Supplementary tibial fixation in female patients undergoing anterior cruciate ligament reconstruction with hamstring tendon graft in addition to a single-size screw significantly improves laxity measurements and clinical stability assessment 2 years after surgery. However, this improvement is at the cost of increased kneeling pain.
It has been stated that the application of a pre-hospital tourniquet could prevent 7% of combat deaths, however their widespread use has been questioned due to the potential risk from prolonged ischaemia. We reviewed members of the UK Armed Forces who sustained severe limb-threatening injuries in Iraq and Afghanistan, and performed a matched cohort study based on the presence or absence of pre-hospital tourniquet application. When a pre-hospital tourniquet had been applied, 19/22 patients had a least one complication compared to 15/22 where no tourniquet had been applied [p = 0.13]. There were 10 limbs with at least one major complication in the pre-hospital tourniquet group but only four in the group with no tourniquet [p = 0.045]. The significant difference in the incidence of major complications is a concern, particularly as the difference was mainly due to a deep infection rate of 32% vs. 4.5%. Although a number of variables could have influenced these small groups, such as choice of fracture fixation implant and method and timing of wound closure, the use of a matched cohort study design with a statistical significance level of p < 0.05, suggests the use of a pre-hospital tourniquet as a factor. Although the use of pre-hospital tourniquets cannot be decried as a result of this study, the need to continually prospectively review their use to determine their risk/benefit ratio remains.
Our data based on this exercise protocol are comparable with the few studies that record dynamic pressure during running-based exercise. There is no accepted diagnostic pressure or exercise protocol. Due to the uncertainty of diagnostic criteria, it is necessary to perform a study measuring dynamic pressures in normal asymptomatic subjects.
Background: There are limited randomized controlled trials with long-term outcomes comparing autologous chondrocyte implantation (ACI) versus alternative forms of surgical cartilage management within the knee. Purpose: To determine at 5 years after surgery whether ACI was superior to alternative forms of cartilage management in patients after a failed previous treatment for chondral or osteochondral defects in the knee. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: In total, 390 participants were randomly assigned to receive either ACI or alternative management. Patients aged 18 to 55 years with one or two symptomatic cartilage defects who had failed 1 previous therapeutic surgical procedure in excess of 6 months prior were included. Dual primary outcome measures were used: (1) patient-completed Lysholm knee score and (2) time from surgery to cessation of treatment benefit. Secondary outcome measures included International Knee Documentation Committee and Cincinnati Knee Rating System scores, as well as number of serious adverse events. Analysis was performed on an intention-to-treat basis. Results: Lysholm scores were improved by 1 year in both groups (15.4 points [95% CI, 11.9 to 18.8] and 15.2 points [95% CI, 11.6 to 18.9]) for ACI and alternative, with this improvement sustained over the duration of the trial. However, no evidence of a difference was found between the groups at 5 years (2.9 points; 95% CI, −1.8 to 7.5; P = .46). Approximately half of the participants (55%; 95% CI, 47% to 64% with ACI) were still experiencing benefit at 5 years, with time to cessation of treatment benefit similar in both groups (hazard ratio, 0.97; 95% CI, 0.72 to 1.32; P > .99). There was a differential effect on Lysholm scores in patients without previous marrow stimulation compared with those with marrow stimulation ( P = .03; 6.4 points in favor of ACI; 95% CI, −0.4 to 13.1). More participants experienced a serious adverse event with ACI ( P = .02). Conclusion: Over 5 years, there was no evidence of a difference in Lysholm scores between ACI and alternative management in patients who had previously failed treatment. Previous marrow stimulation had a detrimental effect on the outcome of ACI. Registration: International Standard Randomised Controlled Trial Number: 48911177
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