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

Optimization of Ramp Area Aircraft Push Back Time Windows in the Presence of Uncertainty

It is well known that airport surface traffic congestion at major airports is responsible for increased taxi-out times, fuel burn and excess emissions and there is potential to mitigate these negative consequences through optimizing airport surface traffic operations. Due to a highly congested voice communication channel between pilots and air traffic controllers and a data communication channel that is used only for limited functions, one of the most viable near-term strategies for improvement of the surface traffic is issuing a push back advisory to each departing aircraft.This dissertation focuses on the optimization of a push back time window for each departing aircraft. The optimization takes into account both spatial and temporal uncertainties of ramp area aircraft trajectories. The uncertainties are described by a stochastic kinematic model of aircraft trajectories, which is used to infer distributions of combinations of push back times that lead to conflict among trajectories from different gates. The model is validated and the distributions are included in the push back time window optimization. Under the assumption of a fixed taxiway spot schedule, the computed push back time windows can be integrated with a higher level taxiway scheduler to optimize the flow of traffic from the gate to the departure runway queue. To enable real-time decision making the computational time of the push back time window optimization is critical and is analyzed throughout