Ulrich, Marisa N.

Study Design: Retrospective. Objective: To examine the long-term perioperative changes in lumbar bone quality, paraspinal muscle size and fat content, and facet degeneration after hemipelvectomy (HP) and hip disarticulation (HD). Summary of Background Data: Emerging evidence shows that transfemoral (TFA) and transtibial (TTA) amputations may accelerate lumbar modic changes and precipitate axial back pain. TFA and TTA amputation studies demonstrate that the severity of postamputation lower back pain is associated with the amputation type (TFA > TTA) and the degree of alteration in lumbopelvic kinematics. Methods: All patients who underwent HP or HD for malignancy or infection at an academic center between 2003 and 2022 were retrospectively identified. Preoperative to postoperative changes in multifidus, erector spinae, quadratus lumborum, and psoas cross-sectional area (CSA), and Hounsfield units (HU) were calculated on CT for the amputated and contralateral side at the level of the L3–4 disc space. Paired univariate analysis was utilized to compare preoperative and postoperative outcomes. Results: A total of 16 patients (8 HP, 8 HD) met the inclusion/exclusion criteria. The preoperative to postoperative changes in HUs in the L1, L3, and L5 vertebral bodies were −27.0 ( P =0.004), −51.5 ( P =0.002), and −48.1 ( P =0.001), respectively. The decrease in L1 HU was greater for prosthesis nonusers (user: −16.50, nonuser: −51.32, P =0.021). L5–S1 segment facet degeneration increased postoperatively ( P =0.030, n=7 progressed). There were significant preoperative to postoperative changes in psoas CSA (preop: 1063.4, postop: 586.5, P =0.005) and psoas HU (preop: 50.95, postop: 33.55, P <0.001) on the amputated but not the contralateral side. Conclusion: Hind-quarter amputations were associated with decreased lumbar bone quality, progression of facet degeneration, and loss of amputated side psoas muscle tone. Daily prosthesis use was moderately protective for lumbar bone quality following amputation. HP but not HD was associated with postoperative loss of amputated side quadratus lumborum tone. Level of Evidence: Level III.

ABSTRACT Introduction The proximal tibia is a common location for bone tumors. Two contemporary reconstruction techniques for limb salvage are endoprosthetic replacement (EPR) and allograft‐prosthesis composite (APC). This study aimed to compare the long‐term oncologic and functional outcomes of EPR and APC reconstructions. Methods Thirty‐eight (19 APC and 19 EPR) patients underwent oncologic proximal tibia resection and reconstruction were reviewed. Patients undergoing APC reconstruction were younger than the EPR group (31 vs. 44 years, p = 0.049), and patients in the EPR group were more likely to have a diagnosis of metastatic disease (32% vs. 0%, p = 0.019). Results For all patients, the 10‐year disease‐specific survival was 63%. With death a competing risk, there was no difference in the 10‐year cumulative risk of failure (41% vs. 26%, p = 0.171) or amputation (11% vs. 19%, p = 0.690) between APC or EPR. There was no difference comparing EPR to APC in the proportion of patients with an extensor lag > 10° (42% vs. 26%, p = 0.495) or 10‐year knee society scores (85 vs. 85, p = 0.710). Conclusion EPR and APC have a similar complication profile and functional outcomes following proximal tibial resection and reconstruction.

Background: We aimed to develop automated data extraction pipelines with large language models (LLMs) to extract registry data from total hip arthroplasty (THA) operative notes and compare the performance with that of existing natural language processing (NLP) algorithms. Methods: We randomly sampled 1,000 primary THA cases from our institutional registry. Two human annotators manually reviewed each operative note for 3 data points: surgical approach, bearing surface, and fixation technique. All labeled THA notes were split into the development set (n = 239) and the testing set (n = 719). We developed a custom data extraction pipeline for each data point by combining an iteratively customized prompt with an LLM. The performance was compared with that of existing rules-based NLP algorithms. Results: The accuracy of LLMs was superior to that of NLP algorithms for all data points: surgical approach (96% compared with 94%), bearing surface (89% compared with 74%), and fixation technique (96% compared with 95%). Furthermore, the LLM accurately inferred the bearing surface for 80% of the notes that were ambiguous about the bearing surface. Conclusions: We developed LLM pipelines for extracting 3 registry-relevant data points from THA operative notes, demonstrating superior performance to existing NLP algorithms. Clinical Relevance: LLMs have the potential to impact clinical care, including the evaluation of electronic medical record free-text data. As registries serve as a cornerstone of orthopaedic evidence, this work demonstrates promise for LLMs to simplify, improve, and democratize the construction of registry databases from operative notes.

Abstract As artificial intelligence (AI) Large Language Models (LLM) like ChatGPT become more common in healthcare, patients increasingly use them to find medical information. While ChatGPT may support health literacy, its readability and accuracy compared to established resources remain unclear. The purpose of this study is to evaluate ChatGPT-4 responses on femoroacetabular impingement (FAI) and its surgical management compared to AAOS OrthoInfo content. We hypothesize that ChatGPT may deliver medically accurate information, but its readability may fall short when compared to OrthoInfo. Nine questions based on the OrthoInfo FAI page were submitted to ChatGPT-4, with and without a readability prompt. Topics included anatomy, pathology, cause, symptoms, workup, imaging, treatment, role of hip arthroscopy, and outcomes. Readability was assessed using validated indices. Accuracy was independently rated using a 4-point scale. Statistical comparisons were made using t-tests and ANOVA (P &lt; 0.01 threshold). OrthoInfo content had a mean reading grade level of 8.0 and a Flesch Reading Ease score of 60.7. Unprompted ChatGPT responses were significantly less readable (grade level 16.2; Flesch score 21.7; P &lt; 0.001). Prompting for readability improved ChatGPT outputs (grade level 10.6; Flesch score 58.2), making them comparable to OrthoInfo (P &lt; 0.09). Accuracy was high across all sources, though OrthoInfo's response on FAI causes scored slightly lower (3.5 versus 4.0; P &lt; 0.46). ChatGPT provides accurate information on FAI. However, without prompting, its complexity may hinder patient understanding. Prompting for readability enables ChatGPT to match established resources like OrthoInfo. Tailored prompting is key to using LLM effectively in patient education and promoting health literacy.

As artificial intelligence (AI) advances in healthcare, encompassing robust applications for the diagnosis and prognostication of musculoskeletal diseases, clinicians must increasingly understand the implications of machine learning and deep learning in their practice. This review article explores computer vision algorithms and patient-specific, multimodal prediction models; provides a simple framework to guide discussion on the limitations of AI model development; and introduces the field of generative AI.

ABSTRACTBackgroundGlenohumeral arthrodesis is a demanding surgical procedure. However, it is an option for reconstruction an oncologic resection, especially for patients in whom the axillary nerve is compromised.MethodsWe reviewed 26 (12 male:14 female) glenohumeral arthrodeses (14 primary:12 revision) following an oncologic resection. The most common method of reconstruction was a free vascularized fibula autograft with a bulk allograft (n = 18). The median follow‐up was 22 years (IQR 19 years).ResultsMedian Musculoskeletal Tumor Society Scores and Toronto Extremity Salvage Scores at final follow‐up were 86% and 80%. MSTS scores were similar in patients receiving arthrodesis for primary versus secondary reconstruction. Fifteen (58%) patients had postoperative complications requiring reoperation. Most reoperations occurred with‐in the first 5 years postoperative, with two procedures occurring after 10‐years. Three patients were diagnosed with metastatic disease, one of which also had a local recurrence.ConclusionGlenohumeral arthrodesis provides satisfactory long‐term outcomes for primary and secondary management of shoulder girdle tumors. While early complication rates were high, long‐term complications were rare.

Abstract Shoulder arthroscopy is a versatile method for treating a variety of shoulder pathologies in a minimally invasive manner. Typically, it is performed with the patient positioned in a beach‐chair or lateral decubitus position with the latter being conventionally preferred for shoulder instability work given the use of traction and creation of a distracted joint. This allows ideal visualization and accessibility of the anterior, inferior, and posterior aspects of the glenoid, labrum, and axillary pouch. Despite the apparent advantages, the lateral decubitus position comes with its own technical challenges. Many of these may stem from surgeon training, experience, and level of familiarity with the positioning and arthroscopic view. This Technical Note demonstrates a reproducible and teachable method for efficient and effective diagnostic shoulder arthroscopy in the lateral decubitus position, along with presenting its associated advantages and disadvantages. Technique Video video See video under supplementary data.

Abstract A broad range of shoulder pathologies are treated with shoulder arthroscopy due to its minimally invasive nature. Mastering the fundamentals is critical for high‐quality care; this includes patient positioning. Surgeons must consider the advantages and disadvantages of the 2 most prominent patient positions: lateral decubitus and beach chair. The beach‐chair position offers an intuitive anatomic view with the advantage of shoulder maneuverability. Understanding the associated pitfalls related to patient hemodynamics; head, neck, and shoulder positioning; and protection of bony prominences can guide the operative care team to obtaining a safe position for the patient. The purpose of this Technical Note and video is to present and demonstrate a reproducible and teachable method for safely positioning a patient in the beach‐chair position for shoulder arthroscopy, as well as to describe the associated advantages and disadvantages. Technique Video video See video under supplementary data.

Abstract Shoulder arthroscopy is one of the most common orthopaedic procedures. Since its introduction in the 1970s, significant advances have been made in surgical techniques and instrumentation. Shoulder arthroscopy is often performed in either the beach‐chair or lateral decubitus position, and each positioning technique has its own benefits. In this work, we will describe the history of lateral decubitus positioning for shoulder arthroscopy. We outline a detailed guide for safe and consistent lateral decubitus positioning, and key steps of lateral decubitus positioning will be emphasized. Pearls, pitfalls, advantages, and disadvantages of this positioning technique will also be discussed. With appropriate technique, lateral decubitus positioning is safe and effective for arthroscopic treatment of various shoulder pathologies. Technique Video video See video under supplementary data.

Abstract Shoulder arthroscopy is a popular modality for the treatment of shoulder pathology. Since its advent in the 1970s, significant advancements have been made in both technology and technique. Shoulder arthroscopy is performed in either the beach‐chair or lateral decubitus positions, and each position has its unique benefits and considerations. Beach‐chair positioning, initially described in the 1980s, has become the preferred method of positioning for most arthroscopic procedures. In this work, we describe the history of beach‐chair positioning for shoulder arthroscopy. We outline a reproducible and teachable method for consistent and comprehensive diagnostic arthroscopy in the beach‐chair position. Pearls, pitfalls, advantages, and disadvantages of diagnostic arthroscopy in this position are discussed. When properly executed, diagnostic arthroscopy in the beach‐chair position can effectively identify and characterize intra‐articular shoulder pathologies. Technique Video video See video under supplementary data.