Editorial Commentary: There Is No Standard for or Standardization of Postoperative Rehabilitation Protocols After Anterior Cruciate Ligament Reconstruction.

The anterior cruciate ligament (ACL) is the most studied ligament in the knee and one of the most studied topics in orthopaedics, with little consensus on best options for surgical technique or graft choice. While there is little question that physical rehabilitation is one of the most important variables in the episode of care before and after ACL reconstruction (ACLR), recent research surveying orthopaedic surgeons demonstrates no consensus of how to rehab ACLR patients and how to get them to return to sport safely and quickly. Seventy-two percent of surgeons prescribe "pre-hab" prior to ACLR, and 83% of surgeons use postoperative bracing, with most (55%) bracing for 3 to 6 weeks postoperatively. Patient-reported outcome measures (35%) and assessments of psychological readiness (23%) are not commonly used to progress patients through the stages of rehab. When asked what they believe is the single most important factor in unrestricted return to sport, 52% of surgeons stated functional testing scores were most important, while 38% stated time since surgery, and 5% stated muscle strength. As for average time to return to full activity, 50% of surgeons waited until 9+ months for full return, and 42% allowed return within 6 to 8 months. Reductions in practice variability have been shown in orthopaedic surgery and other fields to reduce costs of care delivery and improve patient outcomes, and with so much variability in ACLR rehabilitation protocols, the orthopaedic community would be wise to strive for more consensus focused on evidence-based recommendations for rehabilitation and to fill in knowledge gaps with focused, high-quality research where needed.

A Comparison of Radiographic Outcomes After Total Hip Arthroplasty Between the Posterior Approach and Direct Anterior Approach With Intraoperative Fluoroscopy.

BACKGROUND: Radiographic outcomes after total hip arthroplasty (THA) have been linked to clinical outcomes. The direct anterior approach (DAA) for THA has been criticized by some for providing limited exposure and compromised implant position but allows for routine use of intraoperative fluoroscopy. We sought to determine whether radiographic measurements differed by THA approach using prospective cohorts. METHODS: Two reviewers blinded to surgical approach examined 194 radiographs, obtained 4-6 weeks after primary THA, and obtained measurements for acetabular inclination angle, acetabular anteversion, radiographic limb length discrepancy (LLD), and femoral offset. All surgeries were performed at a tertiary academic medical center in rural New England by an experienced fellowship-trained arthroplasty surgeon. Measurements for inclination angle, anteversion, LLD, and offset were made into binary yes/no responses based on whether the mean measurement (between the 2 reviewers) was acceptable or not based on established criteria. Multivariate logistic regression analyses were performed using preoperative and intraoperative characteristics to identify predictors of acceptability for each measurement. RESULTS: The DAA group had higher rates of acceptable acetabular angle (96 vs 85%, P = .005) and was protective against an unacceptable angle in an adjusted predictive model (odds ratios 0.16, P = .005). There were no significant differences between approaches for acceptable anteversion, LLD, or offset. Body mass index of 30-34 was associated with higher odds of unacceptable inclination angle compared to the nonobese group (adjusted odds ratio, 6.82, P = .013). CONCLUSION: DAA for THA was associated with lower odds of unacceptable inclination angle compared to the posterior approach, with no differences in anteversion, LLD, or offset.

Hallux valgus.

Hallux valgus is a common foot problem whose cause and progression is multifactorial, complex, and poorly known. Hallux valgus shows a predilection toward women. It is a progressive disorder with no treatment known to slow or stop progression. Surgery is indicated in healthy individuals when nonoperative measures fail. Adverse effects of surgery include infection and recurrence. Many procedures have been described, including soft tissue and bony reconstruction of the first ray. The procedure that is indicated depends on the severity of the deformity.

Management of type II superior labrum anterior posterior lesions: a review of the literature.

Superior labrum anterior and posterior lesions were first described in 1985 by Andrews et al. and later classified into four types by Synder et al. The most prevalent is type II which is fraying of the superior glenoid labrum with detachment of the biceps anchor. Superior labrum anterior posterior (SLAP) lesions can also be associated with other shoulder pathology. Both MRI and MRA can be utilized in making the diagnosis with the coronal images being the most sensitive. The mechanism of injury can be either repetitive stress or acute trauma with the superior labrum most vulnerable to injury during the late cocking phase of throwing. A combination of the modified dynamic labral shear and O'Brien test can be used clinically in making the diagnosis of SLAP lesion. However, the most sensitive and specific test used to diagnosis specifically a type II SLAP lesion is the Biceps Load Test II. The management of type II SLAP lesions is controversial and dependent on patient characteristics. In the young high demanding overhead athlete, repair of the type II lesion is recommended to prevent glenohumeral instability. In middle-aged patients (age 25-45), repair of the type II SLAP lesion with concomitant treatment of other shoulder pathology resulted in better functional outcomes and patient satisfaction. Furthermore, patients who had a distinct traumatic event resulting in the type II SLAP tear did better functionally than patients who did not have the traumatic event when the lesion was repaired. In the older patient population (age over 45 years), minimum intervention (debridement, biceps tenodesis/tenotomy) to the type II SLAP lesion results in excellent patient satisfaction and outcomes.

Treatment of chronic lateral ankle instability: a modified Broström technique using three suture anchors.

Ankle sprains are very common injuries seen in the athletic and young population. Majority of patients will improve with a course of rest and physical therapy. However, with conservative management about twenty percent of all patients will go on to develop chronic lateral ankle instability. This manuscript describes our detailed surgical technique of a modification to the original Broström procedure using three suture anchors to anatomically reconstruct the lateral ankle ligaments to treat high demand patients who have developed chronic lateral ankle instability. The rationale for this modification along with patient selection and workup are discussed. Both the functional outcomes at the two year follow up along with the complications and the detailed postoperative rehabilitation protocol for the high demand athletes are also presented. This modified Broström procedure is shown in both illustrative format and intra-operative photos.

Psychogenic intractable sneezing: case reports and a review of treatment options.

OBJECTIVE: To report 2 cases of the uncommonly seen diagnosis of psychogenic intractable sneezing, to review the clinical presentation, workup, and various previous treatment modalities, and to present a unique method of treatment. DATA SOURCES: The literature was reviewed using a MEDLINE search of the following keywords: psychogenic intractable sneezing, paroxysmal sneezing, factitious sneezing, respiratory disorders, conversion disorders, habit cough, and psychogenic cough. The search was restricted to articles published from 1966 onward, although older references were cross-referenced from more recent articles. RESULTS: Sneezing alone can be caused by foreign substances, odors, chemical irritants, allergies, and other less common factors. Psychogenic intractable sneezing, although not a particularly common disease, occurs mainly in adolescent girls for which a cause may not be found. Patients are usually refractory to various medications and have an otherwise unremarkable extensive workup. Treatments have included corticosteroids, antihistamines, hydroxyzine hydrochloride, and decongestants among other pharmacologic agents, as well as psychotherapy. Based on the presented case reports, a trial of isotonic sodium chloride solution with suggestion therapy was able to rid the patients of their intractable sneezing. CONCLUSIONS: Psychogenic intractable sneezing is a real disease. Although other diseases may be considered, the workup may merely include an extensive history and physical examination. Many treatments have been tried with varying success, including those that incorporate psychotherapy. A variation of suggestiontherapy is offered as a unique treatment modality.