Strong Correlation Between Standing Long-Leg Radiographs and CT Scans in Measuring Coronal Knee Alignment.

BACKGROUND: The objective of this study was to evaluate the correlation in measurements of the lower-limb coronal alignment between long-leg radiographs (LLRs) and computed tomography (CT) scanograms that were made during preoperative planning for robotic-arm-assisted knee arthroplasty. On the basis of published evidence demonstrating a good correlation between these imaging modalities in measuring the lower-limb mechanical axis, we hypothesized that there would be no significant differences between the 2 in the present study. METHODS: This multicenter cohort study across 3 tertiary centers included 300 patients undergoing primary robotic-arm-assisted total knee arthroplasty (TKA) or unicompartmental knee arthroplasty (UKA) for whom LLRs and CT scanograms were available preoperatively. The study involved measuring the medial proximal tibial angle (MPTA), lateral distal femoral angle (LDFA), hip-knee-ankle angle (HKA), joint line obliquity (JLO), joint-line convergence angle (JLCA), and arithmetic HKA (aHKA). The aHKA represents a method for estimating constitutional alignment using angles that are unaffected by joint-space narrowing. RESULTS: Strong correlations (p < 0.001) between the imaging modalities were found for the HKA (correlation coefficient, 0.912), aHKA (0.883), MPTA (0.820), LDFA (0.871), and JLO (0.778). A weaker correlation was observed for the JLCA in valgus knees as compared with varus knees (Spearman coefficients, 0.412 and 0.518, respectively). Regression models demonstrated that the degree of agreement was associated with the preoperative intra-articular deformity and the positioning of the lower limb during the CT scan (i.e., the lower-limb rotational angle). An initial JLCA within ±5° was associated with higher agreement. CONCLUSIONS: We observed a strong correlation between LLRs and CT scanograms that were made during the preoperative planning stage of robotic-arm-assisted knee arthroplasty, implying that CT scanograms can reliably be utilized to estimate the coronal alignment of the knee, potentially replacing the need for LLRs. Nevertheless, to attain a higher degree of agreement, it is crucial to ensure appropriate radiographic positioning of the lower limb. Additionally, surgeons must remain vigilant regarding potential discrepancies in cases involving substantial deformities. LEVEL OF EVIDENCE: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

Two-Dimensional Versus Three-Dimensional Preoperative Planning In Total Hip Arthroplasty.

BACKGROUND: Pre-operative planning in total hip arthroplasty (THA), involves utilizing radiographs or advanced imaging modalities, including computerized tomography (CT) scans, for precise prediction of implant sizing and positioning. This study aimed to compare Three-Dimensional (3D) versus Two-Dimensional (2D) pre-operative planning in primary THA with respect to key surgical metrics, including restoration of the horizontal and vertical Center of Rotation (COR), combined offset, and leg length. METHODS: This study included 60 patients undergoing primary THA for symptomatic hip osteoarthritis, randomly allocated to either robotic-arm-assisted or conventional THA. Digital 2D templating and 3D planning using the robotic software were performed for all patients. All measurements to evaluate the accuracy of templating methods were conducted on the pre-operative CT scanogram, using the contralateral hip as a reference. Sensitivity analyses explored differences between 2D and 3D planning in patients who had supero-lateral or medial osteoarthritis patterns. RESULTS: Compared to 2D templating, 3D templating was associated with less medialization of the horizontal COR (-1.2 versus -0.2 mm, P = 0.002) and more accurate restoration of the vertical COR (1.63 versus 0.3 mm, P < 0.001) with respect to the contralateral side. Furthermore, 3D templating was superior for planned restoration of leg length (+0.23 versus -0.74 mm, P = 0.019). Sensitivity analyses demonstrated that in patients who had medial osteoarthritis, 3D planning resulted in less medialization of horizontal COR and less offset reduction. Conversely, in patients who had supero-lateral osteoarthritis, there was less lateralization of horizontal COR and less offset increase using 3D planning. Additionally, 3D planning showed superior reproducibility for stem, acetabular cup sizes, and neck angle, while 2D planning often led to smaller stem and cup sizes. CONCLUSION: Our findings indicated higher accuracy in the planned restoration of native joint mechanics using 3D planning. Additionally, this study highlights distinct variances between the two planning methods across different osteoarthritis pattern subtypes, offering valuable insights for clinicians employing 2D planning.

A prospective randomized controlled trial comparing CT-based planning with conventional total hip arthroplasty versus robotic arm-assisted total hip arthroplasty.

Aims: Achieving accurate implant positioning and restoring native hip biomechanics are key surgeon-controlled technical objectives in total hip arthroplasty (THA). The primary objective of this study was to compare the reproducibility of the planned preoperative centre of hip rotation (COR) in patients undergoing robotic arm-assisted THA versus conventional THA. Methods: This prospective randomized controlled trial (RCT) included 60 patients with symptomatic hip osteoarthritis undergoing conventional THA (CO THA) versus robotic arm-assisted THA (RO THA). Patients in both arms underwent pre- and postoperative CT scans, and a patient-specific plan was created using the robotic software. The COR, combined offset, acetabular orientation, and leg length discrepancy were measured on the pre- and postoperative CT scanogram at six weeks following surgery. Results: There were no significant differences for any of the baseline characteristics including spinopelvic mobility. The absolute error for achieving the planned horizontal COR was median 1.4 mm (interquartile range (IQR) 0.87 to 3.42) in RO THA versus 4.3 mm (IQR 3 to 6.8; p < 0.001); vertical COR mean 0.91 mm (SD 0.73) in RO THA versus 2.3 mm (SD 1.3; p < 0.001); and combined offset median 2 mm (IQR 0.97 to 5.45) in RO THA versus 3.9 mm (IQR 2 to 7.9; p = 0.019). Improved accuracy was observed with RO THA in achieving the desired acetabular component positioning (root mean square error for anteversion and inclination was 2.6 and 1.3 vs 8.9 and 5.3, repectively) and leg length (mean 0.6 mm vs 1.4 mm; p < 0.001). Patient-reported outcome measures were comparable between the two groups at baseline and one year. Participants in the RO THA group needed fewer physiotherapy sessions postoperatively (median six (IQR 4.5 to 8) vs eight (IQR 6 to 11; p = 0.005). Conclusion: This RCT suggested that robotic-arm assistance in THA was associated with improved accuracy in restoring the native COR, better preservation of the combined offset, leg length correction, and superior accuracy in achieving the desired acetabular component positioning. Further evaluation through long-term and registry data is necessary to assess whether these findings translate into improved implant survival and functional outcomes.

Anterior cruciate ligament injuries in female athletes: risk factors and strategies for prevention.

Anterior cruciate ligament (ACL) injuries are among the most common and debilitating knee injuries in professional athletes with an incidence in females up to eight-times higher than their male counterparts. ACL injuries can be career-threatening and are associated with increased risk of developing knee osteoarthritis in future life. The increased risk of ACL injury in females has been attributed to various anatomical, developmental, neuromuscular, and hormonal factors. Anatomical and hormonal factors have been identified and investigated as significant contributors including osseous anatomy, ligament laxity, and hamstring muscular recruitment. Postural stability and impact absorption are associated with the stabilizing effort and stress on the ACL during sport activity, increasing the risk of noncontact pivot injury. Female patients have smaller diameter hamstring autografts than males, which may predispose to increased risk of re-rupture following ACL reconstruction and to an increased risk of chondral and meniscal injuries. The addition of an extra-articular tenodesis can reduce the risk of failure; therefore, it should routinely be considered in young elite athletes. Prevention programs target key aspects of training including plyometrics, strengthening, balance, endurance and stability, and neuromuscular training, reducing the risk of ACL injuries in female athletes by up to 90%. Sex disparities in access to training facilities may also play an important role in the risk of ACL injuries between males and females. Similarly, football boots, pitches quality, and football size and weight should be considered and tailored around females' characteristics. Finally, high levels of personal and sport-related stress have been shown to increase the risk of ACL injury which may be related to alterations in attention and coordination, together with increased muscular tension, and compromise the return to sport after ACL injury. Further investigations are still necessary to better understand and address the risk factors involved in ACL injuries in female athletes.

The Value of Computed Tomography Scan in Three-dimensional Planning and Intraoperative Navigation in Primary Total Hip Arthroplasty.

Total hip arthroplasty (THA) is a frequently performed procedure; the objective is restoration of native hip biomechanics and achieving functional range of motion (ROM) through precise positioning of the prosthetic components. Advanced three-dimensional (3D) imaging and computed tomography (CT)-based navigation are valuable tools in both the preoperative planning and intraoperative execution. The aim of this study is to provide a thorough overview on the applications of CT scans in both the preoperative and intraoperative settings of primary THA. Preoperative planning using CT-based 3D imaging enables greater accuracy in prediction of implant sizes, leading to enhancement of surgical workflow with optimization of implant inventory. Surgeons can perform a more thorough assessment of posterior and anterior acetabular wall coverage, acetabular osteophytes, anatomical landmarks, and thus achieve more functional implant positioning. Intraoperative CT-based navigation can facilitate precise execution of the preoperative plan, to attain optimal positioning of the prosthetic components to avoid impingement. Medial reaming can be minimized preserving native bone stock, which can enable restoration of femoral, acetabular, and combined offsets. In addition, it is associated with greater accuracy in leg length adjustment, a critical factor in patients' postoperative satisfaction. Despite the higher costs and radiation exposure, which currently limits its widespread adoption, it offers many benefits, and the increasing interest in robotic surgery has facilitated its integration into routine practice. Conducting additional research on ultra-low-dose CT scans and examining the potential for translation of 3D imaging into improved clinical outcomes will be necessary to warrant its expanded application.

Factors associated with decreased length of stay following robotic arm-assisted and conventional total hip arthroplasty.

Aims: Postoperative length of stay (LOS) and discharge dispositions following arthroplasty can be used as surrogate measurements for improvements in patients' pathways and costs. With the increasing use of robotic technology in arthroplasty, it is important to assess its impact on LOS. The aim of this study was to identify factors associated with decreased LOS following robotic arm-assisted total hip arthroplasty (RO THA) compared with the conventional technique (CO THA). Methods: This large-scale, single-institution study included 1,607 patients of any age who underwent 1,732 primary THAs for any indication between May 2019 and January 2023. The data which were collected included the demographics of the patients, LOS, type of anaesthetic, the need for treatment in a post-anaesthesia care unit (PACU), readmission within 30 days, and discharge disposition. Univariate and multivariate logistic regression models were used to identify factors and the characteristics of patients which were associated with delayed discharge. Results: The multivariate model identified that age, female sex, admission into a PACU, American Society of Anesthesiologists grade > II, and CO THA were associated with a significantly higher risk of a LOS of > two days. The median LOS was 54 hours (interquartile range (IQR) 34 to 78) in the RO THA group compared with 60 hours (IQR 51 to 100) in the CO THA group (p < 0.001). The discharge dispositions were comparable between the two groups. A higher proportion of patients undergoing CO THA required PACU admission postoperatively, although without reaching statistical significance (7.2% vs 5.2%, p = 0.238). Conclusion: We found that among other baseline characteristics and comorbidities, RO THA was associated with a significantly shorter LOS, with no difference in discharge destination. With the increasing demand for THA, these findings suggest that robotic assistance in THA could reduce costs. However, randomized controlled trials are required to investigate the cost-effectiveness of this technology.

Quadriceps injuries.

Injuries to the quadriceps muscle group are common in athletes performing high-speed running and kicking sports. The complex anatomy of the rectus femoris puts it at greatest risk of injury. There is variability in prognosis in the literature, with reinjury rates as high as 67% in the severe graded proximal tear. Studies have highlighted that athletes can reinjure after nonoperative management, and some benefit may be derived from surgical repair to restore function and return to sport (RTS). This injury is potentially career-threatening in the elite-level athlete, and we aim to highlight the key recent literature on interventions to restore strength and function to allow early RTS while reducing the risk of injury recurrence. This article reviews the optimal diagnostic strategies and classification of quadriceps injuries. We highlight the unique anatomy of each injury on MRI and the outcomes of both nonoperative and operative treatment, providing an evidence-based management framework for athletes.

Length of stay and discharge dispositions following robotic arm-assisted total knee arthroplasty and unicompartmental knee arthroplasty versus conventional technique and predictors of delayed discharge.

Aims: In-hospital length of stay (LOS) and discharge dispositions following arthroplasty could act as surrogate measures for improvement in patient pathways, and have major cost saving implications for healthcare providers. With the ever-growing adoption of robotic technology in arthroplasty, it is imperative to evaluate its impact on LOS. The objectives of this study were to compare LOS and discharge dispositions following robotic arm-assisted total knee arthroplasty (RO TKA) and unicompartmental arthroplasty (RO UKA) versus conventional technique (CO TKA and UKA). Methods: This large-scale, single-institution study included patients of any age undergoing primary TKA (n = 1,375) or UKA (n = 337) for any cause between May 2019 and January 2023. Data extracted included patient demographics, LOS, need for post anaesthesia care unit (PACU) admission, anaesthesia type, readmission within 30 days, and discharge dispositions. Univariate and multivariate logistic regression models were also employed to identify factors and patient characteristics related to delayed discharge. Results: The median LOS in the RO TKA group was 76 hours (interquartile range (IQR) 54 to 104) versus 82.5 (IQR 58 to 127) in the CO TKA group (p < 0.001) and 54 hours (IQR 34 to 77) in the RO UKA versus 58 (IQR 35 to 81) in the CO UKA (p = 0.031). Discharge dispositions were comparable between the two groups. A higher percentage of patients undergoing CO TKA required PACU admission (8% vs 5.2%; p = 0.040). Conclusion: Our study showed that robotic arm assistance was associated with a shorter LOS in patients undergoing primary UKA and TKA, and no difference in the discharge destinations. Our results suggest that robotic arm assistance could be advantageous in partly addressing the upsurge of knee arthroplasty procedures and the concomitant healthcare burden; however, this needs to be corroborated by long-term cost-effectiveness analyses and data from randomized controlled studies.

Anterior cruciate ligament injuries in female athletes.

The anterior cruciate ligament (ACL) is frequently injured in elite athletes, with females up to eight times more likely to suffer an ACL tear than males. Biomechanical and hormonal factors have been thoroughly investigated; however, there remain unknown factors that need investigation. The mechanism of injury differs between males and females, and anatomical differences contribute significantly to the increased risk in females. Hormonal factors, both endogenous and exogenous, play a role in ACL laxity and may modify the risk of injury. However, data are still limited, and research involving oral contraceptives is potentially associated with methodological and ethical problems. Such characteristics can also influence the outcome after ACL reconstruction, with higher failure rates in females linked to a smaller diameter of the graft, especially in athletes aged < 21 years. The addition of a lateral extra-articular tenodesis can improve the outcomes after ACL reconstruction and reduce the risk of failure, and it should be routinely considered in young elite athletes. Sex-specific environmental differences can also contribute to the increased risk of injury, with more limited access to and availablility of advanced training facilities for female athletes. In addition, football kits are designed for male players, and increased attention should be focused on improving the quality of pitches, as female leagues usually play the day after male leagues. The kit, including boots, the length of studs, and the footballs themselves, should be tailored to the needs and body shapes of female athletes. Specific physiotherapy programmes and training protocols have yielded remarkable results in reducing the risk of injury, and these should be extended to school-age athletes. Finally, psychological factors should not be overlooked, with females' greater fear of re-injury and lack of confidence in their knee compromising their return to sport after ACL injury. Both intrinsic and extrinsic factors should be recognized and addressed to optimize the training programmes which are designed to prevent injury, and improve our understanding of these injuries.

Functional Component Positioning in Total Hip Arthroplasty and the Role of Robotic-Arm Assistance in Addressing Spinopelvic Pathology.

Hip, spine, and pelvis function as a unified kinetic chain. Any spinal pathology, results in compensatory changes in the other components to accommodate for the reduced spinopelvic motion. The complex relationship between spinopelvic mobility and component positioning in total hip arthroplasty presents a challenge in achieving functional implant positioning. Patients with spinal pathology, especially those with stiff spines and little change in sacral slope, are at high instability risk. In this challenging subgroup, robotic-arm assistance enables the execution of a patient specific plan, avoiding impingement and maximizing range of motion; especially utilizing virtual range of motion to dynamically assess impingement.

London International Consensus and Delphi study on hamstring injuries part 3: rehabilitation, running and return to sport.

Hamstring injuries (HSIs) are the most common athletic injury in running and pivoting sports, but despite large amounts of research, injury rates have not declined in the last 2 decades. HSI often recur and many areas are lacking evidence and guidance for optimal rehabilitation. This study aimed to develop an international expert consensus for the management of HSI. A modified Delphi methodology and consensus process was used with an international expert panel, involving two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering round questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15), comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion around each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. Consensus threshold was set a priori at 70%. Expert response rates were 35/46 (76%) (first round), 15/35 (attendees/invitees to meeting day) and 99/112 (88.2%) for final survey round. Statements on rehabilitation reaching consensus centred around: exercise selection and dosage (78.8%-96.3% agreement), impact of the kinetic chain (95%), criteria to progress exercise (73%-92.7%), running and sprinting (83%-100%) in rehabilitation and criteria for return to sport (RTS) (78.3%-98.3%). Benchmarks for flexibility (40%) and strength (66.1%) and adjuncts to rehabilitation (68.9%) did not reach agreement. This consensus panel recommends individualised rehabilitation based on the athlete, sporting demands, involved muscle(s) and injury type and severity (89.8%). Early-stage rehab should avoid high strain loads and rates. Loading is important but with less consensus on optimum progression and dosage. This panel recommends rehabilitation progress based on capacity and symptoms, with pain thresholds dependent on activity, except pain-free criteria supported for sprinting (85.5%). Experts focus on the demands and capacity required for match play when deciding the rehabilitation end goal and timing of RTS (89.8%). The expert panellists in this study followed evidence on aspects of rehabilitation after HSI, suggesting rehabilitation prescription should be individualised, but clarified areas where evidence was lacking. Additional research is required to determine the optimal load dose, timing and criteria for HSI rehabilitation and the monitoring and testing metrics to determine safe rapid progression in rehabilitation and safe RTS. Further research would benefit optimising: prescription of running and sprinting, the application of adjuncts in rehabilitation and treatment of kinetic chain HSI factors.

London International Consensus and Delphi study on hamstring injuries part 2: operative management.

The key indications for surgical repair of hamstring injuries (HSIs) remain unclear in the literature due to a lack of high-level evidence and expert knowledge. The 2020 London International Hamstring Consensus meeting aimed to highlight clear surgical indications and to create a foundation for future research. A literature review was conducted followed by a modified Delphi process, with an international expert panel. Purposive sampling was used with two rounds of online questionnaires and an intermediate round involving a consensus meeting. The initial information gathering (round 1) questionnaire was sent to 46 international experts, which comprised open-ended questions covering decision-making domains in HSI. Thematic analysis of responses outlined key domains, which were evaluated by a smaller international subgroup (n=15) comprising clinical academic sports medicine physicians, physiotherapists and orthopaedic surgeons in a consensus meeting. After group discussion of each domain, a series of consensus statements were prepared, debated and refined. A round 2 questionnaire was sent to 112 international hamstring experts to vote on these statements and determine level of agreement. The consensus threshold was set a priori at 70% agreement. Rounds 1 and 2 survey respondents were 35/46 (76%) and 99/112 (88.4%), respectively. The consensus group agreed that the indications for operative intervention included: gapping at the zone of tendinous injury (87.2% agreement) and loss of tension (70.7%); symptomatic displaced bony avulsions (72.8%); and proximal free tendon injuries with functional compromise refractory to non-operative treatment (72.2%). Other important considerations for operative intervention included: the demands of the athlete/patient and the expected functional outcome (87.1%) based on the anatomy of the injury; the risk of functional loss/performance deficit with non-operative management (72.2%); and the capacity to restore anatomy and function (87.1%). Further research is needed to determine whether surgery can reduce the risk of reinjury as consensus was not reached within the whole group (48.2%) but was agreed by surgeons (70%) in the cohort. The consensus group did not support the use of corticosteroids or endoscopic surgery without further evidence. These guidelines will help standardise treatment of HSIs, specifically the indications and decision-making for surgical intervention.

London International Consensus and Delphi study on hamstring injuries part 1: classification.

Muscle injury classification systems for hamstring injuries have evolved to use anatomy and imaging information to aid management and prognosis. However, classification systems lack reliability and validity data and are not specific to individual hamstring muscles, potentially missing parameters vital for sport-specific and activity-specific decision making. A narrative evidence review was conducted followed by a modified Delphi study to build an international consensus on best-practice decision-making for the classification of hamstring injuries. This comprised a digital information gathering survey to a cohort of 46 international hamstring experts (sports medicine physicians, physiotherapists, surgeons, trainers and sports scientists) who were also invited to a face-to-face consensus group meeting in London . Fifteen of these expert clinicians attended to synthesise and refine statements around the management of hamstring injury. A second digital survey was sent to a wider group of 112 international experts. Acceptance was set at 70% agreement. Rounds 1 and 2 survey response rates were 35/46 (76%) and 99/112 (88.4%) of experts responding. Most commonly, experts used the British Athletics Muscle Injury Classification (BAMIC) (58%), Munich (12%) and Barcelona (6%) classification systems for hamstring injury. Issues identified to advance imaging classifications systems include: detailing individual hamstring muscles, establishing optimal use of imaging in diagnosis and classification, and testing the validity and reliability of classification systems. The most used hamstring injury classification system is the BAMIC. This consensus panel recommends hamstring injury classification systems evolve to integrate imaging and clinical parameters around: individual muscles, injury mechanism, sporting demand, functional criteria and patient-reported outcome measures. More research is needed on surgical referral and effectiveness criteria, and validity and reliability of classification systems to guide management.

Short term outcomes following robotic arm-assisted lateral unicompartmental knee arthroplasty.

Introduction: Robotic-arm assisted medial unicompartmental knee arthroplasty (RA-UKA) is associated with improved accuracy of implant positioning and excellent early functional outcomes. However, there is paucity of evidence regarding outcomes following RA-UKA for isolated lateral compartment osteoarthritis. The purpose of this study was to assess the short-term clinical and patient reported outcomes of lateral compartment UKA, utilising robotic-arm assistance. Methods: This was a retrospective study of prospectively collected data of 21 consecutive patients who underwent lateral RA-UKA. The study included 9 (42.9%) males and 12 (57.1%) females with a mean age of 63.4 ± 9.2 years. The Oxford Knee Score (OKS) was measured pre-operatively and at 1-year post-operatively, while range of motion (ROM) and complications were also recorded. Results: There was significant improvement of OKS at 1 year's follow up compared with the baseline score (21.8 ± 5.6 vs. 45.2 ± 2.8 respectively; p < 0.001). There was also an improvement in pre-operative ROM when compared to ROM at 1 year's follow up (123.5° ± 8° vs. 131.5° ± 6.3° respectively; p < 0.001). None of the study patients underwent revision surgery within 1 year's follow-up. Conclusion: In our study, lateral RA-UKA resulted in significant improvements in clinical and patient reported outcomes with low complications rates. Further long-term comparative studies are needed to assess the utility of lateral RA-UKA vs. conventional UKA.

Surgical Repair of Stener-like Injuries of the Medial Collateral Ligament of the Knee in Professional Athletes.

BACKGROUND: A "Stener-like" lesion of the knee is defined as a distal avulsion of the superficial medial collateral ligament (sMCL) with interposition of the pes anserinus between the ligament and its tibial insertion-a displacement impeding anatomic healing. Because of the scarcity of these injuries, the literature is limited to case reports and small case series. PURPOSE: To assess the effect of surgical repair of acute Stener-like lesions of the sMCL on the following outcomes: return to preinjury level of sporting function; time to return to preinjury level of sporting function; functional performance; injury recurrence; and any other complications. STUDY DESIGN: Case series: Level of evidence, 4. METHODS: This prospective single-surgeon study included 23 elite athletes with a mean age of 27.2 years (range, 19-37 years). Of the participants, 20 were men (87%) and 3 were women (13%). The mean body mass index was 23.1 ± 2.3. A total of 16 athletes were soccer players (70%) and 7 were rugby players (30%), with isolated acute, traumatic Stener-like lesions of the sMCL of the knee confirmed on preoperative magnetic resonance imaging. Surgical repair was undertaken with primary suture anchor repair with ligament repair or reconstruction system (LARS) augmentation. Predefined outcomes were recorded at regular intervals after surgery. The minimum follow-up time was 24 months (range, 24-108 months) from the date of surgery. RESULTS: The mean time from injury to surgical intervention was 9 days (range, 3-28 days). Overall, 15 (65%) athletes had isolated distal sMCL injuries requiring anatomic suture anchor repair at the distal tibial insertion site only, and 8 (35%) athletes had concomitant injuries of the proximal and distal sMCL and required anatomic suture anchor repair at the proximal and distal attachment sites. Ten athletes required LARS augmentation at the time of the index operation. All study patients returned to their preinjury level of sporting activity in professional soccer or rugby. The mean time from surgical intervention to return to full sporting activity was 16.8 ± 2.7 weeks. At 6 and 24 months' follow-up, all patients had Tegner scores of 10. At a 2-year follow-up, all study patients were still participating at their preinjury level of sporting activity. Three patients developed complications around the LARS that required further surgery to remove synthetic material; however, this did not affect function. CONCLUSION: Surgical repair of acute Stener-like lesions of the sMCL is associated with a high return to preinjury level of sporting function, excellent functional performance, and a low risk of recurrence at short-term follow-up in elite athletes.

There is no difference in the complication or re-operation rates between tension band wiring and locking plate fixation for olecranon fractures. The findings of a multicentre study.

INTRODUCTION: Tension band wire (TBW) and locking plate fixation (LPF) are widely used fixation methods for displaced fractures of the olecranon. The aim of our study was to review the current operative management of olecranon fractures and compare the complication and re-operation rates for patients undergoing TBW and LPF. MATERIALS AND METHODS: Retrospective data were collected for all patients who underwent acute fixation of olecranon fractures in 2016 across nine hospitals in the United Kingdom. We reviewed these cases to determine the incidence of complications and re-operations. RESULTS: One hundred and forty patients were included in the study. Seventy-three (52%) had TBW, 67 (48%) had LPF. Males were more likely to have LPF (p = 0.01) as were patients with comminuted fractures (p < 0.01). The overall complication rate was 25%, including an infection rate of 3%, a prominent metalwork irritation rate of 12% and the overall re-operation rate was 17%. There was no significant difference in the complication rate (p = 0.38), infection rate (p = 0.92) or rate of prominent metalwork irritation (p = 0.10) between patients undergoing TBW and LPF. Sub group analysis of patients with comminuted fractures also demonstrated no significant difference in complication rates (p = 0.75) or re-operation rates (p = 0.26). CONCLUSION: LPF has previously been advocated to be advantageous to TBW due to lower reported complication and re-operation rates despite there being no significant difference in functional outcomes. In this multicentre case series, which is the largest in the literature to date, we did not observe any significant differences in complication rates or re-operation rates between the two, even amongst comminuted fractures (which are traditionally treated with LPF), when decision making was left to surgeon preference. We, therefore, recommend that choice of fixation method should be left to individual surgeon's preference.

The introduction of day-case total knee arthroplasty in a national healthcare system: A review of the literature and development of a hospital pathway.

INTRODUCTION: As we now drive to reinitiate our full capacity elective services in an attempt to tackle an ever-growing demand for lower limb arthroplasty, this pandemic has presented rare opportunities to revise and re-engage elective arthroplasty pathways aimed at improving patient care and healthcare efficiency. AIMS: We present the development of an evidence-based multidisciplinary perioperative care pathway for day-case total knee arthroplasty (TKA) in a United Kingdom National Health Service (NHS) institution, in conjunction with a review of the literature upon which the protocol is founded. METHODOLOGY: We performed a review of the literature reporting complication or readmission rates at ≥30 day postoperative following day-case TKA. Electronic searches were performed using four databases from the date of inception to November 2020. Relevant studies were identified, data extracted, and qualitative synthesis performed. RESULTS: 13 manuscripts with a total of 3370 day-case TKAs, defined as discharged on the same-calendar-day of surgery, were included in analysis. Mean 90-day complication rates (8.31% [range, 0-16.3%] vs 9.49% [range, 0-13.1%], respectively) and readmission rates (2.71% [range, 0-10.0%] vs 3.41% [range, 0-9.9%], respectively) were equivocal between day-case and inpatient TKA. The overall rate of successful same-calendar-day discharge was 95.8%. Our evaluation and critique of the evidence-based literature identifies day-case TKA to be safe, effective and economical, benefitting both patients and healthcare systems alike. CONCLUSION: We further validate the introduction of our institutional Elective Day Surgery Arthroplasty Pathway (EDSAP) based on the evidence presented. Careful patient selection paralleled with well-defined care pathways are essential for successful introduction of day-case TKA into the NHS.