Benefits of Early Thoracic Surgery in the Elderly During the COVID-19 Pandemic: Lessons Learned From Performing a Video-Assisted Thoracotomy.

Elderly patients are often considered poor surgical candidates for intra-thoracic operations due to the number of comorbidities, increased risks associated with general anesthesia, decreased cardiopulmonary reserve, and overall increased frailty. In addition, coronavirus disease 2019 (COVID-19) is a critical psychosocial factor that, through secondary effects, can prevent patients from receiving optimal care. Patients are reduced to having limited contact with family, often a vital support system, which can contribute to feelings of hopelessness, loneliness, and depression. We report the case of a 95-year-old female who presented to the emergency department with increasing supplemental oxygen requirements two weeks after a ground-level fall. She was found to have multiple rib fractures and a left-sided hemothorax. Initial management included aggressive respiratory therapy, multiple pigtail chest tubes, and thrombolytics; however, these measures failed to drain the intrathoracic hematoma. Her care was complicated by the psychosocial and isolation factors of COVID-19 which led to the patient exhibiting symptoms of hopelessness, grief, lack of appetite, and loneliness. As conservative management did not improve her clinical care the patient required a video-assisted thoracoscopic surgery (VATS) to manage the retained hemothorax and facilitate re-expansion of her atelectatic lung. Once the patient was removed from COVID-19 precautions, she was taken to surgery and postoperatively the patient reported minimal pain, participated more in physical therapy, and increased her oral intake. In this unique case, a 95-year-old patient with a hemothorax that was successfully treated with a VATS had her clinical care complicated by the psychosocial implications of COVID-19.

Bronchopulmonary Fistula Development in an Elderly Male With COVID-19 Infection.

COVID-19 pneumonia can cause a wide range of complications including pneumothorax and empyema. However, in severe cases, it can lead to bronchopulmonary fistula (BPF) formation and a persistent air leak due to a connection between the pleural space and the bronchial tree. We report the case of a 77-year-old man with a history of hypertension, who presented to the emergency department for evaluation of dyspnea. Admission labs were significant for a positive rapid antigen SARS-Cov-2 test and elevated troponin I. A chest x-ray demonstrated patchy interstitial opacification and ground glass appearance bilaterally. Within the first 24 hours of presentation, the patient developed a right-sided spontaneous pneumothorax and had a 14 French pigtail catheter placed. The patient subsequently developed a persistent air leak after chest tube placement and required video-assisted thoracoscopic surgery (VATS) with talc pleurodesis and a 32 French chest tube placement. In this unique case, we describe an elderly patient's experience of bronchopulmonary fistula formation as a complication of COVID-19 pneumonia and the successful management of this complication with VATS.

Knee Pain and Patellofemoral Symptoms in Patients With Cerebral Palsy.

BACKGROUND: Knee pain in cerebral palsy (CP) is associated with increased patellofemoral forces present when walking with flexed knees. In typically developing children, knee pain and patellofemoral dysfunction are associated with obesity, genu valgum, femoral anteversion, and external tibial torsion. These problems are also common in CP, and may contribute to knee problems in this population. The purposes of this study were to define the prevalence of knee pain and patellofemoral dysfunction in children with CP, and to identify physical and gait characteristics (using 3-dimensional gait analysis data) that predispose them to such problems. METHODS: Retrospective review of 121 children with CP, Gross Motor Function Classification System level I to IV, who underwent computerized gait analysis testing. Demographics, range of motion, body mass index and hip, knee, and ankle kinematics were compared between subjects with and without knee pain. RESULTS: Twenty-five of 121 subjects (21%) reported knee pain at the time of testing. Three of 121 subjects (2%) had a history of patellar subluxation/dislocation. Age and sex were significantly related to presence of knee pain. The likelihood of knee pain was almost 5 times higher in females (odds ratio=4.9, [95% confidence interval, 1.8-13.3], P=0.002), with a prevalence of 40% (17/42) in females versus 10% (8/79) in males. The likelihood of knee pain increased with age by approximately 13% per year (odds ratio=1.13, [95% confidence interval, 1.00-1.28], P=0.058). Malignant malalignment syndrome showed a potential relationship to more severe knee pain (P=0.05), which warrants further investigation. Body mass index, pes valgus, and degree of stance knee flexion showed no statistically significant relationships to knee pain (P>0.16). CONCLUSIONS: The prevalence of knee pain in ambulatory patients with CP is approximately 21%. Patellar subluxation (2%) and dislocation are rare in these patients. Knee pain is not always related to crouch, femoral anteversion, external tibial torsion, genu valgum, or pes valgus. Knee pain in these patients is more prevalent in females, and increases with increasing age. LEVEL OF EVIDENCE: Level III-case-control study.