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

Background: Anterior 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. Methods: We 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. Findings: Between 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. Interpretation: Surgical 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. Funding: The UK National Institute for Health Research Health Technology Assessment Programme

Training future generations to deliver evidence-based conservation and ecosystem management

Data availability statement: No data was used in this study.Peer review: The peer review history for this article is available at: https://publons.com/publon/10.1002/2688-8319.12032.Supporting Information: eso312032-sup-0001-SuppMat.docx (21.1 KB) available at: https://besjournals.onlinelibrary.wiley.com/action/downloadSupplement?doi=10.1002%2F2688-8319.12032&file=eso312032-sup-0001-SuppMat.docx. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.Copyright © 2021 The Authors. 1. To be effective, the next generation of conservation practitioners and managers need to be critical thinkers with a deep understanding of how to make evidence-based decisions and of the value of evidence synthesis. 2. If, as educators, we do not make these priorities a core part of what we teach, we are failing to prepare our students to make an effective contribution to conservation practice. 3. To help overcome this problem we have created open access online teaching materials in multiple languages that are stored in Applied Ecology Resources. So far, 117 educators from 23 countries have acknowledged the importance of this and are already teaching or about to teach skills in appraising or using evidence in conservation decision-making. This includes 145 undergraduate, postgraduate or professional development courses. 4. We call for wider teaching of the tools and skills that facilitate evidence-based conservation and also suggest that providing online teaching materials in multiple languages could be beneficial for improving global understanding of other subject areas. Making informed conservation and ecosystem management choices is based upon a sound understanding of the relevant evidence. There is an increasing wealth of conservation science available, and access to this is becoming easier. But, are conservation practitioners being trained to utilize this information? In conservation, decision-making is often based upon past experience or expert knowledge, as opposed to the full body of scientific literature (e.g., Pullin, Knight, Stone, & Charman, 2004; Rafidimanantsoa, Poudyal, Ramamonjisoa, & Jones, 2018). The failure to include scientific evidence in decision-making has the potential to reduce the effectiveness of management, or even lead to detrimental actions being undertaken (Walsh, Dicks, & Sutherland, 2015). Evidence-based conservation (EBC) seeks to avoid this by providing tools to facilitate and inform decision-making. To do this, scientific evidence is collated and critically appraised for its quality and relevance, and integrated with other knowledge, experience, values and costs (Sutherland, Pullin, Dolman, & Knight, 2004). Wider adoption of EBC requires conservation professionals to be trained in its principles and taught how to use it to inform conservation decision-making.MAVA Foundation; Arcadia Fund

Effectiveness of nail bed repair in children with or without replacing the fingernail : NINJA multicentre randomized clinical trial

Background Surgery for nail bed injuries in children is common. One of the key surgical decisions is whether to replace the nail plate following nail bed repair. The aim of this RCT was to assess the clinical effectiveness and cost-effectiveness of nail bed repair with fingernail replacement/substitution compared with repair without fingernail replacement. Methods A two-arm 1 : 1 parallel-group open multicentre superiority RCT was performed across 20 secondary-care hospitals in the UK. The co-primary outcomes were surgical-site infection at around 7 days after surgery and cosmetic appearance summary score at a minimum of 4 months. Results Some 451 children presenting with a suspected nail bed injury were recruited between July 2018 and July 2019; 224 were allocated to the nail-discarded arm, and 227 to the nail-replaced arm. There was no difference in the number of surgical-site infections at around 7 days between the two interventions or in cosmetic appearance. The mean total healthcare cost over the 4 months after surgery was €84 (95 per cent c.i. 34 to 140) lower for the nail-discarded arm than the nail-replaced arm (P < 0.001). Conclusion After nail bed repair, discarding the fingernail was associated with similar rates of infection and cosmesis ratings as replacement of the finger nail, but was cost saving

Wetland creation in limestone quarries: enabling colonisation and enriching biodiversity. Quarry Life Award final project report

Wetland habitats, chiefly deep mesotrophic lakes, will be a major component of the final restoration of the Chipping Sodbury limestone quarry complex. This research aimed to develop best practice in creating valuable biodiverse wetland habitats in and around the limestone quarry complex to augment the region

Assessing habitat quality parameters and sand properties on sand lizard 'Lacerta agilis' breeding sites to inform the creation of receptor sites. Quarry Life Award final project report

Research shows that the internationally protected sand lizard Lacerta agilis L. has specific habitat requirements, especially when occurring at the edge of its distribution range. Quarrying for sand and gravel deposits when the occurrence of sand lizards and other rare species has been confirmed necessitates the translocation of the animals to a suitable receptor site to preserve breeding populations and to avoid legislative penalties. The aim of this research project was to compare habitat quality and sand quality parameters in one such receptor site, Hyde Pit at Masters Quarry in Dorset, with nearby known sand lizard breeding sites to inform the future creation of suitable receptor sites within the context of planned resource extraction, and climate change. We were able to confirm that the receptor site features many of the known key habitat parameters essential for sand lizards, both in terms of vegetation structure and floral composition, as well as sand quality. Specifically, multivariate ordination techniques using a comprehensive set of environmental variables confirmed that Hyde Pit clusters in considerable overlap with the other known L. agilis breeding sites but features more extensive areas of bare sand and early successional habitat, which is known to be particularly crucial for breeding activity. Managed removal of dense coniferous woodland releases suppressed and fragmented heathland, and existing low numbers of sand lizards, supplemented by animals translocated from planned sand reserves, can form viable populations under these conditions. Receptor areas may represent important foci for sand lizard population expansion under conditions of climate change and heathland succession. Focusing management on improving conditions for the sand lizard on these newly created heathland mosaic sites may also prove to be important for maintaining populations of other specialist heathland organisms

Wetland creation in limestone quarries: enabling colonisation and enriching biodiversity. Quarry Life Award final project report

Wetland habitats, chiefly deep mesotrophic lakes, will be a major component of the final restoration of the Chipping Sodbury limestone quarry complex. This research aimed to develop best practice in creating valuable biodiverse wetland habitats in and around the limestone quarry complex to augment the region

Assessing habitat quality parameters and sand properties on sand lizard 'Lacerta agilis' breeding sites to inform the creation of receptor sites. Quarry Life Award final project report

Research shows that the internationally protected sand lizard Lacerta agilis L. has specific habitat requirements, especially when occurring at the edge of its distribution range. Quarrying for sand and gravel deposits when the occurrence of sand lizards and other rare species has been confirmed necessitates the translocation of the animals to a suitable receptor site to preserve breeding populations and to avoid legislative penalties. The aim of this research project was to compare habitat quality and sand quality parameters in one such receptor site, Hyde Pit at Masters Quarry in Dorset, with nearby known sand lizard breeding sites to inform the future creation of suitable receptor sites within the context of planned resource extraction, and climate change. We were able to confirm that the receptor site features many of the known key habitat parameters essential for sand lizards, both in terms of vegetation structure and floral composition, as well as sand quality. Specifically, multivariate ordination techniques using a comprehensive set of environmental variables confirmed that Hyde Pit clusters in considerable overlap with the other known L. agilis breeding sites but features more extensive areas of bare sand and early successional habitat, which is known to be particularly crucial for breeding activity. Managed removal of dense coniferous woodland releases suppressed and fragmented heathland, and existing low numbers of sand lizards, supplemented by animals translocated from planned sand reserves, can form viable populations under these conditions. Receptor areas may represent important foci for sand lizard population expansion under conditions of climate change and heathland succession. Focusing management on improving conditions for the sand lizard on these newly created heathland mosaic sites may also prove to be important for maintaining populations of other specialist heathland organisms