Impact of national commissioning of pre-exposure prophylaxis (PrEP) on equity of access in England: a PrEP-to-need ratio investigation.

OBJECTIVES: HIV pre-exposure prophylaxis (PrEP) is highly effective in preventing HIV acquisition. In England, NHS availability was limited to participants of the PrEP Impact Trial until late 2020. Some key populations at greater risk of HIV were under-represented in the trial suggesting inequities in trial PrEP access. We used the PrEP-to-need ratio (PnR; number of PrEP users divided by new HIV diagnoses) to investigate whether PrEP access improved following routine commissioning in October 2020 and identify populations most underserved by PrEP. METHODS: Aggregated numbers of people receiving ≥1 PrEP prescription and non-late new HIV diagnoses (epidemiological proxy for PrEP need) were taken from national surveillance data sets. We calculated the PnR across socio-demographics during Impact (October 2017 to February 2020; pre-COVID-19 pandemic) and post-commissioning PrEP era (2021) in England. RESULTS: PnR increased >11 fold, from 4.2 precommissioning to 48.9 in 2021, due to a fourfold reduction in non-late new HIV diagnoses and near threefold increase in PrEP users. PnR increased across genders, however, the men's PnR increased 12-fold (from 5.4 precommissioning to 63.9 postcommissioning) while the women's increased sevenfold (0.5 to 3.5). This increasing gender-based inequity was observed across age, ethnicity and region of residence: white men had the highest PnR, increasing >13 fold (7.1 to 96.0), while Black African women consistently had the lowest PnR, only increasing slightly (0.1 to 0.3) postcommissioning, suggesting they were the most underserved group. Precommissioning, the PnR was 78-fold higher among white men than Black women, increasing to 278-fold postcommissioning. CONCLUSIONS: Despite the overall increase in PrEP use, substantial PrEP Impact trial inequities widened postcommissioning in England, particularly across gender, ethnicity and region of residence. This study emphasises the need to guide HIV combination prevention based on equity metrics relative to the HIV epidemic. The PnR could support the optimisation of combination prevention to achieve zero new HIV infections in England by 2030.

No difference in return to play rates between different elite sports after primary autograft ACL reconstruction.

PURPOSE: To demonstrate return to play (RTP) rates, the level of RTP and time taken to RTP in different sports after anterior cruciate ligament reconstruction (ACL-R) and compare the differences between football and rugby. The secondary aims were to compare the differences in intra articular injuries and their treatments and reoperation rates between these sports. METHODS: A retrospective review of a consecutive series of all primary ACL-R undertaken by the senior author between 2005 and 2019 was undertaken. Patients were included if they were elite athletes and were a minimum of 2 year post-primary autograft ACL-R. The outcomes measured were RTP (defined as participation in a professional match or in national/international-level competition in amateur sports), time to RTP after surgery and RTP level (Tegner score). RESULTS: Three hundred and ninety-four elite athletes, with 420 ACL-Rs were included. 235 (55.9%) were in footballers and 125 (29.8%) were in rugby players. 399 (95.0%) of all elite athletes returned to competition at an average of 10.3 months after ACL-R. 386 (90.2% played at the same or higher level post-surgery. Although there was no difference in RTP rates between different sports, rugby players RTP significantly faster than footballers (9.6 vs 10.6 months, (p = 0.027). Footballers were more likely to rupture their ACL during jumping/landing manoeuvres and to receive a PT graft than rugby players. There were no other significant differences between football and rugby players regarding patient characteristics, intraoperative findings, re-rupture and re-operation rates. CONCLUSIONS: Over 95% of all elite athletes RTP after primary ACL-R with 90% able to play at the same level. Rugby players RTP significantly faster than footballers. LEVEL OF EVIENCE: Level IV.

Characteristics of HIV post-exposure prophylaxis recipients at six English sexual health clinics during COVID-19.

OBJECTIVES: Disruption to sexual health services during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2; coronavirus disease 2019 [COVID-19]) pandemic may have adversely affected the provision of HIV post-exposure prophylaxis (PEP), possibly leading to increased HIV transmission. Globally, services have reported a reduction in the number of PEP prescriptions dispensed during lockdowns, although it is unclear why. Our primary objective was to describe the temporal change in weekly HIV PEP dispensed at six English sexual health clinics in 2020. METHODS: We performed a cross-sectional review of PEP prescriptions from six English centres during 2020. RESULTS: During 2020, 2884 PEP prescriptions were dispensed across the six centres studied, a fall of 34.5% from the 4403 PEP prescriptions in 2019. Before the COVID-related lockdown in 2020, the PEP dispensed was stable at 82.5 per week. Following the first lockdown, this fell to a nadir of 13 in week 14 (Figure 1). Prescriptions rose to a peak of 79 in week 37 and then declined to 32 prescriptions in the last week of 2020. There was no difference in the following characteristics of PEP recipients before and during the first lockdown: age, ethnicity, country of birth or the service the recipient attended. CONCLUSION: Whatever the reason for the fall in PEP seen in England over 2020, it is essential that HIV testing and access to HIV prevention is maintained for those in need.

Functional outcomes in patient specific instrumentation vs. conventional instrumentation for total knee arthroplasty; a systematic review and meta-analysis of prospective studies.

BACKGROUND: Total Knee Arthroplasty (TKA) is an established surgical option for knee osteoarthritis (OA). There are varying perceptions of the most suitable surgical technique for making bone cuts in TKA. Conventional Instrumentation (CI) uses generic cutting guides (extra- and intra-medullary) for TKA; however, patient specific instrumentation (PSI) has become a popular alternative amongst surgeons. METHODS: A literature search of electronic databases Embase, Medline and registry platform portals was conducted on the 16th May 2021. The search was performed using a predesigned search strategy. Eligible studies were critically appraised for methodological quality. The primary outcome measure was Knee Society Function Score. Functional scores were also collected for the secondary outcome measures: Oxford Knee Score (OKS), Western Ontario and McMaster Universities Arthritis Index (WOMAC), Knee Injury and Osteoarthritis Outcome Score (KOOS) and Visual Analog Scale (VAS) for pain. Review Manager 5.3 was used for all data synthesis and analysis. RESULTS: There is no conclusive evidence in the literature to suggest that PSI or CI instrumentation is better for functional outcomes. 23 studies were identified for inclusion in this study. Twenty-two studies (18 randomised controlled trials and 4 prospective studies) were included in the meta analysis, with a total of 2277 total knee arthroplasties. There were 1154 PSI TKA and 1123 CI TKA. The majority of outcomes at 3-months, 6-months and 12 show no statistical difference. There was statistical significance at 24 months in favour of PSI group for KSS function (mean difference 4.36, 95% confidence interval 1.83-6.89). The mean difference did not exceed the MCID of 6.4. KSS knee scores demonstrated statistical significance at 24 months (mean difference 2.37, 95% confidence interval (CI) 0.42-4.31), with a MCID of 5.9. WOMAC scores were found to be statistically significant favouring PSI group at 12 months (mean difference -3.47, 95% confidence interval (CI) -6.57- -0.36) and 24 months (mean difference -0.65, 95% confidence interval (CI) -1.28--0.03), with high level of bias noted in the studies and a MCID of 10. CONCLUSIONS: This meta-analysis of level 1 and level 2 evidence shows there is no clinical difference when comparing PSI and CI KSS function scores for TKA at definitive post operative time points (3 months, 6 months, 12 months and 24 months). Within the secondary outcomes for this study, there was no clinical difference between PSI and CI for TKA. Although there was no clinical difference between PSI and CI for TKA, there was statistical significance noted at 24 months in favour of PSI compared to CI for TKA when considering KSS function, KSS knee scores and WOMAC scores. Studies included in this meta-analysis were of limited cohort size and prospective studies were prone to methodological bias. The current literature is limited and insufficiently robust to make explicit conclusions and therefore further high-powered robust RCTs are required at specific time points.

Editorial Commentary: Lateral Extra-Articular Tenodesis Reduces Anterior Cruciate Ligament Graft Rerupture Rates: Proper Anterior Cruciate Ligament and Lateral Extra-Articular Tenodesis Technique Is Vital to Prevent Complications.

Lateral extra-articular tenodesis (LET) reduces anterior cruciate ligament (ACL) graft rerupture rates in high-risk patients. I believe in ilio-tibial band (ITB)-related LET to restrain anterolateral rotatory instability (ALRI) in ACL that is injured and reconstructed, and not in the "anterolateral ligament" or related techniques. However, the potential for conflict of a modified Lemaire LET femoral tunnel with an ACL femoral tunnel is higher than appreciated, and it risks iatrogenic ACL graft damage or compromised fixation. For MacIntosh LET, I use a staple to fix a strip of ITB (left attached distally to Gerdy's tubercle) at the lateral femoral metaphysis. The tines of the staple are proximal to the ACL femoral tunnel and fixation, so conflict cannot occur. For modified Lemaire LET, the ITB graft is (taken deep to the LCL and) attached at "Lemaire's point" on the lateral femur (proximal and posterior to the LCL femoral attachment). For fixation, I use a 15-mm length suture anchor, sufficiently short to avoid conflict. I presume fixation is less strong with sutures, so the 2-3 cm of ITB graft proximal to the suture are turned distally back over the LCL and sutured to itself. This does create a thickened contour to the lateral knee, but excellent clinical outcomes. Finally, I recommend the anteromedial bundle (AMB) position for the femoral tunnel, as in my experience in professional soccer players, using the central "anatomic" position increases rates of ACL graft rerupture. Moreover, "anatomic" femoral tunnel position results in a flatter trajectory increasing the risk of conflict with a LET tunnel (or lateral physical damage in patients with open growth plates).

Evidence-based rationale for treatment of meniscal lesions in athletes.

Meniscal injuries in elite athletes are a common cause of missed game time and even have the potential to be career shortening. In this patient group, care must be paid not only to the pathology, but also to a player's contract status, time in the season, specific demands of his/her sport and position on the field, and future consequences. Successful treatment requires the clinician to understand the player's goals and needs, communicate effectively between all stakeholders, and a have knowledge of the challenges posed by the different types of meniscal tear seen in this population. Paramount is the distinction between injuries to the medial and lateral meniscus. Deficiency of the lateral meniscus, as a result of a tear or a meniscectomy, leads to frequent early problems and inexorably to chondral degeneration thereby affecting an athlete's ability to perform. Therefore, it is strongly recommended to repair the majority of lateral meniscal tears. Medial meniscal tears pose a more challenging treatment dilemma, as the success of partial meniscectomy in achieving reproducible, early return to play must be balanced against the long-term degenerative consequences. Many meniscal tears are correctly treated non-operatively.Level of evidence V.

High return to play rate following treatment of multiple-ligament knee injuries in 136 elite athletes.

PURPOSE: The purpose of the study is to assess return to play rate and timing of elite athletes treated for multi-ligament knee injuries with modern surgical techniques. METHODS: A retrospective review was performed of all professional or national/international level athletes treated for a multi-ligament knee injury by the senior author in the period from February 2001 to October 2019, with a minimum of 2-year follow-up. The study cohort consisted of 136 elite athletes who underwent surgery of two or more knee ligaments. Outcomes measures were return to play (RTP), defined as return to elite level sport, return to play time, and further surgical procedures. RESULTS: One hundred and twenty (88.2%) athletes returned to elite level sport at an average of 12.8 months from operation. In unicruciate injuries, ACL and PCL-based injuries had similar return to play rates (89.1% vs. 87.5% respectfully, n.s.) although mean RTP time was longer in those with PCL-based injuries (15.2 vs. 11.9 months, p < 0.01). Bicruciate injuries had longer RTP times compared to unicruciate injuries (mean RTP 16.0vs. 12.4 months, p < 0.05) but were able to return at a similar rate (83.3% vs. 88.9%, n.s.). Medial and lateral sided injuries had similar RTP rates (89.3% vs. 87.9%, n.s.) though lateral sided injuries took longer before returning to play (13.4 vs. 11.6 months, p < 0.05). Further surgery was required in 54 (39.9%) patients including 25 (18.4%) manipulations under anaesthesia. Four (2.9%) of the athletes underwent revision ligament surgery. CONCLUSION: Modern surgical techniques used in the treatment of multi-ligament knee injuries can lead to high return to play rates in elite athletes. LEVEL OF EVIDENCE: IV.

High incidence of superficial and deep medial collateral ligament injuries in 'isolated' anterior cruciate ligament ruptures: a long overlooked injury.

PURPOSE: In anterior cruciate ligament (ACL) injuries, concomitant damage to peripheral soft tissues is associated with increased rotatory instability of the knee. The purpose of this study was to investigate the incidence and patterns of medial collateral ligament complex injuries in patients with clinically 'isolated' ACL ruptures. METHODS: Patients who underwent ACL reconstruction for complete 'presumed isolated' ACL rupture between 2015 and 2019 were retrospectively included in this study. Patient's characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the grade and location of injuries to the superficial MCL (sMCL), dMCL and the posterior oblique ligament (POL) recorded. All patients were clinically assessed under anaesthesia with standard ligament laxity tests. RESULTS: Hundred patients with a mean age of 22.3 ± 4.9 years were included. The incidence of concomitant MCL complex injuries was 67%. sMCL injuries occurred in 62%, dMCL in 31% and POL in 11% with various injury patterns. A dMCL injury was significantly associated with MRI grade II sMCL injuries, medial meniscus 'ramp' lesions seen at surgery and bone oedema at the medial femoral condyle (MFC) adjacent to the dMCL attachment site (p < 0.01). Logistic regression analysis identified younger age (OR 1.2, p < 0.05), simultaneous sMCL injury (OR 6.75, p < 0.01) and the presence of bone oedema at the MFC adjacent to the dMCL attachment site (OR 5.54, p < 0.01) as predictive factors for a dMCL injury. CONCLUSION: The incidence of combined ACL and medial ligament complex injuries is high. Lesions of the dMCL were associated with ramp lesions, MFC bone oedema close to the dMCL attachment, and sMCL injury. Missed AMRI is a risk factor for ACL graft failure from overload and, hence, oedema in the MCL (especially dMCL) demands careful assessment for AMRI, even in the knee lacking excess valgus laxity. This study provides information about specific MCL injury patterns including the dMCL in ACL ruptures and will allow surgeons to initiate individualised treatment. LEVEL OF EVIDENCE: III.

Anterolateral complex injuries occur in the majority of 'isolated' anterior cruciate ligament ruptures.

PURPOSE: The anterolateral soft tissue envelope of the knee is frequently injured at the time of ACL rupture. This study aims to investigate the MRI injury patterns to the Anterolateral complex and their associations in patients with acute 'isolated ligament' ACL ruptures. METHODS: Professional athletes who underwent ACL reconstruction for complete ACL rupture between 2015 and 2019 were included in this study. Patients' characteristics and intraoperative findings were retrieved from clinical and surgical documentation. Preoperative MRIs were evaluated and the injuries to respective structures of the Anterolateral complex and their associations were recorded. RESULTS: Anterolateral complex injuries were noted in 63% of cases. The majority of injuries were to Kaplan Fibre (39% isolated injury and 19% combined with Anterolateral ligament injury). There was a very low incidence of isolated Anterolateral ligament injuries (2%). Kaplan Fibre injuries are associated with the presence of lateral femoral condyle bone oedema, and injuries to the superficial MCL, deep MCL, and ramp lesions. High grade pivot shift test was not associated with the presence of Kaplan Fibre or Anterolateral ligament injuries. Patients with an intact Anterolateral complex sustained injury to other knee structures (13% to medial ligament complex, 14% to medial meniscus, and 16% to lateral meniscus). CONCLUSION: There is a high incidence of concomitant Anterolateral complex injuries in combination with ACL ruptures, with Kaplan Fibre (and therefore the deep capsulo-osseous layer of the iliotibial band) being the most commonly injured structure. Anterolateral ligament injuries occur much less frequently. These findings reinforce the importance of considering the presence of, and if necessary, treating injuries to structures other than the ACL, as a truly isolated ACL injury is rare.

Medial meniscal ramp lesions in ACL-injured elite athletes are strongly associated with medial collateral ligament injuries and medial tibial bone bruising on MRI.

PURPOSE: Medial menisco-capsular separations (ramp lesions) are typically found in association with anterior cruciate ligament (ACL) deficiency. They are frequently missed preoperatively due to low MRI sensitivity. The purpose of this article was to describe demographic and anatomical risk factors for ramp lesions, and to identify concomitant lesions and define their characteristics to improve diagnosis of ramp lesions on MRI. METHODS: Patients who underwent anterior cruciate ligament (ACL) reconstruction between September 2015 and April 2019 were included in this study. The presence/absence of ramp lesions was recorded in preoperative MRIs and at surgery. Patients' characteristics and clinical findings, concomitant injuries on MRI and the posterior tibial slope were evaluated. RESULTS: One hundred patients (80 male, 20 female) with a mean age of 22.3 ± 4.9 years met the inclusion criteria. The incidence of ramp lesions diagnosed at surgery was 16%. Ramp lesions were strongly associated with injuries to the deep MCL (dMCL, p < 0.01), the superficial medial collateral ligament (sMCL, p < 0.01), and a small medial-lateral tibial slope asymmetry (p < 0.05). There was also good correlation between ramp lesions and bone oedema in the posterior medial tibia plateau (MTP, p < 0.05) and medial femoral condyle (MFC, p < 0.05). A dMCL injury, a smaller differential medial-lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. MRI sensitivity was 62.5% and the specificity was 84.5%. CONCLUSION: The presence on MRI of sMCL and/or dMCL lesions, bone oedema in the posterior MTP and MFC, and a smaller differential medial-lateral tibial slope than usual are highly associated with ramp lesions visible on MRI. Additionally, a dMCL injury, a flatter lateral tibial slope than usual, and the identification of a ramp lesion on MRI increases the likelihood of finding a ramp lesion at surgery. Knowledge of the risk factors and secondary injury signs associated with ramp lesions facilitate the diagnosis of a ramp lesion preoperatively and should raise surgeons' suspicion of this important lesion. LEVEL OF EVIDENCE: Diagnostic study, Level III.

Factors affecting return to play and graft re-rupture after primary ACL reconstruction in professional footballers.

PURPOSE: Modern ACL reconstruction (ACL-R) techniques have led to improved outcomes in professional footballers. The aim of this study was to identify and assess patient, surgical and post-operative factors that affected rates and time to return to play (RTP) as well as ACL re-rupture rates. METHODS: A retrospective review of consecutive ACL-R undertaken in professional footballers between 2005 and 2018. RESULTS: Two-hundred and thirty-two knees in 215 professional footballers (17 bilateral) were included. 205 (88.9%) were male and average age at surgery was 23.3 ± 4.4 years. Two-hundred and twenty-two (96.1%) returned to professional football, with 209 (90.1%) returning to the same or higher Tegner level. Subgroup analysis revealed three factors that independently affected RTP rate: (1) Players under 25 years had a higher rate of RTP (99.3% vs 90.2%. p = 0.001); (2) a subsequent operation prior to RTP decreased RTP rate from 98.2 to 89.7% (p = 0.009).; (3) undergoing meniscal surgery at ACL-R decreased RTP rate (p = 0.002). The mean time to RTP from surgery was 10.5 ± 3.6 months. Factors found to increase RTP time included age under 25 (11.0 vs 9.7 months, p = 0.005), recurrent effusions (11.4 vs 10.2 months, p = 0.035), and medial meniscal repair at ACL-R compared to meniscectomy (12.5 vs 9.6 months, p = 0.022). The surgical technique varied over the study period in relation to graft type, femoral tunnel position and addition of lateral extra-articular tenodesis (LET). Overall, the re-rupture rate was 8.2% at 2 years. Patella tendon autograft in an anteromedial bundle femoral tunnel position with addition of LET has the lowest re-rupture rate (2.0%). CONCLUSION: Primary ACL-R in professional footballers yields high rates of RTP (96.1%), with 90.1% at the same level or higher, at a mean 10.5 months. Patients under 25 years not only had a significantly higher RTP rate, but also had a lengthier period of rehabilitation. LEVEL OF EVIDENCE: Level IV.

Developing a whole-school mental health and wellbeing intervention through pragmatic formative process evaluation: a case-study of innovative local practice within The School Health Research network.

BACKGROUND: The evidence-base for whole school approaches aimed at improving student mental health and wellbeing remains limited. This may be due to a focus on developing and evaluating de-novo, research-led interventions, while neglecting the potential of local, contextually-relevant innovation that has demonstrated acceptability and feasibility. This study reports a novel approach to modelling and refining the programme theory of a whole-school restorative approach, alongside plans to scale up through a national educational infrastructure in order to support robust scientific evaluation. METHODS: A pragmatic formative process evaluation was conducted of a routinized whole-school restorative approach aimed at improving student mental health and wellbeing in Wales. RESULTS: The study reports the six phases of the pragmatic formative process evaluation. These are: 1) identification of innovative local practice; 2) scoping review of evidence-base to identify potential programme theory; outcomes; and contextual characteristics that influence implementation; 3) establishment of a Transdisciplinary Action Research (TDAR) group; 4) co-production and confirmation of an initial programme theory with stakeholders; 5) planning to optimise intervention delivery in local contexts; and 6) planning for feasibility and outcome evaluation. The phases of this model may be iterative and not necessarily sequential. CONCLUSIONS: Formative, pragmatic process evaluations can support researchers, policy-makers and practitioners in developing robust scientific evidence-bases for acceptable and feasible local innovations that do not already have a clear evidence base. The case of a whole-school restorative approach provides a case example of how such an evaluation may be undertaken.

Ethnically diverse urban transmission networks of Neisseria gonorrhoeae without evidence of HIV serosorting.

OBJECTIVE: We aimed to characterise gonorrhoea transmission patterns in a diverse urban population by linking genomic, epidemiological and antimicrobial susceptibility data. METHODS: Neisseria gonorrhoeae isolates from patients attending sexual health clinics at Barts Health NHS Trust, London, UK, during an 11-month period underwent whole-genome sequencing and antimicrobial susceptibility testing. We combined laboratory and patient data to investigate the transmission network structure. RESULTS: One hundred and fifty-eight isolates from 158 patients were available with associated descriptive data. One hundred and twenty-nine (82%) patients identified as male and 25 (16%) as female; four (3%) records lacked gender information. Self-described ethnicities were: 51 (32%) English/Welsh/Scottish; 33 (21%) white, other; 23 (15%) black British/black African/black, other; 12 (8%) Caribbean; 9 (6%) South Asian; 6 (4%) mixed ethnicity; and 10 (6%) other; data were missing for 14 (9%). Self-reported sexual orientations were 82 (52%) men who have sex with men (MSM); 49 (31%) heterosexual; 2 (1%) bisexual; data were missing for 25 individuals. Twenty-two (14%) patients were HIV positive. Whole-genome sequence data were generated for 151 isolates, which linked 75 (50%) patients to at least one other case. Using sequencing data, we found no evidence of transmission networks related to specific ethnic groups (p=0.64) or of HIV serosorting (p=0.35). Of 82 MSM/bisexual patients with sequencing data, 45 (55%) belonged to clusters of ≥2 cases, compared with 16/44 (36%) heterosexuals with sequencing data (p=0.06). CONCLUSION: We demonstrate links between 50% of patients in transmission networks using a relatively small sample in a large cosmopolitan city. We found no evidence of HIV serosorting. Our results do not support assortative selectivity as an explanation for differences in gonorrhoea incidence between ethnic groups.

Length-change patterns of the medial collateral ligament and posterior oblique ligament in relation to their function and surgery.

PURPOSE: To define the length-change patterns of the superficial medial collateral ligament (sMCL), deep MCL (dMCL), and posterior oblique ligament (POL) across knee flexion and with applied anterior and rotational loads, and to relate these findings to their functions in knee stability and to surgical repair or reconstruction. METHODS: Ten cadaveric knees were mounted in a kinematics rig with loaded quadriceps, ITB, and hamstrings. Length changes of the anterior and posterior fibres of the sMCL, dMCL, and POL were recorded from 0° to 100° flexion by use of a linear displacement transducer and normalised to lengths at 0° flexion. Measurements were repeated with no external load, 90 N anterior draw force, and 5 Nm internal and 5 Nm external rotation torque applied. RESULTS: The anterior sMCL lengthened with flexion (p < 0.01) and further lengthened by external rotation (p < 0.001). The posterior sMCL slackened with flexion (p < 0.001), but was lengthened by internal rotation (p < 0.05). External rotation lengthened the anterior dMCL fibres by 10% throughout flexion (p < 0.001). sMCL release allowed the dMCL to become taut with valgus rotation (p < 0.001). The anterior and posterior POL fibres slackened with flexion (p < 0.001), but were elongated by internal rotation (p < 0.001). CONCLUSION: The structures of the medial ligament complex react differently to knee flexion and applied loads. Structures attaching posterior to the medial epicondyle are taut in extension, whereas the anterior sMCL, attaching anterior to the epicondyle, is tensioned during flexion. The anterior dMCL is elongated by external rotation. These data offer the basis for MCL repair and reconstruction techniques regarding graft positioning and tensioning.

Claims of causality in health news: a randomised trial.

BACKGROUND: Misleading news claims can be detrimental to public health. We aimed to improve the alignment between causal claims and evidence, without losing news interest (counter to assumptions that news is not interested in communicating caution). METHODS: We tested two interventions in press releases, which are the main sources for science and health news: (a) aligning the headlines and main causal claims with the underlying evidence (strong for experimental, cautious for correlational) and (b) inserting explicit statements/caveats about inferring causality. The 'participants' were press releases on health-related topics (N = 312; control = 89, claim alignment = 64, causality statement = 79, both = 80) from nine press offices (journals, universities, funders). Outcomes were news content (headlines, causal claims, caveats) in English-language international and national media (newspapers, websites, broadcast; N = 2257), news uptake (% press releases gaining news coverage) and feasibility (% press releases implementing cautious statements). RESULTS: News headlines showed better alignment to evidence when press releases were aligned (intention-to-treat analysis (ITT) 56% vs 52%, OR = 1.2 to 1.9; as-treated analysis (AT) 60% vs 32%, OR = 1.3 to 4.4). News claims also followed press releases, significant only for AT (ITT 62% vs 60%, OR = 0.7 to 1.6; AT, 67% vs 39%, OR = 1.4 to 5.7). The same was true for causality statements/caveats (ITT 15% vs 10%, OR = 0.9 to 2.6; AT 20% vs 0%, OR 16 to 156). There was no evidence of lost news uptake for press releases with aligned headlines and claims (ITT 55% vs 55%, OR = 0.7 to 1.3, AT 58% vs 60%, OR = 0.7 to 1.7), or causality statements/caveats (ITT 53% vs 56%, OR = 0.8 to 1.0, AT 66% vs 52%, OR = 1.3 to 2.7). Feasibility was demonstrated by a spontaneous increase in cautious headlines, claims and caveats in press releases compared to the pre-trial period (OR = 1.01 to 2.6, 1.3 to 3.4, 1.1 to 26, respectively). CONCLUSIONS: News claims-even headlines-can become better aligned with evidence. Cautious claims and explicit caveats about correlational findings may penetrate into news without harming news interest. Findings from AT analysis are correlational and may not imply cause, although here the linking mechanism between press releases and news is known. ITT analysis was insensitive due to spontaneous adoption of interventions across conditions. TRIAL REGISTRATION: ISRCTN10492618 (20 August 2015).

Magnetic resonance imaging appearances of the capsulo-osseous layer of the iliotibial band and femoral attachments of the iliotibial band in the normal and pivot-shift ACL injured knee.

BACKGROUND: Biomechanical evidence suggests that the anterolateral structures of the knee may be important restraints against anterolateral rotatory instability (ALRI) in the setting of anterior cruciate ligament (ACL) injury. OBJECTIVE: To describe the anatomy and presence of injury of the capsule-osseous layer of the iliotibial band (CITB), the iliotibial band, and its deep distal femoral attachments in patients with a 'normal' knee (no pivot-shift bone marrow edema (BME) pattern) and patients with a pivot-shift BME pattern indicative of a pivot-shift injury associated with ACL tears. METHODS: Group 1: 20 consecutive patients with no MRI evidence of pivot-shift injury and group 2: 20 consecutive patients with a pivot-shift BME pattern on MRI were identified. Retrospective consensus analysis of the anatomy and appearances of the CITB and the 'proximal' and 'epicondylar' distal femoral attachments of the ITB was performed for each MRI by two experienced musculoskeletal radiologists. RESULTS: The positive predictive value (PPV) of CITB injury for pivot-shift ACL injury was 74%, negative predicted Value (NPV) was 80%. The PPV for injury of the 'proximal' ITB femoral attachment with pivot-shift ACL injury was 93%, NPV was 84%. The PPV for 'epicondylar' iliotibial femoral attachment injury was 62%, NPV was 45%. CONCLUSIONS: Injury of the CITB and 'proximal' deep femoral attachments of the ITB are good markers for ACL injury even in the absence of a Segond fracture and should be evaluated on all MRIs as they may prove important in the further management of ALRI.

Editorial Commentary: The Anterolateral Ligament: The Emperor's New Clothes?

In the following editorial commentary, the lateral soft tissues responsible for resisting the pivot shift phenomenon with the anterior cruciate ligament (ACL) are considered. The recent history of the anterolateral ligament (ALL) has led to rapid adoption of surgical techniques that have often not been investigated with scientific due process. A step-by-step approach starts with biomechanical testing to establish the anatomy and biomechanical characteristics of soft tissue structures and questions the importance of the ALL and proposes a more important role for the iliotibial band (ITB) passing between attachments to the distal lateral femur and tibia. Subsequent laboratory testing of various operative options shows superiority of lateral extra-articular tenodeses (LETs) as compared with ALL reconstruction.

It is safe and effective to use all inside meniscal repair devices for posteromedial meniscal 'ramp' lesions.

PURPOSE: Recently, it has been recognized that meniscocapsular ('ramp') lesions of the posterior one-third of the medial meniscus frequently occur during injuries causing ACL rupture, and that these lesions are easily missed at arthroscopy. Furthermore, it is clear that these lesions are biomechanically significant, adding to the deficits caused by ACL rupture, and that their repair can reverse this. The efficacy of an all inside repair technique has been questioned by some authors and by those who advocate a suture shuttle technique via an accessory posteromedial portal. The use of Ultra FastFix and FastFix 360 meniscal repair devices to repair posteromedial meniscocapsular separations was investigated in terms of safe deployment and the effectiveness. METHODS: Twenty cadaveric fresh frozen knees were used-ten in each of two groups. A ramp lesion was created using a Beaver knife. The lesion was then repaired with either 4 Ultra FastFix (Smith and Nephew) or 4 FastFix 360 (Smith and Nephew) meniscal repair devices. The knees were put through a standardized loading cycle consisting of 10 Lachman's tests and ten maximum loading manual anterior drawer tests at 90° of flexion. Each knee was then flexed and extended fully ten times. The specimens were sectioned just proximal to the menisci and each suture anchor identified and its position recorded and photographed. RESULTS: In the Ultra FastFix group, a single anchor was found to be in an intra-articular position-a failure rate of 2.5%. In the FastFix 360 group, 5 anchors failed-a 12.5% failure rate. In all cases, the anchors were attached to their suture and so not truly loose within the joint. CONCLUSIONS: This study confirms the safe and effective deployment of an all inside repair device for repair of medial meniscal 'ramp' lesions, and therefore its use is advocated in treating these difficult lesions. Ultra FastFix had the lower failure rate of 2.5%, which the authors believe is acceptable, and makes this device preferable to the FastFix360.

The infrapatellar fat pad is a dynamic and mobile structure, which deforms during knee motion, and has proximal extensions which wrap around the patella.

PURPOSE: The infrapatellar fat pad (IFP) is a common cause of knee pain and loss of knee flexion and extension. However, its anatomy and behavior are not consistently defined. METHODS: Thirty-six unpaired fresh frozen knees (median age 34 years, range 21-68) were dissected, and IFP attachments and volume measured. The rectus femoris was elevated, suprapatellar pouch opened and videos recorded looking inferiorly along the femoral shaft at the IFP as the knee was flexed. The patellar retinacula were incised and the patella reflected distally. The attachment of the ligamentum mucosum (LMuc) to the intercondylar notch was released from the anterior cruciate ligament (ACL), both menisci and to the tibia via meniscotibial ligaments. IFP strands projecting along both sides of the patella were elevated and the IFP dissected from the inferior patellar pole. Magnetic resonance imaging (MRI) of one knee at ten flexion angles was performed and the IFP, patella, tibia and femur segmented. RESULTS: In all specimens the IFP attached to the inferior patellar pole, femoral intercondylar notch (via the LMuc), proximal patellar tendon, intermeniscal ligament, both menisci and the anterior tibia via the meniscotibial ligaments. In 30 specimens the IFP attached to the anterior ACL fibers via the LMuc, and in 29 specimens it attached directly to the central anterior tibia. Proximal IFP extensions were identified alongside the patella in all specimens and visible on MRI [medially (100% of specimens), mean length 56.2 ± 8.9 mm, laterally (83%), mean length 23.9 ± 6.2 mm]. Mean IFP volume was 29.2 ± 6.1 ml. The LMuc, attached near the base of the middle IFP lobe, acting as a 'tether' drawing it superiorly during knee extension. The medial lobe consistently had a pedicle superomedially, positioned between the patella and medial trochlea. MRI scans demonstrated how the space between the anterior tibia and patellar tendon ('the anterior interval') narrowed during knee flexion, displacing the IFP superiorly and posteriorly as it conformed to the trochlear and intercondylar notch surfaces. CONCLUSION: Proximal IFP extensions are a novel description. The IFP is a dynamic structure, displacing significantly during knee motion, which is, therefore, vulnerable to interference from trauma or repetitive overload. Given that this trauma is often surgical, it may be appropriate that surgeons learn to minimize injury to the fat pad at surgery.

Biographical background and origin of common eponymous terms in orthopedic surgery: anatomy and fractures in knee surgery.

An eponym is a person after whom an eponymous term is named. These eponymous terms are easy shorthand in communication between surgeons. Therefore, they are often used and hard to eradicate. We discuss eponymous terms that describe anatomical features and fracture types in the knee. With these terms, an overview of the historical background of the eponym and its current clinical implication is discussed. The eponymous terms discussed are Gerdy tubercle, Pellegrini-Stieda lesion, Segond fracture, Hoffa fracture and fat pad. The meaning of the eponymous term is clarified, the biography of the namegiver given and its contemporary clinical implication discussed. Since eponymous terms are used frequently in inter-collegial discussion and literature, the meaning should be clear for everyone, since otherwise it might give room for misunderstanding.