“The feeling of fear is very natural, and every single one of us knows that feeling,” said Stephanie Cheng, MD, DABMA, FAAMA. Dr. Cheng is an anesthesiologist at HSS and developed HSS’s protocols for using acupuncture in the operating room. “For some people, that fear can become irrational and develop into PTSD. Although exact numbers are unknown, reported estimates for the incidence of PTSD in the United States are approximately 6%, with women having twice the rate of men.

“For patients with nosocomephobia, it can make getting care in the hospital setting very hard,” she continues. “We don’t even know how many of these ‘unseen patients’ are out there because they just don’t come to the hospital.”

Current treatments for nosocomephobia include techniques such as cognitive behavioral therapy, exposure therapy, hypnotherapy, and medications.

“It’s worth noting that acupuncture isn’t even listed as a treatment on many patient information websites, despite it being well researched in PTSD patient populations,” Dr. Cheng said. “While acupuncture has been well studied with outpatient PTSD patients, specifically in the military, using it in the operating room is almost unheard of. Our study shows that offering acupuncture to patients is something that can help them feel more in control of the situation and get through surgery successfully.”

For these case studies, two patients were interviewed about their nosocomephobia and their prior hospital experiences. Using Dedoose software, six reviewers coded the interview transcripts line-by-line. The reviewers labeled meaningful words, phrases, and sentences, and created more than 600 codes. The reviewers grouped similar codes to identify themes, and then conducted a thematic analysis to generalize the study’s themes and construct its theoretical framework.

This analysis demonstrated how nosocomephobia affected patients’ perceptions of surgery and helped identify their individual fears. The researchers diagrammed the thought process of the patients to show how they considered whether they felt comfortable enough to get surgery. The appraisal process included three steps: experiencing the stressor (surgery), how they would be able to cope (acupuncture), and their mental state about whether they believed they could go through with the surgery (reappraisal).

In the case of these two patients with nosocomephopbia, acupuncture was a safe, non-invasive way for them to manage their preoperative anxiety and undergo elective surgery.

“Our research is based on a limited number of cases and makes it difficult to draw any major conclusions. We need to study more patients who have a major fear of hospitals and who need surgery and see whether offering acupuncture intraoperatively can successfully get those patients through surgery,” Dr. Cheng explained. “We also need to make more patients and doctors aware that this modality is available, and that it can be really helpful to patients suffering with PTSD.”

“If the addition of intraoperative acupuncture can prove to be helpful for patients who have a fear of hospitals, then we can really change the quality of life of a segment of the population that has historically been difficult to treat. The unseen patient can finally be seen,” Dr. Cheng concluded.

Reference

1. Pa Thor PhD, Andrew Moreno MS, MD, Haoyan Zhong MS, Miriam Sheetz BS, Marko Popovic BS, Sabrina M. Strickland MD, Michael P. Ast MD, Stephanie I. Cheng MD, DABMA, FAAMA. “A Qualitative Analysis of Intraoperative Acupuncture for Nosocomephobia: The Unseen Patient.” Presented at: 6th World Congress on Regional Anaesthesia & Pain Medicine, September 6-9, 2023, Paris, France.

Reconstruction is the current standard of care surgical treatment for tears of the anterior cruciate ligament (ACL). This procedure typically uses a graft, or a piece of tissue, placed in the knee minimally invasively, using small incisions. About 300,000 ACL reconstructions are performed annually in the United States with well documented rates of success.

ACL repair is an older technique that involved suturing (sewing) torn ACL tissue, not rebuilding it with a graft. ACL repair was performed in the 1970s at select institutions, including Hospital for Special Surgery, but was abandoned due to unacceptably high failure rates of up to 50%.

Today, ACL repair has been modernized and can be performed through a minimally invasive approach. Proponents suggest that modern ACL repair techniques may be performed safely and may lead to a quicker recovery than ACL reconstruction. However, the limited studies to date raise questions that must be discussed in detail with your surgeon.

1. It is critically important to get ACL surgery right the first time.

When ACL surgery fails, surgeons must do a revision procedure to correct or revise the problems that were not fully addressed the first time. Revision requires reconstructive ACL surgery with a graft. (ACL repairs cannot be done as revisions.) Redoing ACL surgery may result in higher rates of failure, lower rates of return to sports, and increased risk of osteoarthritis.

The importance of successful initial ACL surgery holds true for people of all ages, but it is particularly critical for young athletes, for whom a failed surgery can have devastating consequences, including years lost from sport in the short term as well as chronic pain and loss of function in the long term.

2. Failure rates for ACL repair appear to be significantly higher than those for ACL reconstruction in people of all ages.

Current studies suggest that modern ACL repair techniques have a failure rate that may be five to ten times higher than that of ACL reconstruction^1,2,3. One major recent study in a prominent sports medicine journal found that arthroscopic ACL repair has unacceptable outcomes in young athletes, with short-term failure rates of close to 50%².

It has been suggested that ACL repair may be appropriate for older adults who have a type of ACL tear called a proximal avulsion and who do not participate in “cutting and pivoting” sports such as basketball, volleyball, and soccer. For these patients, failure rates in the short term appear to be much higher than ACL reconstruction in this age group^1,2,3.

3. There is still much we don’t know about ACL repair.

There has been no scientific evidence that shows a difference in postoperative pain between ACL repair and reconstruction. Rehabilitation and return-to-play protocols for ACL repair have not yet been established. Proper guidelines for rehabilitation and return to sports are essential to keep people safe from re-injury.
 

Andrew D. Pearle, MD

Chief, HSS Sports Medicine Institute

Bryan T. Kelly, MD

HSS Surgeon-in-Chief and Medical Director

Answorth A. Allen, MD

David W. Altchek, MD

Struan H. Coleman, MD, PhD

Frank A. Cordasco, MD, MS

David M. Dines, MD

Joshua S. Dines, MD

Stephen Fealy, MD

Andreas H. Gomoll, MD

Lawrence V. Gulotta, MD

Jo A. Hannafin, MD, PhD

Anne M. Kelly, MD

John D. MacGillivray, MD

Robert G. Marx, MD, MSc, FRCSC

Michael J. Maynard, MD

Moira M. McCarthy, MD

Danyal H. Nawabi, MD, FRCS

Stephen J. O’Brien, MD, MBA

Anil S. Ranawat, MD

Scott A. Rodeo, MD

Howard Anthony Rose, MD

Beth E. Shubin Stein, MD

Sabrina M. Strickland, MD

Karen M. Sutton, MD

Samuel A. Taylor, MD

Russell F. Warren, MD

Thomas L. Wickiewicz, MD

Riley J. Williams III, MD

References

1. Jonkergouw A, van der List J, DiFelice G. Arthroscopic primary repair of proximal ACL tears: outcomes of the first 56 consecutive patients and the role of additional internal bracing. Knee Surg Sports Traumatol Arthrosc. 2019 Jan;27(1):21-28.

2. Gagliardi AG, Carry PM, Parikh HB, Traver JL, Howell DR, Albright JC. ACL repair with suture ligament augmentation is associated with a high failure rate among adolescent patients. Am J Sports Med. 2019 Mar;47(3):560-566.

3. Wright RW et al. Risk of tearing the intact ACL in the contralateral knee and rupturing the ACL graft during the first 2 years after ACLR: A prospective MOON cohort study. Am J Sports Med. 2007 Jul;35(7):1131-4.

For more information visit https://www.hss.edu/condition-list_torn-acl.asp.

Machado underwent a medial patellofemoral ligament (MPFL) in his right knee in 2014 after a similar procedure in his left in 2013.

"The fact he's stayed healthy this long means he has a stable patella," says Sabrina M. Strickland, MD, sports medicine surgeon at HSS, who did not treat Machado.  

"If the surgeries weren't a success, he wouldn't have been able to come back and play like he has," Dr. Strickland adds. "If done right, it may very well never happen again."

Read the full story at NYPost.com. This also appeared in the January 9, 2019 print issue.

A side stitch is a cramp in the muscle that controls breathing, Dr. Strickland explained.

During cardio exercise, or if you abruptly start an intense workout, the diaphragm can cramp up and cause a side stitch, she added.

To prevent side stitches, Dr. Strickland said "I always tell patients who suffer from muscle cramps to eat bananas or drink orange juice."

Read the full article at refinery29.com.

"Research shows that certain exercise programs can benefit people with knee arthritis. However, not all patients obtain sufficient pain relief through exercise," explains Sabrina Strickland, MD, an orthopedic surgeon and lead investigator at HSS. "The new study, which will take place at hospitals around the country including HSS, is designed to enroll a relatively young, active population of people with knee osteoarthritis. It will be interesting to see the results, as hyaluronic acid injections are typically used for an older patient population."

Study participants will be divided into two groups. One group will receive two hyaluronic acid injections combined with a physical exercise program of at least eight weeks. The other group will be provided with an exercise program alone, also to last eight weeks. All patients will receive a diary to record their activity and progress. They will see the physician for follow-up visits three months and six months after enrollment.

The initial doctor exam, x-rays, hyaluronic acid injections, exercise program, and follow-up visits will all be provided free of charge to study participants. Patients who have failed to obtain sufficient pain relief from the exercise program alone at the three-month follow-up will have the option of receiving the hyaluronic acid injections.

Dr. Andreas Gomoll, an orthopedic surgeon at HSS, is also involved in the study, which is open to individuals from 21 to 55 years of age. To qualify, patients must have experienced persistent knee pain lasting at least three months prior to the initial screening; lead an active lifestyle (play a sport or train at least two to three times per week); receive a diagnosis of knee osteoarthritis confirmed by an x-ray; and meet a number of additional requirements.

Anyone interested in learning more about the study is invited to send an email to StricklandOffice@hss.edu or Digirolamod@hss.edu. You can also call 212-606-1725 or 212-774-2673.

Dr. Strickland noted that staying in one position for hours at a time could cause significant muscle tightness and slouching. She recommended taking regular standing and walking breaks.

"If you think you'll forget to get up, download an app that encourages you to stand or set an alarm on your phone to nudge you," noted Dr. Strickland.

This article appeared in the April 2018 print issue.

Read the full article at beckersspine.com

Dr. Strickland, who did not treat Leonard, explained that surgery is not typically required to treat the injury. "If it's just tendinitis, it should get back with rehab," she noted.

According to the segment, the NBA eliminated stretches of four games in five nights. Dr. Strickland commented on the new policy, "I think it's incredibly important. You need some time to rest… Basketball is very hard on the body and especially for a sport like that, I think it's a great idea."

This segment aired live during the January 20, 2018 broadcast.