Effects of the WHO analgesic ladder on pain severity, pain interference, and blood pressure control in hypertensive patients with chronic musculoskeletal pain: a cross-sectional study.

AIM: This study aimed to investigate the effects of pain management according to the World Health Organization (WHO) analgesic ladder on pain severity, pain interference, and blood pressure (BP) in treated hypertensive patients with chronic musculoskeletal pain. BACKGROUND: Pain management can affect BP control owing to the proposed mechanism by which persistent pain contributes to increased BP. However, there are inadequate studies investigating the benefit of pain management in controlling both pain and BP in hypertensive patients who have chronic pain. METHODS: In this cross-sectional study, demographic data and pain characteristics (resting pain score on the numerical pain rating scale, pain severity, and pain interference subscale of the Brief Pain Inventory) were collected via face-to-face interviews. BP was measured thrice on the same day. Data on pain medications taken in the previous 1 month were retrieved from the medical records. Participants were categorized into three groups following pain management patterns according to the WHO analgesic ladder: no, partial, and complete treatment. Multivariate logistic regression analysis (MLRA) was used to analyse the association between the variables and uncontrolled BP. FINDINGS: Among 210 participants, the mean (standard deviation) age was 68 (15.5) years, and 60.47% had uncontrolled BP. The resting pain score, pain severity, and pain interference subscale scores of the complete treatment group were significantly lower than that of the partial treatment group (P = 0.036, 0.026, and 0.044, respectively). The MLRA revealed that pain management patterns were associated with uncontrolled BP (adjusted odds ratio [AOR]: 6.75; 95% confidence interval [CI]: 2.71-16.78; P < 0.001) and resting pain scores (AOR: 1.17; 95% CI: 1.04-1.38; P = 0.048). Our findings suggest that pain management patterns adhering to the WHO analgesic ladder can reduce pain severity and pain interference and also control BP in hypertensive patients with chronic musculoskeletal pain.

Progressive Loss of Acromioclavicular Joint Reduction Correlated with Progressive Clavicular Tunnel Widening after Coracoclavicular Stabilization in Acute High-Grade Acromioclavicular Joint Injury.

Objectives: This study aimed to compare 24-month radiographic follow-ups of clavicular tunnel widenings (CTWs) and coracoclavicular distances (CCDs) and examine correlations between these measurements in patients following combined coracoclavicular stabilization and acromioclavicular capsule repair in treatment of acute high-grade acromioclavicular joint injury. Methods: This retrospective study reviewed the records of patients with acute Rockwood type V acromioclavicular joint injury who underwent surgery within 3 weeks after their injury. All patients had follow-ups at 3 and 6 months and 1 and 2 years. The CTWs were measured on anteroposterior radiographs between the medial and lateral borders at the superior, middle and inferior levels of the tunnels. On anteroposterior radiographs of both clavicles, the CCDs were measured at the shortest distance between the upper border of the coracoid process and the inferior border of the clavicle and reported as the CCD ratio, which was defined as the ratio of the affected and unaffected clavicles. At the final follow-ups, clinical outcomes were assessed using American Shoulder and Elbow Surgeons (ASES) scores. Results: This study included seventeen men and six women with a mean age of 47.26 ± 10.68 years. At the final follow-ups, the mean ASES score of all patients was 95.28 ± 3.62. We found a significant correlation between the increase in the CTWs and the increase in the CCD ratios (Spearman's rho correlation coefficient range 0.578-0.647, all p-values < 0.001). Conclusions: We found long-term postoperative widening of the clavicular tunnels, which correlated positively with a gradual postoperative decline in the acromioclavicular joint alignment reductions.

Right proximal tibia post-traumatic lipoma following a jogging fall.

This case report describes a 70-year-old woman who presented with a lump at the right knee. She had had a fall while jogging two years previously, followed by the development of a painless mass at the injury site. The mass had gradually increased in size over time. At presentation the physical examination revealed a soft, ill-defined mass, and magnetic resonance imaging confirmed a well-circumscribed subcutaneous soft tissue mass consistent with a lipoma. Given the asymptomatic nature and well-defined characteristics of the mass, the patient opted for conservative management with observation. This case highlights the importance of considering post-traumatic lipoma in the differential diagnosis of soft tissue masses, particularly in patients with a history of trauma. Such masses should be regularly monitored to allow timely intervention if indicated.

Using a Nice knot to simplify and strengthen closed reduction in displaced distal clavicle fracture: a technical note.

A displaced distal clavicle fracture often necessitates surgical intervention, with various open and closed reduction options. Open reduction is easier but raises blood supply concerns, while closed reduction can involve complex deforming forces with differing displacement vectors. Herein, we demonstrate how a Nice knot with its sliding and self-locking qualities can be used to make closed reduction easier and the alignment more secure. A case report illustrates this Nice knot application in a 61-year-old male with a distal clavicle fracture. The Nice knot's ability to be loosened and retightened ensured more precise alignment in this case. The Nice knot technique is a versatile option for easier and more secure distal clavicle fracture management.

Assessing Risk of Iatrogenic Peroneal Nerve Injury in All-Inside Lateral Meniscal Repair Between Standard Vs. Arthroscopic MRI.

BACKGROUND: Various studies have examined the risk of peroneal nerve injury with use of standard magnetic resonance imaging (MRI) of the knee. However, the position of the knee during standard MRI is different from that during an actual arthroscopic lateral meniscal repair. The purpose of the present study was to evaluate and compare the risk of peroneal nerve injury during simulated all-inside lateral meniscal repairs on the basis of MRI scans made with the knee in both positions. METHODS: With use of axial MRI scans made with the knee in the standard position (i.e., in 30° of flexion) and in the actual position used during arthroscopic lateral meniscal repair (i.e., in a figure-of-4 position), direct lines were drawn to simulate the passage of a straight all-inside meniscal repair device from the anteromedial and anterolateral portals to the medial and lateral borders of the popliteus tendon. The distance from the closest passage of each line to the peroneal nerve was measured. If a line touched or passed through the peroneal nerve, a risk of iatrogenic injury was noted and a new line was drawn from the same portal to the outer border of the peroneal nerve. The danger area was measured from the first line to the new line along the joint capsule. RESULTS: In 28 Thai patients, the shortest distances from each line to the peroneal nerve were significantly shorter on the MRI scans made with the knee in the standard position than on those made with the knee in the arthroscopic position (p < 0.05 for all). All danger areas on the MRI scans that were made with the knee in the arthroscopic position were included within the danger areas on the scans that were made with the knee in the standard position. CONCLUSIONS: Standard MRI scans of the knee can be used to determine the risk of peroneal nerve injury at the time of arthroscopic lateral meniscal repair, although the risks are slightly overestimated. LEVEL OF EVIDENCE: Diagnostic Level III . See Instructions for Authors for a complete description of levels of evidence.

The Risk of Iatrogenic Posterior Neurovascular Injuries in Lateral Meniscal Repair Based on the Standard Arthroscopic Knee Position: A Magnetic Resonance Imaging Study.

Background: Repair of the posterior horn of the lateral meniscus using an all-inside meniscal repair device involves the risk of iatrogenic posterior neurovascular injuries. Previous studies that have evaluated this risk were based on preoperative magnetic resonance imaging (MRI) with the knee in 30° of flexion and used landmarks that are impractical in the actual operative situation. Purpose: To use an MRI model simulating actual knee arthroscopic conditions to (1) compare the potential risk of injuries related to the lateral border of the posterior lateral meniscus root (LMR) through the anterolateral versus anteromedial portal and (2) establish "safe" and "danger" zones to reduce the possibility of injuries to posterior neurovascular structures when performing lateral meniscal repair in relation to the lateral border of the posterior LMR. Study Design: Descriptive laboratory study. Methods: Using 29 axial MRI scans of knees in the figure-of-4 position with joint fluid dilatation at the level of the lateral meniscus, direct lines were drawn to simulate a straight all-inside meniscal repair device deployed from the anterolateral and anteromedial portals to the lateral border of the posterior LMR, extending 14 mm beyond the joint capsule. If the line passed through or touched a posterior neurovascular structure, a risk of iatrogenic injuries was noted, and measurements were made to determine the safe zone in relation to the lateral border of the posterior LMR. Results: Repairing the lateral meniscus through the anterolateral portal in relation to the lateral border of the posterior LMR resulted in a significantly greater risk of posterior neurovascular injuries compared with repairing through the anteromedial portal, with injury incidences of 68.97% and 10.35%, respectively (P = .001). The safe zones of lateral meniscal repair through the anterolateral and anteromedial portals were 4.15 ± 1.87 and 6.57 ± 0.98 mm, respectively, beyond the lateral border of the posterior LMR. Conclusion: The risk of posterior neurovascular injuries when repairing posterior lateral meniscal tissue was found to be significantly greater through the anterolateral portal compared with the anteromedial portal. Clinical Relevance: Surgeons can use the safe zones as defined in this study to decrease the risk of iatrogenic posterior neurovascular injuries during arthroscopic lateral meniscal repair.

Looping a suture under the coracoid process using a modified pelvic suture needle in coracoclavicular stabilization.

A distal clavicle fracture is a common shoulder injury. Coracoclavicular (CC) stabilization is a popular procedure for treating this injury. However, with this method, there is a technical difficulty in looping the suture under the coracoid base with instruments normally available in the operating room (OR). Herein, the authors describe modifying a pelvic suture needle to ease this process. Case presentation: An 18-year-old Thai female presented with left shoulder pain after a fall while cycling. The physical examination showed tenderness at the prominent distal clavicle. The radiograph of both clavicles showed a displaced distal clavicle fracture of the left shoulder. After discussing the treatment, she decided to have CC stabilization as the authors recommended. Clinical discussion: CC stabilization is one of the main surgical techniques used in treating an acute displaced distal clavicle fracture. The most important but difficult step of the CC stabilization is passing a suture under the coracoid base. To make this step easier, various commercial tools have been created, however, they are expensive ($1400-1500 per piece), and most operating rooms in resource-limited countries do not have them available. The authors modified a pelvic suture needle specifically for use in looping a suture under the coracoid process, which is hard to do with standard surgical tools.

Using a right-angle forceps clamp to pass a suture under the coracoid base in coracoclavicular stabilization: a technical note.

A distal clavicle fracture is a common injury of the shoulder joint. Coracoclavicular (CC) stabilization is one of the recommended procedures for treating the distal clavicle fracture. However, it is difficult to pass the suture under the coracoid process with instruments normally available in the operating room (OR). Herein, the authors describe a simple technique to accomplish this suture passing quickly and easily using tools available in the OR. Case presentation: A 59-year-old Thai female presented with right shoulder pain after a fall. The physical examination showed a prominent bulge and tenderness at the right distal clavicle. A radiograph of both clavicles showed a right displaced distal clavicle fracture. After discussing the possible treatments with her, she decided to have CC stabilization as we recommended. Clinical discussion: In CC stabilization, the most important but difficult step is passing a suture under the coracoid base. There are some specialized commercial instruments which are matched to the shape of the coracoid process to make it easy to perform this step, but all are highly expensive (~$1400-1500 per piece) and thus often not available in ORs in resource-limited settings. Conclusion: The authors devised a technique using standard surgical instruments and materials available in all ORs to enable them to pass a suture easily and quickly under the coracoid base.

Efficacy and Safety of Antibiotic Impregnated Microporous Nanohydroxyapatite Beads for Chronic Osteomyelitis Treatment: A Multicenter, Open-Label, Prospective Cohort Study.

Chronic osteomyelitis is still a serious health problem that causes disabling conditions and has an impact on the quality of life. The objective of this study was to determine the clinical efficacy and safety of localized antibiotics delivery via impregnated microporous nanohydroxyapatite (nHA-ATB) beads for chronic osteomyelitis treatment. A total of 62 patients were enrolled in this study. After radical surgical debridement, the bone defect was filled with three types of antibiotics (vancomycin or gentamicin or fosfomycin) impregnated HA beads. The follow-up period was 48 weeks. It was found that the success rate was approximately 98% with a re-infection in only one patient. Quality of life of all patients after treatment improved significantly over time. Systemic exposure to vancomycin and gentamicin after beads implantation was limited and high local antibiotics concentrations were found in wound drainage fluid at 24, 48 and 72 h. Blood biochemistry measurements did not show any nephrotoxic or hepatotoxic effects. 20 adverse events were reported, but 90% of the events were resolved without having to remove the beads and the patients recovered. Satisfactory outcomes were observed in terms of success rate, quality of life and adverse effect. nHA-ATB beads impregnated by vancomycin or gentamicin or fosfomycin could potentially be employed as an alternative product of choice for localized antibiotics delivery in chronic osteomyelitis treatment.

Displaced varus proximal humerus fracture with conservative treatment: a case report.

The authors report a case of an elderly female with a displaced varus misalignment of a proximal humerus fracture which met the indications for surgery, but the patient was treated conservatively with an arm sling due to the wishes of the patient and her relatives. The clinical outcome was nearly full function compared with the right shoulder. Presentation of case: A 65-year-old Thai female presented with right shoulder pain 1 h after a fall during which her right shoulder hit the floor. Radiographs of the right shoulder in anteroposterior and lateral transcapular views showed a proximal humerus fracture with varus misalignment. The patient and her relatives decided on conservative treatment with an arm sling. At 12 weeks following the fall she was able to move her right shoulder nearly equally to the left shoulder. Intervention and outcome: The authors discussed the treatment options with the patient and her relatives and recommended open reduction and internal fixation with a locking plate and screw, but they decided on conservative treatment with an arm sling. At 12 weeks following the fall she was able to move her right shoulder nearly equally to the left shoulder. She had no pain and could do normal life activities with the right shoulder. Relevance and impact: Patients with severe varus deformity are usually treated with surgery. If there are contraindications for surgery, the stability of the fracture should first be evaluated through radiographs of the fracture in various arm positions.

Osteophyte-related medial collateral ligament injury in asymptomatic osteoarthritis following minor trauma: a case report.

A proximal deep medial collateral ligament (MCL) injury usually occurs in high-impact sports such as football or hockey. This injury is not common in low-energy trauma but the predisposing factor, in this case, was an osteophyte located next to the deep MCL ligament, which had likely caused degenerative changes to the ligament from chronic irritation, resulting in reduced strength of the ligament. Case presentation: A 78-year-old Thai female presented with left knee pain 1 h after a low-energy trauma caused by a fall. The MRI showed deep MCL and medial meniscal root injuries, a nondisplaced lateral femoral condyle, and also revealed a large osteophyte near the midpart of the MCL, with a blunt persistent projection from the osteophyte pushing against the MCL where the injury was located. She was treated with a knee brace, a gait aid for walking, and analgesic pain control. Her symptoms gradually improved over the next few weeks. Clinical discussion: If an osteophyte touches a ligament, it can cause degenerative changes to the ligament from chronic irritation, resulting in reducing the strength of the ligament and may be causing some degree of degenerative changes and tightening of the MCL in its at-rest state, resulting in an increased chance of injury when it is required to resist a sudden external force, even from a minor trauma. Conclusion: When there is an osteophyte pushing against a ligament, there is an increased chance of ligament injury when even a minor trauma stresses that ligament.

Partial infraspinatus tear with bursitis following an mRNA vaccination: a case report.

We report a case of a shoulder injury related to vaccine administration (SIRVA) that developed symptoms 2 weeks following a coronavirus disease 2019 (COVID-19) vaccination and improved after receiving both intraarticular and subacromial corticosteroid injections. Presentation of case: A 52-year-old Thai female without preexisting shoulder pathology and symptom had developed left shoulder pain for 3 days. Two weeks prior to shoulder pain, she received an mRNA COVID-19 vaccination. She positioned her arm in combined internal rotation with 60° of arm abduction. Her symptoms were pain in all directions of shoulder motion and tenderness at the bicipital groove and over the deltoid area. The testing of the rotator cuff power of the infraspinatus tendon showed pain. Intervention and outcome: An MRI showed infraspinatus tendinosis with a low-grade (almost 50%) bursal-surface tear at the footprint of the superior fiber with associated overlying subacromial-subdeltoid bursitis. She was treated with both intraarticular and subacromial corticosteroid injections (triamcinolone acetate (40 mg/ml) 1 ml+1% lidocaine with adrenaline 9 ml). She did not respond to oral naproxen but responded well to intraarticular and subacromial corticosteroid injections. Relevance and impact: The best way to deal with SIRVA is to prevent this condition by using the correct injection technique. First, the injection site should be two or three fingerbreadths below the mid-acromion process. Second, the needle's direction should be perpendicular to the skin. Third, using the correct needle penetration depth.

Using a modified recycled corkscrew suture anchor to pass a suture under the coracoid base.

INTRODUCTION: A common shoulder injury is a distal clavicle fracture which can be treated with various methods such as coracoclavicular (CC) stabilization, fixation with a distal clavicular locking plate, hook plate or tension band wiring. In CC stabilization, the most difficult step is passing a suture under the coracoid base because there is no standard instrument matched to the shape of the coracoid process. We propose a technique using a modified recycled corkscrew suture anchor to pass a suture under the coracoid base. CASE PRESENTATION: A 30-year-old Thai female with a left clavicle fracture was scheduled for CC stabilization. In the step of passing a suture under the coracoid base, we used a modified recycled corkscrew suture anchor to quickly and easily perform this step. CLINICAL DISCUSSION: There are some specialized commercial tools which are designed to pass a suture under the coracoid base but all are very expensive (∼ $1400-1500 per piece). To overcome this problem, we modified a used sterilized corkscrew suture anchor to pass a suture under the coracoid base, normally done from the medial to lateral sides, recycling a device usually discarded after use.

Screening for or diagnosing medial meniscal root injury using peripheral medial joint space width ratio in plain radiographs.

To evaluate the sensitivity and specificity for screening and diagnosis of medial meniscal root injury using the distance ratio of medial joint space width between affected and unaffected knees in patients with potential medial meniscal root injury (MMRI) using plain radiographs, the study enrolled 49 patients with suspected MMRI who were then evaluated for MMRI using plain radiographs of both knees in the anteroposterior view and magnetic resonance imaging (MRI) findings. The ratios of peripheral medial joint space width between the affected and unaffected sides were calculated. The cut point value, sensitivity and specificity were calculated according to a receiver operating characteristic (ROC) curve. In the study, 18 and 31 patients were diagnosed with and without MMRI, respectively. The mean peripheral medial joint space width ratios comparing the affected side to the unaffected side in the standing position of the anteroposterior view of both knees in the MMRI and non-MMRI groups were 0.83 ± 0.11 and 1.04 ± 0.16, respectively, which was a significant difference (p-value < 0.001). The cut point value of the peripheral medial joint space width ratio between the affected and unaffected sides for suspected MMRI was 0.985, with sensitivity and specificity of 0.83 and 0.81, respectively, and for diagnosis was 0.78, with sensitivity and specificity of 0.39 and 1.00, respectively. The area under the ROC curve was 0.881. Patients with a possible MMRI had peripheral medial joint space width ratios less than patients with non-MMRI. This test can be used for reliably screening for or diagnosing medial meniscal root injury in primary or secondary care settings.

No risk of iatrogenic peroneal nerve injury in all-inside lateral meniscal repair with either 14- or 18-mm needles through the popliteus tendon in the standard arthroscopic knee conditions.

PURPOSE: The objectives of this prospective study were to evaluate the risk of peroneal nerve (PN) injury in simulated all-inside lateral meniscal repair with sutures placed through the popliteus tendon (PT) and to determine the optimal needle length. METHODS: Twenty-nine axial magnetic resonance images (MRI) of postoperative knees with infused intra-articular fluid and in a figure-of-four position were used. The cross-sectional length of the PT was divided into four equal parts with measurements performed at the 25%, 50% and 75% points according to their anteroposterior arrangement. Simulated repairs were performed with 14-mm and 18-mm straight needles via the anteromedial (AM) and anterolateral (AL) portals. Distances from the needle tip following full insertion through the PT to the PN and from the anterior PT border to the posterior knee capsule were measured to determine PN injury risk and ideal needle insertion depths at the different landmarks. RESULTS: Simulated repairs on the 29 knee MRI images resulted in no incidences of PN injury. The average distances from the needle tip to the PN of the 14-mm needle were significantly greater than the 18-mm needle in all the simulated repairs (P < 0.02), except at the 25% point in the AM approach. When using the 14-mm needle, capsule underpenetration was found in three knees (10.3%) at the 25% point during the AM approach, in one knee (3.4%) at the 50% and 75% points in the AM approach, and in all repairs from the AL portal. The average distances from the anterior PT border to the capsule at the 25%, 50%, and 75% division points on the PT in the AM approach were 7.7 ± 2.7 mm, 7.9 ± 2.5 mm and 7.6 ± 2.8 mm, respectively, whilst in the AL approach were 8.4 ± 2.9 mm, 8.1 ± 2.8 mm and 7.6 ± 2.7 mm. CONCLUSION: Simulated all-inside lateral meniscal repair with suture placement through the PT with 14-mm and 18-mm needles was safe. The measurements in this study can be used to determine potential PN injury risk in relation to the PT and the appropriate needle length for safe lateral meniscal repairs.

Appropriate intradeltoid muscle needle penetration depth in vaccine administration: an MRI study in Thailand.

Objective: The objective of this study was to evaluate the appropriate vaccination needle penetration depth into the deltoid muscle to avoid injection-site complications from an inappropriate injection depth and/or injection site in the Thai population. Methods: This was a retrospective study using axial proton density-weighted images of MRI shoulders at the level of 2 fingerbreadths below the acromion process to measure the combined thickness of the skin, subcutaneous fat pad and deltoid muscle to evaluate the percentage of injections into the deltoid muscle with various needle penetration depths. Results: There were 509 MRI shoulder images of 222 males and 287 females (265 right shoulders and 244 left shoulders). The average body mass index and age were 24.54 ± 3.54 kg/m2 and 64.81 ± 10.20 years, respectively. Using a needle penetration depth of 12.7 mm (0.5 inches) achieved 100% of injections into the deltoid muscle. Conclusion: We recommend advancing the entire length of a 0.5-inch needle perpendicular to the skin at 2 fingerbreadths below the acromion process for adult intradeltoid vaccinations. This approach ensures optimal vaccine delivery and minimizes the risk of injection-related injuries.

Comparing the Anatomical Landmarks Versus the Coracoid-Based Landmarks Techniques for Coracoclavicular Stabilization After High-Grade Acromioclavicular Injury: A Biomechanical Study.

Background: In acute high-grade acromioclavicular (AC) joint injuries, the aim of treatment is robust reduction and stabilization of the joint. The anatomical landmarks method is most commonly used for stabilization, but loss of reduction often occurs because of the suture tunnels. Purpose/Hypothesis: The purpose was to evaluate and compare the stability of coracoclavicular (CC) stabilization using the anatomical landmarks and coracoid-based landmarks techniques in treating a high-grade AC joint injury. It was hypothesized that stabilization using coracoid-based landmarks would provide better stability. Study Design: Controlled laboratory study. Methods: Twenty fresh-frozen cadaveric shoulders (8 male and 2 female pairs) were randomized into 2 operative technique groups: 10 shoulders in the anatomical landmarks group and 10 shoulders in the coracoid-based landmarks group. The CC ligaments and AC capsule were cut at the midlevel, and CC stabilization and AC capsule repair were performed. For the anatomical landmarks technique, two 2.5-mm clavicular tunnels were created at 25 and 45 mm from the AC joint, while for the coracoid-based landmarks technique, two 2.5-mm clavicular tunnels were drilled using the medial and lateral borders of the coracoid base to choose the tunnel sites. Before injury creation and after stabilization, each shoulder underwent a loading force of 70 N in the superior and anteroposterior directions, and the displacement distance and stiffness were compared between the 2 techniques using the paired t test. Results: The mean difference in displacement before and after stabilization was higher in the anatomical landmarks technique than the coracoid-based landmarks technique (1.82 ± 3.52 vs -0.18 ± 4.78 mm in the superior direction and 7.47 ± 9.35 vs 1.76 ± 3.91 mm in the anteroposterior direction), but none of the differences in displacement or stiffness were statistically significant between the groups. Conclusion: No significant biomechanical differences in displacement or stiffness were seen between the anatomical landmarks technique and the coracoid-based landmarks technique. Clinical Relevance: Either stabilization technique can be utilized for repair of the CC ligaments in an acute AC injury setting.

A simple way to deal with an inadvertently cut suture while inserting the screw in the tibial tunnel during ACL reconstruction.

INTRODUCTION: There are many complications that can occur during or after ACL reconstruction, including a suture inadvertently cut by the screw threads while inserting the interference screw in the tibial tunnel. No fixes for this small but annoying problem have been proposed to date in the literature, and herein we propose a simple way to deal with this situation by bringing the tibial side of the ACL graft through the anterolateral portal and re-suturing with a stronger suture material. CASE PRESENTATION: A 48-year-old Thai female was undergoing an ACL reconstruction with a hamstring graft following a standard technique when the holding suture and distal part of the ACL graft were accidentally cut by the screw. Rather than redoing the graft from the beginning, we did a workaround by bringing the tibial end of the graft through the AL portal and re-suturing. DISCUSSION: In ACL graft fixation, when inserting the interference screw into the tibial tunnel there is a risk of cutting the holding suture with the screw. When this happened in our situation, we decided to attempt to redo the suture by first taking the graft out through the AL portal and then re-suturing with a stronger suture material. CONCLUSION: If inadvertently cutting the holding suture while inserting the screw in the tibial tunnel during ACL reconstruction occurs, the surgeon can use the simple solution we applied in this case to solve this problem or to avoid having to redo the entire procedure.

Septic arthritis of shoulder joint following a COVID-19 vaccination: A case report.

Introduction: Septic arthritis of the shoulder joint is a serious condition which requires early diagnosis and treatment. This condition usually presents with shoulder pain, limited range of motion and/or fever, and is diagnosed by shoulder arthrocentesis with significant synovial fluid leukocytosis or positive synovial fluid gram stain or culture. There are some risk factors for septic arthritis, notably bacteremia, pre-existing joint pathology and an immunocompromised host such as poorly controlled type II diabetes mellitus. Case presentation: A 45-year-old Thai female developed left shoulder septic arthritis after an Astra-Zeneca COVID-19 vaccine administration. The clinical symptoms were left shoulder pain, limited range of motion and fever. The probable risk factors were underlying diabetes mellitus type II and vaccine administration technique. The joint fluid culture showed Staphylococcus aureus. This patient was treated with combined arthroscopic debridement and an intravenous antibiotic for 1 week which was then switched to an oral antibiotic for 5 weeks. Her clinical symptoms gradually improved over the 2 weeks following the initiation of treatment. Conclusion: Septic arthritis is a rare complication after a vaccination. Doctors should be especially careful with immunocompromised patients, and always use a correct injection technique.