COVID-19 Tracheostomy: Experience in a University Hospital With Intermediate Follow-up.

The benefits of percutaneous dilational tracheostomy (PDT) placement have been well documented in patients requiring prolonged mechanical ventilation. However, the data regarding the benefit of PDT in coronavirus-2019 (COVID-19) patients are scarce. The objective of this study is to evaluate the outcomes of a cohort of 37 patients who underwent tracheostomy as part of their COVID-19 care. Retrospective data from a series for 37 patients undergoing tracheostomy was collected using chart review. Primary outcomes included 30 and 60 day mortality, weaning rate, and decannulation rate. Secondary outcomes collected included admission demographics, comorbidities, and procedural information. Thirty-seven (37) patients requiring prolonged mechanical ventilation due to COVID-19. Of these 37 patients, 35 were alive 60 days post-PDT placement, 33 have been weaned from mechanical ventilation and 18 have been decannulated. The low mortality and high decannulation rates in this cohort in is a promising development in the care of critically ill COVID-19 patients. Of note, all participating physicians underwent routine polymerase chain reaction (PCR) testing for infection with the severe acute respiratory syndrome coronavirus-2 virus and no physician contracted COVID-19 as a result of their involvement. Overall, this case series describes the modified PDT technique used by our team and discusses the feasibility and potential benefit to PDT placement in COVID-19 patients requiring long-term mechanical ventilation.

Safety and Efficacy of the Tracheobronchial Bonastent: A Single-Center Case Series.

BACKGROUND: Tracheobronchial stents are widely used devices in interventional pulmonology; however, the current literature on the effectiveness and complication rates of the different types of stents is limited. OBJECTIVE: We report the largest case series of airway Bonastent placement and describe the efficacy and early (<30 days) and late (≥30 days) complication rates. METHODS: We performed a retrospective review of our prospectively collected database of patients who underwent therapeutic bronchoscopy with stent placement. All adult patients who had a tracheal/bronchial Bona-stent placed between July 1, 2017, and July 30, 2019, for any indication at our institution were included. The efficacy as well as intraoperative and short- and long-term complications of Bonastent placement were evaluated. RESULTS: Sixty Bonastents were placed in 50 patients. The etiology was malignant in 90% of the cases, while 2 patients had a tracheoesophageal fistula. All procedures were performed via rigid bronchoscopy. The most common location for stent placement was the bronchus intermedius, followed by the trachea, in 32 and 30% of the cases, respectively. Seventy percent of the patients (35/50) had improvement of respiratory symptoms within 30 days. Twenty-eight stents (48%) were removed at a mean of 74 days. Seventeen patients (34%) died within 30 days of stent placement. The overall complication rate was 54% (27/50 patients) at a mean follow-up of 111 days. The stent-related complication rate was 23.3% (14/60 cases) within <30 days and 53% (18/34 cases) at ≥30 days. CONCLUSIONS: The tracheobronchial Bonastent is effective for the treatment of patients with central airway obstruction and tracheoesophageal fistulae with an acceptable safety profile.

Enhancement of hyaline cartilage and subchondral bone regeneration in a rat osteochondral defect model through focused extracorporeal shockwave therapy.

Aims: To explore the efficacy of extracorporeal shockwave therapy (ESWT) in the treatment of osteochondral defect (OCD), and its effects on the levels of transforming growth factor (TGF)-ß, bone morphogenetic protein (BMP)-2, -3, -4, -5, and -7 in terms of cartilage and bone regeneration. Methods: The OCD lesion was created on the trochlear groove of left articular cartilage of femur per rat (40 rats in total). The experimental groups were Sham, OCD, and ESWT (0.25 mJ/mm2, 800 impulses, 4 Hz). The animals were euthanized at 2, 4, 8, and 12 weeks post-treatment, and histopathological analysis, micro-CT scanning, and immunohistochemical staining were performed for the specimens. Results: In the histopathological analysis, the macro-morphological grading scale showed a significant increase, while the histological score and cartilage repair scale of ESWT exhibited a significant decrease compared to OCD at the 8- and 12-week timepoints. At the 12-week follow-up, ESWT exhibited a significant improvement in the volume of damaged bone compared to OCD. Furthermore, immunohistochemistry analysis revealed a significant decrease in type I collagen and a significant increase in type II collagen within the newly formed hyaline cartilage following ESWT, compared to OCD. Finally, SRY-box transcription factor 9 (SOX9), aggrecan, and TGF-ß, BMP-2, -3, -4, -5, and -7 were significantly higher in ESWT than in OCD at 12 weeks. Conclusion: ESWT promoted the effect of TGF-ß/BMPs, thereby modulating the production of extracellular matrix proteins and transcription factor involved in the regeneration of articular cartilage and subchondral bone in an OCD rat model.

Current trends in rehabilitation of rotator cuff injuries.

Rehabilitation has a fundamental role in the management of rotator cuff pathology whether the final choice is conservative or surgical treatment. Conservative treatment can give excellent results in cases of rotator cuff tendinopathies without rupture, partial tears less than 50% of the thickness of the tendon, chronic full-thickness tears in elderly patients and irreparable tears. It is an option prior to reconstructive surgery in non-pseudo paralytic cases. When surgery is indicated, adequate postoperative rehabilitation is the best complement to obtain a successful result. No consensus has still been established on the optimal postoperative protocol to follow. No differences were found between delayed, early passive and early active protocols after rotator cuff repair. However, early motion improved the range of motion in the short and mid-term, allowing faster recovery. A 5-phase postoperative rehabilitation protocol is described. Rehabilitation is also an option in specific failed surgical procedures. To choose a therapeutic strategy in these cases, it is reasonable to differentiate between Sugaya type 2 or 3 (tendinopathy of the tendon) and type 4 or 5 (discontinuity/retear). The rehabilitation program should always be tailored to the individual patient.

Bracing with Tape and Extensor Refixation of Elbow with Posterolateral Instability Due to Cubitus Varus: A Case Report.

CASE: A 54-year-old patient had lateral ligament insufficiency due to cubitus varus from a childhood supracondylar fracture. Arthrolysis/synovectomy and at a later stage double-row extensor origin refixation and lateral ulnar collateral ligament bracing with nonabsorbent tape and anchors were performed. Follow-up at 3, 6, 12, and 24 months showed excellent Mayo Elbow Performance and Disabilities of Arm, Shoulder, and Hand Scores (24-month follow-up = 100 and 2.5, respectively). CONCLUSION: Suture tape augmentation and double-row extensor refixation in cases of lateral collateral ligament complex insufficiency due to cubitus varus may provide improved short-term functional outcomes, from the third postoperative month.

Shoulder injury related to vaccine administration following SARS-CoV-2 inoculation: Case series and review of literature.

Introduction: Shoulder Injuries Related to Vaccine Administration (SIRVA), describes those cases of shoulder severe post-inoculation complications, including pain and prolonged disability. Most of the reported cases have been secondary to influenza vaccination. This study retrospectively describes a series of 18 patients following SARS-CoV-2 inoculation and compares the findings with those previously reported for other vaccines. Materials and methods: Inclusion criteria was onset of symptoms within 48 h after injection, symptoms duration of at least seven days, and restricted range of motion in absence of symptoms prior to vaccination. Average age was 59.4 years old (38-76), and 72.2% were women. Results: In many cases (58%) the initial diagnosis was not clear, which lead to incorrect treatment. The most common pathological finding was subacromial-subdeltoid bursitis (66.6%). All patients who received depot corticosteroids followed by a gentle rehabilitation program showed strong clinical improvement but did not completely resolve the symptoms at 7.2 months average final follow-up. Surgical intervention was necessary in one of the patients due to the persistence of symptoms despite conservative treatment. Conclusions: Shoulder injury related to vaccine administration is rare, but when present, its torpid evolution makes it difficult to treat. We have found in our case series a similar pattern to that already described for other vaccines. A high index of suspicion helps to pick up the condition promptly and early treatment can bring satisfactory outcome.

Functional results and return to sports on recurrent anterior glenohumeral instability. Influence of the COVID-19 pandemic; Comparative retrospective study and short-term results.

AIMS: Our objective is to compare the functional results in patients that underwent surgery for recurrent anterior shoulder instability (RAGHI) during the COVID-19 pandemic with remotely-based rehabilitation, to those who had surgery before the pandemic and had in-person rehabilitation therapy. METHODS: A retrospective case series of 68 patients were included and divided into two groups: In person-group and Home-based group. Western Ontario Shoulder Instability Index (WOSI) and Subjective Shoulder Value (SSV) scores were used to evaluate objective and subjective clinical parameters. Time and level of return to sports was studied by the Subjective Patient Outcome for Return to Sports (SPORTS) score. RESULTS: The mean SSV score was 82% (40-100) on the In-Person group compared with 87% (65-100) for the Home-Based group. Results for WOSI score were similar, with an average of 210.42 (90%) for In-Person and 261.45 (88%) for the Home-Based group (p 0.12). Return to sports was carried out in an average of 6.6 (4-16) months for In-Person group, compared to 6.5 (5-8) months for Home-Based. CONCLUSION: Follow-up and rehabilitation methods for patients who underwent surgery for RAGHI, during COVID-19 lockdown, were not significantly (p 0.12) affected on functional and athletic return in comparison to traditional methods according to WOSI scale. LEVEL OF EVIDENCE: IV Retrospective series of cases.

Treatment Protocol for Rotator Cuff Calcific Tendinitis Using a Single-Crystal Piezoelectric Focused Shock Wave Source.

Focused shock waves have emerged as a highly effective noninvasive therapeutic option for the treatment of calcific tendinitis of the shoulder. There are three types of focused shock wave generators: electrohydraulic, electromagnetic, and piezoelectric. According to our literature search, there are no reports of results with the use of single-crystal piezoelectric generators in calcific tendinitis of the shoulder. In a consecutive retrospective series of 23 patients with Gärtner type I and II calcifications of the rotator cuff, we performed three applications of high-energy piezoelectric focused waves (4,000 pulses per session with a frequency of 6 Hz). At the final follow-up (average of 14 months), 82.6% of the cases showed complete resorption of the calcification in radiographic controls. In 8.7% of the cases, partial disappearance of the calcification was achieved, and in the remaining 8.7% there were no significant changes. Single-crystal piezoelectric generators have a success rate comparable to those already reported with electrohydraulic and electromagnetic devices.

Assessing kidney development and disease using kidney organoids and CRISPR engineering.

The differentiation of human pluripotent stem cells (hPSCs) towards organoids is one of the biggest scientific advances in regenerative medicine. Kidney organoids have not only laid the groundwork for various organ-like tissue systems but also provided insights into kidney embryonic development. Thus, several protocols for the differentiation of renal progenitors or mature cell types have been established. Insights into the interplay of developmental pathways in nephrogenesis and determination of different cell fates have enabled the in vitro recapitulation of nephrogenesis. Here we first provide an overview of kidney morphogenesis and patterning in the mouse model in order to dissect signalling pathways that are key to define culture conditions sustaining renal differentiation from hPSCs. Secondly, we also highlight how genome editing approaches have provided insights on the specific role of different genes and molecular pathways during renal differentiation from hPSCs. Based on this knowledge we further review how CRISPR/Cas9 technology has enabled the recapitulation and correction of cellular phenotypes associated with human renal disease. Last, we also revise how the field has positively benefited from emerging technologies as single cell RNA sequencing and discuss current limitations on kidney organoid technology that will take advantage from bioengineering solutions to help standardizing the use of this model systems to study kidney development and disease.

Shoulder Injury Related to Vaccine Administration Following Misplaced SARS-CoV-2 Vaccination: A Case Report and Review of Literature.

Introduction: To confront the SARS-CoV-2 pandemic, a large share of the population must be immunized. Intramuscular vaccination of the shoulder is the preferred technique as it is easily exposed and guarantees a good immune reaction. Local side effects, such as pain and swelling, are common after deltoid inoculation. They usually resolve within 3 days. Shoulder injury related to vaccine administration (SIRVA) should be considered if the symptoms persist. The aim of this presentation is to describe a typical case of SIRVA after SARS-CoV-2 vaccination and provide information to the general orthopedic surgeon to properly diagnose, report, and treat these cases. Case Report: A 69-year-old female health-care professional without history of shoulder pain consulted the senior author for persistent severe left shoulder pain 3 months following the second dose of Sputnik V COVID-19 vaccination. She claimed an improper application technique that caused immediate pain and loss of active range of motion (ROM). She underwent medical treatment with several doctors during 3 months with poor results. A magnetic resonance imaging (MRI) of the left shoulder done 5 days after vaccination showed mild subacromial-subdeltoid bursitis. A follow-up MRI at 2 months after application revealed synovial hypertrophy and distention of the subacromial-subdeltoid bursa. We prescribed a dose of depot betamethasone and home-based program of gentle exercises. Although initial response was quick, the patient required shoulder arthroscopy the following months, due to persistence in pain and functional limitations. Conclusion: SIRVA cases may occur and should be suspected in all individuals without a history of shoulder symptoms or dysfunction who experience sudden pain and reduced ROM following deltoid muscle vaccination. Treatment must be initiated early with corticosteroids and rehabilitation. The low probability of this complication does not outweigh the advantages of vaccination.

Current concepts in anterior glenohumeral instability: diagnosis and treatment.

The glenohumeral joint is the most dislocated articulation, accounting for more than 50% of all joint dislocations. The reason behind shoulder instability should be investigated in detail for successful management, and the treatment plan should be individualized for all patients. Several classification systems have been proposed for glenohumeral instability. A physical exam is mandatory no matter what classification system is used. When treating patients with anterior shoulder instability, surgeons need to be aware of the critical size of the bone loss, which is commonly seen. The glenoid track concept was clinically adopted, and the measurement of the glenoid track for surgical decision-making is recommended. Detailed assessment of existing soft tissue injury to the labrum, capsule, glenohumeral ligaments, and rotator cuff is also mandatory as their presence influences the surgical outcome. Rehabilitation, arthroscopic repair techniques, open Bankart procedure, capsular plication, remplissage, Latarjet technique, iliac crest, and other bone grafts offer the surgeon different treatment options according to the type of patient and the lesions to be treated. Three-dimensional (3D) technologies can help to evaluate glenoid and humeral defects. Patient-specific guides are low-cost surgical instruments and can be used in shoulder instability surgery. 3D printing will undoubtedly become an essential tool to achieve the best results in glenohumeral instability surgery.

Mitos, verdades, dudas y confusiones sobre las ondas de choque y su rol en la enfermedad musculoesquelética / Myths, truths, doubts and confusions about shockwave. Therapy and its role in musculoskeletal pathology

El advenimiento de la litotricia renal en la década de los 80 tuvo un efecto disruptivo en el tratamiento de los cálculos renales. El descubrimiento de los efectos biológicos de las ondas de choque expandió rápidamente el uso de este método terapéutico al campo de la Ortopedia y Traumatología. Si bien, en los últimos años, ha tenido un amplio desarrollo, persisten muchas confusiones y dudas en el ambiente de nuestra especialidad, sobre todo entre los profesionales que no están directamente involucrados en el tema. El objetivo de esta presentación es hacer un análisis de los puntos de controversia y las dudas más frecuentes, basado en la bibliografía científica. Nivel de Evidencia: V

The advent of renal lithotripsy in the 1980s had a disruptive effect on the treatment of kidney stones. The discovery of the biological effects of shock waves quickly expanded the use of this therapeutic method to the field of Orthopedics and Traumatology. Although the topic has advanced significantly in recent years, there are still many questions and confusions in our specialty's environment, particularly among professionals who are not directly involved in the field. The objective of this presentation is to provide a scientific analysis of the points of controversy and the most frequent doubts. Level of Evidence: V

Complexity-entropy analysis at different levels of organisation in written language.

Written language is complex. A written text can be considered an attempt to convey a meaningful message which ends up being constrained by language rules, context dependence and highly redundant in its use of resources. Despite all these constraints, unpredictability is an essential element of natural language. Here we present the use of entropic measures to assert the balance between predictability and surprise in written text. In short, it is possible to measure innovation and context preservation in a document. It is shown that this can also be done at the different levels of organization of a text. The type of analysis presented is reasonably general, and can also be used to analyze the same balance in other complex messages such as DNA, where a hierarchy of organizational levels are known to exist.

Descompresión artroscópica para la neuropatía del nervio supraescapular. Reporte de un caso y revisión anatómica / Arthroscopic decompression in suprascapular neuropathy. Case report and anatomical review

La neuropatía del nervio supraescapular es una causa poco común de dolor y debilidad en el hombro y, por lo tanto, a menudo, es mal diagnosticada. Como consecuencia, el diagnóstico erróneo puede llevar a indicar un tratamiento conservador inapropiado o un procedimiento quirúrgico fallido. Se presenta el caso de un hombre de 55 años con síndrome de atrapamiento del nervio supraescapular. El paciente fue sometido a una artroscopia de hombro y se le diagnosticó una compresión del nervio supraescapular por el ligamento transverso escapular superior. La liberación artroscópica del nervio supraescapular alivió el dolor, la debilidad y la atrofia de los músculos supraespinoso e infraespinoso. Nivel de Evidencia: IV

Suprascapular neuropathy is a rare cause of shoulder pain and weakness and is therefore often misdiagnosed. As a consequence, misdiagnosis may lead to inappropriate conservative treatment or a failed surgical procedure. A case of a 55-year-old man suffering from suprascapular nerve entrapment syndrome is presented. The patient underwent shoulder arthroscopy, where the compression of the suprascapular nerve by the superior transverse scapular ligament was diagnosed. Arthroscopic release of the suprascapular nerve relieved pain, weakness, and atrophy of the supraspinatus and infraspinatus muscles. Level of Evidence: IV

The medial coracoclavicular ligament: anatomy, biomechanics,and clinical relevance-a research study.

BACKGROUND: The medial coracoclavicular ligament (MCCL), is a structure that shows defined morphologic and histologic features. However, little attention has been paid to the MCCL to date. This study was conducted to (1) determine whether the MCCL is a constant structure, (2) analyze its mechanical properties, and (3) determine its possible role in acromioclavicular (AC) stability. METHODS: AC joints, lateral coracoclavicular ligaments (LCCLs; conoid and trapezoid), and MCCLs were dissected in 30 fresh frozen upper limbs. In 6 of these specimens, we performed a sequential sectioning following the aforementioned order. A 20-N cephalad force was applied to the lateral clavicle at each step, recording the AC distance and coracoclavicular space and their variation. In 6 other specimens, we evaluated the anteroposterior motion of the clavicle following the MCCL section. Biomechanical testing was performed in 8 specimens, comparing the resistance of the MCCL to the LCCLs. RESULTS: The MCCL in all of the specimens featured a sharp-edge bundle stretching from the coracoid process to the clavicle and subclavius sheath. It showed ligament-like mechanical properties although less tensile resistance than the LCCLs. Once the AC and LCCLs were sectioned, transection of the MCCL determined a significant increase in both cephalad and posterior displacement. CONCLUSION: The MCCL is a constant structure with the mechanical behavior of a ligament. It may act as the last container of the coracoclavicular space both in cephalad and posterior directions, precluding additional displacement in the absence of the LCCLs.

¿Somos los cirujanos argentinos de hombro y codo los peor tratados de Iberoamérica? Comparación de los honorarios y el nivel de satisfacción entre los miembros de la Asociación Argentina de Cirugía de Hombro y Codo, y los colegas de Iberoamérica / Are Argentine shoulder and elbow surgeons the worst treated in Ibero-America? Comparison of fees and level of satisfaction between members of the Argentine Association of Shoulder and Elbow Surgery and colleagues from Ibero-America

Un nivel de satisfacción laboral adecuado de los miembros del equipo de salud es esencial para garantizar una buena prestación de servicios, generar compromiso personal, estimular el deseo de actualización y fomentar la retención dentro del sistema. No hemos encontrado ninguna publicación que aborde específicamente este tema en el ámbito de la Ortopedia y Traumatología en nuestro medio. El objetivo de este estudio es conocer cómo perciben los especialistas que pertenecen a la Asociación Argentina de Cirugía de Hombro y Codo sus condiciones de trabajo, cuál es su remuneración y su grado de satisfacción y compararlos con equivalentes de otros países iberoamericanos. Los resultados de la encuesta mostraron niveles promedio de satisfacción bajos en los profesionales argentinos encuestados. Existen diferencias estadísticamente significativas con profesionales de otros países de Iberoamérica tanto en lo relativo a la remuneración como en los índices de bienestar. Si no se producen profundos cambios en el sistema de atención, la remuneración y las condiciones de trabajo, tarde o temprano aparecerán consecuencias que afectarán no solo a los profesionales, sino también a los pacientes y al sistema en general. Nivel de Evidencia: IV

An adequate level of job satisfaction of the members of a health team is essential to guarantee the quality of the services provided, generate personal commitment, stimulate the desire to update, and promote retention within the system. We have not found any publication that specifically addresses this issue in the field of Orthopedics and Traumatology in our setting. The objective of this study is to know how the specialists who belong to the Argentine Association of Shoulder and Elbow Surgery perceive their work-ing conditions, what their remuneration is and their degree of satisfaction, and to compare them with equivalents from other Ibero-American countries. The results of the survey showed low average levels of satisfaction in the Argentine professionals surveyed. There are statistically significant differences with professionals from other Ibero-American countries both in terms of remuneration and wellbeing indices. If there are no profound changes in the healthcare system, the remuneration and the working conditions, sooner or later consequences will appear that will affect not only professionals but also patients and the system in general. Level of Evidence: IV

Guía práctica de planificación e impresión 3D en Ortopedia y Traumatología / Practical guide to 3D printing and planning in orthopedics and traumatology

El acceso a la tecnología de planificación e impresión 3D está destinado a tener un impacto disruptivo en la práctica quirúrgica de la Ortopedia y Traumatología. Sus ventajas incluyen una mejor comprensión de las lesiones por tratar, mayor precisión técnica, acortamiento de los tiempos quirúrgicos, disminución de la pérdida sanguínea y menor exposición a los rayos. El objetivo de esta publicación es ofrecer una guía práctica paso a paso tomando como ejemplo el tratamiento de una fractura desplazada del tercio medio de la clavícula. Nivel de Evidencia: V

Access to 3D planning and printing technology is destined to have a disruptive impact on the surgical practice of Orthopedics. Its advantages include a better understanding of the injuries, greater technical precision, shortened surgical times, decreased blood loss, and less exposure to X-rays. The aim of this publication is to provide a practical step-by-step guide using the treatment of a displaced middle-third clavicle fracture as an example. Level of Evidence: V