Enhanced recovery after surgery is gaining popularity among orthopaedic surgeons across the globe and hence a strong evidence base had to be reviewed to make an evidence-based sustainable protocol. Methods The following databases, PubMed, OVID, Cochrane database and EMBASE were searched. The search was limited to 15 components of enhanced recovery after surgery programme which is divided into preoperative, intraoperative and postoperative phases. Inclusion criteria were restricted to articles published in English within the last 15 years and articles comprising of unicompartmental arthroplasty, revision knee arthroplasty, bilateral simultaneous knee arthroplasty and only hip arthroplasty excluded. The full texts were analysed and controversies and limitations of various studies were summarised. Discussion Each component of the programme was thoroughly reviewed and strength and weaknesses of the evidence base summarised. The strength of the evidence was assessed by critically appraising the study methodology and justifying the appropriateness of the inclusion in enhanced recovery after surgery protocol. Conclusion Enhanced recovery after surgery has already been used successfully in various surgical specialities. Enhanced recovery after surgery programmes in knee arthroplasty are yet to be established as a universal practice to be adopted globally. This evidence-based review provides an insight into the best evidence linked to each component and their rationale for inclusion in the proposed enhanced recovery after surgery protocol.

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Background: Fibular- and tibiofibular-based reconstructions are the gold standard treatment for posterolateral corner (PLC) injuries of the knee. Despite comparable outcomes in biomechanical studies, clinical results comparing these constructs remain elusive with no consensus reached regarding the best treatment option. Purpose: To perform a systematic review and meta-analysis to compare fibular- and tibiofibular-based techniques for posterolateral corner reconstruction. We aimed to identify whether any differences existed between the 2 techniques in terms of clinical outcomes and rotational and varus stability. Study Design: Meta-analysis; Level of evidence, 4. Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms (“posterolateral corner” OR “fibular collateral ligament” OR “lateral collateral ligament” OR “popliteus tendon” OR “popliteofibular ligament”) AND (“reconstruction” OR “LaPrade” OR “Larson” OR “Arciero”). Data pertaining to all patient-reported outcome measures (PROMs), postoperative complications, and valgus and rotational stability were extracted from each study. The pooled outcome data were analyzed by random- and fixed-effects models. Results: After abstract and full-text screening, 6 clinical studies were included. In total, there were 183 patients, of which 90 received fibular-based and 93 tibiofibular-based reconstruction. The majority of studies used similar surgical techniques regarding tunnel orientation, attachment sites, and graft fixation sequence. There were no differences between the groups in terms of PROMs and subjective knee scores at a mean of 20.3 months. The techniques were equally effective in restoring varus and rotational stability. Subgroup analysis revealed that the stability of a posterior cruciate ligament reconstruction postoperatively was not affected by either construct. Conclusion: Both constructs had comparable clinical outcomes and were equally effective in restoring varus and rotational stability for PLC knee injuries. The fibular-based technique may offer advantages in view of being less technically demanding and invasive and requiring fewer grafts with a quicker operative time. However, higher quality studies are required to reinforce or refute such conclusions, as the majority of studies in this review were poor to fair quality.

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Background: Strong surgical repair is the mechanical basis of early mobilization and prerequisite for biological healing following tendon grafting. Side to side and pulvertaft repairs were developed to meets these demands. However, these techniques have later been modified to improve the strength of repair but their characteristics have not been compared. Methods: We compared biomechanical strength of the modified side-to-side (SS) repair with the modified Pulvertaft (PT) repair technique in turkey tendons keeping overlap length, anchor points, type of suture, suture throw and amount of suture similar. Two investigators performed 34 repairs during one summer month to test the tensile strength of the repair using mechanical strength testing machine. Variables measured were maximum load, load to first failure, modulus, load at break, mode of failure, site of failure, tensile strain, tensile stress. The statistical comparison was carried by Levene’s test and T test for means. Results: The mean maximum load for modified SS repair was 50.3 (SD 13.7) N and modified PT repair was 46.9 (SD 16.4) N. The tensile stress at maximum load for SS and modified PT repair was 4.7 (SD 4) MPa and 4.2 (SD 3) MPa respectively. The suture cut through was the commonest mode of failure. Conclusions: We found no statistical difference between 2 repairs in load at which they started failing (p = 0.16), and maximum load repairs could withstand (p = 0.35). Our study uniquely compares two techniques under standard conditions, and contrary to existing evidence found no difference. However, in our opinion the number of anchor points may have a greater impact than number of weaves on the strength.

Background: After its success in restoring rotational stability and reducing failure rates in primary anterior cruciate ligament reconstruction (ACLR), lateral extra-articular tenodesis (LET) or anterolateral ligament reconstruction (ALLR) has been endorsed for use in revision ACLR surgery, where failure rates are historically higher. Purpose: To perform a systematic review and meta-analysis on whether the addition of a LET or ALLR results in superior clinical outcomes and stability compared with isolated revision ACLR (iACLR). Study Design: Meta-analysis; Level of evidence, 4. Methods: The Cochrane Controlled Register of Trials, PubMed, Medline, and Embase were used to perform a systematic review and meta-analysis of comparative studies using the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) criteria with the following search terms: (“extra-articular” OR “tenodesis” OR “anterolateral ligament” OR “iliotibial”) AND (“anterior cruciate ligament”) AND (“revision” OR “re-operation”). Data pertaining to all patient-reported outcome measures (PROMs), rotational stability, and postoperative complications were extracted from each study. Results: After abstract and full-text screening, 10 clinical comparative studies were included. There were 793 patients, of whom 390 had an iACLR while 403 had an ACLR augmented with a LET or an ALLR (augmented ACLR [aACLR]). The mean time for assessment of PROMs was 35 months. The aACLR group had superior International Knee Documentation Committee (IKDC) scores (standardized mean difference [SMD], 0.27; 95% CI, 0.01 to 0.54; P = .04), rotational stability (odds ratio [OR], 2.77; 95% CI, 1.91 to 4.01; P < .00001), and lower side-to-side difference (OR, −0.53; 95% CI, −0.81 to −0.24; P = .0003) than those without the augmentation. Furthermore, they were less likely to fail (OR, 0.44; 95% CI, 0.24 to 0.80; P = .007). Subgroup analysis in the higher-grade laxity cohort (grade ≥2) revealed an even greater IKDC score (SMD, 0.51; 95% CI, 0.16 to 0.86; P = .005) and an improved Lysholm score (SMD, 0.45; 95% CI, 0.24 to 0.67; P < .0001) in the aACLR group. Conclusion: Revision aACLR with a LET or an ALLR can improve subjective IKDC scores, restore rotational stability, and reduce failure rates compared with iACLR. Although controversy remains on the necessity of augmenting all revision ACLRs, the present meta-analysis advocates adding a lateral procedure, particularly in those with a higher-grade pivot shift.

Tuberculosis is a common infectious disease with a high prevalence in developing countries and presents a major public health issue. Internal jugular vein (IJV) thrombosis is a rare complication in tuberculous cervical lymphadenopathy. We report a case of 26-year male patient with a history of low-grade evening rise in fever, dry cough, loss of appetite, and loss of weight with swelling in lower neck on right side. Ultrasonography (USG) neck showed well-defined hypoechoic lymph nodes posterior to right IJV and common carotid artery in the lower neck at level IV and in the right supraclavicular region showing central necrotic areas with adjoining IJV thrombosis. The association between tuberculosis and deep vein thrombosis is rare. Awareness of IJV thrombosis in isolated cervical lymphadenopathy needs high diagnostic suspicion and prompt treatment to avoid fatal complication. Our case is rare as there was isolated tuberculous cervical lymphadenopathy with adjoining IJV thrombosis. Both USG and computed tomography (CT) are accurate and reliable radiological investigations for detecting IJV thrombosis along with cervical lymph nodes. They are useful in assessing surrounding soft tissue and fat planes and knowing the size and extent of cervical lymphadenopathy. USG is inexpensive and readily available for monitoring response to treatment.