The efficacy of medial patellofemoral ligament reconstruction combined with tibial tuberosity transfer in the treatment of patellofemoral instability

A systematic review of the literature was undertaken to evaluate the efficacy of medial patellofemoral ligament (MPFL) reconstruction combined with tibial tuberosity transfer (TTT) in the treatment of patellofemoral instability. Using PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, a systematic search was carried out to identify and review the published literature pertinent to MFPL reconstruction combined with TTT. Relevant studies were critically appraised with narrative data synthesis. Studies that met the eligibility criteria were suitable for appraisal and consisted of case series and therapeutic series (levels IV & III). All studies had inherent variations in outcomes reporting and limited follow-up. Combined treatment offers restoration of normal anatomy, thus adding clinical value to the currently recommended anatomic approach to MPFL reconstruction. Nevertheless, the current body of evidence does not determine the threshold at which patellofemoral axis requires the need for adjunctive distal realignment as opposed to MPFL reconstruction alone. This review highlighted numerous recurring limitations in the conduct and presentation of the studies, which inadvertently mitigated the interpretation of their results. Future priority should be awarded to larger randomised controlled trials utilising validated patient reported outcome measures

Comparison of outcomes following arthroscopic capsular release for idiopathic, diabetic and secondary adhesive capsulitis of the shoulder: a systematic review

Introduction: Arthroscopic capsular release for adhesive capsulitis of the shoulder is a treatment option. The present study aimed to investigate the clinical outcomes following arthroscopic capsular release among idiopathic, diabetic and secondary adhesive capsulitis. Hypothesis: Different aetiological groups yield variable outcomes following arthroscopic capsular release. Materials and Methods: A literature search was performed using MEDLINE, EMBASE, CINAHL and the Cochrane Database in April 2017. Comparative studies that reported range of motion or functional outcomes following arthroscopic capsular release in patients with adhesive capsulitis were included. A systematic review of the studies was conducted following the PRISMA guidelines. Results: Six studies met the eligibility criteria. The overall population included 463 patients; 203 idiopathic, 61 diabetic and 199 secondary cases. Of four studies comparing idiopathic and diabetic patients, three reported significantly worse range of movement and function in the diabetic group at various follow up points. No significant difference in function and motion was reported between the idiopathic and secondary groups. Recurrent pain was highest in diabetic patients (26%) compared to idiopathic groups (0%) and the secondary group had a higher rate of revision surgery when compared to the idiopathic group (8.1% vs. 2.4%) Discussion: Arthroscopic capsular release has a high success rate regardless of the underlying aetiology. However, diabetic patients are reported to have more residual pain, reduced motion and inferior function compared to idiopathic cases. The rate of revision capsular release is higher among patients with post-surgical adhesive capsulitis when compared to idiopathic cases. Level of evidence: Level IV, systematic review

The perceptions and attitudes of medical students towards trauma and orthopaedic teaching: a cross-sectional study

Objectives: This study aimed to identify how undergraduate students perceive learning opportunities available to them and to determine whether students with an interest in trauma and orthopaedic (T&O) surgery have different perceptions and attitudes towards learning. Methods: All fourth year medical students from the University of Birmingham Medical School (UK) were surveyed regarding their career intentions and their attitudes towards the teaching received in trauma and orthopaedic surgery. The questionnaire was designed to capture student perception of learning environments, core knowledge and career motivations. Results: Of the 157 respondents, 35 (22.3%) expressed an interest in a career in trauma and orthopaedic surgery. Medical students who reported educational value for trauma and orthopaedic surgery revealed that bedside teaching with a consultant was perceived extremely useful by 57.8% (n = 89). A similar ranking was awarded to small group teaching seminars and bedside teaching with a junior doctor or trainee by 54.5% (n = 85) and 51.6% (n = 79) of students, respectively. In contrast, trauma meetings and operating theatre learning environments were perceived to be of low educational value. Seeing patients within the clinical setting and the quality of teaching received were reported as the most motivating factors in career interest towards trauma and orthopaedic surgery, rated 43.9% (n = 69) and 35% (n = 55), respectively. Conclusions: Perceptions of educational benefit derived from each learning environment vary among undergraduate medical students. Overall the most valuable learning environment perceived by the students is formal patient-based teaching. Despite diverging speciality choices students demonstrate similar learning needs

Transfer of arthroscopic skills from computer simulation training to the operating theatre: a review of evidence from two randomised controlled studies.

INTRODUCTION There is paucity in the research on transfer validity of arthroscopic simulator training. The aim of this article is to determine whether skills derived from arthroscopic simulation are transferrable to the operating theatre and retained over time. METHODS A systematic review with rigorous criteria to identify the highest level of evidence available was carried out. The studies were critically appraised with narrative data synthesis. RESULTS Twenty-one studies on arthroscopic simulation were identified. Only two studies were randomised controlled trials. The first article demonstrated improved performance of basic knee arthroscopic tasks following a fixed period of training. The second article showed improved performance of arthroscopic tasks and no deterioration in the levels of skills following a period of six months. In addition, the two studies succeeded in demonstrating the importance of 3D motion analysis using computer simulators in the assessment of technical skills. Components of evaluation such as time to task completion, distance travelled by instruments and incidence of instruments collisions were associated with the highest validity and reliability of assessment. This systematic review highlighted the limitations of these two randomised studies. DISCUSSION Evidence from the two trials suggests that knee arthroscopy simulator training can result in improved performance. This review helped highlight the contribution of the two studies in terms of internal validity and consistency of using arthroscopic skills training. Further level I studies are however required to demonstrate the evidence for transfer and predictive validity of computer simulation as a training instrument

The role of UK national ligament registry as additional source of evidence for anterior cruciate ligament reconstruction: Review of the literature and future Perspectives

Background: There is paucity in studies reporting long-term results following anterior cruciate ligament (ACL) rupture. A UK national ligament registry (NLR) designed to collect demographic, clinical and outcome data on patients undergoing ACL reconstruction was launched in 2013. There was therefore an emergent question on the role of such registry as an additional source of evidence. Study aims: A framework analysis aimed to provide a basis for the evaluation of outcomes following ACL management and formulate a structure of the evidence, which can be derived from the registry. Methods: A systematic approach was adopted to select relevant studies. Qualitative thematic and meta-narrative analyses were conducted. Level-1 registry data were recorded for all primary ACL reconstruction procedures from January to June 2016. Registry data content and validity were evaluated. Results: Seven studies were suitable for analyses yet none defined the pattern of meniscal injury following initial treatment. When reported the incidence varied markedly between 23% and 80%. There was evidence of collection of at least one principal outcome measure in at least 85% of participants across all studies. Thematic analysis identified four key domains of outcome measures (1) intervention selection, (2) Knee stability evaluation, (3) Patient reported outcomes, (4) Radiographic evaluation and risk of secondary osteoarthritis. Graft choice, rate of meniscal and chondral injuries and cumulative risk of revision surgery had incomplete and inconsistent reports. Comparison of demographic and clinical data with the first registry report demonstrated: predominately younger patient population; older female patients at time of intervention; and higher incidence of meniscal tears. Conclusions: Registry data driven quality and research improvement open a new paradigm in ACL reconstruction evidence base and future practice. Early observations have consolidated the importance of associated meniscal injuries in the management of ACL rupture. Further work is needed to improve registry data completeness, accuracy and validity. A proposed data migration process using available technologies can help harmonise data collection without the added burden on clinical services