No differences in subjective knee function between surgical techniques of anterior cruciate ligament reconstruction at 2-year follow-up: a cohort study from the Swedish National Knee Ligament Register

The purpose of this study was to investigate how different techniques of single-bundle anterior cruciate ligament (ACL) reconstruction affect subjective knee function via the Knee injury and Osteoarthritis Outcome Score (KOOS) evaluation 2 years after surgery. It was hypothesized that the surgical techniques of single-bundle ACL reconstruction would result in equivalent results with respect to subjective knee function 2 years after surgery. This cohort study was based on data from the Swedish National Knee Ligament Register during the 10-year period of 1 January 2005 through 31 December 2014. Patients who underwent primary single-bundle ACL reconstruction with hamstrings tendon autograft were included. Details on surgical technique were collected using a web-based questionnaire comprised of essential AARSC items, including utilization of accessory medial portal drilling, anatomic tunnel placement, and visualization of insertion sites and landmarks. A repeated measures ANOVA and an additional linear mixed model analysis were used to investigate the effect of surgical technique on the KOOS4 from the pre-operative period to 2-year follow-up. A total of 13,636 patients who had undergone single-bundle ACL reconstruction comprised the study group for this analysis. A repeated measures ANOVA determined that mean subjective knee function differed between the pre-operative time period and at 2-year follow-up (p < 0.001). No differences were found with respect to the interaction between KOOS4 and surgical technique or gender. Additionally, the linear mixed model adjusted for age at reconstruction, gender, and concomitant injuries showed no difference between surgical techniques in KOOS4 improvement from baseline to 2-year follow-up. However, KOOS4 improved significantly in patients for all surgical techniques of single-bundle ACL reconstruction (p < 0.001); the largest improvement was seen between the pre-operative time period and at 1-year follow-up. Surgical techniques of primary single-bundle ACL reconstruction did not demonstrate differences in the improvement in baseline subjective knee function as measured with the KOOS4 during the first 2 years after surgery. However, subjective knee function improved from pre-operative baseline to 2-year follow-up independently of surgical technique

Towards evidence-based practice 2.0: leveraging artificial intelligence in healthcare

BackgroundEvidence-based practice (EBP) involves making clinical decisions based on three sources of information: evidence, clinical experience and patient preferences. Despite popularization of EBP, research has shown that there are many barriers to achieving the goals of the EBP model. The use of artificial intelligence (AI) in healthcare has been proposed as a means to improve clinical decision-making. The aim of this paper was to pinpoint key challenges pertaining to the three pillars of EBP and to investigate the potential of AI in surmounting these challenges and contributing to a more evidence-based healthcare practice. We conducted a selective review of the literature on EBP and the integration of AI in healthcare to achieve this.Challenges with the three components of EBPClinical decision-making in line with the EBP model presents several challenges. The availability and existence of robust evidence sometimes pose limitations due to slow generation and dissemination processes, as well as the scarcity of high-quality evidence. Direct application of evidence is not always viable because studies often involve patient groups distinct from those encountered in routine healthcare. Clinicians need to rely on their clinical experience to interpret the relevance of evidence and contextualize it within the unique needs of their patients. Moreover, clinical decision-making might be influenced by cognitive and implicit biases. Achieving patient involvement and shared decision-making between clinicians and patients remains challenging in routine healthcare practice due to factors such as low levels of health literacy among patients and their reluctance to actively participate, barriers rooted in clinicians' attitudes, scepticism towards patient knowledge and ineffective communication strategies, busy healthcare environments and limited resources.AI assistance for the three components of EBPAI presents a promising solution to address several challenges inherent in the research process, from conducting studies, generating evidence, synthesizing findings, and disseminating crucial information to clinicians to implementing these findings into routine practice. AI systems have a distinct advantage over human clinicians in processing specific types of data and information. The use of AI has shown great promise in areas such as image analysis. AI presents promising avenues to enhance patient engagement by saving time for clinicians and has the potential to increase patient autonomy although there is a lack of research on this issue.ConclusionThis review underscores AI's potential to augment evidence-based healthcare practices, potentially marking the emergence of EBP 2.0. However, there are also uncertainties regarding how AI will contribute to a more evidence-based healthcare. Hence, empirical research is essential to validate and substantiate various aspects of AI use in healthcare

‘I was young, I wanted to return to sport, and re-ruptured my ACL’ – young active female patients’ voices on the experience of sustaining an ACL re-rupture, a qualitative study

publishedVersio

Generalized Joint Hypermobility and Specific Knee Laxity: Aspects of influence on the Anterior Cruciate Ligament Injured Knee

Injury to the anterior cruciate ligament (ACL) is one of the most serious sports-related injuries, with significant short- and long-term morbidity. Generalized joint hypermobility (GJH) and specific knee laxity are factors that have been associated with an increased risk of ACL injury and inferior postoperative outcome, but the state of the evidence is unclear and the available information is limited. This thesis consists of five studies with the overall aim of investigating how two main concepts, GJH and specific knee laxity, affect the outcome after ACL reconstruction and how the two concepts affect each other. Study I is a systematic review aiming to investigate the influence of GJH on ACL injury risk and postoperative outcome. Study I comprised 21 studies. While the data synthesis demonstrated GJH as a risk factor for ACL injury in males, the results were conflicting in females. Moreover, there was limited evidence indicating that GJH is associated with increased postoperative knee laxity and inferior patient-reported outcome after ACL reconstruction. Study II is a register-based cohort study comprising 142 patients undergoing ACL reconstruction. The outcome variables were assessed one year after ACL reconstruction and were analyzed using two methods: (1) dichotomization based on the presence of GJH and (2) linear regression to investigate continuous associations with the Beighton score. Interestingly, and contrary to the hypothesis, the analysis revealed that the KOOS sports and recreation subscale was associated with the continuous Beighton score. Functional performance, evaluated with hop and strength tests, was acceptable, regardless of the presence of GJH. Study III is an international multicenter cohort study investigating the correlation between the Beighton score and rotatory knee laxity in 96 ACL-injured patients. Rotatory knee laxity was evaluated using with the pivot-shift test, using two devices to quantify laxity. No correlations between GJH and quantitative rotatory knee laxity were observed in the ACL-injured knee. However, in the contralateral healthy knee, a weak yet significant correlation was observed. Study IV is a retrospective register-based cohort study comprising 8,502 patients undergoing ACL reconstruction. The patients were divided into four subgroups based on the degree of hyperextension of the contralateral healthy knee. The degree of contralateral hyperextension was analyzed in relation to anterior tibial translation (ATT), using the KT-1000 arthrometer, and in relation to the frequency of concomitant intra-articular injuries in the ACL-injured knee. The ATT was examined six months postoperatively. The study identified an association between contralateral knee hyperextension and greater ATT in the ACL injured knee. Interestingly, there was an inverse relationship between the degree of contralateral hyperextension and the frequency of meniscal injuries. Study V is a retrospective cohort study, based on two previous randomized, controlled cohorts, comprising 147 patients undergoing ACL reconstruction. The study analyzed the influence of increased knee laxity assessed two years postoperatively on clinical outcome variables 16 years postoperatively. This study determined that increased ATT, measured with the Lachman test and the anterior drawer test, was associated with inferior patient-reported outcome 16 years postoperatively. Moreover, increased rotatory knee laxity, measured with the pivot-shift test, was associated with inferior patient-reported outcome and a lower level of physical activity after 16 years. Taken together, this thesis provides an overview of all the currently available studies on the subject of the influence of GJH on ACL injury risk and postoperative outcome. It further demonstrates that acceptable short-term functional results could be found in patients with GJH after ACL reconstruction and that patients with increased hypermobility may have short-term subjectively perceived advantages. Moreover, the thesis provides the first correlation analysis between quantitative pivot shift and GJH, finding no association in the ACL-injured knee but a weak correlation in the contralateral healthy knee. Knee hyperextension, a part of GJH, is demonstrated to be associated with increased anterior knee laxity. As identified by Study V, increased anterior and rotatory knee laxity is associated with inferior long-term patient-reported outcome and a lower level of activity after 16 years, results that elucidate the importance of reducing postoperative knee laxity. Considering the accumulated evidence from the current thesis, reduction of postoperative knee laxity is probably particularly important in the susceptible group of individuals with GJH

Generalized Joint Hypermobility and Specific Knee Laxity: Aspects of influence on the Anterior Cruciate Ligament Injured Knee

Injury to the anterior cruciate ligament (ACL) is one of the most serious sports-related injuries, with significant short- and long-term morbidity. Generalized joint hypermobility (GJH) and specific knee laxity are factors that have been associated with an increased risk of ACL injury and inferior postoperative outcome, but the state of the evidence is unclear and the available information is limited. This thesis consists of five studies with the overall aim of investigating how two main concepts, GJH and specific knee laxity, affect the outcome after ACL reconstruction and how the two concepts affect each other. Study I is a systematic review aiming to investigate the influence of GJH on ACL injury risk and postoperative outcome. Study I comprised 21 studies. While the data synthesis demonstrated GJH as a risk factor for ACL injury in males, the results were conflicting in females. Moreover, there was limited evidence indicating that GJH is associated with increased postoperative knee laxity and inferior patient-reported outcome after ACL reconstruction. Study II is a register-based cohort study comprising 142 patients undergoing ACL reconstruction. The outcome variables were assessed one year after ACL reconstruction and were analyzed using two methods: (1) dichotomization based on the presence of GJH and (2) linear regression to investigate continuous associations with the Beighton score. Interestingly, and contrary to the hypothesis, the analysis revealed that the KOOS sports and recreation subscale was associated with the continuous Beighton score. Functional performance, evaluated with hop and strength tests, was acceptable, regardless of the presence of GJH. Study III is an international multicenter cohort study investigating the correlation between the Beighton score and rotatory knee laxity in 96 ACL-injured patients. Rotatory knee laxity was evaluated using with the pivot-shift test, using two devices to quantify laxity. No correlations between GJH and quantitative rotatory knee laxity were observed in the ACL-injured knee. However, in the contralateral healthy knee, a weak yet significant correlation was observed. Study IV is a retrospective register-based cohort study comprising 8,502 patients undergoing ACL reconstruction. The patients were divided into four subgroups based on the degree of hyperextension of the contralateral healthy knee. The degree of contralateral hyperextension was analyzed in relation to anterior tibial translation (ATT), using the KT-1000 arthrometer, and in relation to the frequency of concomitant intra-articular injuries in the ACL-injured knee. The ATT was examined six months postoperatively. The study identified an association between contralateral knee hyperextension and greater ATT in the ACL injured knee. Interestingly, there was an inverse relationship between the degree of contralateral hyperextension and the frequency of meniscal injuries. Study V is a retrospective cohort study, based on two previous randomized, controlled cohorts, comprising 147 patients undergoing ACL reconstruction. The study analyzed the influence of increased knee laxity assessed two years postoperatively on clinical outcome variables 16 years postoperatively. This study determined that increased ATT, measured with the Lachman test and the anterior drawer test, was associated with inferior patient-reported outcome 16 years postoperatively. Moreover, increased rotatory knee laxity, measured with the pivot-shift test, was associated with inferior patient-reported outcome and a lower level of physical activity after 16 years. Taken together, this thesis provides an overview of all the currently available studies on the subject of the influence of GJH on ACL injury risk and postoperative outcome. It further demonstrates that acceptable short-term functional results could be found in patients with GJH after ACL reconstruction and that patients with increased hypermobility may have short-term subjectively perceived advantages. Moreover, the thesis provides the first correlation analysis between quantitative pivot shift and GJH, finding no association in the ACL-injured knee but a weak correlation in the contralateral healthy knee. Knee hyperextension, a part of GJH, is demonstrated to be associated with increased anterior knee laxity. As identified by Study V, increased anterior and rotatory knee laxity is associated with inferior long-term patient-reported outcome and a lower level of activity after 16 years, results that elucidate the importance of reducing postoperative knee laxity. Considering the accumulated evidence from the current thesis, reduction of postoperative knee laxity is probably particularly important in the susceptible group of individuals with GJH

ChatGPT (GPT-4) versus doctors on complex cases of the Swedish family medicine specialist examination: an observational comparative study

Background Recent breakthroughs in artificial intelligence research include the development of generative pretrained transformers (GPT). ChatGPT has been shown to perform well when answering several sets of medical multiple-choice questions. However, it has not been tested for writing free-text assessments of complex cases in primary care.Objectives To compare the performance of ChatGPT, version GPT-4, with that of real doctors.Design and setting A blinded observational comparative study conducted in the Swedish primary care setting. Responses from GPT-4 and real doctors to cases from the Swedish family medicine specialist examination were scored by blinded reviewers, and the scores were compared.Participants Anonymous responses from the Swedish family medicine specialist examination 2017–2022 were used.Outcome measures Primary: the mean difference in scores between GPT-4’s responses and randomly selected responses by human doctors, as well as between GPT-4’s responses and top-tier responses by human doctors. Secondary: the correlation between differences in response length and response score; the intraclass correlation coefficient between reviewers; and the percentage of maximum score achieved by each group in different subject categories.Results The mean scores were 6.0, 7.2 and 4.5 for randomly selected doctor responses, top-tier doctor responses and GPT-4 responses, respectively, on a 10-point scale. The scores for the random doctor responses were, on average, 1.6 points higher than those of GPT-4 (p&lt;0.001, 95% CI 0.9 to 2.2) and the top-tier doctor scores were, on average, 2.7 points higher than those of GPT-4 (p&lt;0.001, 95 % CI 2.2 to 3.3). Following the release of GPT-4o, the experiment was repeated, although this time with only a single reviewer scoring the answers. In this follow-up, random doctor responses were scored 0.7 points higher than those of GPT-4o (p=0.044).Conclusion In complex primary care cases, GPT-4 performs worse than human doctors taking the family medicine specialist examination. Future GPT-based chatbots may perform better, but comprehensive evaluations are needed before implementing chatbots for medical decision support in primary care