Prevailing disagreement in the treatment of complex patellar instability cases: an online expert survey of the AGA Knee-Patellofemoral Committee.

PURPOSE: To evaluate the current state of knowledge and potential controversies in the treatment of patellofemoral instability among orthopaedic/trauma surgeons in the German-speaking countries. METHODS: An online survey consisting of 32 questions and three fictitious cases was sent to members of the AGA-Society for Arthroscopy and Joint Surgery. Surgeons were defined by our senior authors as high-volume or low-volume surgeons, depending on the number of their cases. The treatment of 25% of patients with patellofemoral instability and/or the performance of 50 patellofemoral instability cases per year distinguishes high- from low-volume surgeons in this study. RESULTS: The online questionnaire was completed by 541 experienced knee surgeons from Germany (78%), Austria (10.9%), Switzerland (10.4%) and other countries (0.7%). Most surgeons prefer MPFL reconstruction as surgical intervention in patients with recurrent patellar instability (64-81%). Sixty percent of high-volume surgeons as compared to 21.8% of low-volume surgeons have ever performed a trochleoplasty. Of the overall respondents, 25% would not perform any surgical treatment on adolescents with patellar instability and an open growth plate. Of all responding surgeons, 95% would not treat patellofemoral instability with an isolated lateral release. This corresponds to recent literature showing poor outcome of its strictly isolated application. CONCLUSION: This study provides an overview of the current management of acute and recurrent patellofemoral instability in the German-speaking countries. Results show the surgeons' awareness for highly demanding surgical possibilities for complex patellar instability cases. However, disagreement among surgeons still prevails when it comes to selecting individual multimodal treatment options. This highlights the need for treatment guidelines and algorithms for patellofemoral instability. LEVEL OF EVIDENCE: V.

Meta-analysis of venous anastomosis techniques in free flap reconstruction.

BACKGROUND: Coupler devices and hand-sewn anastomosis techniques are both routinely employed for venous anastomosis in microsurgical free flap transfer. However, uncertainty remains about whether those two techniques are different in terms of risk of venous thrombosis. The aim of this review was to evaluate the quality of the evidence and quantify the difference in venous thrombosis rates in both techniques. METHOD: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses compliant systematic review and meta-analysis were performed according to a previously published protocol. MEDLINE and Embase databases were searched from inception to 1 October 2018. Clinical studies using coupler devices for venous anastomoses in free tissue transfer were included. The primary outcome was post-operative venous thrombosis risk. Surgical anastomosis time was a secondary outcome. The risk of bias was assessed with the ROBINS-I or NIH tool and recommendations were made using the GRADE criteria. RESULTS: A total of 10,851 patients across 32 observational retrospective studies were included, with data available for 12,769 free flaps in breast, head and neck, limb and other reconstructions. Direct comparison meta-analysis of 7 studies showed a reduced post-operative thrombosis risk for venous coupler, although this was an imprecise estimate (RR 0.68 [95% CI 0.39-1.19]). The risk of bias was consistently high across all studies. CONCLUSION: Venous couplers may reduce the risk of venous thrombosis, but further randomised trial data are needed to improve the accuracy of this estimate. Further research should also assess size-mismatch between donor and recipient vessel, and the influence of coupler size on outcomes (PROSPERO registration ID: CRD42018110111).