Tibial tubercle to trochlear groove and the roman arch method for tibial tubercle lateralisation are reliable and distinguish between subjects with and without major patellar instability.

PURPOSE: Patellofemoral (PF) instability recurrence depends on several factors including the relative lateralisation of tibial tubercle (TT) regarding the trochlear groove (TG). TT relative lateralisation quantification has long been a topic of debate. Multiple measuring techniques have been described including TT-trochlear groove (TT-TG), TT-posterior cruciate ligament (TT-PCL) and TT-roman arch (TT-RA), with no clear consensus regarding the most reliable index or pathologic threshold. We set out to determine the normal value range of each index and their association with age, sex and PF instability status. Also, this study aims to determine a reliable pathologic distance threshold to effectively predict patellar dislocation. METHODS: Skeletally mature patients up to 45 years of age who presented a CT Scan and an MRI of the same knee between 2014 and 2018 were included and divided into subgroups based on history of PF instability. Three indexes (TT-TG, TT-PCL and TT-RA) were assessed by two independent observers blinded to instability history. ROC curves were performed for each index to obtain the cut point that better predicts instability. Univariate and multivariate models adjusted by age, sex, instability history and type of imaging technique were performed to test the influence of these variables. RESULTS: 208 patients were included. Mean age was 27.93 â€‹± â€‹8.48 years, 67.3% were female and 71 patients (34.1%) presented major instability history. Good or excellent inter and intraobserver reliability was found for all three indexes. All indexes presented significantly different distributions between subjects with and without major instability (p â€‹< â€‹0.001), except for TT-PCL. Different cut point values differing between imaging modalities were found: 11.4 â€‹mm for MRI TT-TG, 17 â€‹mm for CT TT-TG, 15.6 â€‹mm for MRI TT-RA and 18.2 â€‹mm for CT TT-RA. CONCLUSIONS: All indexes studied had good or excellent inter and intraobserver reliability. Measurements between imaging techniques (CT and MR) are not interchangeable. Both TT-TG and TT-RA correctly distinguish between subjects with and without major instability, while TT-PCL does not, recommending caution when evaluated on its own. Specific threshold values depending on imaging technique should be considered for surgical decision-making. LEVEL OF EVIDENCE: Level IV, Diagnostic Test.

Use of electromyographic biofeedback in rehabilitation following anterior cruciate ligament reconstruction: a systematic review and meta-analysis.

BACKGROUND: Rehabilitation following anterior cruciate ligament (ACL) reconstruction surgery is essential to regain functionality and return to previous activity level. Electromyographic biofeedback may be an effective intervention for rehabilitation of patients following ACL surgery. OBJECTIVE: To synthesize the available evidence on the effect of electromyographic biofeedback in the treatment of quadriceps strength following ACL surgery. DESIGN: Systematic review with meta-analysis. DATA SOURCES: PubMed, EMBASE, CENTRAL and Epistemonikos were searched. ELIGIBILITY CRITERIA: Randomized clinical trials with patients undergoing ACL reconstruction surgery comparing biofeedback with a standard rehabilitation control group. DATA EXTRACTION AND DATA SYNTHESIS: Two authors selected articles and performed data extraction. The analysed outcomes were strength, function, pain, knee extension and balance. The risk of bias of individual studies was assessed using the Cochrane Risk of Bias Tool. Results were combined through random-effects meta-analysis, reporting mean differences. RESULTS: Eight articles were included in the qualitative analysis, and four articles were included in the quantitative analysis. The interventions lasted between 4 and 12 weeks. Three studies evaluated the effect of biofeedback on quadriceps strength; of these, two studies showed a significant difference in favour of the biofeedback group. In addition, biofeedback was found to improve knee extension [standardized mean difference - 1.3, 95% confidence interval (CI) - 1.74 to -0.86] and balance (one study). There was no significant difference in Lysholm score (mean difference -6.21, 95% CI -17.51 to 5.08; I2 =59%) or pain between the biofeedback group and the control group. CONCLUSION: Electromyographic biofeedback in knee rehabilitation could be useful following ACL reconstruction surgery. KEY MESSAGES: SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO (CRD42020193768).

Evaluation of the Chilean National Orthopaedic Examination Over 11 Years: Progress and Outcomes of National and International Examinees.

INTRODUCTION: The National Orthopaedics Examination (EMNOT) was initially designed for Chilean orthopaedic program graduates and is now a crucial component of the revalidation process for international orthopaedic surgeons seeking practice in Chile. This study aims to describe participation and performance of EMNOT examinees based on their origin and to analyze the difficulty and discrimination indexes during its first 11 years of implementation. METHODS: A retrospective assessment was conducted on all EMNOT results from 2009 to 2019. The study evaluated the participation and performance of examinees according to their origin and examined the difficulty and discrimination indexes of the examination. RESULTS: A total of 975 examinees were evaluated, with 41.23% from national resident programs (National Medical Graduates) and 58.77% from international examinees (International Medical Graduates). The number of participating universities increased from 4 in 2009 to 17 in 2019. National Medical Graduates examinees achieved a mean score of 66.52 ± 8.67 (0 to 100 points) while International Medical Graduates examinees scored 55.13 ± 11.42 (P < 0.001). The difficulty and discrimination indexes remained adequate throughout this period. DISCUSSION: Over the course of 11 years, the number of EMNOT examinees exhibited notable growth. The examination effectively differentiates between candidates based on their origin and maintains appropriate levels of difficulty and discrimination.

The distance between the fibular collateral ligament tunnel and the common peroneal nerve allows a posterolateral corner reconstruction without neurolysis.

PURPOSE: The most popular knee posterolateral corner (PLC) reconstruction techniques describe that a common peroneal nerve (CPN) neurolysis must be done to safely address the posterolateral aspect of the knee. The purpose of this study was to measure the distance between the CPN and the fibular insertion of the FCL in different degrees of knee flexion in cadaveric specimens, to identify if tunnel drilling could be done anatomically and safely without a CPN neurolysis. METHODS: Ex vivo experimental analytical study. Ten fresh frozen human knees were dissected leaving FCL and CPN in situ. Shortest distance from the centre of the FCL distal tunnel and CPN was measured (antero-posterior and proximal-distal wire-nerve distances) at 90°, 60°, 30°, and 0° of knee flexion. Measurements between different flexion angles were compared and correlation between knee flexion angle and distance was identified. RESULTS: The mean distance between the FCL tunnel and the CPN at 90° were 21.15 ± 6.74 mm posteriorly (95% CI: 16.33-25.97) and 13.01 ± 3.55 mm distally (95% CI: 10.47-15.55). The minimum values were 9.8 mm posteriorly and 8.9 mm, respectively. These distances were smaller at 0° (p ≤ 0.017). At 90° of knee flexion, the mean distance from the fibular tip to the CPN distally was 23.46 ± 4.13 mm (20.51-26.41). CONCLUSION: Anatomic localization and orientation of fibular tunnels can be done safely while avoiding nerve neurolysis. Further studies should aim to in vivo measurements and results.

Skyline view of the patella does not increase fracture detection: A non-inferiority diagnostic study.

PURPOSE: Patella fractures are frequent injuries in the adult population. Initial study is made by plain radiographs and the standard set includes the skyline view of patella. Recommendation for use of this projection is variable among the experts, without data that support its performance in the diagnosis of patella fractures. The main purpose of this study was to determine the sensitivity of the antero-posterior and lateral view of the knee, without skyline view, in the diagnosis of patella fracture. METHODS: A retrospective non-inferiority diagnostic study was designed with all the knee trauma adult patients of an Emergency Department in a single center in five years. A random sample of all the consecutive patella fracture cases were taken to elaborate the case group. The control group was matched by sex and age. Two blinded orthopedic surgeons reviewed the cases and control radiographs and defined the presence of fracture, with or without skyline view, with a wash-out time of three weeks between the two evaluations. Non-inferiority was defined a priori at 90% of minimum sensitivity. RESULTS: 140 patients were evaluated (70 cases and 70 controls). Sensitivity of the set without skyline view was 92.86% (CI 95% 0.90 - 0.96) and the standard set was 97.86% (CI 95% 0.96 - 0.99), without significant differences (p = 0.1) CONCLUSION: Sensitivity of the plain radiograph set without skyline view is non-inferior to the standard set. The routine use of skyline view when suspecting patella fractures is questionable.

The AO classification system for tibial plateau fractures: An independent inter and intraobserver agreement study.

PURPOSE: Classifying tibial plateau fractures is paramount in determining treatment regimens and systemizing decision making. The original AO classification described by Müller in 1996 and the Schatzker classification of 1970 are the most cited classifications for tibial plateau fractures, demonstrating substantial to almost perfect agreement. The main problem with these classifications schemes is that they lack the detail required to convey the variety of fracture patterns encountered. In 2018, the AO foundation published a new classification system for proximal tibia fractures, highlighting a more complete and detailed number of categories and subcategories. We sought to independently determine inter and intraobserver agreement of the AO classification system, compared to the previous systems described by Müller and Schatzker. METHODS: One hundred seven consecutive tibial plateau fractures were screened, and a representative data set of 69 was created. Six independent evaluators (three knee surgeons, three senior orthopedic residents) classified the fractures using the original AO, the Schatzker and the new AO classifications. After six weeks, the 69 cases were randomized and reclassified by all evaluators. The Kappa coefficient (k) was calculated for inter- and intraobserver correlation and is expressed with 95% confidence intervals. RESULTS: interobserver agreement was moderate for all three classifications. k = 0.464 (0.383-0.560) for the original AO; k = 0.404 (0.337-0.489) for Schatzker; and k = 0.457 (0.371-0.545) for the base categories of the new AO classification. The inclusion of subcategories and letter modifiers to the new classification worsened agreement to k = 0.358 (0.302-0.423) and k = 0.174 (0.134-0.222), respectively. There were no significant differences between knee surgeons and residents for the new classification. Intra-observer correlation was also moderate for each of the scores: k = 0.630 (0.578-0.682) for the original AO; k = 0.623 (0.569-0.674) for Schatzker; and k = 0.621 (0.566-0.678) for the new AO base categories; without differences between knee surgeons or residents. CONCLUSIONS: This study demonstrated an adequate inter and intra-observer agreement for the new AO tibial plateau fractures classification system for its base categories, but not at the subcategory or letter modifier levels.

Rendimiento Biomecánico de las Placas de Tibia Proximal Utilizadas en Fracturas de Platillos Tibiales evaluado a través de Modelos de Elementos Finitos: Protocolo de Revisión Sistemática / A systematic Review Protocol Examining the Biomechanical Performance of Proximal Tibial Plates used in Tibial Plate Fractures assessed by Finite Element Analysis

Objetivo. Analizar el rendimiento biomecánico de las placas de tibia proximal utilizadas en fracturas de platillos tibiales evaluado a través de modelos de elementos finitos. Métodos. Se realizará una búsqueda exhaustiva en PubMed/Medline, Embase, Lilacs, Web of Science y Google Scholar. No se utilizará ninguna restricción de idioma o estado de publicación. Dos revisores examinarán de forma independiente los posibles artículos elegibles, de acuerdo con los criterios de selección predefinidos. Se incluirán los estudios que evalúen el rendimiento de los platillos tibiales proximales utilizados en las fracturas del platillo tibial evaluadas mediante el análisis de elementos finitos. La extracción de datos sobre las características del estudio, los métodos, los resultados y la evaluación del riesgo de sesgo se realizará mediante un formulario estandarizado. Considerando el diseño de estudio no se requiere evaluación por comité de ética. Los resultados de esta revisión se difundirán a través de la publicación en revistas revisadas por pares, redes sociales y congresos de la especialidad. Se espera que los resultados de esta revisión permitan optimizar los resultados del manejo quirúrgico de las fracturas de platillos tibiales. Número de registro PROSPERO: CRD42023396015.

Objetive. To analyze the biomechanical performance of proximal tibial plates used in tibial plate fractures evaluated through finite element modeling. Methods. A comprehensive search will be conducted in PubMed/Medline, Embase, Lilacs, Web of Science, and Google Scholar. No language or publication status restrictions will be used. Two reviewers will independently review potential eligible articles according to predefined selection criteria. Studies evaluating the performance of proximal tibial splints used in tibial splint fractures assessed by finite element analysis will be included. Data extraction on study characteristics, methods, results, and risk of bias assessment will be performed using a standardized form. Considering the study design, evaluation by an ethics committee is not required. The results of this review will be disseminated through publication in peer-reviewed journals, social networks and specialty congresses. It is expected that the results of this review will allow optimizing the results of the surgical management of tibial plate fractures. PROSPERO registration number: CRD42023396015.

La mujer en las publicaciones científicas en Chile / Presence of women in medical publications in Chile

BACKGROUND: Despite recent initiatives and efforts, gender inequality still exists in medicine and academia. There is a higher proportion of male authors in international scientific publications. AIM: To compare the proportion of female and male authors in the scientific publications of the main medical journals in Chile. Material and Methods: We reviewed 1,643 Scientific articles published between 2015 and 2020 in two medical journals from Chile. Three authors analyzed the title, abstract, and authors of all published articles, recording the sex of the first author, co-authors, and corresponding author. RESULTS: The reviewed articles had a mean of 5.3 authors and there was a significant difference between men and women (a mean of 2.8 men and 2.4 women; p < 0.001). Forty-six percent (n = 761) of the articles had a female first author. In a higher proportion of papers, men completed both positions (1st and corresponding author) simultaneously. CONCLUSIONS: There are fewer female authors in scientific publications. Chile is one of the countries with a high rate of gender gap in the world. The underrepresentation of women in academia is an example of this.

Validación de medidas de resultados informados por los pacientes en ortopedia y traumatología / Validation of patient-reported outcome measures in orthopedics and traumatology

En los últimos años, ha habido un aumento en la aplicación de cuestionarios diseñados para la medición de resultados (o desenlaces) clínicos en la práctica médica. Para aplicar un cuestionario en una población distinta a la cual fue originalmente creado y diseñado, es necesario llevar a cabo un proceso riguroso de adaptación, con una determinada metodología. El objetivo de esta guía metodológica es describir el proceso de traducción, adaptación transcultural y validación de medidas de resultados informados por los pacientes (MRIPs) en Ortopedia y Traumatología.

In recent years, there has been an increase in the use of questionnaires designed to measure outcomes in the medical practice. To use a questionnaire in a population different from the one for which it was originally created and designed, it is necessary to carry out a rigorous adaptation process, with a certain methodology. The objective of the present methodological guide is to describe the process of translation, crosscultural adaptation, and validation of patient-reported outcome measures in Orthopedics and Traumatology

[Presence of women in medical publications in Chile]. / La mujer en las publicaciones científicas en Chile.

BACKGROUND: Despite recent initiatives and efforts, gender inequality still exists in medicine and academia. There is a higher proportion of male authors in international scientific publications. AIM: To compare the proportion of female and male authors in the scientific publications of the main medical journals in Chile. MATERIAL AND METHODS: We reviewed 1,643 Scientific articles published between 2015 and 2020 in two medical journals from Chile. Three authors analyzed the title, abstract, and authors of all published articles, recording the sex of the first author, co-authors, and corresponding author. RESULTS: The reviewed articles had a mean of 5.3 authors and there was a significant difference between men and women (a mean of 2.8 men and 2.4 women; p < 0.001). Forty-six percent (n = 761) of the articles had a female first author. In a higher proportion of papers, men completed both positions (1st and corresponding author) simultaneously. CONCLUSIONS: There are fewer female authors in scientific publications. Chile is one of the countries with a high rate of gender gap in the world. The underrepresentation of women in academia is an example of this.

The use of intraoperative comparative fluoroscopy allows for assessing sagittal reduction and predicting syndesmosis reduction in ankle fractures.

Intraoperative fluoroscopic parameters have shown to be poor predictors for ankle syndesmosis reduction, with up to 52% of syndesmotic malreduction (SMR) reported in the literature. Anteroposterior Tibio-Fibular index (APTF) was previously described to evaluate sagittal tibiofibular alignment in lateral ankle radiographs with a high correlation between both ankles in uninjured subjects. Reproducible intraoperative measurements for sagittal syndesmotic reduction are lacking. We propose the use of the "cAPTF," calculated as the absolute difference between the APTF of the non-injured and the operated ankle, to evaluate sagittal syndesmotic reduction. OBJECTIVE: Determine the predictive capability of cAPTF for SMR. METHOD: Prospective observational study. INCLUSION CRITERIA: patients with unstable ankle fractures requiring syndesmotic fixation, with a healthy contralateral ankle. Intraoperatively APTF was measured in both ankles after syndesmotic fixation. Postoperatively cAPTF was calculated. Only direct syndesmosis visualization through the lateral approach and AP and mortise views were used by surgeons to assess syndesmotic reduction. Quality of syndesmotic reduction was evaluated with bilateral postoperative CT. To estimate cAPTF discriminatory power for SMR, a receiver operative characteristic (ROC) curve was obtained and the area under the ROC curve was calculated. Youden index was used to determine the ideal cAPTF cut-off value for predicting SMR. For this determined cut-off value, sensitivity, specificity, and likelihood ratio were calculated. RESULTS: Fifty-two patients were included. Sixteen (30%) had SMR. Patients with SMR had a statistically significant higher cAPTF value than the well reduced (median 0.26 vs 0.09; P < 0.01). The cAPTF cut-off value to predict SMR was 0.161. A cAPTF greater than 0.161 had 100% sensitivity and 97,2% specificity for SMR. The area under the ROC curve was 0.99. CONCLUSION: Intraoperative cAPTF has excellent discriminatory power for predicting syndesmotic malreduction. We propose the routine use of intraoperative bilateral comparative fluoroscopy to assess sagittal syndesmotic reduction.

Tibial Cut Accuracy in Mechanically Aligned Total Knee Arthroplasty Using Extensor Hallucis Longus Tendon to Determine Extramedullary Tibial Guide Position.

This study aimed to determine the tibial cut (TC) accuracy using extensor hallucis longus (EHL) tendon as an anatomical landmark to position the total knee arthroplasty (TKA) extramedullary tibial guide (EMTG), and its impact on the TKA mechanical alignment (MA). We retrospectively studied 96 TKA, performed by a single surgeon, using a femoral tailored intramedullary guide technique. Seventeen were prior to the use of the EHL and 79 used the EHL tendon to position the EMTG. We analyzed preoperative and postoperative standing total lower extremity radiographs to determine the tibial component angle (TCA) and the correction in MA, comparing pre-EHL use and post-EHL technique incorporation. Mean TCA was 88.89 degrees and postoperative MA was neutral in 81% of patients. Pre- and postoperative MAs were not correlated. As a conclusion of this study, using the EHL provides a safe and easy way to determine the position of EMTG.

Mid and lower thoracic kyphosis changes during adulthood: the influence of age, sex and thoracic coronal curvature.

INTRODUCTION: There is conflicting data on how thoracic kyphosis changes throughout adulthood. We evaluated mid and lower thoracic kyphosis (MTK) in various age groups and the influence of age, sex and coronal curve (CC) on MTK. MATERIAL AND METHODS: We studied 1323 patients 15-80 years-old (54.4% females) previously evaluated with chest radiographs. We established three groups: patients 15-40 (group 1); 41-60 (group 2) and 61-80 years old (group 3). MTK (T5-T12) and CC were measured using Cobb's method. We established differences in MTK between groups using ANOVA with Bonferroni correction. We performed a correlation analysis of MTK with age and CC, and a linear regression analysis to determine if age, sex and CC independently predicted MTK. RESULTS: MTK increased with older age: mean MTK group 1 = 23.4°; group 2 = 27.9° and group 3 = 34.4°, p < 0.01. The increase in MTK was observed in both genders. Scoliosis was more common in females (15.4%) than in males (6.7%), p < 0.01. MTK was correlated with age (r = 0.4; p < 0.01) and slightly correlated with CC (r = 0.07, p < 0.01). MTK was larger in females than in males (29.1° vs. 27.6°, p < 0.01). Age (ß-coefficient = 0.26) and CC (ß-coefficient = 0.14), but not sex, independently influenced MTK in the regression analysis. CONCLUSION: MTK increases with advancing age during adulthood in both genders; CC, but not sex, was an independent predictor of MTK.

The new AO classification system for intertrochanteric fractures allows better agreement than the original AO classification. An inter- and intra-observer agreement evaluation.

BACKGROUND: A new AO classification for intertrochanteric fractures was recently published; no studies have evaluated its inter- and intra-observer agreement. METHODS: Six evaluators (three hip subspecialists and three residents) assessed radiographs of 68 intertrochanteric fractures; fractures were classified using the original and the new AO classifications. The cases were displayed in a random sequence after a six-week interval for repeat evaluation. We used the Kappa coefficient (k) to determine inter- and intra-observer agreement. RESULTS: Inter-observer agreement was slight (k = 0.128 [0.092-0.170]) using the original and fair (k = 0.250 [0.186-0.327]), with the new AO classification. Orthopedic residents exhibited better agreement than hip surgeons using the original classification (k = 0.302 [0.210-0.416] and k= -0.018 [-0.058-0.029], respectively) and the new classification (k = 0.388 [0.294-0.514] and k = 0.109 [0.031-0.192], respectively). Using both classifications as dichotomous variables (stable or unstable patterns), the agreement was slight (k = 0.158 [0.074-0.246]) using the original classification and moderate (k = 0.425 [0.308-0.550]) with the new AO classification. INTRA-OBSERVER: The agreement was fair using the original (k = 0.350 [0.278-0.424]) and the new (k = 0.295 [0.239 to 0.353]) AO classifications, respectively. Residents had better agreement than hip specialists using the original (k = 0.405 [0.303-0.512]) versus (k = 0.292 [0.193-0.293]) and the new classification (k = 0.449 [0.370 to 0.528] versus k = 0.129 [0.064 to 0.208]). CONCLUSION: The inter-observer agreement using the new AO classification was significantly better than using its original version. Also, the new AO classification system allowed better agreement when distinguishing stable from unstable patterns.

An Isolated Transosseous Flexible Suture Frame in the Treatment of Patellar Tendon Rupture Provides Adequate Mechanical Resistance.

INTRODUCTION: Acute patellar tendon ruptures are frequently observed in patients with metabolic comorbidities, and the benchmark treatment is surgical repair. It is desirable not to harm an already fragile biologic environment with sutures and hardware. We aimed to compare the mechanical requirements of an isolated, flexible, high-strength nonabsorbable transosseous suture frame with that of the Krackow suture technique. METHODS: A total of 12 cadaveric pieces were randomized into two groups: the isolated flexible frame group (n = 6) and the standard Krackow fixation group (n = 6). A traumatic rupture of the patellar tendon was performed, and a transosseous displacement sensor was installed on a validated biomechanical system. Gap formation was measured during 50 cycles of flexion and extension with traction on the quadriceps (250 N). Subsequently, specimens underwent progressive loading in a fixed flexion position until failure occurred. The data were analyzed using nonparametric statistical tools with a significance level of 5%. RESULTS: The isolated frame group had a smaller gap formation (1.7 mm) than the Krackow group (3.4 mm; P = 0.01). No significant difference existed in the median failure end points of the two groups (676 and 530 N, respectively; P = 0.11). DISCUSSION: Patellar tendon repair using an isolated, transosseous, flexible, suture frame outperformed using the traditional Krakow repair technique in gap formation. Further studies are needed to determine if this will result in better functional outcomes or fewer clinical failures. LEVEL OF EVIDENCE: Level IV, experimental case series.

Anterior and distal tunnel orientation for anatomic reconstruction of the medial patellofemoral ligament is safer in patients with open growth plates.

PURPOSE: In patients with open growth plates, the direction of tunneling that avoids distal femoral physis (DFP) damage in anatomic reconstructions of the medial patellofemoral ligament (MPFL) has been a topic of discussion. The objective of this study was to determine the ideal orientation for anatomic reconstructions of MPFL tunneling that minimized DFP damage while avoiding breaching the intercondylar notch. METHODS: Eighty magnetic resonance images of patients aged 10 through 17 were obtained, randomly sampled from the institutional database. A de novo software was developed to obtain 3D models of the distal femur and DFP. In each model, the anatomical insertion point of the MPFL was determined as defined by Stephen. A 20-mm-depth drilling was simulated, starting from the insertion point at every possible angle within a 90° cone using 5-, 6- and 7-mm drills. Physeal damage for each pair of angles and each drill size was determined. Damage was expressed as a percentage of total physis volume. Statistical analysis was conducted using Student's t test and one-way ANOVA. RESULTS: Maximum physeal damage (5.35% [4.47-6.24]) was obtained with the 7-mm drill when drilling 3° cephalic and 15° posterior from insertion without differences between sexes (n.s.). Minimal physeal damage (0.22% [0.07-0.37]) was obtained using the 5-mm drill aimed 45° distal and 0° anteroposterior, not affected by sex (n.s.). Considering intra-articular drilling avoidance, the safest zone was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. CONCLUSION: Ideal femoral tunnel orientation, avoiding physeal damage and breaching of the intercondylar notch, was obtained when aiming 30°-40° distal and 5°-35° anterior, regardless of sex. This area is a safe zone that allows anatomic MPFL reconstruction of patients with an open physis.

Management of patients with low back pain in the emergency department: Is it feasible to follow evidence-based recommendations?

OBJECTIVE: Low back pain is frequently seen in patients visiting the ED, but many patients receive medical care with no demonstrable benefits. We studied the clinical characteristics of patients visiting two EDs in Santiago, Chile, and their management to evaluate how it adheres to evidence-based recommendations. METHODS: We studied 519 patients and retrieved their demographic and clinical data, imaging testing and treatments. We determined the effect of sex, age, time from initial symptoms, pain measured with the visual analogue scale, presence of nerve radiation and the presence of red flags and neurological impairment on image testing and the management received. RESULTS: Mean age was 43.8 years; 57.8% were females. Females presented more often red flags (7.3 vs 3%, P = 0.04) and worse pain (visual analogue scale = 7 vs 6, P = 0.04) than males. Imagings were performed in 18.9% of patients; they were more frequently performed in patients with neurological impairment (P = 0.03) and red flags (P = 0.01). Intravenous non-opioids were administered in 25.6%; opioids were administered in 40.1%. Median time in the ED was 91 min (range 18-591); 16 (3.08%) patients were admitted. Age (odds ratio [OR] 1.04 [1.03-1.05], P < 0.01) and red flags (OR 4.9 [1.60-20.08], P < 0.01) influenced imaging testing; pain intensity influenced opioid use (OR 1.6 [1.29-1.95], P < 0.01), hospital admissions (1.95 [1.14-3.33], P < 0.01) and time in the ED (ß = 0.5, P < 0.01). CONCLUSION: Older age, the presence of red flags and pain intensity influenced the management of patients with low back pain in the ED. Future strategies should emphasise avoiding costly and ineffective management in these patients.

An Independent Validation of the Brighton Spondylodiscitis Score and a Proposal to Modify the Score.

INTRODUCTION: The Brighton Spondylodiscitis Score (BSS) aims to identify patients with pyogenic spinal infections (PSIs) requiring surgery; an independent assessment of the BSS is required. METHODS: We evaluated 60 patients with PSIs. Using the BSS, we determined whether patients with low, moderate, and high risk (LMHR) had different rates of surgery. We proposed a modified score (MS) using a logistic regression (LOGR). Applying the MS, we determined whether patients with LMHR exhibited different rates of surgery. Another LOGR determined the association of the BSS and the MS with surgery. A C-statistic using the BSS and the MS was generated. RESULTS: We studied 60 patients (mean age = 63 years); 37 (62%) were men; 30 (50%) required surgery. Using the BSS, patients with LMHR had similar rates of surgery (P = 0.53). LOGR showed that cervical PSIs had a larger chance of surgery (odds ratio [OR] = 7.3 [1.1 to 51.3]) than other locations. Using the MS, patients with moderate- and high-risk were operated more frequently than low-risk patients (P = 0.04). The BSS did not predict surgery (OR = 1.07; P = 0.31), but the MS did (OR = 1.16; P = 0.02). The C-statistic using the BSS (0.59) improved using the MS (0.69), P = 0.03. DISCUSSION: The discriminatory capacity to predict surgery of the BSS augmented using the MS. LEVEL OF EVIDENCE: II (Diagnostic study: Transverse study).

Orthopaedic Residents' Transfer of Knee Arthroscopic Abilities from the Simulator to the Operating Room.

INTRODUCTION: The ultimate goal for any surgical simulation program is to prove the capability of transferring the skills learned to real-life surgical scenarios. We designed an arthroscopic partial meniscectomy (APM) training program and sought to determine its ability to transfer skills to real patients. METHODS: Eleven junior orthopaedic residents and three expert knee surgeons were included. A low-fidelity knee simulator was used. Trainees had two baseline assessments of completing APM on a supervised real patient and on the simulator, measured using the Arthroscopic Surgical Skill Evaluation Tool (ASSET). After baseline, the trainees completed an APM training program and had a final evaluation of proficiency on the simulator and in real patients. Experts were also assessed for comparison. Statistical analysis was performed, assuming nonparametric behavior of variables. RESULTS: All trainees improved from a base score of 14 points in real patients and 10 points on the simulator to a final score of 39 points and 36 points, respectively (P < 0.01). The final trainee simulator score did not differ from experts on the simulator and was lower in real patients (36 versus 39 points, respectively, P ≤ 0.01), which resulted in a 92% transfer ratio for the simulator. DISCUSSION: Simulated training of APM in orthopaedic residents using a low-fidelity knee simulator proved to not only improve simulated proficiency but also successfully transfer skills to a real clinical scenario with a high model transfer ratio. LEVEL OF EVIDENCE: Level II (Prospective Cohort Study).