BET 1: Ruling out cerebellar infarct in the emergency department with CT scan.

A short-cut review of the available medical literature was carried out to establish whether CT scanning can rule out cerebellar infarction. After abstract review, two papers were found to answer this clinical question using the detailed search strategy. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. It is concluded that there is insufficient evidence to draw a conclusion.

The Role of Deltoid Ligament Repair in Ankle Fractures With Syndesmotic Instability: A Systematic Review.

Ankle fractures are the fourth most common fracture requiring surgical management. The deltoid ligament is a primary ankle stabilizer against valgus forces. It is frequently ruptured in ankle fractures; however, there is currently no consensus regarding repair. A systematic database search was conducted with Medline, PubMed, and Embase for relevant studies discussing patients with ankle fractures involving deltoid ligament rupture and repair. Screening, quality assessment, and data extraction were performed independently and in duplicate. Data extracted included pain, range of motion (ROM), function, medial clear space (MCS), syndesmotic malreduction, and complications. After screening, 9 eligible studies from 1990 to 2018 were included (N = 508). Compared to nonrepair groups, deltoid ligament repair patients had lower syndesmotic malreduction rates (0%-9% vs 20%-35%, p ≤ .05), fewer implant removals (5.8% vs 41% p ≤ .05), and longer operating time by 16-20 minutes (p ≤ .05). There was no significant difference for pain, function, ROM, MCS, and complication rate (p ≤ .05). In conclusion, deltoid ligament repair offers lower syndesmotic malreduction rates and reduced re-operation rates for hardware removal in comparison to trans-syndesmotic screws. Repair groups demonstrated equivalent or better outcomes for pain, function, ROM, MCS, and complication rates. Other newer syndesmotic fixation methods such as suture-button fixation require further evaluation when compared to the outcomes of deltoid ligament repair. A randomized control trial is required to further examine the outcomes of ankle fracture patients who undergo deltoid ligament repair versus trans-syndesmotic screw fixation.

ACL Reconstruction with Augmentation: a Scoping Review.

PURPOSE OF REVIEW: We reviewed the recent literature to identify and summarize new research surrounding anterior cruciate ligament reconstruction (ACLR) with augmentation in the form of additional soft tissue procedures or biologic augmentation. Specifically, we wanted to review the failure rates of these procedures in both the primary and revision settings. METHODS: The databases Embase, PubMed, and Medline were searched on August 13, 2018, for English-language studies that reported on the use of anterior cruciate ligament reconstruction (primary and revision) in conjunction with either soft tissue or biologic augmentation. The studies were systematically screened and data abstracted in duplicates. RECENT FINDINGS: Advancements in ACLR surgery, including soft tissue augmentation, may decrease primary and revision surgery failure rates for high-risk patients. The use of biological augmentation has shown histologic and radiographic improvements. These differences, however, have failed to be statistically significant and have not resulted in clinically significant improvements in outcome. The limited body of evidence has shown that the addition of soft tissue procedures may in fact lower the risk of graft re-rupture rates particularly in revision or in patients wishing to return to high-risk sports and activities. The use of biologic augmentation although promising in laboratory studies has yet to show any significant clinical results and therefore will require further studies to prove any efficacy.

Indications and outcomes of simultaneous high tibial osteotomy and ACL reconstruction.

PURPOSE: The purpose of this study was to systematically review the existing literature reporting surgical outcomes of simultaneous high tibial osteotomy (HTO) and anterior cruciate ligament reconstruction (ACLR) in anterior cruciate ligament deficient (ACLD) knees. METHODS: This study was conducted per the methods of the Cochrane Handbook for Systematic Reviews of Intervention, with findings reported per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The electronic databases MEDLINE, EMBASE, and PubMed were searched for relevant studies and pertinent data was extracted. Studies reporting post-operative outcomes following simultaneous HTO and ACLR in ACLD knees were included. RESULTS: The search identified 515 studies, of which 18 (n = 516) were included. The mean MINORS scores for non-comparative and comparative studies were 11.6 ± 1.34 and 17.3 ± 1.9, respectively. Simultaneous HTO and ACLR resulted in improved functional subjective patient outcomes across a variety of scales. Simultaneous HTO and ACLR was effective in correcting varus angulation, with the post-operative mechanical angle ranging from 0.3° valgus to 7.7° valgus. The reported complication rate ranged from 0 to 23.5%. Across six studies, a total of 13 (6.5%) patients required revision HTO; while across four studies, 20 (17.5%) patients had failure of the ACL graft, with one receiving revision ACLR. CONCLUSIONS: Combined HTO and ACLR may be indicated in patients with ACLD knees with varus angulation. This systematic review found that the combined surgery resulted in significant improvement in post-operative functional subjective outcomes. However, it remains unclear if HTO with ACLR is superior to ALCR or HTO alone due to the lack of comparative studies. Overall, HTO with ACLR was found to have low rates of complications, re-ruptures, and need for revision surgery. This review found that patients continued to have progression of OA despite combined HTO with ACLR. Future research is required to better understand the effects of combined HTO and ACLR compared to ACLR or HTO alone and to evaluate the long-term post-operative progression of medial compartment OA following combined HTO and ACLR. LEVEL OF EVIDENCE: IV.