A practical guide to the implementation of AI in orthopaedic research, Part 6: How to evaluate the performance of AI research?

Artificial intelligence's (AI) accelerating progress demands rigorous evaluation standards to ensure safe, effective integration into healthcare's high-stakes decisions. As AI increasingly enables prediction, analysis and judgement capabilities relevant to medicine, proper evaluation and interpretation are indispensable. Erroneous AI could endanger patients; thus, developing, validating and deploying medical AI demands adhering to strict, transparent standards centred on safety, ethics and responsible oversight. Core considerations include assessing performance on diverse real-world data, collaborating with domain experts, confirming model reliability and limitations, and advancing interpretability. Thoughtful selection of evaluation metrics suited to the clinical context along with testing on diverse data sets representing different populations improves generalisability. Partnering software engineers, data scientists and medical practitioners ground assessment in real needs. Journals must uphold reporting standards matching AI's societal impacts. With rigorous, holistic evaluation frameworks, AI can progress towards expanding healthcare access and quality. Level of Evidence: Level V.

ChatGPT can yield valuable responses in the context of orthopaedic trauma surgery.

Purpose: To assess the possibility of using Generative Pretrained Transformer (ChatGPT) specifically in the context of orthopaedic trauma surgery by questions posed to ChatGPT and to evaluate responses (correctness, completeness and adaptiveness) by orthopaedic trauma surgeons. Methods: ChatGPT (GPT-4 of 12 May 2023) was asked to address 34 common orthopaedic trauma surgery-related questions and generate responses suited to three target groups: patient, nonorthopaedic medical doctor and expert orthopaedic surgeon. Three orthopaedic trauma surgeons independently assessed ChatGPT's responses by using a three-point response scale with a response range between 0 and 2, where a higher number indicates better performance (correctness, completeness and adaptiveness). Results: A total of 18 (52.9%) of all responses were assessed to be correct (2.0) for the patient target group, while 22 (64.7%) and 24 (70.5%) of the responses were determined to be correct for nonorthopaedic medical doctors and expert orthopaedic surgeons, respectively. Moreover, a total of 18 (52.9%), 25 (73.5%) and 28 (82.4%) of the responses were assessed to be complete (2.0) for patients, nonorthopaedic medical doctors and expert orthopaedic surgeons, respectively. The average adaptiveness was 1.93, 1.95 and 1.97 for patients, nonorthopaedic medical doctors and expert orthopaedic surgeons, respectively. Conclusion: The study results indicate that ChatGPT can yield valuable and overall correct responses in the context of orthopaedic trauma surgery across different target groups, which encompassed patients, nonorthopaedic medical surgeons and expert orthopaedic surgeons. The average correctness scores, completeness levels and adaptiveness values indicated the ability of ChatGPT to generate overall correct and complete responses adapted to the target group. Level of Evidence: Not applicable.

A practical guide to the implementation of artificial intelligence in orthopaedic research-Part 2: A technical introduction.

Recent advances in artificial intelligence (AI) present a broad range of possibilities in medical research. However, orthopaedic researchers aiming to participate in research projects implementing AI-based techniques require a sound understanding of the technical fundamentals of this rapidly developing field. Initial sections of this technical primer provide an overview of the general and the more detailed taxonomy of AI methods. Researchers are presented with the technical basics of the most frequently performed machine learning (ML) tasks, such as classification, regression, clustering and dimensionality reduction. Additionally, the spectrum of supervision in ML including the domains of supervised, unsupervised, semisupervised and self-supervised learning will be explored. Recent advances in neural networks (NNs) and deep learning (DL) architectures have rendered them essential tools for the analysis of complex medical data, which warrants a rudimentary technical introduction to orthopaedic researchers. Furthermore, the capability of natural language processing (NLP) to interpret patterns in human language is discussed and may offer several potential applications in medical text classification, patient sentiment analysis and clinical decision support. The technical discussion concludes with the transformative potential of generative AI and large language models (LLMs) on AI research. Consequently, this second article of the series aims to equip orthopaedic researchers with the fundamental technical knowledge required to engage in interdisciplinary collaboration in AI-driven orthopaedic research. Level of Evidence: Level IV.

Timing of Anterior Cruciate Ligament Surgery.

This narrative review examines the current literature for the influence of the surgical timing in the setting of anterior cruciate ligament (ACL) reconstruction on various outcomes. Although the exact definition of early and delayed ACL reconstruction (ACLR) is a subject of controversy, surgical timing influences arthrofibrosis and postoperative stiffness, quadriceps strength, postoperative knee function, and the incidence of intra-articular injuries to the menisci and cartilage. Additionally, there is a shortage of evidence regarding the role of ACLR timing in the setting of multiligament knee injury and when concurrent procedures are performed during the operative treatment of the ACL-injured knee.

Return to Work After Anterior Cruciate Ligament Reconstruction: A Systematic Review.

Background: The timing of return to work (RTW) after anterior cruciate ligament (ACL) reconstruction (ACLR) is a less studied milestone compared with return to sports. Purpose: To systematically review the rate and postoperative timing of RTW after ACLR. Study Design: Systematic review; Level of evidence, 4. Methods: This study was conducted in accordance with the 2020 PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement. A literature search was performed in PubMed, Embase, Cochrane, and Ovid databases for clinical studies reporting RTW after ACLR, and 806 studies were identified in August 2022. A quality assessment was performed using the Methodological Index of Nonrandomized Studies (MINORS) grading system. The following data were extracted from studies: study characteristics, cohort demographics, ACLR technique, concomitant meniscal and/or cartilage procedures, preoperative patient-reported outcomes, rates of RTW, and days required for RTW after ACLR. Results: A total of 13 studies met inclusion criteria, totaling 1791 patients (86.4% male). Wide variability was observed in the methodological quality of the assessed studies (MINORS score range, 8-17). Hamstring tendon (HT) autograft was used in 76.8% (n = 1377; mean age, 30.5 years old), allograft in 17.1% (n = 308; mean age, 33.1 years old), the ligament advanced reinforcement system in 2.5% (n = 46; mean age, 33.2 years old), bone-patellar tendon-bone autograft in 2% (n = 36; mean age, 28.5 years old), and quadriceps tendon autograft in 1.3% (n = 24; mean age, 24.1 years old). Among the included patients, 99.1% (n = 1781) reported successful RTW after surgery. The mean time to RTW was 84.2 days (range, 31.4-107.1 days) for HT and 69.5 days (range, 49-56.6 days) for allograft. Conclusion: While data regarding work intensity before and after ACL injury were absent, our study results suggested that patients most often RTW within 90 days of surgery. Patients with allograft ACLR may RTW earlier than patients undergoing ACLR with HT autograft.

Metal interference screw fixation combinations show high revision rates in primary hamstring tendon ACL reconstruction.

BACKGROUND: Different fixation methods in anterior cruciate ligament reconstruction (ACLR) have been associated with different revision rates, specifically in the early postoperative period. However, most previous research has either grouped together different fixation types or evaluated femoral-sided fixation or tibial-sided fixation separately. Therefore, the purpose of this study was to determine ACL revision rates for specific combinations of femoral and tibial fixation methods within 2 years of primary hamstring tendon autograft ACLR based on data from the Swedish National Knee Ligament Registry (SNKLR). METHODS: Patients that underwent primary hamstring tendon autograft ACLR between 2005 and 2018 in the SNKLR were included. The collected data included patient characteristics (age, sex, body mass index [BMI]), activity at time of injury, surgical information (concomitant injuries, time from injury to surgery, fixation types at the femur and tibia), and subsequent revision ACLR. Revision rate within 2 years of the index procedure was chosen, as ACLR fixation is most likely to contribute to ACLR revision within the first 2 years, during graft maturation. RESULTS: Of the 23,238 included patients undergoing primary hamstring ACLR, 581 (2.5%) underwent revision ACLR within 2 years of the index procedure. Among the combinations used for > 300 patients, the femoral metal interference screw/tibial metal interference screw fixation combination had the highest revision rate followed by metal interference screw/resorbable screw and Endobutton/AO screw fixation combinations, with respective revision rates of 4.0, 3.0, and 3.0%. The lowest revision rate within 2 years of ACLR was found in the Endobutton/metal interference screw with backup Osteosuture fixation combination, used in 433 cases, with a failure rate of 0.9%. CONCLUSION: Different early ACL revision rates were found across different combinations of femoral and tibial fixation devices within 2 years of primary hamstring tendon autograft ACLR. Metal interference screw fixation, particularly when performed on both the femoral and tibial sides, most frequently resulted in revision ACLR. These findings may be helpful for surgeons in selecting appropriate fixation devices for hamstring ACLR. LEVEL OF EVIDENCE: IV.

Better Safe Than Sorry? A Systematic Review with Meta-analysis on Time to Return to Sport After ACL Reconstruction as a Risk Factor for Second ACL Injury.

OBJECTIVE: To compare the time to return to sport (RTS) between patients who did and did not suffer a second anterior cruciate ligament (ACL) injury after ACL reconstruction. DESIGN: Etiology systematic review with meta-analysis. LITERATURE SEARCH: Cochrane Library, Embase, Medline, AMED, and PEDro databases were searched in August 2021 and again in November 2022. STUDY SELECTION CRITERIA: Clinical studies reporting time to RTS after ACL reconstruction and second ACL injury were eligible. DATA SYNTHESIS: We pooled continuous data (time [months] and proportions [%]), with random-effects meta-analyses. Pooled estimates were summarized in forest plots. A qualitative data synthesis was also performed. RESULTS: Twenty-one studies were included in the meta-analysis and 33 in the qualitative synthesis. Pooled incidence of second ACL injury was 16.9% (95% confidence interval [CI]: 12.8, 21.6). Patients who suffered a second ACL injury returned to sport significantly earlier (25 days; 95% CI: 9.5, 40.4) than those who did not suffer another injury. There was no difference in time to RTS for professional athletes who suffered a second ACL injury and those who did not. The certainty of evidence was very low. CONCLUSION: There was very low-certainty evidence that patients who suffered a second ACL injury had returned to sport 25 days earlier than patients who did not have another injury. For professional athletes, there was no difference in time to RTS between athletes who suffered a second ACL injury and athletes who did not. J Orthop Sports Phys Ther 2024;54(3):1-15. Epub 30 November 2023. doi:10.2519/jospt.2023.11977.

A practical guide to the implementation of AI in orthopaedic research - part 1: opportunities in clinical application and overcoming existing challenges.

Artificial intelligence (AI) has the potential to transform medical research by improving disease diagnosis, clinical decision-making, and outcome prediction. Despite the rapid adoption of AI and machine learning (ML) in other domains and industry, deployment in medical research and clinical practice poses several challenges due to the inherent characteristics and barriers of the healthcare sector. Therefore, researchers aiming to perform AI-intensive studies require a fundamental understanding of the key concepts, biases, and clinical safety concerns associated with the use of AI. Through the analysis of large, multimodal datasets, AI has the potential to revolutionize orthopaedic research, with new insights regarding the optimal diagnosis and management of patients affected musculoskeletal injury and disease. The article is the first in a series introducing fundamental concepts and best practices to guide healthcare professionals and researcher interested in performing AI-intensive orthopaedic research studies. The vast potential of AI in orthopaedics is illustrated through examples involving disease- or injury-specific outcome prediction, medical image analysis, clinical decision support systems and digital twin technology. Furthermore, it is essential to address the role of human involvement in training unbiased, generalizable AI models, their explainability in high-risk clinical settings and the implementation of expert oversight and clinical safety measures for failure. In conclusion, the opportunities and challenges of AI in medicine are presented to ensure the safe and ethical deployment of AI models for orthopaedic research and clinical application. Level of evidence IV.

Applications of Extended Reality in Orthopaedic Surgery.

➤ Extended reality is a term that encompasses different modalities, including virtual reality, augmented reality, and mixed reality.➤ Although fully immersive virtual reality has benefits for developing procedural memory and technical skills, augmented and mixed reality are more appropriate modalities for preoperative planning and intraoperative utilization.➤ Current investigations on the role of extended reality in preoperative planning and intraoperative utilization are still in the early stages, but preliminarily show that extended reality technologies can help surgeons to be more accurate and efficient.

Failure Rates and Complications After Multiple-Revision ACL Reconstruction: Comparison of the Over-the-Top and Transportal Drilling Techniques.

Background: Multiple-revision anterior cruciate ligament reconstruction (ACLR) presents several technical challenges, often due to residual hardware, tunnel widening, malposition, or staged surgeries. Purpose: To compare failure and complication rates between the over-the-top (OTT) and transportal drilling (TD) techniques in patients undergoing surgery for failed revision ACLR. Study Design: Cohort study; Level of evidence, 3. Methods: The medical records of patients with at least 2 revision ACLRs using either the OTT or TD technique were reviewed retrospectively. Data on patient demographics, graft characteristics, number of revisions, concomitant procedures, complications, and failures were collected. Between-group comparisons of continuous and categorical variables were conducted with the independent-samples t test and the Fisher exact or chi-square test, respectively. Results: A total of 101 patients undergoing multiple-revision ACLR with OTT (n = 37, 37%) and TD (n = 64, 63%) techniques were included for analysis. The mean follow-up time was 60 months (range, 12-196 months). There were no significant differences in age, sex, body mass index, laterality, or follow-up length between groups (P > .05). Allograft was the graft used most frequently (n = 64; 67.3%) with no significant differences between groups in graft diameter (P > .05). There were no statistically significant differences between groups regarding rate of concurrent medial and lateral meniscus, cartilage, or lateral extra-articular procedures (P > .05). There was also no significant66 between-group difference in complication rate (OTT: n = 2 [5.4%]; TD: n = 8 [13%]) or graft failure rate (OTT: n = 4 [11%]; TD: n = 14 [22%]) (P > .05 for both). Conclusion: The results of this study showed notably high failure and complication rates in challenging multiple-revision ACLR. Complication and failure rates were similar between techniques, demonstrating that the OTT technique is a valuable alternative that can be used in a revision ACLR, particularly as a single-stage approach when the single-stage TD technique is not possible.

Anatomic Anterior Cruciate Ligament Reconstruction.

Anterior cruciate ligament reconstruction (ACLR) techniques have substantially evolved over the past several decades, driven by evidence that nonanatomic techniques increase the risk for instability, loss of motion, surgical failure, and posttraumatic osteoarthritis. Early techniques used transtibial femoral tunnel drilling, although improved understanding of the anatomy and biomechanics has led to independent femoral tunnel. Anatomic ACLR requires careful consideration of the native ACL dimensions and orientation. Although there is significant variation between patients, understanding of anatomic patterns allows for reliable identification of the ACL footprints and appropriate tunnel positioning, particularly in chronic injuries where the remanent ACL stump is degraded or absent. The femoral tunnel should be placed low and posterior on the lateral femoral condyle using the lateral intercondylar and bifurcate ridges as landmarks. The center of the tibial footprint can be determined by referencing the medial tibial spine and posterior border of anterior horn of lateral meniscus. Measurement of the dimensions of the native ACL and intercondylar notch is also critical for determining graft size and minimizing the risk of impingement, with a goal of reconstructing 50% to 80% of the tibial footprint area. Clinical outcome studies have demonstrated superior anteroposterior and rotatory knee stability with low surgical revision rates (reported between 3% and 5%). By adhering to the principles of anatomic ACLR, surgeons can produce an appropriately sized and located graft for the individual patient, thereby best restoring native knee kinematics and maximizing function. The aim of this infographic is to highlight essential features of anatomic ACLR techniques, which a focus on the native anatomy and surgical planning to achieve an anatomic ACLR.

Exploring the potential of ChatGPT as a supplementary tool for providing orthopaedic information.

PURPOSE: To investigate the potential use of large language models (LLMs) in orthopaedics by presenting queries pertinent to anterior cruciate ligament (ACL) surgery to generative pre-trained transformer (ChatGPT, specifically using its GPT-4 model of March 14th 2023). Additionally, this study aimed to evaluate the depth of the LLM's knowledge and investigate its adaptability to different user groups. It was hypothesized that the ChatGPT would be able to adapt to different target groups due to its strong language understanding and processing capabilities. METHODS: ChatGPT was presented with 20 questions and response was requested for two distinct target audiences: patients and non-orthopaedic medical doctors. Two board-certified orthopaedic sports medicine surgeons and two expert orthopaedic sports medicine surgeons independently evaluated the responses generated by ChatGPT. Mean correctness, completeness, and adaptability to the target audiences (patients and non-orthopaedic medical doctors) were determined. A three-point response scale facilitated nuanced assessment. RESULTS: ChatGPT exhibited fair accuracy, with average correctness scores of 1.69 and 1.66 (on a scale from 0, incorrect, 1, partially correct, to 2, correct) for patients and medical doctors, respectively. Three of the 20 questions (15.0%) were deemed incorrect by any of the four orthopaedic sports medicine surgeon assessors. Moreover, overall completeness was calculated to be 1.51 and 1.64 for patients and medical doctors, respectively, while overall adaptiveness was determined to be 1.75 and 1.73 for patients and doctors, respectively. CONCLUSION: Overall, ChatGPT was successful in generating correct responses in approximately 65% of the cases related to ACL surgery. The findings of this study imply that LLMs offer potential as a supplementary tool for acquiring orthopaedic knowledge. However, although ChatGPT can provide guidance and effectively adapt to diverse target audiences, it cannot supplant the expertise of orthopaedic sports medicine surgeons in diagnostic and treatment planning endeavours due to its limited understanding of orthopaedic domains and its potential for erroneous responses. LEVEL OF EVIDENCE: V.

Delayed multiligament PCL reconstruction is associated with a higher prevalence of intraarticular injury and may influence treatment.

BACKGROUND: The aim of this study was to investigate differences in concomitant injury patterns and their treatment in patients undergoing early (≤ 12 weeks) and delayed (> 12 weeks) primary multiligament posterior cruciate ligament (PCL) reconstruction (PCL-R). METHODS: This study was a retrospective chart review of patients undergoing primary multiligament PCL-R at a single institution between 2008 and 2020. Multiligament PCL-R was defined as PCL-R and concurrent surgical treatment of one or more additional knee ligament(s). Exclusion criteria included isolated PCL-R, PCL repair, and missing data for any variable. Patients were dichotomized into early (≤ 12 weeks) and delayed (> 12 weeks) PCL-R groups based on the time elapsed between injury and surgery. Between-group comparison of variables were conducted with the Chi-square, Fisher's exact, and independent samples t-tests. RESULTS: A total of 148 patients were eligible for analysis, with 57 (38.5%) patients in the early and 91 (61.1%) patients in the delayed multiligament PCL-R groups. Concomitant LCL/PLC reconstruction (LCL-R/PLC-R) was performed in 55 (60%) of delayed multiligament PCL-Rs and 23 (40%) of early PCL-Rs (p = 0.02). Despite similar rates of meniscus injury, concomitant meniscus surgery was significantly more prevalent in the early (n = 25, 44%) versus delayed (n = 19, 21%) multiligament PCL-R group (p = 0.003), with a significantly greater proportion of medial meniscus surgeries performed in the early (n = 16, 28%) compared to delayed (n = 13, 14%) PCL-R group (p = 0.04). The prevalence of knee cartilage injury was significantly different between the early (n = 12, 24%) and delayed (n = 41, 46%) multiligament PCL-R groups (p = 0.01), with more frequent involvement of the lateral (n = 17, 19% vs. n = 3, 5%, respectively; p = 0.04) and medial (n = 31, 34% vs. n = 6, 11%, respectively; p = 0.005) femoral condyles in the delayed compared to the early PCL-R group. CONCLUSIONS: Given higher rates of chondral pathology and medial meniscus surgery seen in delayed multiligament PCL-R, early management of PCL-based multiligament knee injury is recommended to restore knee stability and potentially prevent the development of further intraarticular injury. LEVEL OF EVIDENCE: Level III.

Single-Stage Correction of Genu Valgum Recurvatum by Distal Femoral and High Tibial Opening Wedge Osteotomies: A Case Report.

CASE: A 32-year-old woman with genu valgum recurvatum presented to clinic complaining of long-standing anterior knee pain. Radiographs demonstrated a 13° anterior tibial slope and 15° valgus malalignment. She underwent a single-stage 2-level osteotomy at the distal femur and proximal tibia to simultaneously correct genu valgum and recurvatum. This procedure achieved precise correction in both planes. At 1 year, the patient was pain-free and ambulated without restriction. CONCLUSION: This procedure should be considered among the available surgical options when treating genu valgum recurvatum because it produced excellent results for the studied patient.

Generalised joint hypermobility leads to increased odds of sustaining a second ACL injury within 12 months of return to sport after ACL reconstruction.

OBJECTIVES: To determine the 12-month risk of a second anterior cruciate ligament (ACL) injury in a population of patients with and without generalised joint hypermobility (GJH) who return to sports (RTS) at competition level after ACL reconstruction (ACL-R). METHODS: Data were extracted from a rehabilitation-specific registry for 16-50-year-old patients treated with ACL-R between 2014 and 2019. Demographics, outcome data and the incidence of a second ACL injury within 12 months of RTS, defined as a new ipsilateral or contralateral ACL, were compared between patients with and without GJH. Univariable logistic regression and Cox proportional hazards regression were performed to determine the influence of GJH and time of RTS on the odds of a second ACL injury, and ACL-R survival without a second ACL injury after RTS. RESULTS: A total of 153 patients, 50 (22.2%) with GJH and 175 (77.8%) without GJH, were included. Within 12 months of RTS, 7 (14.0%) patients with GJH and 5 (2.9%) without GJH had a second ACL injury (p=0.012). The odds of sustaining a second ipsilateral or contralateral ACL injury were 5.53 (95% CI 1.67 to 18.29) higher in patients with GJH compared with patients without GJH (p=0.014). The lifetime HR of a second ACL injury after RTS was 4.24 (95% CI 2.05 to 8.80; p=0.0001) in patients with GJH. No between-group differences were observed in patient-reported outcome measures. CONCLUSION: Patients with GJH undergoing ACL-R have over five times greater odds of sustaining a second ACL injury after RTS. The importance of joint laxity assessment should be emphasised in patients who aim to return to high-intensity sports following ACL-R.

Arthroscopic all-inside repair of challenging meniscus tears.

Meniscus tears are prevalent in isolation and in combination with anterior cruciate ligament (ACL) injury. Meniscus lesions can be difficult to access and often display complex tear patterns, which result in technical challenges for the operating surgeon during surgical treatment. The aim of this video article is to demonstrate technical tips and tricks for performing all-inside repair of challenging meniscus tears. The presented techniques are indicated in young, physically active patients with symptomatic tears of the lateral and medial menisci, with or without concomitant ACL injury. The procedure is performed using standard anterolateral and anteromedial arthroscopic portals for direct visualization of complex meniscus tear patterns and all-inside instrument access. A suture passing device is used for the placement of suture loops for meniscus root repair. All-inside repair devices are used to repair the radial meniscal tears along the native circumferential fibers using a horizontal mattress suture configuration, with curved devices to achieve optimal access to challenging tears affecting the anterior and posterior aspects at the mid-body of the meniscus. Repair of radial tears at the avascular zone of the meniscus may be augmented with an autologous fibrin clot delivered using an arthroscopic cannula.

Treatment of Primary Dorsal Wrist Ganglion-A Systematic Review.

Purpose The aim of this study was to compare the rates of recurrence and wound infection in patients with primary dorsal wrist ganglion treated with aspiration (with or without an injection of an additive), open excision, or arthroscopic resection. Methods This systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines and registered on PROSPERO. Systematic electronic searches in PubMed (MEDLINE), EMBASE, Web of Science, and the Cochrane Library of Controlled Trials were performed on May 5, 2020, and June 1, 2021, respectively. All clinical studies written in English determining the recurrence and wound infection rates after treatment of primary dorsal wrist ganglion with aspiration, open excision, or arthroscopic resection in patients over the age of 16 years were eligible for inclusion. Quality assessment was guided by the Cochrane Collaboration's tool for randomized controlled trials (RCTs) and the methodological index for nonrandomized studies (MINORS) tool for observational studies. Results The literature searches resulted in 1,691 studies. After screening, five RCTs, enrolling 233 patients, and six observational studies, enrolling 316 patients with primary dorsal wrist ganglions were included. Quality assessment of the included RCTs and observational studies determined the existing level of evidence pertaining to primary dorsal wrist ganglion treatment to be low. About 11 studies reported on recurrence rate, which ranged between 7 and 72% for patients initially treated with aspiration (with or without an injection of an additive). In comparison, the recurrence rate for the open excision and arthroscopic resection groups ranged between 6 to 41% and 0 to 16%, respectively. Four studies investigated wound-related complications, for which zero infections were reported, irrespective of treatment. Conclusion The evidence summarized in this systematic review demonstrates a considerable variability in recurrence rate following aspiration and open or arthroscopic resection of a primary dorsal wrist ganglion. The greatest variability in recurrence was displayed among studies on aspiration. The overall infection rate after treatment of dorsal wrist ganglions seems to be low regardless of the treatment type. However, the divergent results of individual studies highlight a pressing need for prospective controlled trials assessing outcomes following dorsal wrist ganglion treatment. Level of Evidence Systematic review on level 1 to 4 clinical therapeutic studies.

Sports activity and quality of life improve after isolated ACL, isolated PCL, and combined ACL/PCL reconstruction.

PURPOSE: To compare patient-reported outcomes following isolated anterior cruciate ligament reconstruction (ACL-R), isolated posterior cruciate ligament reconstruction (PCL-R), and combined ACL-R and PCL-R (ACL/PCL-R), at a minimum follow-up of 2 years. METHODS: This was a prospective observational registry cohort study based on the Swedish National Knee Ligament Registry. Patients undergoing isolated ACL-R, isolated PCL-R, and combined ACL/PCL-R between 2005 and 2019 were eligible for inclusion. Demographic characteristics as well as injury- and surgery-related data were queried from the SNKLR. To evaluate functional outcomes, the Knee Injury and Osteoarthritis Outcome Score (KOOS) was collected preoperatively and at 1- and 2-year follow-ups and compared between the treatment groups. RESULTS: In total, 45,169 patients underwent isolated ACL-R, 192 patients isolated PCL-R, and 203 patients combined ACL/PCL-R. Preoperatively, and at the 1- and 2-year follow-ups, KOOS subscales were highest for the isolated ACL-R group, followed by the isolated PCL-R, and lowest for the combined ACL/PCL-R groups. Significant improvements were observed across all treatment groups in the majority of KOOS subscales between the preoperative, and 1- and 2-year follow-ups. All treatment groups showed the greatest improvements between the preoperative and 2-year follow-ups in the knee-related quality of life (mean improvement: isolated ACL-R, + 28 points; isolated PCL-R, + 23 points; combined ACL/PCL-R, + 21 points) and the function in sport and recreation (mean improvement: isolated ACL-R, + 26 points; isolated PCL-R, + 20 points; combined ACL/PCL-R, + 19 points) subscales. CONCLUSION: Clinically relevant improvements in knee function can be expected after isolated ACL-R, isolated PCL-R, and combined ACL/PCL-R. Functional improvements were particularly pronounced in the KOOS function in sport and recreation subscale, indicating the importance of knee stability for sports activity. This study facilitates more comprehensive patient education about functional expectations after surgical treatment of isolated and combined ACL and PCL injuries. LEVEL OF EVIDENCE: Level 2.