The deltoid ligament is constantly formed by four fascicles reaching the navicular, spring ligament complex, calcaneus and talus.

PURPOSE: The medial collateral ligament of the ankle, or deltoid ligament, can be injured in up to 40% of patients who sustain an ankle inversion sprain. Reporting injuries of the deltoid ligament is not easy due to confusion in the current anatomical descriptions, with up to 16 fascicles described, with variable frequencies. The purpose of this study was to clarify the anatomy of the deltoid ligament. METHODS: Thirty-two fresh-frozen ankle specimens were used for this study. Careful dissection was undergone until full visualization of the deltoid ligament was achieved and measurements taken. RESULTS: The deltoid ligament was found to have four constant fascicles in two layers. The superficial layer consists of the tibionavicular, tibiospring and tibiocalcaneal fascicles, while the deep layer consists of the tibiotalar fascicle. Measurements of these fascicles are given in detail. The tibiotalar fascicle and the anterior part of the tibionavicular fascicle were found to be intra-articular structures. CONCLUSION: The deltoid ligament has a constant number of fascicles divided into a superficial and a deep layer. This clarification of the anatomy and terminology of the deltoid ligament and its fascicles will help clinical view, diagnosis and (interdoctor)communication and treatment. The ligamentous fibres of the deep layer, as well as the anterior fibres of the superficial layer (tibionavicular fascicle) are intra-articular, which could negatively impact its healing capacity, explaining chronicity of these types of injuries. LEVEL OF EVIDENCE: Not applicable (cadaveric study).

Central aspects when implementing an electronic monitoring system for assessing hand hygiene in clinical settings: A grounded theory study.

Background: New technologies, such as electronic monitoring systems, have been developed to promote increased adherence to hand hygiene among healthcare workers. However, challenges when implementing these technologies in clinical settings have been identified. Aim: The aim of this study was to explore healthcare workers' experiences when implementing an electronic monitoring system to assess hand hygiene in a clinical setting. Method: Interviews with healthcare workers (registered nurses, nurse assistants and leaders) involved in the implementation process of an electronic monitoring system (n = 17) were conducted and data were analyzed according to the grounded theory methodology formulated by Strauss and Corbin. Results: Healthcare workers' experiences were expressed in terms of leading and facilitating, participating and contributing, and knowing and confirming. These three aspects were merged together to form the core category of collaborating for progress. Leaders were positive and committed to the implementation of the electronic monitoring system, endeavouring to enable facilitation and support for their co-workers (registered nurses and nurse assistants). At the same time, co-workers were positive about the support they received and contributed by raising questions and demands for the product to be used in clinical settings. Moreover, leaders and co-workers were aware of the objective of implementing the electronic monitoring system. Conclusion: We identified dynamic collective work between leaders and co-workers during the implementation of the electronic monitoring system. Leadership, participation and knowledge were central aspects of enhancing a collaborative process. We strongly recommend involving both ward leaders and users of new technologies to promote successful implementation.

A practical guide to the development and deployment of deep learning models for the orthopaedic surgeon: Part III, focus on registry creation, diagnosis, and data privacy.

Deep learning is a subset of artificial intelligence (AI) with enormous potential to transform orthopaedic surgery. As has already become evident with the deployment of Large Language Models (LLMs) like ChatGPT (OpenAI Inc.), deep learning can rapidly enter clinical and surgical practices. As such, it is imperative that orthopaedic surgeons acquire a deeper understanding of the technical terminology, capabilities and limitations associated with deep learning models. The focus of this series thus far has been providing surgeons with an overview of the steps needed to implement a deep learning-based pipeline, emphasizing some of the important technical details for surgeons to understand as they encounter, evaluate or lead deep learning projects. However, this series would be remiss without providing practical examples of how deep learning models have begun to be deployed and highlighting the areas where the authors feel deep learning may have the most profound potential. While computer vision applications of deep learning were the focus of Parts I and II, due to the enormous impact that natural language processing (NLP) has had in recent months, NLP-based deep learning models are also discussed in this final part of the series. In this review, three applications that the authors believe can be impacted the most by deep learning but with which many surgeons may not be familiar are discussed: (1) registry construction, (2) diagnostic AI and (3) data privacy. Deep learning-based registry construction will be essential for the development of more impactful clinical applications, with diagnostic AI being one of those applications likely to augment clinical decision-making in the near future. As the applications of deep learning continue to grow, the protection of patient information will become increasingly essential; as such, applications of deep learning to enhance data privacy are likely to become more important than ever before. Level of Evidence: Level IV.

Machine learning/artificial intelligence in sports medicine: state of the art and future directions.

Machine learning (ML) is changing the way health care is practiced and recent applications of these novel statistical techniques have started to impact orthopaedic sports medicine. Machine learning enables the analysis of large volumes of data to establish complex relationships between "input" and "output" variables. These relationships may be more complex than could be established through traditional statistical analysis and can lead to the ability to predict the "output" with high levels of accuracy. Supervised learning is the most common ML approach for healthcare data and recent studies have developed algorithms to predict patient-specific outcome after surgical procedures such as hip arthroscopy and anterior cruciate ligament reconstruction. Deep learning is a higher-level ML approach that facilitates the processing and interpretation of complex datasets through artificial neural networks that are inspired by the way the human brain processes information. In orthopaedic sports medicine, deep learning has primarily been used for automatic image (computer vision) and text (natural language processing) interpretation. While applications in orthopaedic sports medicine have been increasing exponentially, one significant barrier to widespread adoption of ML remains clinician unfamiliarity with the associated methods and concepts. The goal of this review is to introduce these concepts, review current machine learning models in orthopaedic sport medicine, and discuss future opportunities for innovation within the specialty.

Hand hygiene in a clinical setting: Evaluation of an electronic monitoring system in relation to direct observations.

BACKGROUND: This study evaluated the accuracy of an electronic monitoring system for assessing hand hygiene in a clinical setting in relation to direct observations. METHODS: An electronic monitoring system was installed in a surgical ward at a tertiary hospital in Sweden. Hand hygiene events registered by the system were compared with direct observations conducted simultaneously by a trained observer following the World Health Organization's "My five moments for hand hygiene". A 4-step protocol was developed to evaluate the system's ability to accurately monitor hand hygiene in a clinical setting. RESULTS: A total of 947 opportunities for hand hygiene were observed during June to December 2019. Of these, 484 opportunities were correctly captured by the electronic monitoring system and included in the calculations for accuracy. Sensitivity was 90.2% with a positive predictive value of 95.7%, while specificity was 50.0% with a negative predictive value of 29.0%. Overall accuracy was 87.1%. CONCLUSIONS: Evaluating technical systems assessing hand hygiene in clinical settings is hampered by several challenges. The 4-step protocol helped to identify the limitations and strengths of the evaluated electronic monitoring system, revealing high accuracy while also detecting system errors.

Only 10% of Patients With a Concomitant MCL Injury Return to Their Preinjury Level of Sport 1 Year After ACL Reconstruction: A Matched Comparison With Isolated ACL Reconstruction.

BACKGROUND: There is a need for an increased understanding of the way a concomitant medial collateral ligament (MCL) injury may influence outcome after anterior cruciate ligament (ACL) reconstruction. HYPOTHESIS: Patients with a concomitant MCL injury would have inferior clinical outcomes compared with a matched cohort of patients undergoing ACL reconstruction without an MCL injury. STUDY DESIGN: Matched registry-based cohort study; case-control. LEVEL OF EVIDENCE: Level 3. METHODS: Data from the Swedish National Knee Ligament Registry and a local rehabilitation outcome registry were utilized. Patients who had undergone a primary ACL reconstruction with a concomitant nonsurgically treated MCL injury (ACL + MCL group) were matched with patients who had undergone an ACL reconstruction without an MCL injury (ACL group), in a 1:3 ratio. The primary outcome was return to knee-strenuous sport, defined as a Tegner activity scale ≥6, at the 1-year follow-up. In addition, return to preinjury level of sport, muscle function tests, and patient-reported outcomes (PROs) were compared between the groups. RESULTS: The ACL + MCL group comprised 30 patients, matched with 90 patients in the ACL group. At the 1-year follow-up, 14 patients (46.7%) in the ACL + MCL group had return to sport (RTS) compared with 44 patients (48.9%) in the ACL group (P = 0.37). A significantly lower proportion of patients in the ACL + MCL group had returned to their preinjury level of sport compared with the ACL group (10.0% compared with 25.6%, adjusted P = 0.01). No differences were found between the groups across a battery of strength and hop tests or in any of the assessed PROs. The ACL + MCL group reported a mean 1-year ACL-RSI after injury of 59.4 (SD 21.6), whereas the ACL group reported 57.9 (SD 19.4), P = 0.60. CONCLUSION: Patients with a concomitant nonsurgically treated MCL injury did not return to their preinjury level of sport to the same extent as patients without an MCL injury 1 year after ACL reconstruction. However, there was no difference between the groups in terms of return to knee strenuous activity, muscle function, or PROs. CLINICAL RELEVANCE: Patients with a concomitant nonsurgically treated MCL injury may reach outcomes similar to those of patients without an MCL injury 1 year after an ACL reconstruction. However, few patients return to their preinjury level of sport at 1 year.

Anaesthesia practice, quality indices including all-cause 30-day mortality associate to wrist fracture repositioning and surgery in Sweden: A perioperative register-based study 2018-2021.

BACKGROUND: Wrist fracture is one of most common fractures frequently requiring surgical anaesthesia. There is limited information related to the anaesthetic practice and quality including 30-day mortality associated with wrist fracture in Sweden in recent years. AIM: The aim of the present register-based study was to investigate the anaesthesia techniques used and quality indices including 30-day mortality associated with wrist fracture surgery in Sweden during the period 2018-2021. MATERIALS AND METHODS: All fracture repositions, and surgical interventions related to wrist fracture requiring anaesthesia in patients aged >18 years registered in the Swedish Perioperative Register (SPOR) between 2018 and 2021 were included in the analysis. Information on age, ASA class, anaesthesia technique, severe operative events, most reported side-effects during recovery room stay and all-cause 30-day mortality was collected. RESULTS: The data set included 25,147 procedures split into 14,796 females and 10,252 males (missing information n = 99) with a mean age of 52.9 ± 18.7 years and a significant age difference between females and males, 60.3 ± 15.4 and 42.2 ± 17.7 years, respectively. Mean age and ASA class increased during the study period (2018-2021), from 52.8 ± 18.6 to 54.0 ± 18.4 and ASA class 3-5 from 8.1% to 9.4% (p < .001 and p < .041, respectively). General anaesthesia (GA), GA combined with regional anaesthesia (RA), RA with or without sedation and sedation only was used in 41%, 13%, 40% and 6% of procedures, respectively, with minor changes over the study period. Pain at arrival in the recovery room (RR), (3.4%), severe pain during RR stay (2.1%), hypothermia (1.4%), postoperative nausea and vomiting (PONV) (1.2%) and urinary retention (0.5%) were the most reported side-effects during the RR stay. (RA) was associated with significantly lower occurrence of pain and PONV, and shorter RR stay, compared with GA (p < .001). The all-cause 30-day mortality was low (19 of 25,147 (0.08%)) with no differences over the period studied or anaesthetic technique. CONCLUSION: General anaesthesia or general anaesthesia combined with regional anaesthesia are the most used anaesthetic techniques for wrist fracture procedures in Sweden. Recovery room pain, PONV, hypothermia and urinary retention is reported in overall low frequencies, with no change over the period studied, but in lower frequencies for regional anaesthesia. All-cause 30-day mortality was low; 0.08% with no change over time or between anaesthetic techniques. Thus, the present quality review based on SPOR data supports high quality of perioperative anaesthesia care.

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.

Tips and tricks for how to become a good reviewer.

Peer review is an essential process to ensure that scientific articles meet high standards of methodology, ethics and quality. The peer-review process is a part of the academic mission for physicians in the university setting. The work of reviewers is of great value for authors, as it gives constructive criticism and improves manuscript quality before publication. Often, however, reviews are of suboptimal quality. Usually, reviewers do not receive formal training either on how to perform a review or on the peer-review process. In addition, it is generally believed that experienced authors are great reviewers, but this may not always be true. The overarching goal of a review is to make the manuscript better; to help the authors. The purpose of this article is to offer relevant suggestions and provide a checklist on how to perform a useful review.

Improving the reliability of measurements in orthopaedics and sports medicine.

A large space still exists for improving the measurements used in orthopaedics and sports medicine, especially as we face rapid technological progress in devices used for diagnostic or patient monitoring purposes. For a specific measure to be valuable and applicable in clinical practice, its reliability must be established. Reliability refers to the extent to which measurements can be replicated, and three types of reliability can be distinguished: inter-rater, intra-rater, and test-retest. The present article aims to provide insights into reliability as one of the most important and relevant properties of measurement tools. It covers essential knowledge about the methods used in orthopaedics and sports medicine for reliability studies. From design to interpretation, this article guides readers through the reliability study process. It addresses crucial issues such as the number of raters needed, sample size calculation, and breaks between particular trials. Different statistical methods and tests are presented for determining reliability depending on the type of gathered data, with particular attention to the commonly used intraclass correlation coefficient.

Greater self-efficacy, psychological readiness and return to sport amongst paediatric patients compared with adolescents and young adults, 8 and 12 months after ACL reconstruction.

PURPOSE: The purpose of this study was to evaluate differences in rehabilitation-specific outcomes between paediatric patients, adolescents and young adults within the first 2 years after anterior cruciate ligament (ACL) reconstruction. A further aim was to determine whether patient age was associated with an increased risk of not achieving symmetrical muscle function within the first 2 years after ACL reconstruction. METHODS: The patient data in the present study were extracted from the rehabilitation outcome registry, Project ACL. Patients aged 11-25 years registered for primary ACL reconstruction with a hamstring tendon autograft between April 1, 2013 and November 23, 2020 were included. A total of 691 patients met the inclusion criteria and were included in the study; 41 paediatric patients (females 11-13, males 11-15 years), 347 adolescents (females 14-19, males 16-19 years) and 303 young adults (females 20-25, males 20-25 years). RESULTS: The comparison between groups revealed that 70% of paediatric patients, 39% of adolescents and 35% of young adults had returned to knee-strenuous sport at 8 months and that 90% of paediatric patients, 71% of adolescents and 62% of young adults had returned to sport at 12 months. Paediatric patients also reported higher scores compared with both the other patient groups on the Knee Self-Efficacy Scale (K-SES) and the Anterior Cruciate Ligament Return to Sport after Injury scale (ACL-RSI) at 8 and 12 months. CONCLUSIONS: A larger proportion of paediatric patients had returned to sport compared with adolescents and young adults 8 and 12 months after ACL reconstruction. Paediatric patients also reported higher self-efficacy and greater psychological readiness to return to sport at 8 and 12 months than the other two groups. No differences in terms of muscle function tests when comparing paediatric patients, adolescents and young adults were found. LEVEL OF EVIDENCE: II.

What it takes to have a high-grade pivot shift-focus on bony morphology.

PURPOSE: Variations in femoral and tibial bony morphology have been associated with higher clinical grading and increased quantitative tibial translation, but not tibial acceleration, during the pivot shift test following anterior cruciate ligament (ACL) injury. The purpose of this study was to determine the impact of femoral and tibial bony morphology, including a measurement influenced by both parameters (the Lateral Tibiofemoral Articular Distance (LTAD)), on the degree of quantitative tibial acceleration during the pivot shift test and rates of future ACL injury. METHODS: All patients who underwent primary ACL reconstruction from 2014 to 2019 by a senior orthopedic surgeon with available quantitative tibial acceleration data were retrospectively reviewed. All patients underwent a pivot shift examination under anesthesia with a triaxial accelerometer. Measurements of femoral and tibial bony morphology were performed by two fellowship-trained orthopedic surgeons using preoperative magnetic resonance imaging and lateral radiographs. RESULTS: Fifty-one patients were included at a mean follow-up of 4.4 years. The mean quantitative tibial acceleration during the pivot shift was 13.8 m/s2 (range: 4.9-52.0 m/s2). A larger Posterior Condylar Offset Ratio (r = 0.30, p = 0.045), smaller medial-to-lateral width of the medial tibial plateau (r = - 0.29, p = 0.041), lateral tibial plateau (r = - 0.28, p = 0.042), and lateral femoral condyle (r = - 0.29, p = 0.037), and a decreased LTAD (r = - 0.53, p < 0.001) significantly correlated with increased tibial acceleration during the pivot shift. Linear regression analysis demonstrated an increase in tibial acceleration of 1.24 m/s2 for every 1 mm decrease in LTAD. Nine patients (17.6%) sustained ipsilateral graft rupture and 10 patients (19.6%) sustained contralateral ACL rupture. No morphologic measurements were associated with rates of future ACL injury. CONCLUSION: Increased convexity and smaller bony morphology of the lateral femur and tibia were significantly associated with increased tibial acceleration during the pivot shift. Additionally, a measurement, termed the LTAD, was found to have the strongest association with increased tibial acceleration. Based on the results of this study, surgeons can utilize these measurements to preoperatively identify patients at risk of increased rotatory knee instability. LEVEL OF EVIDENCE: Level IV.