n = 6), readmissions (n = 1), revision (n = 2), patient-reported outcome measures (n = 4), patient satisfaction (n = 4), inpatient status and length of stay (LOS) (n = 9), opioid usage (n = 3), and patient function (n = 1). Studies involved TKA (n = 12), THA (n = 11), or a combination (n = 7). Less than 35% of predictive outcomes had an area under the receiver operating characteristic curve (AUC) in the excellent or outstanding range. Additionally, only 9 of the studies found improvement over logistic regression, and only 9 studies were externally validated. CONCLUSION/CONCLUSIONS:Supervised machine learning algorithms are powerful tools that have been increasingly applied to predict patient outcomes after total hip and knee arthroplasty. However, these algorithms should be evaluated in the context of prognostic accuracy, comparison to traditional statistical techniques for outcome prediction, and application to populations outside the training set. While machine learning algorithms have been received with considerable interest, they should be critically assessed and validated prior to clinical adoption.

INTRODUCTION/BACKGROUND:Operating room air quality can be affected by several factors including temperature, humidity, and airborne particle burden. Our study examines the role of operating room (OR) size on air quality and airborne particle (ABP) count in primary total knee arthroplasty (TKA). MATERIALS AND METHODS/METHODS:We analyzed all primary, elective TKAs performed within two ORs measuring 278 sq ft. (small) and 501 sq ft. (large) at a single academic institution in the United States from April 2019 to June 2020. Intraoperative measurements of temperature, humidity, and ABP count were recorded. p values were calculated using t test for continuous variables and chi-square for categorical values. RESULTS:91 primary TKA cases were included in the study, with 21 (23.1%) in the small OR and 70 (76.9%) in the large OR. Between-groups comparisons revealed significant differences in relative humidity (small OR 38.5% ± 7.24% vs. large OR 44.4% ± 8.01%, p = 0.002). Significant percent decreases in ABP rates for particles measuring 2.5 μm (- 43.9%, p = 0.007) and 5.0 μm (- 69.0%, p = 0.0024) were found in the large OR. Total time spent in the OR was not significantly different between the two groups (small OR 153.09 ± 22.3 vs. large OR 173 ± 44.6, p = 0.05). CONCLUSIONS:Although total time spent in the room did not differ between the large and small OR, there were significant differences in humidity and ABP rates for particles measuring 2.5 μm and 5.0 μm, suggesting the filtration system encounters less particle burden in larger rooms. Larger studies are required to determine the impact this may have on OR sterility and infection rates.

INTRODUCTION/BACKGROUND:Round or oval implants are used in patellar resurfacing during total knee arthroplasty (TKA). However, whether component geometry affects clinical outcomes is unclear. This study aimed to determine if one implant shape conferred superior outcomes to the other. METHODS:A retrospective review of primary TKA cases performed from 2016 to 2020 was conducted at an urban, tertiary academic center. 400 consecutive, primary TKAs were included in these analyses. Cases were included if a surgeon used the round design then oval design for fifty consecutive cases. Baseline demographic data and radiographic measurements were assessed. Surgical data, reasons for revision, and patient reported outcome measures were analyzed. Independent samples t- and chi-squared tests were used to compare means and proportions. There were no demographic differences between the cohorts. RESULTS:Post-operative patellar tilt was statistically different between the cohorts. Sixteen patients required revision surgery; however, revision rates did not differ between cohorts. Of the nine round, one button was revised for infection. Of the seven oval, one button was revised for infection and one for loosening. Veterans RAND 12 Physical Component Score at three-months postoperatively was higher for the round cohort, but no differences were observed at one-year. CONCLUSION/CONCLUSIONS:While radiographic patellar tilt was significantly different between the cohorts, there was no clinical correlation in outcomes at three-months or one-year postoperatively. Longer-term follow-up studies are needed to evaluate the implications of patellar component design on outcomes and function. Nevertheless, the current study affirms that both designs are clinically equivalent which should be used to guide clinical decision-making.

BACKGROUND:Over the past decade, reimbursement models and target payments have been modified in an effort to decrease costs of revision total knee arthroplasty (rTKA) while maintaining the quality of care. The goal of this study was to investigate trends in revenue and costs associated with rTKA. METHODS:We retrospectively reviewed all patients who underwent rTKA between 2011 and 2021 at our institution. Patients were stratified into groups based on insurance coverage: Medicare, government-managed or Medicaid (GMM), or commercial insurance. Patient demographics were collected, as well as revenue, costs, and contribution margin (CM) of the inpatient episode. Changes over time as a percentage of 2011 numbers were analyzed. Linear regressions were used to determine trend significance. In the 10-year study period, 1,698 patients were identified with complete financial data. RESULTS:Overall total cost has increased significantly (P < .01). While revenues and CM for Medicare and Commercial patients remained steady between 2011 and 2021, CM for GMM patients decreased significantly (P = .01) to a low of 53.2% of the 2011 values. Since 2018, overall CM and revenues decreased significantly (P = .05, P = .01, respectively). CONCLUSION/CONCLUSIONS:While from 2011 to 2018 general revenues and CM were relatively steady, since 2018 they have decreased significantly to their lowest values in over a decade for GMM and commercial patients. This trend is concerning and may potentially lead to decreased access to care. Re-evaluation of reimbursement models for rTKA may be necessary to ensure the financial viability of this procedure and prevent issues with access to care. LEVEL OF EVIDENCE/METHODS:III.

BACKGROUND:Revision total hip arthroplasty (rTHA) is a costly procedure, and its prevalence has been steadily increasing over time. This study aimed to examine trends in hospital cost, revenue, and contribution margin (CM) in patients undergoing rTHA. METHODS:We retrospectively reviewed all patients who underwent rTHA from June 2011 to May 2021 at our institution. Patients were stratified into groups based on insurance coverage: Medicare, government-managed Medicaid, or commercial insurance. Patient demographics, revenue (any payment the hospital received), direct cost (any cost associated with the surgery and hospitalization), total cost (the sum of direct and indirect costs), and CM (the difference between revenue and direct cost) were collected. Changes over time as a percentage of 2011 numbers were analyzed. Linear regression analyses were used to determine the overall trend's significance. Of the 1,613 patients identified, 661 were covered by Medicare, 449 by government-managed Medicaid, and 503 by commercial insurance plans. RESULTS:Medicare patients exhibited a significant upward trend in revenue (P < .001), total cost (P = .004), direct cost (P < .001), and an overall downward trend in CM (P = .037), with CM for these patients falling to 72.1% of 2011 values by 2021. CONCLUSION/CONCLUSIONS:In the Medicare population, reimbursement for rTHA has not matched increases in cost, leading to considerable reductions in CM. These trends affect the ability of hospitals to cover indirect costs, threatening access to care for patients who require this necessary procedure. Reimbursement models for rTHA should be reconsidered to ensure the financial feasibility of these procedures for all patient populations.

BACKGROUND:Prior research has demonstrated that the prescription of opioid medications may be associated with the desire to treat pain in order to achieve favorable patient satisfaction. The purpose of the current study was to investigate the effect of decreased opioid prescribing following total knee arthroplasty (TKA) on survey-administered patient satisfaction scores. METHOD/METHODS:This study is a retrospective review of prospectively collected survey data for patients who underwent primary elective TKA for the treatment of osteoarthritis (OA) between September 2014 and June 2019. All patients included had completed Hospital Consumer Assessment of Healthcare Providers and Systems (HCAPS) survey information. Patients were stratified into two cohorts based on whether their surgery took place prior to or subsequent to the implementation of an institutional-wide opioid-sparing regimen. RESULTS:Of the 613 patients included, 488 (80%) were in the pre-protocol cohort and 125 (20%) in the post-protocol cohort. Rate of opioid refills (33.6% to 11.2%; p < 0.001) as well as length of stay (LOS, 2.40 ± 1.05 to 2.13 ± 1.13 days; p = 0.014) decreased significantly after protocol change while rate of current smokers increased significantly (4.1% to 10.4%; p = 0.011). No significant difference was observed in "top box" percentages for satisfaction with pain control (Pre: 70.5% vs Post: 72.8%; p = 0.775). CONCLUSIONS:Protocols calling for reduced prescription of opioids following TKA resulted in significantly lower rates of opioid refills, and were associated with significantly shorter LOS, while causing no statistically significant deleterious changes in patient satisfaction, as measured by HCAPS survey. LOE: III. CLINICAL RELEVANCE/CONCLUSIONS:This study suggests that HCAPS scores are not negatively impacted by a reduction in postoperative opioid analgesics.

» Chronic lower back pain (LBP) is common in both nonathletes and weight lifters, but the diagnosis and treatment should be approached differently in these 2 populations based on the unique movement patterns causing the pain.» Injury rates of weight lifters are far less than those of contact sports, ranging from 1.0 to 4.4 injuries per 1,000 workout hours. However, the lower back was consistently one of the top 2 injury sites for weight lifters, accounting for anywhere from 23% to 59% of all injuries. LBP was most often associated with the squat or deadlift.» Guidelines for evaluating general LBP are applicable to weight lifters, including a thorough history and physical examination. However, the differential diagnosis will change based on the patient's lifting history. Of the many etiologies of back pain, weight lifters are most likely to be diagnosed with muscle strain or ligamentous sprain, degenerative disk disease, disk herniation, spondylolysis, spondylolisthesis, or lumbar facet syndrome.» Traditional recommended therapies include nonsteroidal anti-inflammatory drugs, physical therapy, and activity modification, which are often insufficient to resolve pain and prevent injury recurrence. Because most athletes will want to continue to lift weights, lifting-specific behavior modifications focused on improved technique and correcting mobility and muscular imbalances are important aspects of management in this patient population.