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BackgroundArtificial intelligence (AI) has gained tremendous popularity recently, especially the use of natural language processing (NLP). ChatGPT is a state-of-the-art chatbot capable of creating natural conversations using NLP. The use of AI in medicine can have a tremendous impact on health care delivery. Although some studies have evaluated ChatGPT’s accuracy in self-diagnosis, there is no research regarding its precision and the degree to which it recommends medical consultations. ObjectiveThe aim of this study was to evaluate ChatGPT’s ability to accurately and precisely self-diagnose common orthopedic diseases, as well as the degree of recommendation it provides for medical consultations. MethodsOver a 5-day course, each of the study authors submitted the same questions to ChatGPT. The conditions evaluated were carpal tunnel syndrome (CTS), cervical myelopathy (CM), lumbar spinal stenosis (LSS), knee osteoarthritis (KOA), and hip osteoarthritis (HOA). Answers were categorized as either correct, partially correct, incorrect, or a differential diagnosis. The percentage of correct answers and reproducibility were calculated. The reproducibility between days and raters were calculated using the Fleiss κ coefficient. Answers that recommended that the patient seek medical attention were recategorized according to the strength of the recommendation as defined by the study. ResultsThe ratios of correct answers were 25/25, 1/25, 24/25, 16/25, and 17/25 for CTS, CM, LSS, KOA, and HOA, respectively. The ratios of incorrect answers were 23/25 for CM and 0/25 for all other conditions. The reproducibility between days was 1.0, 0.15, 0.7, 0.6, and 0.6 for CTS, CM, LSS, KOA, and HOA, respectively. The reproducibility between raters was 1.0, 0.1, 0.64, –0.12, and 0.04 for CTS, CM, LSS, KOA, and HOA, respectively. Among the answers recommending medical attention, the phrases “essential,” “recommended,” “best,” and “important” were used. Specifically, “essential” occurred in 4 out of 125, “recommended” in 12 out of 125, “best” in 6 out of 125, and “important” in 94 out of 125 answers. Additionally, 7 out of the 125 answers did not include a recommendation to seek medical attention. ConclusionsThe accuracy and reproducibility of ChatGPT to self-diagnose five common orthopedic conditions were inconsistent. The accuracy could potentially be improved by adding symptoms that could easily identify a specific location. Only a few answers were accompanied by a strong recommendation to seek medical attention according to our study standards. Although ChatGPT could serve as a potential first step in accessing care, we found variability in accurate self-diagnosis. Given the risk of harm with self-diagnosis without medical follow-up, it would be prudent for an NLP to include clear language alerting patients to seek expert medical opinions. We hope to shed further light on the use of AI in a future clinical study.

A select 10-30% of patients with recurrent lateral ankle sprains develop chronic ankle instability (CAI). Patients with chronic ankle instability describe a history of the ankle "giving way" with or without pathological laxity on examination. Evaluation includes history, identification of predisposing risk factors for recurrent sprains, and the combination of clinical tests (eg, laxity tests) with imaging to establish the diagnosis. There are a variety of nonoperative strategies to address chronic ankle instability, which include rehabilitation and taping or bracing to prevent future sprains. Patients who fail conservative treatment are candidates for surgery. The anatomic approaches (eg, modified Broström) are preferred to nonanatomic procedures since they recreate the ankle's biomechanics and natural course of the attenuated ligaments. There is a growing interest in minimally invasive procedures via ankle arthroscopy that also address the associated intra-articular disorders. This article provides a review of chronic lateral ankle instability consisting of relevant anatomy, associated disorders, evaluation, treatment methods, and complications.Level of evidenceLevel V, expert opinion.

Congenital pancreatic cysts (CPCs) are rare developmental anomalies that arise in-utero from the pancreas. They are exceedingly rare in the literature, and most are discovered postnatally. Prenatal diagnosis is uncommon with only 21 published reports of prenatally diagnosed CPCs in the literature. CPCs may form unilocular or multilocular macrocysts which can distort normal anatomy. There is considerable overlap of imaging features with other macrocystic lesions of the neonatal abdomen. Ultrasound-guided biopsy and analysis of cyst aspirate for pancreatic enzymes may assist with obtaining an accurate preoperative diagnosis. We report a case of a 37-week gestational age female infant born with a known prenatal 9.5 cm macrocystic intrabdominal mass. An intrabdominal lymphatic malformation was initially diagnosed based on clinical and imaging features. Since conservative therapy with with cyst drainage and serial sclerotherapy was not effective, an ultrasound-guided biopsy was performed to rule out malignancy. Pancreatic tissue was identified on pathology. An exploratory laparotomy and total cystectomy was performed which confirmed the diagnosis of congenital pancreatic cyst originating from the pancreatic tail. This case highlights the diagnostic challenge of congenital pancreatic cysts and the importance of a multimodal and multidisciplinary diagnostic approach.

Abstract Aims Acute pulmonary disorders are known physical triggers of takotsubo syndrome (TTS). This study aimed to investigate prevalence of acute pulmonary triggers in patients with TTS and their impact on outcomes. Methods and results Patients with TTS were enrolled from the International Takotsubo Registry and screened for triggering factors and comorbidities. Patients were categorized into three groups (acute pulmonary trigger, chronic lung disease, and no lung disease) to compare clinical characteristics and outcomes. Of the 1670 included patients with TTS, 123 (7%) were identified with an acute pulmonary trigger, and 194 (12%) had a known history of chronic lung disease. The incidence of cardiogenic shock was highest in patients with an acute pulmonary trigger compared with those with chronic lung disease or without lung disease (17% vs. 10% vs. 9%, P = 0.017). In‐hospital mortality was also higher in patients with an acute pulmonary trigger than in the other two groups, although not significantly (5.7% vs. 1.5% vs. 4.2%, P = 0.13). Survival analysis demonstrated that patients with an acute pulmonary trigger had the worst long‐term outcome (P = 0.002). The presence of an acute pulmonary trigger was independently associated with worse long‐term mortality (hazard ratio 2.12, 95% confidence interval 1.33–3.38; P = 0.002). Conclusions The present study demonstrates that TTS is related to acute pulmonary triggers in 7% of all TTS patients, which accounts for 21% of patients with physical triggers. The presence of acute pulmonary trigger is associated with a severe in‐hospital course and a worse long‐term outcome.

Paediatric trigger finger is rare compared to adult trigger finger or paediatric trigger thumb, and the aetiology is unclear. Proposed causes include local trauma, anatomical anomalies and systemic conditions. The aim of the present study was to detail the anatomical causes of surgically treated paediatric trigger fingers and provide an operative algorithm based on the anatomical findings. A total of 76 trigger fingers in 38 patients were identified retrospectively at our institution between 1975 and 2022. In total, 41 fingers in 26 patients had anatomical variations. A nodular thickening on the tendon, similar to Notta's nodule in trigger thumbs, was the most common anatomical cause. Abnormal decussation of the flexor digitorum superficialis tendon was the second most common variation. The recurrence rate was significantly lower after resection of one slip of the flexor digitorum superficialis tendon compared to other surgical techniques in these patients. We recommend that surgeons assess for possible anatomical variation during surgery for the trigger finger. Level of evidence: IV [ABSTRACT FROM AUTHOR]

We present a rare case of acute febrile neutrophilicdermatosis, also known as Sweet syndrome,associated with recurrence of metastatic cervicalcancer. This report highlights similar reports andserves as an important reminder of the relationshipbetween Sweet syndrome and cervical cancer.Increasing awareness of Sweet syndrome assistsclinicians in recognizing characteristic findings andencourages evaluation of patients for new-onsetor recurrent neoplastic disease. Additionally, wediscuss the typical presentation of the syndrome, theproper workup and treatment, and a common pitfallencountered in the diagnosis of Sweet syndrome.

Abstract Catastrophic antiphospholipid antibody syndrome (CAPS) is a rare form of antiphospholipid syndrome, an autoimmune condition characterized by vascular thromboses, pregnancy loss, and antiphospholipid (aPL) antibodies. Diagnosis of CAPS relies on thrombosis of at least three different organs systems over 1 week, histopathological evidence of small vessel occlusion, and high aPL antibody titers. In a subset of precipitating circumstances, activation or disruption of endothelial cells in the microvasculature may occur along with cardiomyopathy. We present two cases of CAPS‐associated dilated cardiomyopathy at our institution, focusing on disease management, pathophysiology, and treatment. These patients were of Southeastern Asian descent, raising the possibility of genetic polymorphisms contributing to the development of cardiomyopathy. Both met CAPS criteria and both demonstrated clinicopathologic thrombotic microangiopathy (TMA) and complement activation and developed severe dilated cardiomyopathy with shock. Complement activation plays an important role in the development of CAPS and may be important in the pathogenesis of CAPS‐associated cardiomyopathy. Clinical suspicion for TMA as a pathophysiologic mechanism of unexplained heart failure in CAPS is important and increased awareness of cardiac side effects is necessary so that early treatment can be initiated to halt further cardiac and systemic complications.

Background Atrial fibrillation (AF) is a major risk factor for mortality. The prevalence, clinical correlates, and prognostic impact of AF in Takotsubo syndrome (TTS) have not yet been investigated in a large patient cohort. This study aimed to investigate the prevalence, clinical correlates, and prognostic impact of AF in patients with TTS. Methods and Results Patients with TTS were enrolled from the International Takotsubo Registry, which is a multinational network with 26 participating centers in Europe and the United States. Patients were dichotomized according to the presence or absence of AF at the time of admission. Of 1584 patients with TTS, 112 (7.1%) had AF. The mean age was higher (P

Category: Ankle; Trauma Introduction/Purpose: Syndesmotic disruption occurs in 10 to 13% of all ankle fractures. It is present in 15 cases per 100,000 of the general population. There has been debate on the best treatment for syndesmotic injuries. The typical surgical treatments include fixation with either screws or suture button devices. The purpose of this study is to compare clinical outcomes of syndesmotic injuries treated surgically with either screws or suture button devices. It was hypothesized that suture button fixation would provide equal clinical results with less need for hardware removal. Methods: This was a multi-center, randomized, prospective clinical trial comparing two surgical interventions for treatment of acute syndesmotic injury. Subjects were placed into either screw fixation or the Suture-button device group. Subjects with clinical signs or radiographic evidence of syndesmotic injury were asked to participate in this study. Inclusion criteria was ages 18 to 65 years old with confirmed syndesmotic instability. The primary outcomes of the study were VAS scores (activity, pain, satisfaction) and FFI scores (pain, disability, activity) which were collected at preoperative state, 6 weeks, and 12 months postoperatively. Results: Sixty-five subjects were enrolled in this study. Thirty-two subjects received Suture-button fixation (49%) and 33 received screw fixation (51%). VAS scores and FFI scores for subjects treated with the Suture-button device or screw fixation comparing preoperative, six-week, and 12-month scores all showed clinical improvement. There was no significant difference between the two treatment groups (p >0.05).Nine subjects (27%) in the syndesmotic screw fixation group experienced adverse events, and only one subject (3%) in the suture-button group had adverse event. Conclusion: The short-term clinical outcomes suggest that both syndesmotic screws and suture-button devices are effective treatment options to address acute syndesmotic injuries. In the short-term (12-months), suture-button fixation resulted in significantly less adverse events compared to syndesmotic screw fixation group.

Background Left ventricular (LV) recovery in takotsubo syndrome (TTS) occurs over a wide‐ranging interval, varying from hours to weeks. We sought to investigate the clinical predictors and prognostic impact of recovery time for TTS patients. Methods and Results TTS patients from the International Takotsubo Registry were included in this study. Cut‐off for early LV recovery was determined to be 10 days after the acute event. Multivariable logistic regression was used to assess factors associated with the absence of early recovery. In‐hospital outcomes and 1‐year mortality were compared for patients with versus without early recovery. We analyzed 406 patients with comprehensive and serial imaging data regarding time to recovery. Of these, 191 (47.0%) had early LV recovery and 215 (53.0%) demonstrated late LV improvement. Patients without early recovery were more often male (12.6% versus 5.2%; P=0.011) and presented more frequently with typical TTS (76.3% versus 67.0%, P=0.040). Cardiac and inflammatory markers were higher in patients without early recovery than in those with early recovery. Patients without early recovery showed unfavorable 1‐year outcome compared with patients with early recovery (P=0.003). On multiple logistic regression, male sex, LV ejection fraction

Category: Flatfoot reconstruction Introduction/Purpose: Adult acquired flatfoot often results from posterior tibial tendon dysfunction followed by attenuation of the ligamentous support of the medial longitudinal arch of the foot. The spring ligament is the strongest ligamentous support for the talonavicular joint making it a viable target for flatfoot reconstruction procedures. There are concerns that direct repair of the spring ligament complex could result in failure as the already attenuated tissues of the ligament stretch out with mobilization and weight bearing. Suture tape augmentation of ligament repairs has shown greater loads to failure in biomechanical testing; however, there is a paucity of data surrounding clinical and radiographic outcomes of flatfoot reconstruction with augmented spring ligament repair. Methods: A retrospective review was performed of patients who underwent flatfoot reconstruction including spring ligament repair with suture tape augmentation between July 2014 and August 2017. Weight bearing radiographs were obtained for all patients both pre-operatively and at their last available follow-up. All radiographs were assessed by two surgeons for validated radiographic parameters including AP talocalcaneal angle, AP talo-first metatarsal angle, AP talar uncoverage, lateral talocalcaneal angle, lateral talo-first metatarsal (Meary) angle, lateral medial cuneiform-fifth metatarsal height, and lateral calcaneal pitch. Paired sample T-tests were used to compare pre-operative and post-operative radiographic measurements to assess for correction of these parameters. Results: 57 patients met inclusion criteria. The average time to final radiographic evaluation was 47 weeks (10 to 200 weeks). All radiographic parameters assessed showed significant correction when compared to pre-operative measurements. The average correction for each parameter included 6.02 degrees for AP talocalcaneal angle (p

Background Clinical characteristics and outcomes of takotsubo syndrome (TTS) patients with malignancy have not been fully elucidated. This study sought to explore differences in clinical characteristics and to investigate short‐ and long‐term outcomes in TTS patients with or without malignancy. Methods and Results TTS patients were enrolled from the International Takotsubo Registry. The TTS cohort was divided into patients with and without malignancy to investigate differences in clinical characteristics and to assess short‐ and long‐term mortality. A subanalysis was performed comparing long‐term mortality between a subset of TTS patients with or without malignancy and acute coronary syndrome (ACS) patients with or without malignancy. Malignancy was observed in 16.6% of 1604 TTS patients. Patients with malignancy were older and more likely to have physical triggers, but less likely to have emotional triggers compared with those without malignancy. Long‐term mortality was higher in patients with malignancy (P

A select 10-30% of patients with recurrent lateral ankle sprains develop chronic ankle instability (CAI). Patients with chronic ankle instability describe a history of the ankle “giving way” with or without pathological laxity on examination. Evaluation includes history, identification of predisposing risk factors for recurrent sprains, and the combination of clinical tests (eg, laxity tests) with imaging to establish the diagnosis. There are a variety of nonoperative strategies to address chronic ankle instability, which include rehabilitation and taping or bracing to prevent future sprains. Patients who fail conservative treatment are candidates for surgery. The anatomic approaches (eg, modified Broström) are preferred to nonanatomic procedures since they recreate the ankle’s biomechanics and natural course of the attenuated ligaments. There is a growing interest in minimally invasive procedures via ankle arthroscopy that also address the associated intra-articular disorders. This article provides a review of chronic lateral ankle instability consisting of relevant anatomy, associated disorders, evaluation, treatment methods, and complications. Level of Evidence: Level V, expert opinion.

The Watchman device is a transcatheter left atrial appendage (LAA) occluding device used in patients with nonvalvular atrial fibrillation (NVAF) and a high CHADS2-VA2SC score who are poor long-term anticoagulation candidates. Pericardial effusion related to device deployment and perforation can be a life-threatening complication. While not common in hands of experienced operators, management may require surgical intervention. Here we present a rare case of LAA perforation, which was corrected by successful repositioning of the device foregoing the need for surgical management.

We present a case of a 48-year-old female who developed myocarditis and near fatal arrhythmias during high dose Il-2 therapy for metastatic renal cancer. On day 5 of therapy, the patient developed sudden onset chest pain, elevated cardiac enzymes and ST segment changes on EKG. Coronary angiogram was normal, however echocardiogram showed reduced ejection fraction and hemodynamic measurements showed elevated bilateral elevated filling pressures. The patient then developed episodes of recurrent ventricular arrhythmia, precipitated by bradycardia and PVC, requiring defibrillation and temporary pacemaker placement. Endomycardial biopsy was nonspecific showing fibrosis with subsequent cardiac MRI showed evidence of myocardial edema, consistent with Il-2 induced myocarditis in the setting of no prior cardiac history. After the discontinuation of Il-2 therapy, the patient displayed clinical improvement as well as improved ejection fraction. This case brings attention to the cardiac toxicities associated with high dose Il-2 therapy including potentially lethal arrhythmias and highlights the importance of careful cardiac screening prior to initiation of treatment.

Background: The opioid epidemic has driven renewed interest in local anesthesia to reduce postoperative opioid use. Our objective was to determine if local anesthesia decreased hospital pain scores, oral morphine equivalents (OME), length of stay (LOS), and nausea/vomiting. Methods: Single institution retrospective study of females who underwent mastectomy without reconstruction. Results: Overall, 712 patients were included; 63 (8.8%) received bupivacaine (B), 512 (72%) liposomal bupivacaine (LB), and 137 (19%) no local. 95% were discharged on POD1. Liposomal bupivacaine use increased from 2014 to 2019. Additional factors associated with use of local regimen were surgeon and extent of axillary surgery. Fewer patients used postop opioids during their hospital stay if any local was used compared to none (76 vs 88%; 0.003). Compared to none, local had shorter mean PACU LOS (95 vs 87 min; P =.02), lower mean intraoperative-OME (96 vs 106; P <.001), and lower mean postoperative OME/hr (1.4 vs 1.8 P =.001). Multivariable analysis (MVA) showed lower OME/hr with LB compared to B and none (P =.002); this translates to 22 mg and 30 mg of oxycodone in a 24-hr period, respectively. MVA showed lower POD1 pain scores with LB relative to none (P =.049). Local did not impact nausea/emesis. Conclusion: Local anesthesia was superior to no local in several measures. However, a consistent benefit of a specific local anesthetic agent was not demonstrated (LB vs B). A prospective study is warranted to determine the optimal local regimen for this cohort and further inform clinical relevance. [ABSTRACT FROM AUTHOR]

Malignant pleural effusions are common complications in patients with primary or metastatic cancer to the lungs. In this article, we describe a unique case of a patient with history of diffuse pulmonary metastases from gallbladder adenocarcinoma who acutely developed a bilious pleural effusion following endoscopic retrograde cholangiopancreatography. We believe the bilious pleural effusion (cholethorax or bilothorax) developed as a complication of endoscopic retrograde cholangiopancreatography rather than tumor burden causing a fistula from the biliary tree to the right pleural space. We discuss possible mechanisms of formation of the bilious pleural effusion in our patient and present a literature review of previously reported cases of bilious pleural effusions.

This report presents a case of tacrolimus cardiotoxicity in an adult patient who received tacrolimus immunosuppression for orthotopic liver transplant (OLT). Tacrolimus-associated cardiotoxicity has been described in the literature, however this is the first case to document the development of a dilated cardiomyopathy in a patient shortly after initiating tacrolimus therapy post transplant. With the growing use of tacrolimus in transplant medicine, this case report expands the literature of tacrolimus cardiotoxicity and can aid clinicians in the evaluation and management of patients exposed to this form of immunosuppression.