Can ChatGPT Answer Patient Questions Regarding Total Knee Arthroplasty?

The internet has introduced many resources frequently accessed by patients prior to orthopaedic visits. Recently, Chat Generative Pre-Trained Transformer, an artificial intelligence-based chat application, has become publicly and freely available. The interface uses deep learning technology to mimic human interaction and provide convincing answers to questions posed by users. With its rapidly expanding usership, it is reasonable to assume that patients will soon use this technology for preoperative education. Therefore, we sought to determine the accuracy of answers to frequently asked questions (FAQs) pertaining to total knee arthroplasty (TKA).Ten FAQs were posed to the chatbot during a single online interaction with no follow-up questions or repetition. All 10 FAQs were analyzed for accuracy using an evidence-based approach. Answers were then rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."Of the 10 answers given by the chatbot, none received an "unsatisfactory" rating with the majority either requiring minimal (5) or moderate (4) clarification. While many answers required nuanced clarification, overall, answers tended to be unbiased and evidence-based, even when presented with controversial subjects.The chatbot does an excellent job of providing basic, evidence-based answers to patient FAQs prior to TKA. These data were presented in a manner that will be easily comprehendible by most patients and may serve as a useful clinical adjunct in the future.

Assessing ChatGPT Responses to Common Patient Questions Regarding Total Hip Arthroplasty

BACKGROUND

The contemporary patient has access to numerous resources on common orthopaedic procedures before ever presenting for a clinical evaluation. Recently, artificial intelligence (AI)-driven chatbots have become mainstream, allowing patients to engage with interfaces that supply convincing, human-like responses to prompts. ChatGPT (OpenAI), a recently developed AI-based chat technology, is one such application that has garnered rapid growth in popularity. Given the likelihood that patients may soon call on this technology for preoperative education, we sought to determine whether ChatGPT could appropriately answer frequently asked questions regarding total hip arthroplasty (THA).

METHODS

Ten frequently asked questions regarding total hip arthroplasty were posed to the chatbot during a conversation thread, with no follow-up questions or repetition. Each response was analyzed for accuracy with use of an evidence-based approach. Responses were rated as "excellent response not requiring clarification," "satisfactory requiring minimal clarification," "satisfactory requiring moderate clarification," or "unsatisfactory requiring substantial clarification."

RESULTS

Of the responses given by the chatbot, only 1 received an "unsatisfactory" rating; 2 did not require any correction, and the majority required either minimal (4 of 10) or moderate (3 of 10) clarification. Although several responses required nuanced clarification, the chatbot's responses were generally unbiased and evidence-based, even for controversial topics.

CONCLUSIONS

The chatbot effectively provided evidence-based responses to questions commonly asked by patients prior to THA. The chatbot presented information in a way that most patients would be able to understand. This resource may serve as a valuable clinical tool for patient education and understanding prior to orthopaedic consultation in the future.

Is cement mantle thickness a primary cause of aseptic tibial loosening following primary total knee arthroplasty?

BACKGROUND

Aseptic tibial loosening following primary total knee replacement is one of the leading causes of long-term failure. Cement mantle thickness has been implicated as a source of aseptic tibial loosening. Therefore, the following study was designed to determine (1) what is the cement mantle thickness in patients that develop aseptic tibial loosening, and (2) is there a difference in cement mantle thickness based on the interface of failure?

METHOD

This retrospective cohort included 216 patients revised for aseptic tibial loosening. Patient demographics, operative data, and clinical outcomes were recorded. A preoperative radiographic assessment was performed to determine the interface of failure and the thickness of the cement mantle using the Knee Society Radiographic Evaluation System zones.

RESULTS

The average patient age was 65 years and body mass index was 33.7 kg/m². 203 patients demonstrated radiographic failure at the implant-cement interface and 13 patients demonstrated failure at the cement-bone interface. The average cement mantle thickness of each radiographic zone for the entire cohort on the AP and lateral views was 4.4 and 4.5 mm, respectively. The average cement mantle thickness of patients that developed failure at the implant-cement interface was significantly greater than patients that failed at the cement-bone interface in each radiographic zone (p < 0.001).

CONCLUSIONS

Patients that develop implant loosening at the cement-bone interface were noted to have a significantly decreased cement mantle compared to patients that failed at the implant-cement interface. Methods for decreasing tibial implant loosening should likely focus on improving the fixation at the implant-cement interface.

Do Corticosteroids Attenuate the Peri-Operative Acute Phase Response After Total Knee Arthroplasty?

BACKGROUND

Following tissue injury, the acute phase response (APR) functions to survive and then repair injured tissue. An exuberant APR, which can be evoked by total knee arthroplasty (TKA), results in a hyper-inflammatory state, leading to pain, nausea, venous thromboembolism, or potentially life-threatening complications. Here, we observed the effects of peri-operative dexamethasone on the APR following TKA by trending C-reactive protein (CRP, mg/L) and fibrinogen (mg/dL). We hypothesize that the anti-inflammatory effects of dexamethasone can attenuate the APR after TKA and will be associated with decreased post-operative pain and nausea.

METHODS

A retrospective case-control study was performed on 188 unilateral TKA procedures. The patients were divided into a group receiving dexamethasone (10 mg intra-operatively and on post-operative day [POD] 1) and a group receiving no corticosteroids. Post-operative CRP, fibrinogen, morphine equivalents, and anti-emetic doses were recorded.

RESULTS

Compared to the non-steroid group, patients receiving dexamethasone yielded a significantly decreased CRP on POD0 (5.5 vs 8.3), POD1 (11.8 vs 22.0), and POD2 (85.5 vs 148.9). A significant decrease in fibrinogen in patients receiving dexamethasone was seen on POD2 (460.0 vs 530.2). There was an increase in fibrinogen within the dexamethasone cohort at the 2-week visit (535.4 vs 488.9). Post-operative morphine equivalents administered were significantly decreased in patients receiving dexamethasone, but no difference in anti-emetic use was appreciated.

CONCLUSION

These data support the hypothesis that the APR following TKA can be attenuated pharmacologically by corticosteroids. Further studies are needed to determine whether the attenuation of the APR with the use of corticosteroids prevents complications following TKA.

Characterizing the Acute Phase Response in Healthy Patients Following Total Joint Arthroplasty: Predictable and Consistent

BACKGROUND

During surgery, trauma to musculoskeletal tissue induces a systemic reaction known as the acute phase response (APR). When excessive or prolonged, the APR has been implicated as an underlying cause of surgical complications. The purpose of this study was to determine the typical APR following total joint arthroplasty in a healthy population defined by the Charlson Comorbidity Index (CCI).

METHODS

This retrospective study identified 180 healthy patients (CCI < 2) who underwent total joint arthroplasty by a single surgeon for primary osteoarthritis from 2013 to 2015. Serial measurements of C-reactive protein (CRP) and fibrinogen were obtained preoperative, perioperative, and at 2 and 6 weeks postoperative.

RESULTS

Postoperative CRP peaked during the inpatient period and returned to baseline by 2 weeks. Fibrinogen peaked after CRP and returned to baseline by 6 weeks. Elevated preoperative CRP correlated with a more robust postoperative APR for both total hip arthroplasty and total knee arthroplasty, suggesting that a patient's preoperative inflammatory state correlates with the magnitude of the postoperative APR.

CONCLUSION

Measurement of preoperative acute phase reactants may provide an objective means to predict a patient's risk of postoperative dysregulation of the APR and complications.

Is intra-articular hyaluronic acid effective in treating osteoarthritis of the hip joint?

Hyaluronic acid (HA) injections are used to treat osteoarthritis of the hip but their efficacy has not been clearly established. The purpose of this meta-analysis was to determine the effect of HA injections on hip pain. There were twenty-three studies that met our criteria and the mean decrease in visual analog scores (VAS) was -1.97 (95% CL, 2.83 to -1.12, P<0.0001). However, the clinical relevance of this change is difficult to determine since the decrease in VAS was only -0.27 in the six randomized trials in the study and the duration of follow-up in most studies was less than six months. Multicenter randomized trials are needed to determine the true efficacy of HA injections in decreasing pain associated with hip osteoarthritis.

Which factors influence preservation of the osteonecrotic femoral head?

BACKGROUND

Although surgeons use many procedures to preserve the femoral head in patients with hip osteonecrosis, there is no consensus regarding the best procedure.

QUESTIONS/PURPOSES

We raised the following questions: (1) Is one surgical treatment preferred based on published data? (2) What are the rates of radiographic progression or conversion to THA after treatment of pre- and postcollapse hips? (3) Does lesion size in the femoral head influence progression? And (4) does the extent of involvement of the weightbearing surface of the femoral head influence outcome?

METHODS

We searched MEDLINE and Scopus for articles published between 1998 and 2010. We included only articles assessing an operative intervention for hip osteonecrosis and having a level of evidence of I to IV. We included 54 of the 488 reviewed manuscripts.

RESULTS

No procedure was superior to others. In pre- and postcollapse hips, 264 of 864 hips (31%) and 419 of 850 hips (49%), respectively, exhibited radiographic disease progression. There were lower failure rates when the lesion involved less than 15% of the femoral head or had a necrotic angle of less than 200° (14%-25%) and when the osteonecrotic lesion involved only the medial 1/3 of the weightbearing surface (4.6%).

CONCLUSIONS

The best treatment of precollapse lesions is difficult to determine due to the limitations of the available literature. However, the data suggest operative intervention prevents collapse of small lesions of the femoral head or when there is a limited amount of the weightbearing surface involved. Patients with head collapse have a high progression rate after a femoral head-saving procedure.

Immunodiagnosis of human granulocytic ehrlichiosis by using culture-derived human isolates

Human granulocytic ehrlichiosis (HGE) is an emerging infection caused by an Ehrlichia species closely related to Ehrlichia equi and Ehrlichia phagocytophila. Recent advances in the isolation and cultivation of this organism have allowed us to develop an immunofluorescence assay (IFA), enzyme immunoassay (EIA), and Western immunoblotting (WB) using HL-60 cell culture-derived human isolates. Antibody was detected in sera from culture-confirmed HGE patients by IFA and EIA, and these samples were reactive when analyzed by immunoblot analysis. HGE patient sera had high antibody titers and did not react with uninfected HL-60 cells. When IFA, EIA, and WB were used to analyze sera from healthy donors or those with a range of other disorders, including infections caused by Ehrlichia chaffeensis, Rickettsia rickettsii, and Coxiella burnetti, no significant cross-reactivity could be detected by EIA or immunoblot analysis with the exception of two of four serum samples from R. rickettsii-infected patients that were reactive by IFA only. Sera from HGE patients did not significantly cross-react in serologic tests for Borrelia burgdorferi. Using sera from patients previously enrolled in two clinical trials of treatment for early Lyme disease, we evaluated a two-step approach for estimation of the seroprevalence of antibodies reactive with the etiologic agent of HGE. On the basis of the immunoblot assay results for sera from culture-confirmed HGE patients, WB was used to confirm the specificity of the antibody detected by EIA and IFA. EIA was found to be superior to IFA in the ability to detect WB-confirmed antibodies to the HGE agent. When EIA and WB were used, 56 (19.9%) patients with early Lyme disease (n = 281) had either specific immunoglobulin M (IgM) or IgG antibodies; 38 patients (13.5%) had IgM only, 6 (2.1%) had IgG only, and 12 (4.3%) had both IgM and IgG. Therefore, Lyme disease patients are at high potential risk for exposure to Ehrlichia. Analysis by immunoblotting of serial samples from persons with culture-confirmed HGE or patients with Lyme disease and antibodies to the agent of HGE revealed a reproducible pattern of the immune response to specific antigens. These samples confirmed the importance of the 42- to 45-kDa antigens as early, persistent, and specific markers of HGE infection. Other significant immunogenic proteins appear at 20, 21, 28, 30, and 60 kDa. Use of the two-test method of screening by EIA and confirming the specificity by WB appears to offer a sound approach to the clinical immunodiagnosis of HGE.

Resistance to tick-borne spirochete challenge induced by Borrelia burgdorferi strains that differ in expression of outer surface proteins

Hamsters were immunized with thimerosal-killed Borrelia burgdorferi 297 or a mutant of 297 (M297) that lacks the 49-kb linear plasmid and expression of outer surface proteins A and B (OspA and OspB). Ixodes scapularis nymphs infected with either the B. burgdorferi sensu stricto strain 297 or JMNT, similar in OspA and OspB but differing in OspC expression, were used to evaluate protection. In a homologous challenge, 24 hamsters were vaccinated, 8 each with 297 or M297 and 8 sham (adjuvant)-vaccinated controls. Hamsters vaccinated with either bacterin were completely protected against a natural tick bite or subcutaneous (s.c.) inoculation of 297. Borreliae were effectively eliminated from 80 to 90% of the 297-infected ticks that fed on four hamsters immunized with the 297 bacterin. Cultures of spirochetes isolated from the ticks that remained infected were infectious and induced joint inflammation in naive hamsters. There was no reduction of strain 297 spirochetes in ticks that fed on four hamsters immunized with M297, but the hamsters were protected. Results with the M297 bacterin indicate that proteins other than OspA or OspB can protect hamsters against a tick challenge without eliminating B. burgdorferi in the tick. In a heterologous challenge, 36 hamsters were vaccinated, 12 with each bacterin and 12 controls. None of the hamsters immunized with either bacterin were protected from a challenge involving JMNT-infected ticks, while two of four were protected against an s.c. challenge. Hamsters challenged s.c. with strain 297 spirochetes were protected. There was partial elimination of JMNT spirochetes in ticks that fed on the group of four hamsters immunized with the 297 bacterin, and infection rates were reduced by 50 to 60%. JMNT spirochetes reisolated from the ticks that fed on 297-vaccinated hamsters also remained infectious for hamsters. In the JMNT-infected ticks that fed on four M297-immunized hamsters, there was no decline in the proportion of infected ticks. Destruction of spirochetes in ticks that fed on the hamsters vaccinated with the 297 bacterin suggests that antibodies to OspA and OspB may have been responsible, since the mutant did not induce this activity.

Immunoblot interpretation criteria for serodiagnosis of early Lyme disease

We monitored the antibody responses of 55 treated patients with early Lyme disease and physician-documented erythema migrans. Six sequential serum samples were obtained from patients before, during, and until one year after antibiotic therapy and analyzed by in-house enzyme-linked immunosorbent (ELISA) and immunoblot assays. An immunoblot procedure utilizing a gradient gel and an image analysis system was developed. A relational database management system was used to analyze the results and provide criteria for early disease immunoblot interpretation. Recommended criteria for the immunoglobulin M (IgM) immunoblot are the recognition of two of three proteins (24, 39, and 41 kDa). The recommended criteria for a positive IgG immunoblot are the recognition of two of five proteins (20, 24 [> 19 intensity units], 35, 39, and 88 kDa). Alternatively, if band intensity cannot be measured, the 22-kDa protein can be substituted for the 24-kDa protein with only a small decrease in sensitivity. Monoclonal antibodies were used to identify all these proteins except the 35-kDa protein. With the proposed immunoblot interpretations, the sequential serum samples were examined. At visit 1, the day of diagnosis and initiation of treatment, 54.5% of the serum samples were either IgM or IgG positive. The peak antibody response, with 80% of the serum samples positive, occurred at visit 2, 8 to 12 days into treatment. The sensitivities of the IgM and IgG immunoblot for detecting patients that were seropositive into the study period were 58.5 and 54.6%, respectively, at visit 1 and 100% at visit 2. Twenty percent of the patients remained seronegative throughout the study. The specificities of the IgM and IgG immunoblots were 92 to 94% and 93 to 96%, respectively. The IgM immunoblot and ELISA were similar in sensitivities, whereas the IgG immunoblot had greater sensitivity than the IgG ELISA (P = 0.006).

Protective immunity is induced by a Borrelia burgdorferi mutant that lacks OspA and OspB

A mutant of virulent Borrelia burgdorferi 297 was apparently selected for by long-term storage at 5 degrees C. This mutant was found to lack the plasmid which encodes outer surface protein A (OspA) and OspB. In addition to the loss of the OspA and OspB proteins, the mutant lacked two lipoproteins, of 20 and 7.5 kDa, that were observed in the wild type. Since the mutant was not recovered from the tissues or blood of hamsters injected with the mutant, the mutant was determined to be noninfectious. Hamsters vaccinated with noninfectious mutant 297 were protected completely from challenge with virulent wild-type 297 spirochetes. Prechallenge sera from hamsters vaccinated with mutant 297 lacked antibodies to OspA and OspB, while those from hamsters vaccinated with virulent wild-type 297 or avirulent 297 exhibited antibodies to these proteins. Hamsters vaccinated with virulent wild-type 297 or mutant 297 elicited antibodies to OspC and a 39-kDa protein (P39), whereas hamsters vaccinated with avirulent 297 lacked these antibodies. These results suggest that OspC and/or P39 are important for the development of a protective immune response. Study of this mutant may elucidate factors important to the development of a Lyme disease vaccine.

Isolation and characterization of Borrelia burgdorferi from blood of a bird captured in the Saint Croix River Valley

Field investigations were conducted to further evaluate the role of birds in the maintenance and dissemination of Borrelia burgdorferi. Blood specimens were taken from 39 passerine birds of 17 species captured during June 1991 at the Saint Croix National Riverway in Wisconsin, and one isolate, WI91-23, was cultured from an adult song sparrow (Melospiza melodia). This isolate was shown to be infectious for Peromyscus leucopus and Mesocricetus auratus (golden hamster). Isolate WI91-23 was confirmed as B. burgdorferi by immunofluorescence assay by using species-specific anti-OspA monoclonal antibodies H3TS and H5332 and anti-OspB antibody H5TS. Isolate WI91-23 was compared with Borrelia anserina Es, Borrelia hermsii MAN-1, and other B. burgdorferi strains (ATCC 53210, CT-1, and Catharus fuscescens [veery] liver 10293). Pulsed-field gel electrophoresis of in situ-lysed spirochetes revealed that the DNA plasmid profile of WI91-23 was most similar to those of plasmids from B. burgdorferi and most different from those of plasmids from B. anserina and B. hermsii. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis analysis indicated that the protein profile of WI91-23 was like that of other B. burgdorferi strains studied, with dominant proteins corresponding to OspA and OspB, and that it differed from the protein profiles of B. anserina and B. hermsii. These findings indicate that passerine birds may serve as reservoirs for B. burgdorferi.