Single bundle hamstrings autograft preparation techniques for anterior cruciate ligament reconstruction: current concepts.

Anterior cruciate ligament reconstruction (ACLR) is one of the most common orthopedic procedures, and huge variation exists in the surgical technique. Single bundle hamstrings autograft reconstruction is a common method and has good clinical outcomes. A criticism of the hamstrings autograft is a small graft diameter, often less than 8-mm, which has been associated with increased re-rupture rates. Several graft preparation techniques for single bundle hamstrings autograft exist. Perioperative decisions include the number of tendons utilized, number of graft strands, graft configuration, and femoral and tibial fixation methods. Awareness of the minimum tendon and graft length required to produce each graft variation is necessary to avoid common pitfalls. However, intraoperative graft modification is possible to maximize graft diameter, and obtain proper fixation. The objective of this current concepts review is to describe the indications, surgical anatomy, technique, intraoperative tips, clinical outcomes, and complications for single bundle hamstrings autograft preparation techniques in ACLR.

Outcomes After Hip Arthroscopy Show No Differences Between Sexes: A Systematic Review.

PURPOSE: To assess differences in postoperative outcomes between male and female patients following hip arthroscopy. METHODS: A systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Medline, Embase, Cochrane, and PubMed databases were searched. Key words included "hip," "arthroscopy," "outcome," "gender difference," "sex difference," "gender," and "patient-reported outcome." Studies were included that reported sex-specific analysis of outcomes following primary hip arthroscopy with minimum 2-year follow-up. Methodological Index for Non-Randomized Studies criteria were applied to each study. Data collected included patient-reported outcome measures (PROMs), complications, rates of revision arthroscopy (RA), and conversion to total hip arthroplasty (THA). Forest plots were generated for the most frequently reported PROMs, RA, and THA rates. RESULTS: In total, 38 studies met the inclusion criteria, with 40,194 (57% female) hips included. The most common indications for hip arthroscopy were femoroacetabular impingement and labral tears. Eighteen studies reported PROMs, with no clear trend towards sex differences. Eleven studies reported on RA rates, with 4 showing a significantly greater rate of RA in female patients. Seventeen studies reported on conversion to THA, with an overall conversion rate of 9.64%. There were no clear sex differences in conversion to THA. CONCLUSIONS: There was no difference between sexes for postoperative PROM scores. Male patients were less likely to reach the MCID for the HOS-SSS than female patients in the majority of studies, and there were no sex differences for PASS rates. There were no significant differences between sexes in revision arthroscopy rates and conversion to total hip arthroplasty. LEVEL OF EVIDENCE: Level IV, systematic review of Level II, III and IV studies.

Arthroscopic rotator cuff repair without antibiotic prophylaxis does not increase the infection rate.

PURPOSE: Rotator cuff repair is a commonly performed shoulder procedure. In the past 20 years, there has been a shift from mini-open towards arthroscopic repair, and many units exclusively use arthroscopic techniques for rotator cuff surgery. The aim of this study was to find out whether withholding antibiotics had any effect on the infection rate in patients undergoing arthroscopic rotator cuff repair. METHODS: A retrospective analysis of 336 consecutive patients with an arthroscopic rotator cuff repair (RCR) and a minimum 2-year follow-up was performed. The control group received prophylactic antibiotics (controls) and the cases of interest did not receive perioperative antibiotics. A power analysis was performed according to literature regarding infection proportions. The primary outcome was an infection (superficial or deep) in the operated shoulder. RESULTS: There were 336 patients who underwent a RCR. Two-hundred-and-twelve in the control group and 124 in the non-antibiotic group. Average ages were 57.3 ± 12.5 and 56.8 ± 13.2 years in each group, respectively. The follow-up times ranged from 24 to 76 months. Equipment used and surgical techniques were identical, only operating times were statistically different between the groups (control 77.2 ± 41.3 min versus no antibiotic cases 52.9 ± 16.7 min) (p = 0.000009). There was no recorded infection in either group. CONCLUSION: Infection following arthroscopic surgery is uncommon. Small incisions, constant lavage with saline, minimal hardware insertion and short operating times all combine to minimise the risks. Current results point towards no detriment in withholding prophylactic antibiotics in low-risk patients undergoing routine rotator cuff repair surgery. Therefore, judicious use of prophylactic antibiotics in patients undergoing this procedure is advocated to prevent potential harm to those it is administered to. LEVEL OF EVIDENCE: Level III.

An international, multicenter cohort study comparing 6 shoulder clinical scores in an asymptomatic population.

HYPOTHESIS: The study purpose was to assess 6 shoulder patient-reported outcome measure (PROM) values in asymptomatic, healthy, pathology-free individuals. We hypothesized that there would be no difference in PROM values in pathology-free individuals when considering sex, age, ethnicity, and geographical location. METHODS: Electronic questionnaires were completed by 635 individuals (323 Australians and 312 Canadians) without dominant shoulder pathology for the American Shoulder and Elbow Surgeons (ASES) shoulder score; Constant-Murley Shoulder Score (CSS); Oxford Shoulder Score (OSS); University of California, Los Angeles (UCLA) shoulder score; Shoulder Pain and Disability Index (SPADI); and Stanmore Percentage of Normal Shoulder Assessment (SPONSA). Shoulder range of motion and strength were assessed. RESULTS: No difference was identified between subjective-only and subjective-objective PROMs. Handedness and a current elbow or wrist problem were not associated with differences in PROM values. Poorer PROM values were associated with a history of an inactive shoulder problem and increasing age. Female participants tended to report similar or poorer PROM scores. No significant difference was found between ethnicities. Geographical location was associated with differences in the ASES shoulder score, UCLA shoulder score, and SPADI but not the CSS, SPONSA, and OSS. CONCLUSIONS: Differences in sex, age, and geographical location will affect PROM shoulder scores in pathology-free individuals and should be taken into consideration when PROMs are being used to compare patient outcomes. This study has established normative values for the ASES shoulder score, CSS, OSS, UCLA shoulder score, SPADI, and SPONSA. Future studies assessing a pathologic patient cohort should perform comparisons against a sex- and age-matched control cohort, ideally sourced from the same geographical location.

Asymptomatic population reference values for three knee patient-reported outcomes measures: evaluation of an electronic data collection system and implications for future international, multi-centre cohort studies.

OBJECTIVES: The aim was to assess whether the Knee Society Score, Oxford Knee Score (OKS) and Knee Injury and Osteoarthritis Outcome Score (KOOS) were comparable in asymptomatic, healthy, individuals of different age, gender and ethnicity, across two remote continents. The purpose of this study was to establish normal population values for these scores using an electronic data collection system. HYPOTHESIS: There is no difference in clinical knee scores in an asymptomatic population when comparing age, gender and ethnicity, across two remote continents. METHODS: 312 Australian and 314 Canadian citizens, aged 18-94 years, with no active knee pain, injury or pathology in the ipsilateral knee corresponding to their dominant arm, were evaluated. A knee examination was performed and participants completed an electronically administered questionnaire covering the subjective components of the knee scores. The cohorts were age- and gender-matched. Chi-square tests, Fisher's exact test and Poisson regression models were used where appropriate, to investigate the association between knee scores, age, gender, ethnicity and nationality. RESULTS: There was a significant inverse relationship between age and all assessment tools. OKS recorded a significant difference between gender with females scoring on average 1% lower score. There was no significant difference between international cohorts when comparing all assessment tools. CONCLUSIONS: An electronic, multi-centre data collection system can be effectively utilized to assess remote international cohorts. Differences in gender, age, ethnicity and nationality should be taken into consideration when using knee scores to compare to pathological patient scores. This study has established an electronic, normal control group for future studies using the Knee society, Oxford, and KOOS knee scores. LEVEL OF EVIDENCE: Diagnostic Level II.

Not all patient-reported outcome measures are equivalent at two years compared to one year after anterior cruciate ligament reconstruction based on a retrospective analysis.

OBJECTIVE: This article aims to assess for clinically important differences in patient-reported outcome measures (PROMs) at one and two years post anterior cruciate ligament reconstruction (ACLR). METHODS: A retrospective comparison of prospectively collected PROMs for a single cohort who underwent a primary ACLR with or without associated meniscal surgery from 2016 to 2020 was assessed. Six externally validated PROMs were collected preoperatively and at standardized times postoperatively. Descriptive statistics and paired equivalence testing of PROMs at one and two years after surgery was completed using previously published or calculated minimal clinically important differences as upper and lower equivalence limits. A repeated measures analysis of PROMs that were not clinically equivalent at one and two years after surgery was completed to assess for a clinically significant difference. Subgroup analyses based on sex, age and associated meniscal injury were completed. RESULTS: One-hundred and forty-five participants with a mean age of 28.7 years (standard deviation: 9.9 years) were included in the final analysis. All PROMs were clinically equivalent at two years compared to one year after ACLR except the quality of life and sport and recreation domains of the Knee Injury and Osteoarthritis Outcome Score (KOOS). The quality of life (mean difference (MD):12.3, P â€‹< â€‹0.01, effect size (η2): 0.65) and sport and recreation (MD: 8.78, P â€‹< â€‹0.01, η2: 0.50) domains of the KOOS were clinically different at two years compared to one year postoperatively. No major differences were found in the subgroup analyses compared to the entire included sample. CONCLUSION: While most PROMs were equivalent at two years compared to one year after ACLR, the quality of life and sport and recreation domains of the KOOS, which reflect knee performance during higher demand activities, exhibited a clinically significant difference. LEVEL OF EVIDENCE: IV.

The future of coronary artery bypass grafting.

Coronary artery bypass grafting has evolved considerably since it was introduced approximately 50 years ago, with continuously improved patient outcomes as a result of this growth. The most up-to-date evidence on topics such as graft patency, grafting strategy, approaches to graft harvesting, minimally invasive coronary artery bypass grafting, and postoperative pharmacotherapy may lead to changes in current accepted practice. In addition, several unanswered questions in the field of coronary artery bypass grafting may benefit from further investigation and, if resolved, might advance the field and change practice. Current or upcoming clinical trials seek to answer these unanswered questions and may generate data that yields improved outcomes and quality of life for all patients after coronary artery bypass grafting. In addition, cutting edge clinical trials designed specifically for women and racial and ethnic minorities who have had poorer outcomes and have traditionally been underrepresented in cardiovascular surgery research, have recently been launched that may change the way that a large portion of the coronary artery bypass grafting population is treated in the future.

Re-exploration for bleeding and long-term survival after adult cardiac surgery: a meta-analysis of reconstructed time-to-event data.

BACKGROUND: Postoperative bleeding requiring re-exploration is a serious complication that occurs in 2.8% to 4.6% of patients undergoing cardiac surgery. Re-exploration has previously been associated with a higher risk of short-term mortality. However, a comprehensive analysis of long-term outcomes after re-exploration for bleeding has not been published. MATERIALS AND METHODS: We performed a systematic, three databases search to identify studies reporting long-term outcomes in patients who required re-exploration for bleeding after cardiac surgery compared to patients who did not, with at least 1 year of follow-up. Long-term survival was the primary outcome. Secondary outcomes were operative mortality, myocardial infarction, stroke, renal and respiratory complications, and hospital length of stay. Random-effects models was used. Individual patient survival data was extracted from available survival curves and reconstructed using restricted mean survival time. RESULTS: Six studies totaling 135,456 patients were included. The average follow-up was 5.5 years. In the individual patient data, patients who required re-exploration had a significantly higher risk of death compared with patients who did not (hazard ratio [HR]: 1.21; 95% confidence interval [CI]: 1.14-1.27; P<0.001), which was confirmed by the study-level survival analysis (HR: 1.32; 95% CI: 1.12-1.56; P<0.01). Re-exploration was also associated with a higher risk of operative mortality (odds ratio [OR]: 5.25, 95% CI, 4.74-5.82, P<0.0001), stroke (OR: 2.05, 95% CI, 1.72-2.43, P<0.0001), renal (OR: 4.13, 95% CI, 3.43-4.39 P<0.0001) respiratory complications (OR: 3.91, 95% CI, 2.96-5.17, P<0.0001), longer hospital length of stay (mean difference [MD]: 2.69, 95% CI, 1.68 to 3.69, P<0.0001), and myocardial infarction (OR: 1.85, 95% CI, 1.30-2.65, P=0.0007). CONCLUSION: Postoperative bleeding requiring re-exploration is associated with lower long-term survival and increased risk of short-term adverse events including operative mortality, stroke, renal and respiratory complications, and longer hospital length of stay. To improve both short- and long-term outcomes, strategies to prevent the need for re-exploration are necessary.

Association between lipoprotein levels and outcomes after coronary artery bypass grafting surgery: a systematic review and meta-analysis.

INTRODUCTION: Lipoprotein(a) (Lp[a]) is a variant of low-density lipoprotein (LDL) and has been associated with increased risk of vascular inflammation and thrombosis. Coronary artery bypass grafting (CABG) has been associated with local inflammation of the myocardium. It is plausible, therefore, that patients with elevated baseline Lp(a) may be prone to unfavorable clinical outcomes following CABG. We evaluate differences in outcomes between CABG patients with high and low serum Lp(a) in this meta-analysis. EVIDENCE ACQUISITION: A comprehensive literature search was performed to identify studies reporting outcomes in CABG patients stratified by preoperative Lp(a) level. When possible, the outcomes were pooled in a meta-analysis. We assessed post-operative mortality, major cardiovascular events, stroke occurrence and saphenous graft occlusion. EVIDENCE SYNTHESIS: Eight studies involving 8681 patients were included. Articles used varying cut-offs for high versus low Lp(a), and outcomes varied. In the three studies evaluating mortality, two showed no statistically significant difference between groups while one reported increased mortality associated with high Lp(a) level. Both studies investigating major adverse cardiovascular events reported higher risk in patients with high Lp(a). A study-level meta-analysis of four studies reporting saphenous vein graft occlusion incidence after CABG was performed. High (≥30 mg/dL) preoperative Lp(a) was not associated with an increased risk of graft occlusion compared with low (<30 mg/dL) preoperative Lp(a) (OR=1.88, 95% CI: 0.66-5.36; P=0.15). CONCLUSIONS: Studies evaluating the impact of Lp(a) on outcomes in CABG patients are few, with heterogenous cut-offs and outcomes. In the limited published studies, Lp(a) level was not associated with graft occlusion.

Subclinical hypothyroidism and clinical outcomes after cardiac surgery: A systematic review and meta-analysis.

Background: Subclinical hypothyroidism (SCH) is associated with major adverse cardiovascular events. Despite the recognized negative impact of SCH on cardiovascular health, research on cardiac postoperative outcomes with SCH has yielded conflicting results, and patients are not currently treated for SCH before cardiac surgery procedures. Methods: We performed a study-level meta-analysis on the impact of SCH on patients undergoing nonurgent cardiac surgery, including coronary artery bypass grafting and valve and aortic surgery. The primary outcome was operative mortality. Secondary outcomes were hospital length of stay (LOS), intensive care unit (ICU) stay, postoperative atrial fibrillation (POAF), intra-aortic balloon pump (IABP) use, renal complications, and long-term all-cause mortality. Results: Seven observational studies, with a total of 3445 patients, including 851 [24.7%] diagnosed with SCH and 2594 [75.3%] euthyroid patients) were identified. Compared to euthyroid patients, the patients with SCH had higher rates of operative mortality (odds ratio [OR], 2.57; 95% confidence interval [CI], 1.09-6.04; P = .03), prolonged hospital LOS (standardized mean difference, 0.32; 95% CI, 0.02-0.62; P = .04), a higher rate of renal complications (OR, 2.53; 95% CI, 1.74-3.69; P < .0001), but no significant differences in ICU stay, POAF, or IABP use. At mean follow-up of 49.3 months, the presence of SCH was associated with a higher rate of all-cause mortality (incidence rate ratio, 1.82; 95% CI, 1.18-2.83; P = .02). Conclusions: Patients with SCH have higher operative mortality, prolonged hospital LOS, and increased renal complications after cardiac surgery. Achieving and maintaining a euthyroid state prior to and after cardiac surgery procedures might improve outcomes in these patients.

Association between overweight and obesity with coronary artery bypass graft failure: an individual patient data analysis of clinical trials.

OBJECTIVES: The association between obesity and graft failure after coronary artery bypass grafting has not been previously investigated. METHODS: We pooled individual patient data from randomized clinical trials with systematic postoperative coronary imaging to evaluate the association between obesity and graft failure at the individual graft and patient levels. Penalized cubic regression splines and mixed-effects multivariable logistic regression models were performed. RESULTS: Six trials comprising 3928 patients and 12 048 grafts were included. The median time to imaging was 1.03 (interquartile range 1.00-1.09) years. By body mass index (BMI) category, 800 (20.4%) patients were normal weight (BMI 18.5-24.9), 1668 (42.5%) were overweight (BMI 25-29.9), 983 (25.0%) were obesity class 1 (BMI 30-34.9), 344 (8.8%) were obesity class 2 (BMI 35-39.9) and 116 (2.9%) were obesity class 3 (BMI 40+). As a continuous variable, BMI was associated with reduced graft failure [adjusted odds ratio (aOR) 0.98 (95% confidence interval (CI) 0.97-0.99)] at the individual graft level. Compared to normal weight patients, graft failure at the individual graft level was reduced in overweight [aOR 0.79 (95% CI 0.64-0.96)], obesity class 1 [aOR 0.81 (95% CI 0.64-1.01)] and obesity class 2 [aOR 0.61 (95% CI 0.45-0.83)] patients, but not different compared to obesity class 3 [aOR 0.94 (95% CI 0.62-1.42)] patients. Findings were similar, but did not reach significance, at the patient level. CONCLUSIONS: In a pooled individual patient data analysis of randomized clinical trials, BMI and obesity appear to be associated with reduced graft failure at 1 year after coronary artery bypass grafting.

The VEST External Support for Saphenous Vein Grafts in Coronary Surgery: A Review of Randomized Clinical Trials.

Saphenous vein grafts (SVGs) are the most frequently used conduits in coronary artery bypass grafting (CABG), but their higher rate of occlusion compared to arterial conduits remains a concern. Previous studies have shown that SVG failure is mainly driven by intimal hyperplasia, an adaptative response to higher pressures of the arterial circulation. The VESTTM device (Vascular Graft Solutions, Tel Aviv, Israel), an external support designed to mitigate intimal hyperplasia in SVGs, has been tested in few clinical trials (RCTs). Herein, we descriptively evaluated the randomized evidence on the VEST device.

External Stenting for Saphenous Vein Grafts in Coronary Surgery: A Systematic Review and Meta-Analysis.

The external stenting of saphenous vein grafts (SVGs) during coronary artery bypass grafting (CABG) has been proven to reduce intimal hyperplasia (IH) in animal models, paving the way for human randomized controlled trials (RCTs) to be conducted. Herein, we performed a study-level meta-analysis to assess the impact of the Venous External SupporT (VEST) device, an external stent, on the outcomes of SVGs. A systematic search was conducted to identify all RCTs comparing VEST-stented to non-stented SVGs in patients undergoing CABG. The primary outcome was graft occlusion. The main secondary outcomes were repeat revascularization, SVG IH area, and intimal-medial thickness. Two RCTs totaling 407 patients were included. At a mean follow-up of 1.5 years, there was no difference in graft occlusion between groups (incidence rate ratio: 1.11; 95% confidence interval (CI): 0.80-1.53). The rate of repeat revascularization was also similar (odds ratio: 0.66; 95% CI: 0.27-1.64). The IH area (standardized mean difference (SMD): -0.45; 95% CI: -0.79 to -0.10) and intimal-medial thickness (SMD: -0.50; 95% CI: -0.90 to -0.10) were significantly reduced in the VEST group. Our findings show that significant reductions in the IH area and the intimal-medial thickness in VEST-stented SVGs do not currently translate into a lesser need for repeat revascularization or less graft occlusion events compared to non-stented SVGs at 1.5 years after CABG.

The Association of Traumatic Brain Injury with Neurologic and Psychiatric Illnesses among Individuals Experiencing Homelessness: A Systematic Review and Meta-analysis.

Homeless individuals are more likely than others to experience a traumatic brain injury (TBI), but it is uncertain if such individuals are more likely to experience neuropsychiatric illnesses. METHODS: A systematic review was performed with searches in Medline, Embase, and PsychINFO for studies reporting on homeless persons with TBI and neuropsychiatric illnesses. A random-effects model was used to calculate odds ratios for having any neuropsychiatric diagnosis. RESULTS: Of 420 articles indexed, 19 were included for systematic review and 17 for meta-analysis reporting on 11,474 and 8,757 individuals, respectively. The pooled odds of a homeless individual with a TBI having any neurologic illness were 2.57 (95% CI [1.97, 3.44]; I2 = 68.0%) and 2.01 (95% CI [1.81, 2.25]; I2 = 79.2%) for any psychiatric illness. CONCLUSIONS: The odds of having a neuropsychiatric illness among homeless individuals with TBI are substantially higher than in the domiciled population with TBI.

Intra-articular Soft Tissue Pathology of the Postpartum Hip: A Systematic Review.

PURPOSE OF REVIEW: Pregnancy-related lumbopelvic and hip pain affects over half of postpartum females and has multiple aetiologies. The relative contribution of intra-articular soft tissue pathology to pregnancy-related hip pain is unknown. The current review investigates the available evidence regarding underlying intra-articular soft tissue aetiologies of hip pain in females during pregnancy and in the acute postpartum period. RECENT FINDINGS: Three online databases (Embase, PubMed and Ovid [MEDLINE]) were searched from database inception until 11 April 2021. All titles, relevant abstracts and full-text articles were screened by two reviewers independently. The methodological quality of the included studies was assessed using the Methodological Index for Non-Randomized Studies (MINORS) instrument. Descriptive study characteristics are presented in a narrative summary. Five level IV evidence articles were eligible for inclusion. Twenty-two females were included. Twenty patients presented with labral pathology, 15 of which necessitated hip arthroscopy with labral debridement or repair with or without acetabuloplasty and/or femoroplasty. One patient presented with an incidental labral tear in the context of osteitis condensans illi. One patient presented with posttraumatic osteoarthritis necessitating a hip arthroplasty. The contribution of intra-articular soft tissue injury is a documented, albeit sparse, aetiology contributing to pregnancy-related hip pain. Further research to better delineate the prevalence, natural history and optimal management options for females who sustained these injuries at a life-altering juncture is necessary to advance the care of these patients.

Surgical Results of Chronic Distal Biceps Ruptures: A Systematic Review.

BACKGROUND: Distal biceps tendon tears can cause weakness and fatigue with activities requiring elbow flexion and supination. Surgical management of chronic tears (>21 days) is not well described in the literature. PURPOSE: To determine the clinical outcomes of chronic distal biceps repairs and reconstructions. STUDY DESIGN: Systematic review; Level of evidence, 4. METHODS: We performed a search of Medline (PubMed and Ovid), EMBASE, CINAHL physical therapy, Cochrane Database of Systematic Reviews and Central Register of Controlled Trials, and PubMed Central from inception until September 29, 2020, to identify articles on chronic distal biceps ruptures. The inclusion criteria were studies with at least 1 outcome measure and 10 patients with chronic distal biceps ruptures treated surgically. The quality of the included studies was assessed with the methodological index for nonrandomized studies (MINORS) score. Functional outcomes and complications were reviewed. RESULTS: A total of 12 studies were included after systematic database screenings. The MINORS scores ranged from 5 to 19. There were a total of 1704 distal biceps ruptures, of which 1270 were acute and 434 were chronic. Average follow-up time was 12 months to 5.1 years. Single-incision (n = 3), 2-incision (n = 2), or both (n = 6) surgical techniques were used in these studies. Four studies described the use of autografts, and 4 articles used allografts in the chronic repair. Range of motion, function, and strength outcomes were similar when compared with the contralateral arm. Pain was reduced to minimal levels. Main postoperative complications were of paresthesia (specifically to the lateral antebrachial cutaneous nerve), which were temporary in 69.1% of cases. CONCLUSION: The results of this review indicate that surgical management of chronic distal biceps ruptures demonstrates improvement in outcomes including pain reduction and functional ability. Although there may be a slightly higher immediate complication rate, the functional outcomes remain comparable with those seen in the patient population with acute distal biceps.

Graft Options in Hip Labral Reconstruction.

PURPOSE OF REVIEW: The last decade has seen a boom in hip arthroscopy with refined indications. Improved understanding of pathoanatomy and disease progression has allowed for the development of advanced techniques. Labral reconstruction has been developed to substitute a non-functional or absent labrum. It has become an important technique in the armamentarium of high-volume arthroscopic hip surgeons. RECENT FINDINGS: Basic science studies have improved understanding of hip biomechanics in the presence and absence of a labrum with a labral reconstruction allowing for reconstitution of normalcy. Current techniques have shown success with autograft and allograft tissue options. While autograft tissue allows for easy access intra-operatively and maintains patient biology, donor site morbidity is possible. Allografts negate donor site morbidity and allow for an abundance of tissue but can be resource-intensive and face availability concerns. Recent studies support outcomes of labral reconstructions using both autograft and allograft. Promising results have also allowed for performing labral reconstruction in a primary setting. Labral reconstruction can be successfully performed using both autograft and allograft. Patient biology should be respected, and native hip biomechanics restored. The literature is plentiful for appropriate surgical decision-making allowing the surgeon with multiple graft choices depending on training, experience, and resources.

Graft tensioning in anterior cruciate ligament reconstruction: a systematic review of randomized controlled trials.

PURPOSE: The purposes of this study were to (1) perform a systematic review of randomized controlled trials evaluating graft tensioning in anterior cruciate ligament (ACL) reconstruction, and (2) determine the scientific quality of published randomized controlled trials evaluating graft tensioning in ACL reconstruction. METHODS: The search strategy included a computerized literature search, a citation search, and a manual search of key journals and conference proceedings. Eligible studies were randomized controlled trials evaluating the effect of graft tensioning on the outcomes of ACL reconstruction. Two reviewers independently performed the literature searches. The validity of the trials was scored using the Detsky quality scale. Consensus was achieved by a study committee of 3 investigators. RESULTS: Five randomized controlled trials met the inclusion criteria. The mean standardized Detsky score was 61.3 +/- 15.2%. Only 2 of the studies scored >or=75%. All trials consisted of autogenous graft sources, with 3 involving a bone-patellar tendon-bone graft, 1 involving a 5-strand semitendinosus-polyester (5STP) graft, and 1 involving a semitendinosus-gracilis-polyester (STGP) graft. CONCLUSIONS: Based on the evidence in this systematic review, there is a trend that suggests that 80 N of tension is the most effective amount of tension to apply during ACL reconstruction using hamstring-polyester graft sources. For ACL reconstruction using semitendinosus-gracilis or patellar tendon graft sources, there is no clear trend in terms of statistically significant or clinically relevant differences in terms of the amount of applied tension to apply to the graft during graft fixation. We are unable to provide recommendations as to the amount of tension to apply to 4-strand semitendinosus-gracilis autografts without polyester augmentation because there has been no randomized clinical trial conducted to determine the most effective amount of tension to apply when using this graft source.

Type II error in the shoulder and elbow literature.

Although the randomized controlled trial (RCT) has been recognized as the gold standard for comparing interventions, trials that fail to show a difference between 2 interventions may suffer from type II error. This study was conducted to determine if the published RCTs in the shoulder and elbow literature have sufficient power to minimize potential type II error and conclude accurately that no difference between interventions exists. We searched Medline for RCTs with negative results in Arthroscopy, the Journal of Bone and Joint Surgery (American), and the Journal of Shoulder and Elbow Surgery (1994 through 2007) with strict inclusion criteria pertaining to care of shoulder and elbow injuries. Eligible studies were analyzed for type II error and the power of their conclusions. The power to detect a difference, if in fact one was present, was only 41% (common standard, 80%). It is a critically important distinction to conclude no difference was observed rather than no true difference between interventions exists.

Are Prophylactic Intravenous Antibiotics Required in Routine Shoulder Arthroscopic Surgery? A Systematic Review of the Literature.

Purpose The purpose of this study was to find out from the literature the difference in infection rates between patients who did and patients who did not receive prophylactic antibiotics in arthroscopic shoulder surgery. Methods We conducted a comprehensive search of the literature using Medline Ovid for prospective studies that looked at infection as the primary outcome following shoulder arthroscopy. The articles were then assessed for study design, outcome, and relevance to the specific question as part of the critical appraisal. Results Eight partially relevant articles were obtained from the search, but there were no prospective studies comparing infection in patients who had prophylactic antibiotics versus those who did not in shoulder arthroscopy. Conclusion No compelling evidence exists on the role of prophylactic antibiotics in preventing infections in shoulder arthroscopy. Level of Evidence Level IV, systematic review of level IV studies.