Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Umbeli Belli Rock Shelter, a forgotten piece from the puzzle of the Middle Stone Age in KwaZulu-Natal, South Africa

Lithic technology in the Middle Stone Age (MSA) of southern Africa is key to reconstructing human daily life, people's interaction with their environment and technological and cultural change through time. Ongoing discussions about the evolution of technology in the MSA debate the causes of lithic variability within and between different assemblages across southern Africa. The well-known MSA sites such as Blombos Cave, Klasies River, Diepkloof and Sibudu serve as anchors for comparative studies by providing high resolution stratigraphies that cover long parts of the archaeological sequence. Researchers, however, should recognize that these and other key sites are often situated many hundreds kilometers away from each other and are located in diverse geographic settings, which raises questions about their comparability. It is therefore important to consider the archaeological signatures from less spectacular sites to help identify regional patterns and test models of cultural change at smaller spatial scales. KwaZulu-Natal serves as an excellent starting point to bring questions about continuity and change within the MSA into clearer focus, since the province contains several sites in close proximity to each other in comparable environments. Many of these sites, however, are still understudied or have even been forgotten completely. In this paper we describe the archaeological sequence of one such site, Umbeli Belli near Scottburgh. This site was excavated in 1979 by Charles Cable and contributes important information to the regional record of the MSA in KwaZulu-Natal

Regional sharing optimizes arterial switch outcomes

Although the arterial switch operation has been performed with very low mortality and morbidity in large pediatric cardiac surgical centers, we sought to determine if similar arterial switch results could be achieved in two medium-sized pediatric cardiac surgical centers that share one full-time surgeon who implements a comprehensive management protocol for both centers. Patients with D-transposition of the great arteries undergoing arterial switch operations at two medium-sized pediatric cardiac surgery centers were evaluated for 30-day mortality and morbidity during three time periods: Period 1, before protocol was implemented at either center (Center 1: 11/1982–8/1995, Center 2: 3/1992–11/1999); Period 2, protocol implemented only at Center 1 (9/1995–11/1999); Period 3, protocol implemented at both centers with regional sharing of one surgeon (12/1999–1/2003). Ninety-six consecutive patients undergoing an arterial switch operation were reviewed. Mortality data were available for all cases. Mortality was 0% and significantly lower in Periods 2 and 3 versus Period 1 ( p<0.001). Mortality in both centers during Period 1 did not differ. New York State morbidity data were available for 59 patients born after state reporting was instituted (Period 1, 16/43; Period 2, 13/23; Period 3, 30/30). In Period 1, there were significantly more pre-operative risk factors ( p<0.001) and post-operative complications ( p<0.002) than in Periods 2 and 3. There were no significant differences in performance between Centers 1 and 2 in any time period. There were significant performance improvements between Period 1 versus Periods 2 and 3. There was no significant degradation in performance between Periods 2 and 3. Outstanding surgical results for the arterial switch operation, similar to those in the largest pediatric cardiac surgical centers, are obtainable in two medium-sized pediatric cardiac surgery centers that share one full-time congenital heart surgeon. This model may be applicable in many other regions of the United States, where several medium-sized pediatric cardiac centers are within acceptable driving distance

Colonial surgeon Patrick Hill (1794-1852) : unacknowledged pioneer of Australian mental healthcare

Despite making a substantial contribution to the development of mental health services in colonial Australia, until now the story of Dr Patrick Hill’s (1794–1852) life has been overlooked by historians. This paper reviews primary sources including clinical notes, patient lists, letters, government documents and newspaper articles which reveal that Dr Hill was a dedicated physician who played a vital role in the development of Australian mental healthcare. He was held in such esteem that by the time of his sudden death in 1852 he had been elevated to the most senior medical office in New South Wales. Dr Hill’s career serves to exemplify how the local practice of individual colonial doctors helped build the reputation of medicine in the modern era