Corticosteroid-Associated Avascular Necrosis of the Femoral Head in Patients with Severe COVID-19: A Single-Center Study.

BACKGROUND Avascular necrosis (AVN) of the femoral head can result from high-dose corticosteroid therapy. Given that severe COVID-19 pneumonia patients respond positively to corticosteroids, this study aimed to explore the incidence of femoral head AVN associated with corticosteroid therapy in 24 patients diagnosed with severe COVID-19 at a single center. MATERIAL AND METHODS The study included 24 patients who were diagnosed with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection through real-time reverse transcription polymerase chain reaction test (rRT-PCR) and with COVID-19 pneumonia via high-resolution computed tomography (HRCT). Moderate cases received 2×4 mg Dexamethasone while severe cases were also administered with 3×40 mg Methylprednisolone. Diagnosis of femoral head AVN was confirmed with magnetic resonance imaging (MRI) and radiographs, which was subsequently treated by a total hip arthroplasty (THA) or a core decompression surgery (CDS) in line with the Ficat and Arlet classifications RESULTS Among the patients, 8 had a moderate infection course, while 16 were severe. The mean corticosteroid duration was 15±5 days for Dexamethasone and 30 days for Methylprednisolone. Severe patients presented with higher grade femoral head AVN and greater pain levels compared to moderate cases (p<0.05). Four patients developed bilateral AVN. The treatment resulted in 23 THAs and 5 CDSs CONCLUSIONS The data from this study corroborate earlier studies and case reports, suggesting an increased occurrence of AVN of the femoral head during the COVID-19 pandemic due to the high-dose corticosteroid therapy employed for patients hospitalized with severe COVID-19 pneumonia.

Lateral ulnar collateral ligament reconstruction enhancing secondary stabilizers in chronic PLRI of the elbow provides good to excellent clinical results with no recurrent instability.

PURPOSE: The adopted treatment for chronic elbow PLRI is lateral ulnar collateral ligament reconstruction. However, the most frequently reported complication after primary reconstruction is recurrent instability - up to 25 %. It was thus hypothesized that enhancing the secondary stabilizers will provide successful results with a lower rate of recurrent instability in comparison to techniques with primary reconstruction only. This study aimed to demonstrate a novel surgical technique involving secondary stabilizers. METHODS: In this retrospective study of 29 cases with chronic PLRI the mean duration of symptoms was 39.6 ± 4.9 months. The mean age was 47.9 years with mainly male patients. The surgeries were performed by one senior surgeon at a single institution. The Mayo Elbow Performance Score (MEPS) and the Disabilities of the Arm, Shoulder and Hand questionnaire (DASH) were recorded. RESULTS: The mean follow-up was 36.8 ± 7.7 months. The MEPS score improved significantly from 59.8 ± 13.1 to 84.7 ± 7.6 (p < 0.001). 23/29 patients (79.2 %) had converted to good and excellent results (MEPS >75 points). The DASH score improved from 40.8 ± 4.6 to 20.9 ± 7.2 (p < 0.001). The total complication rate was 10.3 % (N = 3). No recurrent instability was recorded in comparison to 12.2 % for primary reconstruction only, as reported in the literature (p < 0.05). CONCLUSION: Enhancing the secondary stabilizers by utilizing an adjacently located autograft provided good and excellent results with no recurrent instability. This novel surgical procedure is easy to reproduce and provides a safe and reliable alternative in cases of chronic PLRI when compared to techniques with primary reconstruction only.

A systematic review of elbow arthroscopy complications : Complications, risk factors, and safety tips.

PURPOSE: To determine the complications from elbow arthroscopy for the past 16 years, and to summarize the most reported safety techniques and risk factors. METHODS: Eligibility criteria included level I to IV evidence articles that were published after 2005 in the English language. Excluded were vet, paediatric, and cadaver studies. Open and arthroscopic-assisted elbow procedures were not included. Two online databases were comprehensively searched (PubMed and PMC) in April 2021. Relevant paper selection was conducted by two independent reviewers. MINORS score, demographic properties, indications, procedure type, complication rates, reoperation rates, reported risk factors, and safety techniques were recorded. RESULTS: Fifty-two articles met the criteria and were included. No relevant level I to II evidence studies were discovered. The mean age ranged from 31 to 65 years. The average body mass indexes were between 26 and over 40 kg/m2. There was a prevalence of male sex (from 50.2 to 79.2%). Most of the studies reported a minimum follow-up (range, 4 weeks-12 months). The most common arthroscopic procedure was debridement (up to 73% in Leong et al.'s study). The average MINORS score was 12 (range, 10-16). The total complications rate ranged from 1.5 to 11%, with a few studies reporting over 25%. Nerve injury rate was 1.26-7.5%. Re-operation rate ranged from none (100 procedures) to 11.8%. CONCLUSIONS: Elbow arthroscopy is a successful procedure with a low overall complications rate (from 1.5 to 11%), and a low nerve injury rate (from 1.26 to 7.5%). Risk factors include patient-related factors (obesity, female sex, age over 65 years, elevated blood sugar levels, hypercoagulable disorder, tobacco and alcohol use), preoperative elbow impairment/previous surgery, and periprocedural steroid injections. Our review discovered a re-operation rate of 2 to 18%.

Portal-site epinephrine injections improve visualisation in arthroscopic rotator cuff repair.

OBJECTIVES: The aim of this study was to evaluate if portal-site injections of 1:200,000 epinephrine improve intraoperative visualisation in arthroscopic rotator cuff repair. METHODS: Patients with partial-thickness supraspinatus tears were selected for the study. They were assigned consecutive numbers and were divided into two groups-control group and intervention group. The surgeries were done by a single surgeon. Every odd-numbered patient was injected. Johnson's visibility classification, surgeon 5-point ordinal Likert scale (LS), and other parameters were recorded. RESULTS: A total of 221 participants (58.4 â€‹± â€‹6.1 years) were selected. Intraoperative visibility was better in the intervention group according to Johnson's classification-satisfactory visibility was achieved in 68 of 110 patients (62%, control group) compared to 89 of 111 patients (80%) (p â€‹= â€‹0.003). Surgeon LS was superior in the intervention group, with a notable decrease in worsened visibility cases. The operative time did not alter statistically significantly-82.2 â€‹± â€‹14.4 â€‹min for the control group, compared to 80.9 â€‹± â€‹10.8 â€‹min in the intervention group (p â€‹= â€‹0.056). No injection-associated complications were recorded. CONCLUSIONS: Portal-site injection of diluted epinephrine solution is safe and improves intraoperative visualisation in arthroscopic rotator cuff repair. This addition does not increase operative time. LEVEL OF EVIDENCE: Level 3, case-control study.

Arthroscopic Extensor Carpi Radialis Brevis Muscle Resection for Chronic Elbow Lateral Epicondylitis.

Recalcitrant elbow lateral epicondylitis presents a difficult challenge for both the patient and the doctor. Surgical treatment consists of open resection and debridement of the extensor carpi radialis brevis muscle. However, advances in arthroscopic surgery provide for a more elegant method. There are several comparative studies between arthroscopic and open treatment that have shown equivalent outcomes. There is no consensus on which treatment is better and no defined indications of when to choose one over the other. This article presents our technique for arthroscopic extensor carpi radialis brevis muscle resection.

Functional results after reconstruction with modular tumor endoprostheses in patients with malignant bone tumors.

INTRODUCTION: The functional outcome in patients after limb salvage surgery, and in particular reconstructions with modular tumor endoprostheses, has been the subject of many international series, but only a few publications mention the functionality in a Bulgarian patient group. AIM: The aim of the present study was to analyze the functional outcome in a Bulgarian group of patients with malignant bone tumors that underwent resection and reconstruction with modular tumor endoprostheses. MATERIALS AND METHODS: Our series consists of 14 patients with malignant bone tumors who underwent limb salvage surgery and reconstruction with modular tumor endoprostheses between February 2012 and January 2021. Staging was done using the AJCC staging system for bone sarcoma. The MSTS score system was used to evaluate the functional results. RESULTS: The mean follow-up time was 38.5 months (range, 8 to 96). The mean MSTS score for our series was 70%. Distant metastases were found in 4 (28%) patients. Local recurrence occurred in 3 (21%) patients. The most severe late complication was a mechanical failure of the expanding mechanism in 1 patient. CONCLUSIONS: Reconstruction with modular tumor endoprostheses offer superb functionality and improved life quality in patients with primary malignant bone tumors.

A Challenging Case of Using Manta Ray Skin Flaps in a Severe Post-Traumatic First Web Space Contracture.

BACKGROUND First web space contracture affects thumb function and grasping capacity. This pathology alters normal anatomy and results in decreased ability to use the hand. Appropriate release and resurfacing are needed to restore normal hand function. Principles of successful treatment also include providing healthy compliant skin for a tension-free closure and a smooth healing period. The Manta Ray skin flaps are utilized in children, allowing the position of as much local skin as possible with minimal dorsal scarring. The technique has potential use in adults who have less skin plasticity and pliability. CASE REPORT We present the case of a 36-year-old patient with a severe first web space contracture of the dominant hand. Primary concerns of the patient were loss of hand mobility, limited grasping ability, and an inability to "give a proper handshake". Medical history suggests a gunshot wound in early childhood treated operatively by a mild web release after the point of trauma, with insufficient outcomes. We proceeded with the Manta Ray flap technique using 3 dorsally-based flaps and 4 palmar-based flaps, with excellent results. CONCLUSIONS Although the Manta Ray flap procedure was developed for moderate web space contractures in children, it combines advantages of several flap techniques. It ensures sufficient web space lengthening and may be applicable in older patients if enough healthy unscarred skin is available. These unique properties and potential led us to use the method for this challenging case.