Anterior Cruciate Ligament Injury Prevention and Rehabilitation.

At all levels of American football, knee injuries are common, with injuries to the anterior cruciate ligament (ACL) making up a significant proportion. Historically, ACL injuries were career-altering for professional players, but innovative techniques in surgery and rehabilitation have returned many to the field. While there is a consensus on surgical techniques for ACL reconstruction, significant discrepancies remain on injury prevention and rehabilitation programs. This review article describes the burden of ACL injury on players in the National Football League, best practices in injury prevention and rehabilitation, and evidence-based recommendations for preparing injured athletes to return to play.

Intensity of overground robotic exoskeleton training in two persons with motor-complete tetraplegia: a case series.

INTRODUCTION: Participation in moderate-to-vigorous intensity physical activity (MVPA) is recommended to reduce chronic disease risk in individuals with tetraplegia. Assessing exercise intensity using traditional methods, such as heart rate, may be inaccurate in patients with motor-complete tetraplegia due to autonomic and neuromuscular dysfunction. Direct gas analysis may be more accurate. Overground robotic exoskeleton (ORE) training can be physiologically demanding. Yet, its utility as an aerobic exercise modality to facilitate MVPA in patients with chronic and acute motor-complete tetraplegia has not been explored. CASE PRESENTATION: We present the results of two male participants with motor-complete tetraplegia who completed one ORE exercise session while intensity was assessed using a portable metabolic system and expressed in metabolic equivalents (METs). METs were calculated using a rolling 30-s average with 1 MET defined as 2.7 mL/kg/min and MVPA defined as MET ≥ 3.0. Participant A (28-year-old) with a chronic (12 yrs) spinal cord injury (C5, AIS A) completed 37.4 min of ORE exercise (28.9 min walking) achieving 1047 steps. Peak METs were 3.4 (average 2.3) with 3% of walk time spent in MVPA. Participant B (21-year-old) with an acute (2 months) spinal cord injury (C4, AIS A) completed 42.3 min of ORE exercise (40.5 min walking) achieving 1023 steps. Peak METs were 3.2 (average 2.6) with 12% of walk time spent in MVPA. Both participants tolerated activity well without observed adverse responses to activity. DISCUSSION: ORE exercise may be an effective aerobic exercise modality that may increase participation in physical activity in patients with motor-complete tetraplegia.

Relation of tranexamic acid therapy to length of stay in the hip fracture population.

Tranexamic acid (TXA) is a medication that is routinely used to minimize blood loss during surgery. There is minimal literature evaluating the effects of TXA in hip fractures in regards to length of stay, readmission rates, and location of discharge. This study included adult patients who were admitted for hip fracture that required surgery over a 22-month period (May 2017-February 2019). A total of 525 hip fractures were operated on during this time period. Retrospective analysis was performed on patients treated with TXA (n = 27) vs those who were not (n = 498). Primary outcomes were length of stay, disposition after discharge, need for transfusion, mobilization with therapy, and readmission rates. TXA during hip fractures reduced median length of stay in the hip fracture cohort to 3 vs 5 days (P < 0.01). Patients were more likely to be discharged home as opposed to a nursing facility. Patients who received TXA during their hip fracture surgery were less likely to need transfusions while admitted (P < 0.01). No increased readmission rates were seen within 30 days after discharge (P = 0.59). In conclusion, when indicated, TXA appears to be safe for utilization in hip fracture surgery, resulting in decreased length of stay, less transfusions, and no increase in readmission rates.

Design and Retrospective Application of a Spine Trauma DVT Prophylaxis Protocol on Level 1 Trauma Center Patient Database.

STUDY DESIGN: Systematic literature review. OBJECTIVES: The impact of thromboembolic disease on the morbidity and mortality of patients with acute spinal cord injury is well documented, with rates as high as 67%-100% among untreated patients. The efficacy of mechanical prophylaxis as a stand-alone measure has been questioned, so we sought to determine a safe perioperative window for chemical anticoagulation use after spine surgery. Many surgeons have concerns anticoagulants may cause post-operative hematoma. METHODS: A systematic literature review was performed, ultimately yielding 13 articles. Based on the existing literature and input from our multidisciplinary institutional trauma committee, a Spine Trauma DVT Prophylaxis Protocol was developed. RESULTS: Effort was placed to identify cases within our institution in which patients suffered vertebral column fractures and/or spinal cord injuries. Of these 466 vertebral column fractures and/or spinal cord injuries, 4 patients were identified and diagnosed with DVTs while admitted. CONCLUSIONS: Of these patients, there is a clear dilemma with regard to safety of chemoprophylaxis use versus risk of developing a DVT. Though none of the patients developed a PE, utilizing the protocol would have led to earlier IVC filter placement or initiation of a VTE surveillance protocol in 2 of the patients. Initiation of enoxaparin before surgery in one patient (despite delay of surgical timing) may have avoided his subsequent LUE DVT. Though not appropriate for all clinical scenarios, we are confident that our treatment algorithm will prove beneficial for patient care in avoiding DVTs and helping trauma surgeons with evidence-based clinical decision making.

Usefulness of magnetic resonance imaging to diagnose greater trochanteric-ischial impingement.

Extra-articular impingement between the femur and ischium is increasingly recognized as a cause of hip pain. The purpose of this study was to assess the diagnostic parameters for greater trochanteric-ischial impingement (GTI) in magnetic resonance imaging (MRI) studies. Seven patients (seven hips) diagnosed with GTI were retrospectively identified. For each of these seven patients, three controls were matched by gender, height, and weight to create a control group of 21 asymptomatic hips. The same technique and positioning were utilized to acquire the MRIs in the GTI and control groups. The MRI was performed with the lower limbs in a functional position reproducing the midstance phase of the gait cycle. The greater trochanteric-ischial distance was measured in the axial cut showing the shortest distance between the greater trochanter and the ischial tuberosity. The mean greater trochanteric-ischial distance was 26.2 mm in the GTI group and 33.8 mm in the control group (P < 0.01). Greater trochanteric-ischial distance ≤28 mm had a sensitivity of 86% and specificity of 86% in identifying GTI. In conclusion, utilizing MRI with functional positioning of the lower limbs, greater trochanter-ischial distance ≤28 mm is helpful to diagnose GTI in women.

Transulnar access for coronary intervention in a 23-year-old with accelerated coronary atherosclerosis due to congenital aortic hypoplasia.

The use of alternative arterial access and advanced imaging is not only applicable to mainstream adult cardiology, but helpful and sometimes necessary in taking care of adult patients with complex congenital heart disease.