Background: The objective of this study was to systematically review the literature on anterior cruciate ligament (ACL) injury prevention programs and to perform a meta-analysis to address three questions: First, what is the effectiveness of ACL injury prevention programs? Second, is there evidence for a “best” program? Third, what is the quality of the current literature on ACL injury prevention? Methods: We conducted a systematic review with use of the online PubMed, MEDLINE, EMBASE, CINAHL (Cumulative Index to Nursing and Allied Health), and Cochrane Central Register of Controlled Trials databases. Search terms were anterior cruciate ligament, knee, injury, prevention, and control. Data on study design and clinical outcomes were extracted independently in triplicate. After assessment of between-study heterogeneity, DerSimonian-Laird random-effect models were used to calculate pooled risk ratios and risk differences. The risk difference was used to estimate the number needed to treat (the number of individuals who would need to be treated to avoid one ACL tear). Results: The pooled risk ratio was 0.38 (95% confidence interval [CI], 0.20 to 0.72), reflecting a significant reduction in the risk of ACL rupture in the prevention group (p = 0.003). The number needed to treat ranged from five to 187 in the individual studies. Stratified by sex, the pooled risk ratio was 0.48 (95% CI, 0.26 to 0.89) for female athletes and 0.15 (95% CI, 0.08 to 0.28) for male athletes. Conclusions: Our study indicated strong evidence in support of a significant effect of ACL injury prevention programs. Our pooled estimates suggest a substantial beneficial effect of ACL injury prevention programs, with a risk reduction of 52% in the female athletes and 85% in the male athletes. Level of Evidence: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.

Purpose With the COVID-19 crisis, recommendations for personal protective equipment (PPE) are necessary for protection in orthopaedics and traumatology. The primary purpose of this study is to review and present current evidence and recommendations for personal protective equipment and safety recommendations for orthopaedic surgeons and trauma surgeons. Methods A systematic review of the available literature was performed using the keyword terms “COVID-19”, “Coronavirus”, “surgeon”, “health-care workers”, “protection”, “masks”, “gloves”, “gowns”, “helmets”, and “aerosol” in several combinations. The following databases were assessed: Pubmed, Cochrane Reviews, Google Scholar. Due to the paucity of available data, it was decided to present it in a narrative manner. In addition, participating doctors were asked to provide their guidelines for PPE in their countries (Austria, Luxembourg, Switzerland, Germany, UK) for consideration in the presented practice recommendations. Results World Health Organization guidance for respiratory aerosol-generating procedures (AGPs) such as intubation in a COVID19 environment was clear and included the use of an FFP3 (filtering face piece level 3) mask and face protection. However, the recommendation for surgical AGPs, such as the use of high-speed power tools in the operating theatre, was not clear until the UK Public Health England (PHE) guidance of 27 March 2020. This guidance included FFP3 masks and face protection, which UK surgeons quickly adopted. The recommended PPE for orthopaedic surgeons, working in a COVID19 environment, should consist of level 4 surgical gowns, face shields or goggles, double gloves, FFP2-3 or N95-99 respirator masks. An alternative to the mask, face shield and goggles is a powered air-purifying respirator, particularly if the surgeons fail the mask fit test or are required to undertake a long procedure. However, there is a high cost and limited availabilty of these devices at present. Currently available surgical helmets and toga systems may not be the solution due to a permeable top for air intake. During the current COVID-19 crisis, it appeared that telemedicine can be considered as an electronic personal protective equipment by reducing the number of physical contacts and risk contamination. Conclusion Orthopaedic and trauma surgery using power tools, pulsatile lavage and electrocautery are surgical aerosol-generating procedures and all body fluids contain virus particles. Raising awareness of these issues will help avoid occupational transmission of COVID-19 to the surgical team by aerosolization of blood or other body fluids and hence adequate PPE should be available and used during orthopaedic surgery. In addition, efforts have to be made to improve the current evidence in this regard. Level of evidence IV.

It has been suggested that platelet-rich plasma (PRP) improves healing after arthroscopic rotator cuff repair. The current literature provides ample but inconsistent data on this topic. To systematically review the current in vivo evidence for the use of platelet concentrates (PRP) in the arthroscopic treatment of rotator cuff tears to assess effectiveness, safety, and cost-effectiveness. Meta-analysis and cost-effectiveness analysis. Published evidence from controlled, human trials of rotator cuff repair augmented with platelet concentrates was systematically gathered, and data on retear rates were extracted. Mathematical and clinical heterogeneity was evaluated, and fixed-effect meta-analysis was performed to calculate the risk ratio (RR) of retears and the number needed to treat (NNT). Subgroup analyses were made for small/medium tears (n = 404) and large/massive tears (n = 374). Cost-effectiveness was assessed using data from this meta-analysis and using cost data from the literature, including extensive sensitivity analyses, to calculate the incremental cost-effectiveness ratio (ICER). Thirteen studies published between 2010 and 2014 were identified for analysis. The RR for retear for all patients was 0.87 (95% CI, 0.67-1.12; P = .286). For small- and medium-sized tears (<3 cm), the RR for retear was 0.60 (95% CI, 0.37-0.97), consistent with a significant difference in favor of PRP use (P = .038). This translated into an NNT of 14 (95% CI, 7-125). However, at an ICER of US$127,893 per quality-adjusted life year gained, assuming a 5% revision rate, the use of PRP was not cost-effective for small- and medium-sized tears. In large tears, even with double-row repair, the beneficial effects of PRP alone are insufficient to compensate the progressed tissue damage. The study data suggest that PRP may promote healing of small- and medium-sized tears to reduce retear rates. However, despite the substantial biological effect, at current cost, the use of PRP is not cost-effective in arthroscopic repair of small- and medium-sized tears.

Intraoperative radiography imaging is essential for accurate spinal implant placement. Hazards caused by ionizing radiation raised concern on personnel’s work life long exposure in the operating room (OR). To particularize a cumulative risk estimation of radiation of personnel and patient, depending on used methods (C-arm fluoroscopy, O-arm navigation) and patient characteristics during spinal surgery, detailed investigation of radiation exposure in a clinical setting is required. Lumbosacral dorsal spinal fusion was performed in 37 patients (19 navigated, 18 fluoroscopy) during this prospective study. Radiation exposure was measured on several body regions with thermoluminescent dosimeters on patient and OR personnel (surgeon, assistant, sterile nurse, radiology technologist). Comparison between patient characteristics and radiation exposure was included. The highest patients values were measured in the surgery field and gonads area during navigation (43.2 ± 19.4 mSv; fluoroscopy: 27.7 ± 31.3 mSv; p = 0.02), followed by the thoracic region during fluoroscopy (7.7 ± 14.8 mSv; navigation: 1.1 ± 1.0 mSv; p = 0.06), other measured regions can be considered marginal in comparison. Amongst OR personnel exposure of the surgeon was significant higher during fluoroscopy (right hand: 566 ± 560 µSv and thoracic region: 275 ± 147 µSv; followed by thyroid and forehead) compared to navigation (right finger: 49 ± 19 µSv; similar levels for all regions; p < 0.001 in all regions). When compared to the surgeon, other OR personnel had significantly lower radiation doses on all body regions using fluoroscopy, and similar dose during navigation. The highest eye’s lens region value was measured during fluoroscopy for the patient (185 ± 165 µSv; navigation: 205 ± 60 µSv; p = 0.57) and the surgeon (164 ± 74 µSv; navigation: 92 ± 41 µSv; p < 0.001). There was a significant correlation between patient BMI and radiation exposure to the surgery field during fluoroscopy. To our knowledge, these data present the first real life, detailed comparison of radiation exposure on OR personnel and patients between clinical use of navigation and fluoroscopy. Although patient’s radiation dose is approximately 3-fold during navigation compared to the fluoroscopy, we found that a spinal surgeon could perform up to 10-fold number of surgeries (10.000 versus 883) until maximum permissible annual effective radiation dose would be reached. Especially for a spinal surgeon, who is mainly exposed amongst OR personnel, radiation prevention and protection must remain a main issue.