Review of evolution of tunnel position in anterior cruciate ligament reconstruction

Anterior cruciate ligament(ACL) rupture is one of the commonest knee sport injuries. The annual incidence of the ACL injury is between 100000-200000 in the United States. Worldwide around 400000 ACL reconstructions are performed in a year. The goal of ACL reconstruction is to restore the normal knee anatomy and kinesiology. The tibial and femoral tunnel placements are of primordial importance in achieving this outcome. Otherfactors that influence successful reconstruction are types of grafts, surgical techniques and rehabilitation programmes. A comprehensive understanding of ACL anatomy has led to the development of newer techniques supplemented by more robust biological and mechanical concepts. In this review we are mainly focussing on the evolution of tunnel placement in ACL reconstruction, focusing on three main categories, i.e., anatomical, biological and clinical outcomes. The importance of tunnel placement in the success of ACL reconstruction is well researched. Definite clinical and functional data is lacking to establish the superiority of the single or double bundle reconstruction technique. While there is a trend towards the use of anteromedial portals for femoral tunnel placement, their clinical superiority over trans-tibial tunnels is yet to be established.

Predicting lower limb periprosthetic joint infections: A review of risk factors and their classification

AIM To undertook a systematic review to determine factors that increase a patient's risk of developing lower limb periprosthetic joint infections(PJI).METHODS This systematic review included full-text studies that reviewed risk factors of developing either a hip or knee PJI following a primary arthroplasty published from January 1998 to November 2016. A variety of keywords were used to identify studies through international databases referencing hip arthroplasty, knee arthroplasty, infection, and risk factors. Studies were only included if they included greater than 20 patients in their study cohort, and there was clear documentation of the statistical parameter used; specifically P-value, hazard ratio, relative risk, or/and odds ratio(OR). Furthermore a quality assessment criteria for the individual studies was undertaken to evaluate the presence of record and reporting bias. RESULTS Twenty-seven original studies reviewing risk factors relating to primary total hip and knee arthroplasty infections were included. Four studies(14.8%) reviewed PJI of the hip, 3(11.21%) of the knee, and 20(74.1%) reviewed both joints. Nineteen studies(70.4%) were retrospective and 8(29.6%) prospective. Record bias was identified in the majority of studies(66.7%). The definition of PJI varied amongst the studies but there was a general consensus to define infection by previously validated methods. The most significant risks were the use of preoperative high dose steroids(OR = 21.0, 95%CI: 3.5-127.2, P < 0.001), a BMI above 50(OR = 18.3, P < 0.001), tobacco use(OR = 12.76, 95%CI: 2.47-66.16, P= 0.017), body mass index below 20(OR = 6.00, 95%CI: 1.2-30.9, P = 0.033), diabetes(OR = 5.47, 95%CI: 1.77-16.97, P = 0.003), and coronary artery disease(OR = 5.10, 95%CI: 1.3-19.8, P = 0.017).CONCLUSION We have highlighted the need for the provider to optimise modifiable risk factors, and develop strategies to limit the impact of non-modifiable factors.

Return to sport after lower limb arthroplasty-why not for all?

BACKGROUND Total hip and knee replacements are being performed in increasing numbers in progressively younger patients with higher activity demands. Many such patients have expectations of returning to athletic activity post-operatively yet are not always able to do so and the reasons behind this have not been extensively examined. We hypothesise that any reasons for a failure to return to athletic activity post-operatively are multi-factorial.AIM To quantify the return to athletic activity following lower limb joint arthroplasty and understand qualitative reasons for altered activity participation.METHODS A single centre, single surgeon retrospective questionnaire for hip and knee arthroplasty patients under age 60 years, minimum two years post-surgery with exclusion criteria of multiple degenerative joint involvement and multiple medical co-morbidities. Outcomes were validated joint-specific(Oxford hip and knee) and lifestyle questionnaires [short form 12(SF-12) and University of California, Los Angeles(UCLA)] and an activity questionnaire assessing ability participation in athletic activity post-operatively. Statistical analysis was performed on the validated outcome data, including comparison between hip and knee replacements. Frequency tables were produced to quantify the different athletic activities participated in by patients.RESULTS Responses were received from 64 patients(80% response rate). There was a statistically significant improvement in Oxford hip and knee scores following surgery. SF-12 scores also improved for all patients, but no statistically significant difference was seen between joints(P = 0.88). Mean UCLA scores pre-operatively were 7.67 and at two years post-operatively were 7.69, with no statistically significant change(P = 0.91). All patients reported high satisfaction and improved ability to perform athletic activity at a higher frequency compared to pre-operatively. The most common reasons for changing activity participation were not wanting to stress their joint replacement or instructions by other doctors or the lead surgeon. There was no difference in the responses to the questionnaire based on type of joint replacement(P = 0.995).CONCLUSION Patients receiving a joint replacement are able to participate in athletic activity to high levels and are satisfied with their outcomes. Reasons for non-participation are multi-factorial.