Jordan Eskenazi

Purpose: To investigate the relationship between postoperative activity levels, measured via a smartphone application, and the incidence of iliopsoas tendinitis (IPT) following hip arthroscopy for femoroacetabular impingement syndrome (FAIS). We hypothesized that lower postoperative activity levels across the monitored 12-week period would be associated with increased IPT risk. Methods: This prospective cohort study enrolled patients undergoing hip arthroscopy for femoroacetabular impingement syndrome (FAIS) from June 2022 to February 2023. Average weekly step counts across the 12-week postoperative monitoring period were tracked via a smartphone application. Patients were stratified into IPT and non-IPT groups, and preoperative and postoperative outcomes, including the modified Harris Hip Score (mHHS), Nonarthritic Hip Score (NAHS), and Visual Analog Scale (VAS), were compared. Activity levels were categorized into low, moderate, and high groups based on percentile distributions. Results: A total of 54 patients (mean age 37.8 ± 11.6 years, 59.3% female) were included, with 16 (29.6%) developing IPT at an average of 2.5 ± 1.2 months postoperatively. IPT patients had lower preoperative mHHS (62.2 vs. 74.9, p = 0.026) and NAHS (53.9 vs. 66.9, p = 0.023), and greater pain (VAS 6.3 vs. 5.0, p = 0.054). Mean weekly step counts were lower in the IPT group in every postoperative week, reaching statistical significance at Weeks 3 and 12 (p = 0.042 and p = 0.012). In penalized regression adjusted for preoperative mHHS and age, each additional 1000 steps per day during Weeks 1–3 was associated with lower odds of IPT (OR 0.63, 95% CI 0.32 to 0.98, p = 0.037); associations for later periods were in the same direction but did not reach statistical significance (Weeks 10–12: OR 0.89, 95% CI 0.66 to 1.10, p = 0.29). Functional improvements at 3 months did not differ between groups. Conclusions: Lower postoperative step counts were associated with a higher risk of IPT development, with the most robust association observed in the immediate postoperative period (Weeks 1–3), highlighting the potential importance of monitored, progressive rehabilitation following hip arthroscopy. These findings are exploratory and hypothesis-generating and require prospective interventional validation.

Since the introduction of large language models (LLMs) such as ChatGPT, there has been a race to test its capability in medical problem solving across specialties to varying degrees of success. Retrieval augmented generation (RAG) allows LLMs to leverage subject specific knowledge to provide context, a greater number of sources, and the ability to cite medical literature to increase the accuracy and credibility of its answers. The use of LLM + RAG has not yet been used in the appraisal of artificial intelligence’s capability of orthopedic problem solving. The purpose of this study is to assess the performance of ChatGPT + RAG against the performance of ChatGPT without RAG as well as against humans on orthopedic examination assessment questions. The American Academy of Orthopaedic Surgeons (AAOS) OrthoWizard question bank was used as the source of questions. After 13 textbooks and 28 clinical guidelines were made available for RAG, text-only multiple-choice questions were presented in a zero-shot learning fashion to ChatGPT-4 + RAG, ChatGPT-4, and ChatGPT-3.5. On 1,023 questions tested, ChatGPT-3.5, ChatGPT-4, ChatGPT-4+RAG, and humans scored 52.98%, 64.91%, 73.80%, and 73.97%, respectively. There was no statistical difference between orthopedic surgeons and ChatGPT-4 + RAG on overall accuracy (P>0.99). Both orthopedic surgeons and ChatGPT4 + RAG scored better than ChatGPT-4 (P<0.001) and ChatGPT-3.5 (P<0.001). Of the 13 textbooks available to RAG, RAG used AAOS Comprehensive Review 3 Volume 3 for 39.6% of questions, more often than any other resource available to it. ChatGPT-4 + RAG was able to answer 1,023 questions from the OrthoWizard question bank at the same accuracy as Orthopedic surgeons. Both ChatGPT-4 + RAG and orthopedic surgeons had superior accuracy on these specialty exam questions compared to ChatGPT-4 and ChatGPT-3.5. Artificial intelligence is becoming increasingly accurate in its ability to answer orthopaedic surgery test questions with the guidance of orthopaedic surgery textbooks. RAG enables an LLM to effectively cite its sources after providing an answer to a question, which is an important tool for the integration of LLMs to orthopaedic surgery education and can function as a valuable tool for anyone studying for an orthopedic examination.

The purpose of this work was to provide a simple method to determine reactive strength during the 6-meter timed hop test (6mTH) and evaluate its association with isokinetic peak torque in patients following anterior cruciate ligament reconstruction (ACLR). Twenty-nine ACLR patients who were at least four months from surgery were included in this analysis. Participants were brought into the laboratory on one occasion to complete functional testing. Quadriceps and hamstring isokinetic testing was completed bilaterally at 60, 180, and 300 deg∙s^-1, using extension peak torque from each speed as the outcome measure. The 6mTH was completed bilaterally using a marker-based motion capture system, and reactive strength ratio (RSR) was calculated from the vertical velocity of the pelvis during the test. An adjustment in RSR was made using the velocity of the 6mTH test to account for different strategies employed across participants. Repeated measures correlations were used to determine associations among isokinetic and hop testing variables. A two-way mixed analysis of variance was used to determine differences in isokinetic and hop testing variables between operated and non-operated legs and across male and female participants. Moderate positive associations were found between RSR (and adjusted RSR) and isokinetic peak torque at all speeds (r = .527 to .577). Mean comparisons showed significant main effects for leg and sex. Patients showed significant deficits in their operated versus non-operated legs in all isokinetic and hop testing variables, yet only isokinetic peak torque and timed hop time showed significant differences across male and female groups. Preliminary results are promising but further development is needed to validate other accessible technologies available to calculate reactive strength during functional testing after ACLR. Pending these developments, the effects of movement strategies, demographics, and levels of participation on RSR can then be explored to translate this simple method to clinical environments.

Purpose: To investigate the rate of return to sports and sport psychological readiness between patients who underwent isolated MPFLR (iMPFLR) compared to a matched cohort of patients who underwent MPFLR with anteromedializing tibial tubercle osteotomy (MPFLR/TTO).Methods: Patients who underwent primary MPFLR with or without TTO for recurrent patellar instability were retrospectively reviewed from 2012 to 2020 at a single institution. Preinjury sport and work information, Kujala, Tegner, Visual Analogue Score for pain, satisfaction and MPFL‐Return to Sport after Injury (MPFL‐RSI) score were collected. Two readers independently measured the tibial tuberosity‐trochlear groove distance, Caton–Deschamps index and Dejour classification for trochlear dysplasia. Patients in iMPFLR and MPFLR/TTO groups were matched 1:1 on age, sex, body mass index and follow‐up length. Multivariate regression analysis was performed to determine whether the MPFL‐RSI was associated with a return to sport.Results: This study included 74 patients at mean follow‐up of 52.5 months (range: 24–117). These groups returned to sport at similar rates (iMPFLR: 67.6%, MPFLR/TTO: 73.0%, not significant [ns]), though iMPFLR patients returned more quickly (8.4 vs. 12.8 months, p = 0.019). Rates of return to preinjury sport level were also similar (45.9% vs. 40.5%, ns). Patients with Dejour B/C took more time to return to sport compared to patients with mild/no trochlear pathology (13.8 vs. 7.9 months, p = 0.003). Increasing MPFL‐RSI score was significantly predictive of the overall return to sport (odds ratio [OR]: 1.08, 95% confidence interval [CI] [1.03, 1.13], p < 0.001) and return to preinjury level (OR: 1.07, 95% CI [1.04, 1.13], p < 0.001). Most patients in iMPFLR and MPFLR/TTO groups resumed work (95.7% vs. 88.5%, ns), though iMPFLR patients who returned to preinjury work levels did so more quickly (1.7 vs. 4.6 months, p = 0.005).Conclusion: Patients who underwent MPFLR with anteromedializing TTO demonstrated similar rates of return to sport and psychological readiness compared to an isolated MPFLR matched comparison group, though iMPFLRs returned more quickly. Patients with more severe trochlear pathology required more time to return to sports.Level of Evidence: Level III.

Objective: To evaluate the effect of fear of reinjury on return to sport (RTS), return to work (RTW), and clinical outcomes following autologous chondrocyte implantation (ACI). Design: A retrospective review of patients who underwent ACI with a minimum of 2 years in clinical follow-up was conducted. Patient-reported outcomes collected included the Visual Analog Scale (VAS) and Knee Injury and Osteoarthritis Outcome Score (KOOS). Kinesiophobia and pain catastrophizing was assessed using the Tampa Scale of Kinesiophobia-11 (TSK-11) and Pain Catastrophizing Scale (PCS), respectively. Patients were surveyed on their RTS and RTW status. Results: Fifty-seven patients (50.9% female) were included in our analysis. Twenty-two (38.6%) patients did not RTS. Of the 35 patients (61.4%) who returned, nearly half (48.6%) returned at a lower level of play. TSK-11 ( P = 0.003), PCS ( P = 0.001), and VAS pain scores ( P < 0.001) were significantly greater in patients that did not RTS than in those who returned. All KOOS subscores analyzed were significantly lower ( P < 0.001) in patients that did not RTS than in those who returned at the same level or higher. Of the 44 (77.2%) patients previously employed, 97.7% returned to work. Increasing TSK-11 scores were associated with lower odds of returning to sport ( P = 0.003). Conclusion: Fear of reinjury decreases the likelihood that patients will return to sport after ACI. Patients that do not return to sport report significantly greater levels of fear of reinjury and pain catastrophizing and lower clinical knee outcomes. Nearly all patients were able to return to work after surgery. Level of Evidence: IV case series.

Objectives: Return to preinjury function in work and sport is dependent on both postoperative physical function and psychological readiness. Kinesiophobia has been studied following various orthopedic surgeries, but data remains scant in patients undergoing cartilage restoration procedures. The purpose of our investigation is to evaluate the effect of fear of reinjury on return to sport (RTS), return to work (RTW), and clinical outcomes following autologous chondrocyte implantation. Methods: A retrospective review of patients who underwent autologous chondrocyte implantation (ACI) and matrix-associated autologous chondrocyte implantation (MACI) at a single institution between 2012 – 2020 with a minimum of 2 year clinical follow-up was conducted. Patient-reported outcomes were measured using the Visual Analog Scale (VAS) for pain and satisfaction and the Knee Injury and Osteoarthritis Outcome Score (KOOS; subscores: symptoms, pain, sport, and quality of life (QOL)). Kinesiophobia was assessed using the Tampa Scale of Kinesiophobia-11 (TSK-11). The Pain Catastrophizing Scale (PCS) was used to analyze individuals’ response to pain. T-tests or non-parametric tests and Chi-squared tests were used to analyze continuous variables and categorical variables, respectively. A one-way ANOVA was used to compare outcomes based on RTS status, using a post-hoc Tukey’s HSD test for multiple comparisons. Logistic regression controlling for age, sex, and BMI was used to determine if TSK-11 scores is predictive of RTS. Results: Forty-nine patients, mainly male (55.1%) aged 29.35 (± 6.28) with a mean follow-up of 5.7 ± 3.2 years were included in our analysis. Sixteen patients (32.7%) did not RTS. Of the 33 patients (67.3%) who returned to sport, 16 (32.7%) returned at their preoperative level or higher, and 17 (34.7%) returned at a lower level. TSK-11 scores (26.44 vs. 20.62, p=0.019) and VAS pain scores (47.94 vs. 6.88, p<0.001) were significantly greater in patients that that did not return to sport compared to those who return at the same level or higher. All KOOS subscores (Symptom: 59.69 vs. 85.62, Pain: 71.35 vs. 94.97, Sports: 37.19 vs. 86.56, QOL: 29.69 vs. 82.42, p <0.001) were significantly lower in patients who did not RTS compared to those who returned at the same level or higher. Patients who returned to sport, but at a lower level, had significantly greater KOOS-QOL (58.82 vs. 29.69, p<0.001) and KOOS-pain subscores (89.22 vs. 71.35, p6 months postoperatively. Conclusions: Fear of reinjury decreases the likelihood that patients will return to preinjury level of sport or higher after autologous chondrocyte implantation. Those who did not return to work had significantly worse KOOS scores. [Table: see text]

Objectives: Prior studies report lower return to preinjury level of sport in patients who undergo bilateral anterior cruciate ligament (ACL) reconstructions compared to unilateral reconstructions, with the most common cited reason being fear of reinjury. The purpose of our investigation was to compare subsequent return rates and psychological readiness to return to sport (RTS) in patients who underwent bilateral versus unilateral ACL reconstructions. Methods: A retrospective review of patients who underwent ACL reconstruction at a single academic institution between 2012-2021 with a minimum of 1-year follow-up was conducted. Patients were divided into bilateral and unilateral cohorts. Those who underwent bilateral ACL reconstruction were matched 1:3 to unilateral reconstruction based on age, sex, BMI, and primary sport. Primary outcomes included return to sport, level of RTS and psychological readiness to RTS, assessed by the validated ACL- Return to Sport after Injury (ACL-RSI) scale. Within the ACL-RSI questionnaire, fear and confidence to return to sport were specifically analyzed. Fear to RTS was measured on a scale of 0-100 with 0 equal to extremely fearful and 100 equal to no fear at all. Confidence to RTS was measured on a scale of 0-100 with 0 equal to not at all confidence and 100 equal to fully confident. Statistical analysis was performed in R studio, with chi-square used for categorical values and two-sided t-test for continuous. Results: One hundred eighty-one patients were included, forty-three bilateral ACL reconstructions and one hundred thirty-eight unilateral. The unilateral cohort included 69 (50.0%) males and 69 (50.0%) females and the bilateral cohort included 22 (51.2%) males and 21 (48.8%) females. Mean age was 26.0 (14-56) in the unilateral cohort and 25.2 (14-50) in the bilateral cohort. Mean BMI was 25 (15.3-39.2) in the unilateral cohort and 28 (15.1-39.7[SM1] ) in the bilateral cohorts (p=.08). The percentage of individuals who returned to sport in the bilateral reconstruction cohort was not significantly different from those who returned in the unilateral cohort (79.6% vs 76.7%, p=0.85). There was no significant difference in psychological readiness to RTS (mean score 52.6 for bilateral and 47.4 for unilateral, p=0.31). There was also no significant difference between the level at which bilateral versus unilateral patients returned to sport. 59.6% unilateral returned to the same or higher level and 60.6% bilateral returned to the same or higher level, p=0.92. There was no significant difference in the reported scale of psychological readiness to return to sport (52.6 for bilateral and 47.4 for unilateral, p=0.31). When asked about fear to RTS, the mean scale response was 42.2 in the unilateral cohort and 46.5 in the bilateral (p=0.45). Conclusions: There is no difference in RTS and level of sport returned to between patients who undergo bilateral ACL reconstructions compared to patients who undergo unilateral ACL reconstructions. Psychological readiness, fear and confidence to return to sport were not different between unilateral and bilateral injuries.