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. Other factors 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.

Background: Observational studies have suggested that accelerated surgery is associated with improved outcomes in patients with a hip fracture. The HIP ATTACK trial assessed whether accelerated surgery could reduce mortality and major complications. Methods:We randomised 2970 patients from 69 hospitals in 17 countries. Patients with a hip fracture that required surgery and were ≥45 years of age were eligible. Patients were randomly assigned to accelerated surgery (goal of surgery within 6 hours of diagnosis; 1487 patients) or standard care (1483 patients). The co-primary outcomes were 1.) mortality, and 2.) a composite of major complications (i.e., mortality and non-fatal myocardial infarction, stroke, venous thromboembolism, sepsis, pneumonia, life-threatening bleeding, and major bleeding) at 90 days after randomisation. Outcome adjudicators were masked to treatment allocation, and patients were analysed according to the intention-to-treat principle; ClinicalTrials.gov, NCT02027896. Findings:The median time from hip fracture diagnosis to surgery was 6 hours (interquartile range [IQR] 4-9) in the accelerated-surgery group and 24 hours (IQR 10-42) in the standard-care group, p<0.0001. Death occurred in 140 patients (9%) assigned to accelerated surgery and 154 patients (10%) assigned to standard care; hazard ratio (HR) 0.91, 95% CI 0.72-1.14; absolute risk reduction (ARR) 1%, 95% CI -1-3%; p=0.40. The primary composite outcome occurred in 321 patients (22%) randomised to accelerated surgery and 331 patients (22%) randomised to standard care; HR 0.97, 95% CI 0.83-1.13; ARR 1%, 95% CI -2-3%; p=0.71.Interpretation: Among patients with a hip fracture, accelerated surgery did not significantly lower the risk of mortality or a composite of major complications compared to standard care.

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BackgroundAs life expectancy of patients increases, more elderly patients are undergoing primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). There is a general perception of increased risk of complications in elderly patients. Our objective was to analyse the incidence of in-hospital medical and surgical complications following THA and TKA in octogenarian and nonagenarians.Materials and methodsThis was a prospective review of 202 consecutive patients aged more than 80 years who underwent total hip and total knee arthroplasty (101 THA, 101 TKA) over an 18-month period. In this single-centre observational study, collected data included patient demographics, American Society of Anethesiologists (ASA) grade, length of hospital stay and peri-operative medical and surgical complications during their hospital stay.ResultsMedian age of patients was 83 years. Median ASA grade was 3. Mean length of hospital stay was 7.5 days. There were 14 major systemic complications in the THA group and 13 in the TKA group. While 1 major local complication occurred in each group, there were 6 minor local complications in THA and 7 in the TKA group. All the complications occurred within 5 post-operative days. There was no in-hospital mortality.ConclusionIn our study, we found that the incidence of peri-operative medical and surgical complications is higher in those over 80 years, compared to the published literature in patients of all age groups undergoing THA and TKA. Awareness of a higher incidence of major systemic complications should alert the treating surgeon to carry out comprehensive peri-operative management in this subset of patients, which could lead to better outcomes.

In our study, obesity was not a predictor of recurrent IDP following lumbar microdiscectomy. Our literature review confirmed that this study reports the largest series to date analysing the relationship between obesity and recurrent IDP following lumbar microdiscectomy in the British population.