David H. Sohn

Purpose Several surgical techniques are used to treat large to massive reparable rotator cuff tears, including arthroscopic rotator cuff repair (ARCR), graft augmentation (GA), and superior capsular reconstruction (SCR). However, direct comparisons among these three approaches remain limited in the current literature. Methods PubMed, Embase, Cochrane, and Web of Science databases were searched for randomized clinical trials (RCTs) and comparative studies focusing on large to massive rotator cuff tears. Outcomes included American Shoulder and Elbow Surgeons (ASES) scores, Constant-Murley scores, and retear rates. Data analyses were performed using Cochrane Review Manager, with statistical significance set at p ≤ 0.05. Results A total of 10 studies (606 patients) were included in this analysis. The comparison between ARCR and GA comprised 7 RCTs and 1 comparative study. Although no significant difference was observed in Constant-Murley scores (mean difference 3.24, 95% Confidence Interval [CI] –1.36, 7.83), the ARCR group exhibited a higher retear rate than the GA group (Risk Ratio [RR] 0.53, 95% CI 0.28, 0.98, p < 0.05). One RCT comparing GA to SCR demonstrated similar ASES scores (GA 77.9 ± 19.9; SCR 74.8 ± 23.9), with SCR having slightly lower retear rates (GA 36%, SCR 25%). Only one cohort study compared SCR to ARCR, which reported similar ASES scores (SCR 85.4 ± 15; ARCR 85.4 ± 16.5) and retear rates (SCR 7%, ARCR 3.5%). Conclusions All three surgical interventions were effective in repairing large to massive rotator cuff tears. However, this analysis found no significant evidence favoring one surgical method, aside from a lower risk of retear in patients with GA compared to ARCR.

Background: The anterior cruciate ligament (ACL) is the most commonly injured ligament in the knee. ACL reconstruction (ACLR) proves the standard for treating this injury. However, graft choice and method of fixation remain a heavily debated topic. This study investigates the following: bone-patellar tendon-bone (BPTB) vs. hamstring tendon (HT) autograft, single-bundle vs. double-bundle hamstring graft, and metal vs. bioabsorbable screws in ACLR. Methods: A systematic review was performed on PubMed and Google Scholar according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data were collected on patient demographics, complications, and functionality scores including International Knee Documentation Committee (IKDC) and Lysholm scores. A systematic review and meta-analysis were conducted with Review Manager. Outcome measurements were determined using forest plots with significant differences considered p < 0.05. Results: Twenty-five studies were included, accounting for 2,170 patients. No statistically significant difference was appreciated when comparing BPTB to hamstring autografts. Patients who received a double bundle HT autograft exhibited significantly superior outcomes in terms of revision (p = 0.05), failure (p = 0.002), normal pivot shift tests (p = 0.04), and normal IKDC (p = 0.008). When comparing screw types, bioabsorbable screws had a greater Lysholm score (p = 0.01) and lower failure rates for copolymer screws (p = 0.03). Conclusion: Overall, the data collected suggested that BPTB and HT autografts display similar postoperative results. However, if an HT autograft is used, the data suggest a double-bundle graft improves both functionality and decreases the possible complications. Finally, bioabsorbable screws prove superior to metal screws when looking at both functionality and failure rates. Further research into the superior graft type is still needed. Level of Evidence: Level II. See Instructions for Authors for a complete description of levels of evidence.

Case: Combined medial and lateral patellar instability is exceptionally rare with only 3 reported cases to date. Here, we present the case of a 37-year-old White woman with multiple recurrent medial and lateral patellar instability. After failure of conservative care with bracing and therapy, she underwent surgical stabilization with medial and lateral allograft reconstruction. Conclusion: This case provides an example of the condition and successful surgical follow-up.

Negligence, genuine error, and litigation David H SohnDepartment of Orthopedic Surgery, University of Toledo Medical Center, Toledo, OH, USA Not all medical injuries are the result of negligence. In fact, most medical injuries are the result either of the inherent risk in the practice of medicine, or due to system errors, which cannot be prevented simply through fear of disciplinary action. This paper will discuss the differences between adverse events, negligence, and system errors; the current medical malpractice tort system in the United States; and review current and future solutions, including medical malpractice reform, alternative dispute resolution, health courts, and no-fault compensation systems. The current political environment favors investigation of non-cap tort reform remedies; investment into more rational oversight systems, such as health courts or no-fault systems may reap both quantitative and qualitative benefits for a less costly and safer health system.Keywords: medical malpractice, tort reform, no fault compensation, alternative dispute resolution, system errors

Estions/purposes (1) Why is ADR needed? (2) Is ADR useful in health care? (3) What are the current legal and political developments favoring ADR? (4) What obstacles remain? Methods We performed MEDLINE, PubMed, and Google Scholar searches with key words “medical malpractice”, “ADR”, and “alternative dispute resolution” to obtain public policy studies, law review articles, case analyses, ADR surveys, and healthcare review articles. Results Early apology and disclosure programs report 50% to 67% success in avoiding litigation as well as substantial reductions in the amount paid per claim. Mediation boasts 75% to 90% success in avoiding litigation, cost savings of $50,000 per claim, and 90% satisfaction rates among both plaintiffs and defendants. Arbitration is viewed as less satisfying and less efficient than mediation but still more time- and cost-effective than litigation. The current legal environment is favorable to ADR with recent court decisions upholding pretreatment arbitration clauses. The main obstacle to ADR is the mandatory reporting requirement of the National Practitioner Data Bank (NPDB). Conclusions ADR has the potential to help reform the current tort system, reducing cost and increasing both parties’ satisfaction. Easing the reporting requirements for the NPDB would lead to more widespread acceptance of ADR among physicians....