Pediatric Patients with Osteomyelitis and/or Septic Joint Undergoing Surgical Debridement Have Equivalent Short-Term Outcomes with or without Preoperative MRI.

The purpose of this study was to determine if short-term outcomes differed for pediatric patients with suspected musculoskeletal infection with or without a preoperative MRI. This was a multicenter, retrospective review of patients aged 0-16 years who presented with atraumatic extremity pain, underwent irrigation and debridement (I&D), and received at least one preoperative or postoperative MRI over a 10-year period. Primary outcomes were time to OR, total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Secondary outcomes entailed the rate at which concurrent osteomyelitis was identified in patients with septic arthritis and the extent of the resulting surgical debridement. Of the 104 patients, 72.1% had a preoperative MRI. Patients with a preoperative MRI were significantly less likely to have surgery on the day of admission. No difference was found between groups regarding total I&Ds, readmission rate, time from OR to discharge, and total number of MRIs. Of the 57 patients diagnosed with septic arthritis, those with a preoperative MRI were significantly more likely to have concurrent osteomyelitis identified and to undergo bony debridement in addition to arthrotomy of the joint. In conclusion, patient outcomes are not adversely affected by obtaining a preoperative MRI despite the delay in time to OR. Although preoperative MRI can be beneficial in ruling out other pathologies and identifying the extent of concurrent osteomyelitis, the decision to obtain a preoperative MRI and timing of surgery should be left to the discretion of the treating surgeon.

Effectiveness and Safety of Intrathecal Morphine for Pediatric Patients Undergoing Scoliosis Surgery: A Systematic Review and Meta-Analysis.

Adolescent idiopathic scoliosis (AIS) often necessitates spinal fusion surgery in pediatric patients, posing significant challenges in postoperative pain management. Standard care involves the administration of intravenous opioids perioperatively, often requiring high doses to achieve adequate analgesia following an operation. This increases the risk of adverse events, may delay recovery and prolong hospital stay, and increases the likelihood of future abuse and dependence. In this systematic review and meta-analysis, we assess the safety and effectiveness of intrathecal morphine (ITM) in pediatric patients undergoing posterior spinal fusion. Ovid Embase and MEDLINE were searched in October 2023 for articles that directly compared ITM use with standard pain management approaches for pediatric patients undergoing posterior spinal fusion. Our primary outcome was postoperative pain scores. Secondary outcomes included opioid usage details, adverse events, and blood loss. Of the 384 unique studies identified, nine studies (one randomized control trial, one prospective review, and seven retrospective reviews) met the inclusion criteria. The total number of patients within the ITM and control groups were 1384 and 676, respectively. Meta-analysis revealed significantly lower pain scores in the ITM group (standardized mean difference (SMD): -1.30 (-2.29, -0.31); p = 0.01). Similarly, ITM patients had significantly lower opioid usage, both intraoperatively (mean difference (MD): -0.71 mg/kg (-0.99, -0.44); p < 0.00001) as well as postoperatively (SMD: -2.10 (-3.48, -0.73); p = 0.003), and significantly lower blood loss (MD: -0.88 L (-1.34, -0.43); p = 0.0001). The occurrence of adverse events was similar across both groups. Our analysis of the available data demonstrates that a low to moderate dose of ITM is a safe and effective adjunct to improve standard postoperative care without increasing the risk of respiratory depression. When compared to control, ITM patients had superior analgesia while using fewer opioids had significantly reduced intraoperative blood loss when ITM was administered before spinal fusion, and had a similar complication profile. While further studies are warranted to establish optimal dosing, these findings underscore the potential of ITM as a valuable addition to multimodal pain management.

Natural history of degenerative cervical myelopathy: a meta-analysis and neurologic deterioration survival curve synthesis.

BACKGROUND CONTEXT: Cervical spine surgery is rapidly increasing, and our knowledge of the natural history of degenerative cervical myelopathy (DCM) is limited. PURPOSE: To synthesize accurate time-based estimates of meaningful neurologic decline in patients with DCM managed conservatively and to provide formulae to help communicate survivorship estimates to patients. STUDY DESIGN: Systematic review and meta-analysis. METHODS: A systematic review and meta-analysis was conducted using Cochrane and PRISMA guidelines. A librarian-assisted search strategy using multiple databases with broad search terms and validated filter functions was used. All articles were reviewed in duplicate. RESULTS: A total of 9570 studies were captured in the initial search, which after deletion of duplicates and manual review of abstracts and full texts revealed 6 studies for analyses. All studies were prospective cohorts or randomized controlled trials. The pooled survival estimates for neurologic stability (95% CrI) for mild DCM patients are: 91% (83%-97%) at one year; 85% (72%-94%) at 2 years; 84% (70%-94%) at 3 years; 75% (54%-90%) at 5 years; 66% (40%-86%) at 15 years; and 65% (39%-86%) at 20 years. The pooled survival estimates for neurologic stability (95% CrI) for moderate/severe DCM patients are: 83% (76%-89%) at 1 year; 72% (62%-81%) at 2 years; 71% (60%-80%) at 3 years; 55% (41%-68%) at 5 years; 44% (27%-59%) at 15 years; and 43% (25%-58%) at 20 years. CONCLUSIONS: This is the first quantitative synthesis of the totality of published data on DCM natural history. Our review confirms a slow decline in neurologic function. We developed formulae which can be easily used by surgeons to communicate to patients their risk of neurologic deterioration. These formulae can be used to facilitate the shared decision-making process.

Failure of Surgical Equipoise in Posterior Cord Syndrome Myelopathy.

We suggest that a clinical diagnosis of posterior cord syndrome indicates primary posterior decompression in cervical spondylotic myelopathy cases. We present two unique cases of failed anterior decompression in neutrally aligned necks with compressive myelopathy and a literature review. Two recent cases of cervical spondylotic myelopathy that failed to respond after anterior surgical decompression and fusion surgery were observed at our institution. Both patients had motor strength preservation but were unable to stand and walk independently and had other clinical findings consistent with posterior cord syndrome rather than the more common anterior or central cord syndromes, and both responded well to staged posterior decompression. Posterior cervical decompression successfully relieved posterior cord syndrome symptoms after a failed anterior decompression in both of our cases. Posterior cord syndrome is a rare syndrome best diagnosed clinically and should be considered in cases of cervical spondylotic myelopathy in which motor strength testing is preserved.

Incidence and Recurrence of Deep Spine Surgical Site Infections: A Systematic Review and Meta-analysis.

STUDY DESIGN: Systematic review and meta-analysis. OBJECTIVE: To determine a pooled incidence rate for deep surgical site infection (SSI) and compare available evidence for deep SSI management among instrumented spinal fusions. SUMMARY OF BACKGROUND DATA: Deep SSI is a common complication of instrumented spinal surgery associated with patient morbidity, poorer long-term outcomes, and higher health care costs. MATERIALS AND METHODS: We systematically searched Medline and Embase and included studies with an adult patient population undergoing posterior instrumented spinal fusion of the thoracic, lumbar, or sacral spine, with a reported outcome of deep SSI. The primary outcome was the incidence of deep SSI. Secondary outcomes included persistent deep SSI after initial debridement, mean number of debridements, and microbiology. The subsequent meta-analysis combined outcomes for surgical site infection using a random-effects model and quantified heterogeneity using the χ 2 test and the I2 statistic. In addition, a qualitative analysis of management strategies was reported. RESULTS: Of 9087 potentially eligible studies, we included 54 studies (37 comparative and 17 noncomparative). The pooled SSI incidence rate was 1.5% (95% CI, 1.1%-1.9%) based on 209,347 index procedures. Up to 25% of patients (95% CI, 16.8%-35.3%), had a persistent infection. These patients require an average of 1.4 (range: 0.8-1.9) additional debridements. Infecting organisms were commonly gram-positive, and among them, staphylococcus aureus was the most frequent (46%). Qualitative analysis suggests implant retention, especially for early deep SSI management. Evidence was limited for other management strategies. CONCLUSIONS: The pooled incidence rate of deep SSI post-thoracolumbar spinal surgery is 1.5%. The rate of recurrence and repeat debridement is at least 12%, up to 25%. Persistent infection is a significant risk, highlighting the need for standardized treatment protocols. Our review further demonstrates heterogeneity in management strategies. Large-scale prospective studies are needed to develop better evidence around deep SSI incidence and management in the instrumented thoracolumbar adult spinal fusion population.

Denervation as a Treatment for Arthritis of the Hands: A Systematic Review of the Current Literature.

Joint denervation has been proposed as a less invasive option for surgical management of hand arthritis that preserves joint anatomy while treating pain and decreasing postoperative recovery times. The purpose of this systematic review was to investigate the efficacy and safety of surgical joint denervation for osteoarthritis in the joints of the hand. EMBASE, MEDLINE, and PubMed databases were searched from January 2000 to March 2019. Studies of adult patients with rheumatoid arthritis or osteoarthritis of the hand who underwent joint denervation surgery were included. Two reviewers performed the screening process, data abstraction, and risk of bias assessment (Methodological Index for Non-Randomized Studies). This review followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines and was registered with PROSPERO (#125811). Ten studies were included, 9 case series and 1 cohort study, with a total of 192 patients. In all studies, joint denervation improved pain and hand function at follow-up (M = 36.8 months, range = 3-90 months). Pooled analysis of 3 studies on the first carpometacarpal joint showed a statistically significant (P < .001) reduction in pain scores from baseline (M = 6.61 ± 2.03) to postoperatively (M = 1.69 ± 1.27). The combined complication rate was 18.8% (n = 36 of 192), with neuropathic pain or unintended sensory loss (8.8%, n = 17 of 192) being the most common. This review suggests that denervation may be an effective and low-morbidity procedure for treating arthritis of the hand. Prospective, comparative studies are required to further understand the outcomes of denervation compared with traditional surgical interventions.

Long-Term Survivorship of Cervical Spine Procedures; A Survivorship Meta-Analysis and Meta-Regression.

STUDY DESIGN: Systematic Review. OBJECTIVES: To conduct a meta-analysis on the survivorship of commonly performed cervical spine procedures to develop survival function curves for (i) second surgery at any cervical level, and (ii) adjacent level surgery. METHODS: A systematic review of was conducted following PRISMA guidelines. Articles with cohorts of greater than 20 patients followed for a minimum of 36 months and with available survival data were included. Procedures included were anterior cervical discectomy and fusion (ACDF), cervical disc arthroplasty (ADR), laminoplasty (LAMP), and posterior laminectomy and fusion (PDIF). Reconstructed individual patient data were pooled across studies using parametric Bayesian survival meta-regression. RESULTS: Of 1829 initial titles, 16 citations were included for analysis. 73 811 patients were included in the second surgery analysis and 2858 patients in the adjacent level surgery analysis. We fit a Log normal accelerated failure time model to the second surgery data and a Gompertz proportional hazards model to the adjacent level surgery data. Relative to ACDF, the risk of second surgery was higher with ADR and PDIF with acceleration factors 1.73 (95% CrI: 1.04, 2.80) and 1.35 (95% CrI: 1.25, 1.46) respectively. Relative to ACDF, the risk of second surgery was lower with LAMP with deceleration factor .06 (95% CrI: .05, .07). ADR decreased the risk of adjacent level surgery with hazard ratio .43 (95% CrI: .33, .55). CONCLUSIONS: In cases of clinical equipoise between fusion procedures, our analysis suggests superior survivorship with anterior procedures. For all procedures, laminoplasty demonstrated superior survivorship.

Assessing the Outcomes Associated with Accessory Navicular Bone Surgery-a Systematic Review.

PURPOSE OF REVIEW: The purpose of this review is to evaluate the existing literature in order to compare the clinical outcomes and complications associated with the kidner procedure and simple excision procedure. Furthermore, this review will help determine if one procedure is advantageous over the other in treating accessory navicular among patients. RECENT FINDINGS: Previous research on this topic has seen a low success rate in treating patients with symptomatic accessory navicular using conservative treatment options such as shoe-wear modification, braces, and/or nonsteroidal anti-inflammatory. Surgical treatment such as simple excision and kidner procedure has shown to have minor complications including scarring and wound irritation with a generally high satisfaction rate from patients. However, cases where patients that had planovalgus or hindfoot valgus accompanying the accessory navicular were required to undergo revision surgery to treat the recurrent pain following the kidner procedure. Similarly, patients that underwent simple excision procedure with having flat foot were unable to complete the heel test postoperatively despite not reporting feelings of pain. Both simple excision and the Kidner procedure appear to be efficacious procedures with low complication profiles and high rates of patient satisfaction. Moreover, it has appeared that the female demographic is more likely to present symptomatic accessory navicular and undergo surgical treatment. To further explore the ideal indication for each, more prospective comparative studies are needed as well as radiological assessments pre- and post-operatively to evaluate anatomical changes in the posterior tibialis tendon area between both procedures.

Management of deep surgical site infections of the spine: a Canadian nationwide survey.

Background: Deep surgical site infections after spinal instrumentation represent a significant source of patient morbidity and poorer outcomes. Given lack of evidence or guidelines on the variety of procedural options in the management of deep spine surgical site infections, the purpose of this survey was to document and investigate the use of these techniques across Canada. Methods: A 34-question survey evaluating surgical techniques for irrigation and debridement in postoperative thoracolumbar infection was distributed to Canadian adult spine surgeons. Results were analyzed qualitatively, and comparisons by specialty, years of training, and number of cases were completed using Fischer's exact tests. We defined consensus as >70% agreement. Results: We received 53 responses (62% response rate) from a comprehensive sample of Canadian adult spine surgeons. There was a consensus to retain hardware (80%) and interbody implants (93%) in acute infection, to retain interbody implants in chronic/recurrent infection (71%), and application of topical antibiotics in recurrent infection (85%). There was consensus on the use of absorbable suture to close fascia in acute (83%) and chronic (87%) infection. Eighty-five percent of surgeons used nonabsorbable materials such as Nylon or staples for skin closure in chronic infection, however, there was no consensus in acute infection. Surgeons varied significantly in type, volume and pressure of fluids, adjuvant solvents, graft management, use of topical antibiotics acutely, and the use of negative pressure wound therapy. Partial hardware exchange was controversial. Additionally, specialty or surgeon experience had no impact on management strategy. Conclusions: This survey demonstrates significant heterogeneity amongst Canadian adult spine surgeons regarding key steps in the surgical management of deep instrumented spine infection, concordant with scarce literature addressing these steps.

Local antibiotics in primary hip and knee arthroplasty: a systematic review and meta-analysis.

BACKGROUND: Infection is a truly devastating complication of total joint arthroplasty, causing most patients to undergo a revision surgery, and to bear significant psychological and financial burden. The purpose of this study is to systematically evaluate the literature to determine the efficacy and complication profile of local antibiotic application in primary total joint arthroplasty. METHODS: All studies of primary total joint arthroplasty which assessed local antibiotics in any form other than antibiotic-impregnated cement as an intervention were included. Studies that reported at least one outcome related to infection and were available in full text in English were eligible for inclusion. Studies which included both primary and revision cases but did not report the stratified data for each type of surgery and studies on fracture populations were excluded. RESULTS: A total of 9 studies involving 3,714 cases were included. The pooled deep infection rate was 1.6% in the intervention groups and 3.5% in the control groups. Meta-analysis revealed a RR of 0.53 (95%CI: 0.35-0.79, p = 0.002) with no heterogeneity (I2 = 0%) for infection in the intervention groups. Meta-analysis revealed a non-significant reduction in superficial infection rates in the intervention groups; however, there was a significant increase in aseptic wound complications in the intervention groups. CONCLUSION: Local antibiotic application results in a moderate reduction in deep infection rates in primary total joint arthroplasty, with no significant impact on superficial infection rates. However, local antibiotic application may be associated with a moderate increase in aseptic wound complications.

Surgical stabilization of pediatric anterior shoulder instability yields high recurrence rates: a systematic review.

PURPOSE: The purpose of this systematic review was to assess the surgical techniques, indications outcomes and complications for pediatric patients (≤ 19 years old) undergoing shoulder stabilization procedures for anterior shoulder instability. METHODS: The electronic databases MEDLINE, EMBASE, CINAHL, and Web of Science were searched from data inception to March 14, 2019 for articles addressing surgery for pediatric patients with anterior shoulder instability. The Methodological Index for Non-randomized Studies (MINORS) tool was used to assess the quality of included studies. RESULTS: Overall 24 studies, with a total of 688 patients (696 shoulders) and a mean age of 16.6 ± 2.5 years met inclusion criteria. Mean follow-up was 49 ± 26 months. The majority (59%) of studies only offered shoulder stabilization procedures to patients with more than one shoulder dislocation, however, three studies reported operating on pediatric patients after first time dislocations. Of the included patients 525 had arthroscopic Bankart repair (78%), 75 had open Bankart repair (11%), 34 had modified Bristow (5%), and 26 had Latarjet (4%) procedures. The overall complication rate was 26%. Patients undergoing arthroscopic Bankart repair experienced the highest recurrence rate of 24%. There were no significant differences in recurrent instability (n.s.) or loss of external rotation (n.s.) in pediatric patients treated with arthroscopic Bankart repair compared to open Latarjet. Patients had a 95% rate of return to sport at any level (i.e. preinjury level or any level of play) postoperatively (95%). CONCLUSIONS: Pediatric patients are at high risk of recurrent instability after surgical stabilization. The majority of pediatric patients with anterior shoulder instability were treated with arthroscopic Bankart repair. Most studies recommend surgical stabilization only after more than one dislocation. However, given the high rates of recurrence with non-operative management, it may be reasonable to perform surgery at a first-time dislocation, particularly in those with other risk factors for recurrence. With the current evidence and limited sample sizes, it is difficult to directly compare the surgical interventions and their post-operative efficacy (i.e. re-dislocation rates or range of motion). There was an overall high rate of return to sport after surgical stabilization at final follow-up. LEVEL OF EVIDENCE: IV.

Surgical Management of Glenohumeral Osteoarthritis With Glenoid Erosion and Static Posterior Subluxation (Walch B2): Techniques, Outcomes, and Survivorship Rates.

The purpose of this study was to systematically assess the surgical techniques and outcomes related to the management of Walch B2 glenoids. PubMed, Medline, and Embase were searched from inception to July 2018. Overall, 24 studies (787 B2 glenoids) were identified. Revision-free survivorship was highest for reverse total shoulder arthroplasty (98.6%) and anatomic total shoulder arthroplasty with asymmetric reaming and a non-augmented glenoid implant (95.6%). Walch B2 glenoids are most commonly managed by asymmetric reaming in the context of anatomic total shoulder arthroplasty, and by the ream-and-run technique in hemiarthroplasty. The optimal treatment strategy remains elusive due to a lack of high-quality, comparative studies with long-term surveillance. [Orthopedics. 2020;43(4):e191-e201.].

Traction table versus standard table total hip arthroplasty through the direct anterior approach: a systematic review.

BACKGROUND: The direct anterior approach (DAA) for total hip arthroplasty (THA) was originally performed with a supine patient on a specialised traction table, but the approach can also be performed on a standard operating table. Despite cost and safety implications, there are few studies directly comparing these techniques and table choice remains largely surgeon preference. The purpose of this review was to compare the clinical outcomes and complication profiles of traction and standard table DAA for primary THA. METHODS: The authors searched databases for relevant studies, screening in duplicate. Study quality was assessed using MINORS criteria or Cochrane Risk of Bias Tool. Data pertaining to patient demographics, clinical outcomes, and complications were abstracted. RESULTS: Of 3085 initial titles, 44 studies containing a total 26,353 patients were included and analysed. Mean operative time was 70.9 ± 21.2 minutes for standard table (n = 4402) and 100.1 ± 32.6 minutes for traction table (n = 3518). Mean estimated blood loss was 382.3 ± 246.4 mL for standard (n = 2992) and 531.7 ± 364.3 mL for traction table (n = 2675). Intra-operative fracture rate was 1.3% for standard table (n = 3940) and 1.7% for traction table (n = 8386). Complication rates including revisions, dislocations and peri-prosthetic fractures were qualitatively similar between traction and standard table studies. CONCLUSION: Standard table and traction table DAA have similar outcomes and complications. Both techniques offer the short-term advantages of DAA when compared to other THA approaches. However, the standard table technique may offer perioperative advantages including decreased blood loss, shorter operative time, and fewer intraoperative fractures. In the context of rising global healthcare costs and lack of access to specialised orthopaedic traction tables, this review at minimum confirms the short-term safety of standard table DAA THA and prompts the need for future studies to directly compare these techniques.

A Case Report of Pneumococcal Septic Arthritis Following a Respiratory and Gastrointestinal Prodrome with Accompanying Literature Review.

We report an uncommon case of septic arthritis of the ankle from a Streptococcus pneumoniae infection and provide an update of the literature reported since 2002. A 58-year-old female presented to the hospital with right ankle pain and an inability to bear weight. She reported a history of productive cough, vomiting, diarrhea, and subjective fevers 4 days earlier. Streptococcus pneumonia was identified in her ankle aspirate, and she was treated urgently with operative incision and debridement, followed by postoperative intravenous antibiotics. At her 7-week follow-up, she demonstrated complete resolution of symptoms and near-complete recovery of range of motion. This case demonstrates the importance of early identification, as the majority of patients recover fully with prompt treatment. The literature review included 44 cases of pneumococcal septic arthritis and found that the knee was the most commonly affected joint, followed by the shoulder and ankle. Blood cultures were positive for S. pneumoniae in 27 of 38 adults (71%) and 4 of 6 children (67%). Comorbid conditions were present in 32 of 38 adults (84%) and 4 of 7 children (57%), the most frequent of which were alcoholism and osteoarthritis in adults and malignancy or immunosuppression in children. Additionally, roughly half of included adults had an extra-articular focus of pneumococcal disease, most frequently pneumonia. Operative treatment was undertaken in 32 of 38 adults (84%) and all 7 children. Of adults with data available, 24 of 33 (73%) recovered with complete joint function, compared with 5 of 7 children (71%).

Correction to: Anterior cruciate ligament reconstruction with concomitant meniscal surgery: a systematic review and meta-analysis of outcomes.

Unfortunately, the middle name of Olufemi R. Ayeni was accidentally omitted in the original publication and the author name is corrected here. The original article has been corrected.

Anterior cruciate ligament reconstruction with concomitant meniscal surgery: a systematic review and meta-analysis of outcomes.

PURPOSE: The aim of this review was to compare the clinical outcomes of anterior cruciate ligament reconstruction (ACLR) with either meniscal repair or meniscectomy for concomitant meniscal injury. The primary hypothesis was that short-term clinical outcomes (≤ 2-year follow-up) for ACLR concomitant with either meniscal repair or resection would be similar. The secondary hypothesis was that ACLR with meniscal repair would result in better longer term outcomes compared with meniscal resection. METHODS: The authors searched two online databases (EMBASE and MEDLINE) from inception until March 2018 for the literature on ACLR and concurrent meniscal surgery. Two reviewers systematically screened studies in duplicate, independently, and based on a priori criteria. Quality assessment was also performed in duplicate. The Knee injury and Osteoarthritis Outcome Score (KOOS) sub-scale scores at 2 years post-operatively were combined in a meta-analysis of proportions using a random-effects model. RESULTS: Of 2566 initial studies, 25 studies satisfied full-text inclusion criteria. Mean follow-up was 2.09 years, with a total sample of 37,087 subjects including controls. The meta-analysis demonstrated equivocal results at 2 years, except for KOOS symptom scores which favoured meniscal resection over repair. Mean KT-1000 side-to-side difference (SSD) scores were 1.51 ± 0.60 mm for meniscal repair, 1.96 ± 0.36 mm for meniscal resection, and 1.58 ± 0.20 for control patients (isolated ACLR). Medial meniscal repair showed decreased anterior knee joint laxity compared to medial meniscal resection (P < 0.001). Patients with meniscal repair had higher rates of re-operation (13.3% vs 0.8% for meniscal resection, P < 0.001). CONCLUSION: Patients with ACLR combined with meniscal resection demonstrate better symptoms at 2-year follow-up compared to patients with ACLR combined with meniscal repair. ACLR combined with meniscal repair results in decreased anterior knee joint laxity with evidence of improved patient-reported outcomes in the long term, but also higher re-operation rates. LEVEL OF EVIDENCE: III.

Over-the-top ACL reconstruction yields comparable outcomes to traditional ACL reconstruction in primary and revision settings: a systematic review.

PURPOSE: To assess clinical outcomes of over-the-top (OTT) ACL reconstruction (ACLR) in skeletally mature patients, where physeal sparing is not a consideration. The hypothesis is that OTT will produce successful yet inferior outcomes compared to anatomic ACL approaches in both primary and revision settings. METHODS: Two reviewers searched two online databases (EMBASE and MEDLINE) from inception to October 2017 for literature on OTT ACLR in skeletally mature patients. The systematic screening process was completed in duplicate, independently, and based on predetermined criteria. An expert in the field was consulted to resolve disagreements for full-text screening. Quality assessment of included papers was performed independently and in duplicate. RESULTS: From 3148 initial studies, 16 eligible studies (three RCTs and 13 case series) satisfied inclusion criteria. Three focused on the revision setting. The mean age of patients undergoing primary reconstruction was 26.9 ± 3.6, with 21.3% female patients and 31.4 ± 1.2 (26.1% female) in revision settings. Of primary studies reporting return to sport (n = 151), 69% of patients returned to pre-injury sports participation, with a total 94% returning to any sports activity. In revision settings (n = 48), 52.1% of patients returned to pre-injury sports participation, 25.2% returned to a lower level and 12.5% ceased sporting activity. Primary reconstruction studies reported a mean post-operative Tegner score of 6.5 ± 0.5 (n = 181) and mean KOOS of 82.8 ± 8.1 (n = 96). Primary studies reported a total 13 graft failures (3.7%), seven of which were re-ruptures (2.0%). The revision failure rate was 8.4% (four patients). CONCLUSION: Clinically important outcomes for OTT ACLR are comparable to literature figures for traditional all-inside, transtibial and/or anteromedial portal drilling techniques. This holds true in revision settings. LEVEL OF EVIDENCE: IV.

Combined effects of the C161T and Pro12Ala PPARγ2 gene variants with insulin resistance on metabolic syndrome: a case-control study of a central Tunisian population.

We investigated the synergism between variants at the PPARγ locus (C161T and Pro12Ala polymorphisms) with insulin resistance on metabolic syndrome (MS). Five hundred twenty-two subjects were investigated for biochemical and anthropometric measurements. The diagnosis of MS was based on the IDF definition (2009). The HOMA 2 was used to determine HOMA-ß, HOMA-S, and HOMA-IR from FPG and FPI concentrations. PCR-RFLP was performed for DNA genotyping. We showed that carriers of the Pro/Pro had a significantly higher FPG, FPI, and HOMA-IR. In addition, Pro/Pro subjects also display reduced HOMA-ß and HOMA-S together compared to X/Ala (Pro/Ala and Ala/Ala) subjects. Furthermore, subjects with C/C have a significantly lower FPG, FPI, and HOMA-IR and higher HOMA-S compared to X/T (C/T and T/T) subjects. The C/C genotype carriers with an Ala allele group had significantly reduced FPG, FPI, HOMA-IR, and TG and elevated HOMA-S and HOMA-ß than the different genotype combinations. We suggest that the haplotype composed of the C/C genotype carriers with an Ala allele of PPARγ2 group enhances susceptibility to the MS in a central Tunisian population.