Bupivacaine-Induced Hepatotoxicity in a Healthy Patient Without Chronic Liver Disease After Shoulder Arthroscopy

Introduction: Bupivacaine is a local anesthetic which has been increasingly used in the post-operative state for pain control. Hepatotoxicity is a rare complication, and few cases are reported in patients with chronic liver disease. We present a case of acute liver injury from bupivacaine use in a healthy patient without prior history of liver disease. Case Description/Methods: A 68-year-old female with a past medical history of primary hypertension and recent nontraumatic complete tear of the right rotator cuff, presents to the hospital with fatigue, loss of appetite, and nausea. She recently underwent an arthroscopy of the right shoulder with repair of the rotator cuff two weeks prior. Her surgery was uncomplicated, and patient was started on bupivacaine ONQ pump infusion at 5 ml/hr for three days for post-operative pain. Further history reveals patient is non-alcoholic without prior liver disease, including cirrhosis. Review of systems is concerning for associated generalized abdominal discomfort. Physical exam demonstrated jaundice with scleral icterus with mild periumbilical tenderness to palpation without hepatosplenomegaly or ascites. Labs demonstrated elevated total bilirubin of 10.2 mg/dL with Alkaline phosphatase, ALT, and AST being 924 U/L, 429 U/L, and 279 U/L, respectively. Imaging studies including CT abdomen and pelvis with contrast, abdominal ultrasound, MRCP, and portal vein doppler were negative. Additional work up for underlying liver disease including acetaminophen and ethanol levels, SARS-CoV2, Hepatitis panel, EBV antigen, and urine toxicology were negative. It was determined patient had bupivacaine induced hepatotoxicity. Patient's health improved with conservative management and she was discharged with instructions for close monitoring of her LFTs. Discussion(s): Bupivacaine is an amino-amide anesthetic which binds to the intracellular portion of voltage-gated sodium channels and prevents depolarization of pain signals. It is metabolized by the liver and thus reports of hepatotoxicity, although rare, occur in patients with underlying liver pathology. Our patient became symptomatic with acute rise in LFTs. An extensive workup for other etiologies of acute liver toxicity was negative. Rapid vascular uptake of the drug is the most common reason for bupivacaine toxicity;and this remains a possibility for the mechanism of toxicity in our patient. A prior case report of bupivacaine hepatotoxicity demonstrated a cholestatic pattern, which is consistent with our findings.

Comparison of Survivorship and Failure Modes Between Anatomic and Reverse Total Shoulder Arthroplasty Across Multiple Government Joint Registries for a Single Platform Shoulder System

[...]recent years have seen a dramatic shift in utilization of rTSA in which rTSA is increasingly used to treat OA in patients with an intact rotator cuff, with a corresponding decline in use of aTSA.1-5 The reasons for this shift in usage are multi-factorial but may be due to the perceived lower risk of revision surgery with rTSA relative to aTSA, as the quality of the rotator cuff muscles and tendon are not necessary for a functional rTSA but are pre-requisite for a functional aTSA. Furthermore, these registries have high rates of government-mandated compliance such that all patients are enrolled and very few patients are lost to follow-up, thus minimizing the potential for selection bias that is inherently present in nearly all nongovernment registry clinical outcome studies. [...]to better understand the relative differences in primary aTSA and primary rTSA usage and performance, we analyzed two different government joint registries for survivorship and for reasons for revision associated with one platform shoulder system and compared trends in usage of aTSA and rTSA over a period of over 10 years to elucidate reasons for any market trends. Additionally, reasons for revision and the cumulative revision rate were assessed across the government joint registries to quantify and compare the performance of this platform shoulder prosthesis for primary aTSA and primary rTSA in each country over the study period. Over the period of analysis, use of primary aTSA and primary rTSA with the particular platform system has increased year to year in both Australia and the UK, with the exception of a decline in 2020 and 2021 due to COVID-19.

A one-stop shoulder clinic to save time and resources

There is now a need more than ever to streamline services. A one-stop shoulder clinic was introduced during the COVID-19 pandemic. A total of 861 patients were seen, saving 794 future appointments. 111 patients had an ultrasound scan and 285 patients had an ultrasound-guided procedure, saving an average waiting time of 134 days. 327 patients had physiotherapy, and the average Oxford Shoulder Score improved by 8.56 at 1 year.Copyright © Royal College of Physicians 2023. All rights reserved.

Postoperative rehabilitation of shoulder pain.

Background: Shoulder joint diseases such as rotator cuff tear, adhesive capsulitis, calcific tendinitis, shoulder instability, and glenohumeral osteoarthritis often require surgical treatment. Surgical outcomes can change significantly depending on whether the postoperative rehabilitation was appropriately performed. Current Concepts: The focus of postoperative rehabilitation should be to remove pain and restore functional movement through improving the dynamic stability of the rotator cuff and shoulder muscles. However, rehabilitation should not include activities that aggravate the injury. Therefore, rehabilitation treatment should be carried out with gradual increments in exercise intensity. Postoperative rehabilitation is not only related to exercise but may also include drug administration, such as steroid injection. In particular, many investigations have been performed to identify the clinical risks and benefits of steroid injection after rotator cuff repair. Notably, telemedicine can be used as a solution for the problematic situations that have been caused by coronavirus disease 2019 pandemic. Discussion and Conclusion(s): A thorough understanding and appropriate application of postoperative rehabilitation protocols are essential to improve surgical outcomes.Copyright © Korean Medical Association.

Postoperative rehabilitation of shoulder pain

Background: Shoulder joint diseases such as rotator cuff tear, adhesive capsulitis, calcific tendinitis, shoulder instability, and glenohumeral osteoarthritis often require surgical treatment. Surgical outcomes can change significantly depending on whether the postoperative rehabilitation was appropriately performed. Current Concepts: The focus of postoperative rehabilitation should be to remove pain and restore functional movement through improving the dynamic stability of the rotator cuff and shoulder muscles. However, rehabilitation should not include activities that aggravate the injury. Therefore, rehabilitation treatment should be carried out with gradual increments in exercise intensity. Postoperative rehabilitation is not only related to exercise but may also include drug administration, such as steroid injection. In particular, many investigations have been performed to identify the clinical risks and benefits of steroid injection after rotator cuff repair. Notably, telemedicine can be used as a solution for the problematic situations that have been caused by coronavirus disease 2019 pandemic. Discussion and Conclusion: A thorough understanding and appropriate application of postoperative rehabilitation protocols are essential to improve surgical outcomes.

WHY YOU SHOULDN'T AIM TOO HIGH ALL THE TIME: A CASE OF SHOULDER INJURY RELATED TO VACCINE ADMINISTRATION (SIRVA) OF COVID-19 MRNA

CASE: A 23-year-old female presented to resident clinic for 7 months of right shoulder pain. She received her second COVID-19 mRNA vaccine just prior to onset of pain. She noted vaccine administration was “traumatic” with significant bleeding and bruising. She started noticing pain with overhead activities several days later. She is very active with cardiovascular exercises. She lifts weights but none requiring overhead motions. The pain was worst at the front of the shoulder but radiated to the lateral aspect. She had not tried, ice, heat, medications or physical therapy. Because of her injury, she was hesitant to receive her COVID-19 booster. BMI was low at 16.65. Exam showed thin build and overall low muscle bulk. Right shoulder showed no signs of muscle atrophy. There was tenderness of subacromial and coracoid areas. No pain along biceps tendon or AC joint. She had full ROM with shoulder abduction, internal and external rotation. She had full strength of supraspinatus, infraspinatus, teres minor, and subscapularis muscles. She noted pain with abduction, internal rotation and lift-off maneuver. Her Hawkins and Neer's maneuvers were positive. No pain with Yergason's and Speed's maneuvers. The patient was diagnosed with right shoulder subacromial bursitis and impingement syndrome. IMPACT/DISCUSSION: Mild shoulder pain is expected after vaccine administration and typically resolves in days. However, SIRVA is an increasingly recognized complication of improper vaccine administration particularly in the occupational setting. SIRVA results from vaccine being delivered inadvertently within the subdeltoid bursa or joint space. It is thought to result from an immune mediated reaction to the vaccine components as injury tends to be greater than expected from a needle injury. We were able to find 5 cases of reported SIRVA related to the COVID vaccine. All included some form of subacromial, subdeltoid, or subcoracoid bursitis. One case noted a supraspinatus tear. Ultrasound has demonstrated the subacromial bursa can extend distal to the acromion by up to 6 cm, so administration to bursa is possible in the superior deltoid. Appropriate injection technique can reduce the risk of injury;administrators should use landmarks of the acromion and distal insertion point of deltoid mid-humerus. Proper needle length is important. It has been suggested a smaller deltoid fat pat and smaller deltoid muscle bulk are risk factors for SIRVA. Women tend to have a higher incidence. CONCLUSION: We presented the case of a slender female who developed shoulder bursitis and impingement following administration of COVID-19 mRNA vaccine. She was referred to PT for rotator cuff strengthening, instructed to refrain from aggravating activities, and provided NSAIDs for pain relief. She reports pain relief. Another option for a more severe case would be a subacromial bursa steroid injection. It is important for providers to be aware of this pathology to provide appropriate treatment and decrease vaccine hesitancy.

Wide-awake local anesthesia for open rotator cuff repair: A case report.

INTRODUCTION AND IMPORTANCE: Improper treatment of rotator cuff tear might result in progression of tear and deterioration of patient function. The rotator cuff tear can be managed conservatively in most cases however surgical treatment is inevitable in persistent patients. PRESENTATION OF CASE: A 45-year-old woman presented to our clinic with shoulder pain and restricted range of motion following a fall from a height three months before the current presentation. Due to the lack of favorable response to conservative treatment and the fact that rotator cuff rupture was traumatic, she became a candidate for rotator cuff repair surgery. Due to financial issues and the patient's refusal of undergoing general anesthesia we considered the WALANT technique. Prior to surgery, we explained the whole procedure to the patient, referring to its pros and cons. CLINICAL DISCUSSION: The WALANT procedure is a relatively recent technique that has become widespread in orthopedic surgery in the past decade. The advantages of the WALANT technique are that it is simple, feasible, and safe and that the analgesic is adequate during the operation and for the first few hours afterward (5). Concerns with this method include patient discomfort and pain during surgery, which can be managed by educating the patient and minute-by-minute explanation during the procedure. CONCLUSION: We advocate open rotator cuff repair with the WALANT approach as an effective, cost-saving, safe, simple, and quick alternative to general and regional anesthesia for certain patients or with limited anesthetic resources. LEVEL OF EVIDENCE: V.

Self-Reported Outcomes in Early Postoperative Management After Shoulder Surgery Using a Home-Based Strengthening and Stabilization System With Telehealth.

BACKGROUND: Multiple rehabilitation protocols after shoulder surgery have been proposed. The coronavirus pandemic adds an extra layer of complexity to postoperative rehabilitation after shoulder surgery. HYPOTHESIS: The combined use of a home-based rehabilitation system, the Shoulder Strengthening and Stabilization System (SSS), and telehealth visits will lead to acceptable patient self-reported outcomes and satisfaction after shoulder surgery. STUDY DESIGN: Prospective observational cohort. LEVEL OF EVIDENCE: Level 4. METHODS: A total of 132 patients were prescribed SSS after shoulder surgery. A virtual clinical specialist monitored patients through telehealth visits as prescribed by the treating physician. Data were collected prospectively during each telehealth visit. Patients completed an exit survey during their last telehealth visit. RESULTS: The use of SSS with telehealth revealed a positive impact on postoperative shoulder rehabilitation (96%), pain (71%), and stiffness (92%) as reported by patients. Both pain scores and pain medication use decreased from the 1st to 8th postoperative telehealth session (P < 0.01). Nearly all (93%) patients recommended SSS after shoulder surgery upon completing the SSS protocol. CONCLUSION: Postoperative management of shoulder surgery with SSS combined with telehealth results in a reduction in patient pain levels in the early postoperative period. Patients reported high levels of improvement with SSS in shoulder rehabilitation, pain, and stiffness. The overwhelming majority (93%) of patients recommended SSS for postoperative shoulder rehabilitation and SSS yielded high patient satisfaction scores. Elucidating the impact of SSS on clinical outcomes and function in comparison with traditional rehabilitation protocols is warranted. CLINICAL RELEVANCE: SSS in combination with telehealth was tolerated well by patients and may represent an alternative or adjunct to traditional rehabilitation protocols.

Sportskongres 2022

The proceedings contain 40 papers. The topics discussed include: graft failure, revision ACLR, and reoperation rates after ACLR with quadriceps tendon versus hamstring tendon autografts;meniscal surgery or exercise therapy in alleviating patient-reported mechanical symptoms in young adults with a meniscal tear;'it's second best': mixed-methods evaluation of the experiences of people with musculoskeletal pain towards physiotherapist delivered telehealth during COVID-19 pandemic;outcome predictors for recovery of rotator cuff tendinopathy: an international prospective cohort study;are patients satisfied? a systematic review and meta-analysis of exercise therapy in the management of tendinopathy;numerous treatments are efficacious for patellofemoral pain: a systematic review and meta-analysis;and a single bout of eccentric exercise increases the gene expression of nestin and osteocrin in human myotendinous junctions.

‘Down to the person, the individual patient themselves’: A qualitative study of treatment decision‐making for shoulder pain

IntroductionMany inconsistencies have been identified in the translation of evidence‐based treatment recommendations for musculoskeletal shoulder pain into healthcare services, with little known about factors influencing decision‐making. The objective of this study was to explore the views and experiences of healthcare providers (HCPs) and people living with shoulder pain on treatment decision‐making.MethodsAdopting a qualitative design, purposeful sampling was employed to recruit 13 individuals with nonspecific musculoskeletal shoulder pain and 30 HCPs. Data were collected through 1:1 semi‐structured interviews and analysed using an approach informed by Constructivist Grounded Theory. To facilitate analysis, two patient and public involvement (PPI) meetings were conducted.ResultsMost participants (69%) had shoulder pain of ≥1‐year duration. Biomechanical beliefs about shoulder pain predominated and were heavily influential in decision‐making for both patients and HCPs. Despite a consensus that therapeutic alliance facilitated decision‐making, the extent of collaboration between HCPs and patients in treatment decision‐making was rather limited. In addition to condition‐specific factors, Individual patient characteristics and resources also influenced treatment decisions.ConclusionFindings revealed the complexity of the decision‐making process for both patients and HCPs, exposing substantial gaps between the reported views and experiences of participants and the principles of client‐centred and evidence‐based practice. There is a pressing need to enhance the translation of evidence‐based knowledge into practice in this clinical area.Patient or Public ContributionIn line with a consultative approach to collaborative data analysis, a subgroup of participants attended two PPI meetings to provide commentary and feedback on preliminary findings.

Massive cutback in orthopaedic healthcare services due to the COVID-19 pandemic.

PURPOSE: Due to the lack of evidence, it was the aim of the study to investigate current possible cutbacks in orthopaedic healthcare due to the coronavirus disease 2019 pandemic (COVID-19). METHODS: An online survey was performed of orthopaedic surgeons in the German-speaking Arthroscopy Society (Gesellschaft für Arthroskopie und Gelenkchirurgie, AGA). The survey consisted of 20 questions concerning four topics: four questions addressed the origin and surgical experience of the participant, 12 questions dealt with potential cutbacks in orthopaedic healthcare and 4 questions addressed the influence of the pandemic on the particular surgeon. RESULTS: Of 4234 contacted orthopaedic surgeons, 1399 responded. Regarding arthroscopic procedures between 10 and 30% of the participants stated that these were still being performed-with actual percentages depending on the specific joint and procedure. Only 6.2% of the participants stated that elective total joint arthroplasty was still being performed at their centre. In addition, physical rehabilitation and surgeons' postoperative follow-ups were severely affected. CONCLUSION: Orthopaedic healthcare services in Austria, Germany, and Switzerland are suffering a drastic cutback due to COVID-19. A drastic reduction in arthroscopic procedures like rotator cuff repair and cruciate ligament reconstruction and an almost total shutdown of elective total joint arthroplasty were reported. Long-term consequences cannot be predicted yet. The described disruption in orthopaedic healthcare services has to be viewed as historic. LEVEL OF EVIDENCE: V.

COVID-19-related rotator cuff repair delay.

BACKGROUND: Although nonoperative treatment is effective for degenerative rotator cuff tears (RCTs), it remains unclear whether the delay created by a trial of nonoperative treatment negatively influences the outcome of a subsequent surgical repair. In March 2020, the COVID-19 pandemic resulted in an involuntary delay in the surgical treatment of rotator cuff disease, creating a natural experiment. The purpose of this study was to evaluate the outcomes and healing of patients who underwent delayed surgical treatment of chronic degenerative RCTs as compared with the nondelayed surgical treatment of RCTs. METHODS: This was a prospective study of two groups: patients planned to undergo arthroscopic rotator cuff repair between March 16, 2020 and May 1, 2020-the end of the ban on elective surgery-and patients who underwent rotator cuff repair starting six weeks after the ban on elective surgery had been lifted. Preoperatively and at six months postoperatively, we collected the Simple Shoulder Test, the American Shoulder and Elbow Surgeons (ASES) score, and the visual analog scale for pain. We also obtained magnetic resonance imaging (MRI) at six months postoperatively. A power analysis was conducted, and assuming a mean ± standard deviation ASES score of 93.1 ± 13.9 points and a minimum clinically important difference in the ASES score of 27.1 points, 7 patients per group (14 patients in total) would be necessary to have 90% chance of finding a difference. RESULTS: We included 15 patients within each group and obtained 100% follow-up at six months. In the delay group, the mean ± standard deviation delay was 63 ± 24 days. There were no significant preoperative differences between groups in demographics or tear characteristics. Intraoperatively, there were no differences between groups in repair characteristics. Using a repeated-measures analysis of variance, there were significant preoperative vs. postoperative differences in ASES scores (P < .001), visual analog scale scores (P < .001), and Simple Shoulder Test scores (P < .001), but no differences between groups (P = .910, .519, and 0.852, respectively). On MRI, within the delay group, 58% had healed, whereas within the control group, 85% had healed (P = .202). CONCLUSION: COVID-19 caused a two-month delay in the operative treatment of RCTs. This delay did not significantly alter patient-reported outcomes. This delay resulted in a 27% difference in MRI healing rates, which was not statistically significant in this small study. Larger studies should be conducted as our results suggest that a delay in treatment may negatively impact healing rates.

Do bio-psycho-social self-reported factors distinguish rotator cuff tendinopathy from other shoulder problems and explain shoulder severity? A case–control study

Keywords: Tendinopathy;Rotator cuff;Digital transformation Purpose: Similar associations between self-reported bio-psycho-social factors and the presentation of people with various shoulder disorders and rotator cuff (RC) tendinopathy have been reported;however, only limited numbers of variables have been assessed, often in small cohorts. We aimed to test whether RC tendinopathy could be distinguished from other shoulder problems using a range of bio-psycho-social self-reported factors and the degree to which they explain severity. Methods: Self-reported bio-psycho-social factors were collected via an online survey battery from an international sample. The dependent variables were diagnosis (having RC tendinopathy or other shoulder problems) and severity. After group comparison and univariate regression analyses, multivariable logistic and linear regression analyses were used to construct explanatory models for group differences and severity. Results: 82 people with RC tendinopathy (42.8 ± 13.9 years, 50 female) and 54 people with other shoulder problems (40.2 ± 14.1 years, 33 female) were recruited and found not to differ in severity on four patient-reported PROMs (Shoulder Pain and Disability Index (SPADI) = 37.3 ± 24.5 vs 33.7 ± 22.5, Western Ontario Rotator Cuff Index (WORCI) = 56.2 ± 22.0 vs 60.3 ± 22.2, Single Assessment Numeric Evaluation = 56.6 ± 25.3 vs 56.5 ± 28.7 and Patient Acceptable Symptomatic State (yes:no) 51:31 vs 23:22, respectively). Eight self-reported factors individually distinguished RC tendinopathy from other shoulder problems, with the model distinguishing tendinopathy from other shoulder problems including 4 variables;having a previous injury in the shoulder (OR (95% CI) = 0.30 (0.13–0.69)), activity effect on pain (OR (95% CI) = 2.24 (1.02–4.90)), General Self-Efficacy Score (OR (95% CI) = 1.12 (1.02–1.22)) and activity level according to Global Physical Activity Questionnaire (moderately active OR (95% CI) = 3.97 (1.29–12.18) and highly active OR (95% CI) = 3.66 (1.41–9.48)), with acceptable overall model accuracy. Univariate linear regression analysis showed that 32 variables were associated with RC tendinopathy severity with a multivariable model consisting of quality of life (β coefficient = −0.38), having night pain (β = 0.19), having unilateral morning stiffness (β = 0.25), BMI (β = 0.29), FABQ (work) score (β = 0.25);and pain catastrophising (β = 0.21) explaining 68% of the variance in severity. Conclusion(s): Well validated patient-reported outcomes to explain severity do not distinguish RC tendinopathy from other shoulder problems however self-reported bio-psycho-social factors do, so may be useful for clinical evaluation. Further, these factors were strongly associated with severity, reinforcing the potential to improve patient assessment, for example, using pre-consultation online data collection in usual care. The models warrant prospective validation and consideration alongside data from physical and imaging assessment. Impact: Online survey including self-reported bio-psycho-social factors may help augment diagnosis and, more importantly, provide some of the detail needed for holistic assessment by complementing physical examination and imaging. Therefore, the online survey may be useful to minimise the clinical time commitment and optimising safety during the Covid-19 pandemic. Funding acknowledgements: The review is a part of Mehmet Delen's Ph.D., which is sponsored by the Turkish Ministry of National Education. The sponsors had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

"Debaryomyces subglobosus" - Management of a rare case of fungal septic arthritis post arthroscopic rotator cuff repair - a case report.

Fungal septic arthritis of the shoulder is extremely rare in post arthroscopic rotator cuff repair patients. We report our experience in successfully identifying and managing a rare case of fungal septic arthritis with Debaryomyces subglobosus in an uncontrolled diabetic patient who underwent arthroscopic rotator cuff repair in 2019. Our patient had complete resolution of symptoms and a reasonable functional recovery within 2 months of debridement and initiation of the specific anti-fungal. This case highlights the importance of high clinical suspicion for atypical fungal infections, and the use of culture-independent modern diagnostic tools like DNA-PCR as adjuncts to successfully identify rare pathogens in immunodeficient patients presenting with vague, nonspecific symptoms of infection.

COVID-19 associated aortitis

Case report-IntroductionSince the emergence of Coronavirus disease 2019 (COVID-19) there has been increasing recognition of the potential associated cardio-vascular manifestations. There have been reports of Kawasaki like disease in children. However, in adults there are very few reports of non-cutaneous vasculitis. Here we report the case of an adult male presenting with an inflammatory aortitis associated with COVID-19 infection.Case report-Case descriptionA 71-year-old Caucasian male with a background of cholecystectomy and rotator cuff repair presented to hospital in May 2020 with a 3-month history of feeling generally unwell, weight loss and worsening thoraco-lumbar back pain. Prior to the onset of these symptoms he had had a 2-week illness in March 2020 clinically consistent with COVID-19 infection comprising fevers, hot sweats, dry cough, and chest tightness for which he had not sought medical attention. He had no recent travel history. Physical examination was unremarkable.On admission, COVID-19 tests revealed evidence of prior infection with negative SARS-CoV-2 polymerase chain reaction test but positive SARS-CoV-2 antibodies. Blood tests revealed a marked inflammatory state with a C-reactive protein of 122mg/L, plasmas viscosity of 2.76, Ferritin 777ug/L, Interleukin-6 of 25 ng/L and normocytic anaemia with a Haemoglobin of 77g/L. Immunology tests were negative for anti-neutrophil cytoplasmic antibody, anti-glomerular basement antibodies, HLA-B27, anti-citrullinated protein antibody, rheumatoid factor, and nuclear antibodies, with normal IgG 4 subclasses. Microbiology workup showed negative blood cultures, syphilis screen and Hepatitis B and C serology. Temporal artery ultrasound was unremarkable. Troponin-T, pro-B-type natriuretic peptide, electrocardiogram and echocardiogram were normal. CT thorax abdomen pelvis revealed inflammatory change surrounding the aortic arch extending all the way down the aorta in keeping with a florid inflammatory aortitis with no aneurysms seen.Rapid resolution of symptoms was seen with commencement of Prednisolone 40mg once daily, with normalisation of CRP one week later and subsequent normalisation of haemoglobin and plasma viscosity. A repeat CT aorta 2 weeks after commencement of prednisolone demonstrated a reduction in the thickness of the inflammatory rind over the aorta from 6mm to 2mm. The patient now continues a reducing regime of prednisolone and remains in clinical remission.Case report-DiscussionIn children, Kawasaki like disease associated with COVID-19 is well described and can result in coronary artery inflammation and aneurysm. In adults, COVID-19 associated cutaneous vasculitis is well recognised however there are only a small number of case reports of organ specific vasculitis including the central nervous system, retina, and small bowel. To our knowledge this is the first reported case of aortitis associated with COVID-19 infection in an adult patient.The mechanisms underlying the development of COVID-19 associated vasculitis are not established but may be secondary to endothelial inflammation. Findings from a histological case series suggest that SARS-CoV-2 can infect endothelial cells directly, possibly via endothelial ACE2 receptors, leading to inflammation in the endothelium. Another postulated mechanism is that endothelial cell dysfunction and inflammation is caused by the cytokine storm that can be seen in some patients with COVID-19 infection.Our patient responded very well to corticosteroid treatment. However, in case of a relapse his cytokine profile could be helpful in directing further therapeutic options. IL-6 levels were elevated in our patient. Studies show that IL-6 appears to play a dominant role in the cytokine storm. In a report of 150 patients IL-6 was found to be significantly higher in the group with severe disease and possibly predictive of mortality. The IL-6 antagonist, Tocilizumab, has also been used with promising results. The first report of its use was in China in 21 critically ill COVID-19 patients with significant improvements Since this first report, further clinical trials are underway investigating the efficacy and tolerability of IL-6 antagonists in patients with COVID-19 disease. Expanding our understanding of the pathogenesis of COVID-19 associated vasculitis is a critical area for future research to identify other immune targets for novel/existing therapeutic agents.Case report-Key learning points Vasculitis including aortitis can be a complication of COVID-19 infection.Endothelial cell inflammation is likely to play key role in the pathogenesis of COVID-19 associated vasculitis.In addition to corticosteroids, other immune-modulating drugs presently used in rheumatology may be effective therapeutic agents.

Spontaneous Intramuscular Abscesses Involving the Rotator Cuff Muscles in Two Cases Presenting During the COVID-19 Pandemic.

Spontaneous abscesses involving the rotator cuff muscles are a rare surgical occurrence. Patients with such abscesses are often initially misdiagnosed or there is a significant diagnostic delay. Herein, we report one case of a spontaneous intramuscular abscess involving the subscapularis muscle and a second case of an abscess involving the supraspinatus muscle. There is a multitude of predisposing risk factors to developing an intramuscular abscess formation, which includes immunodeficiency, trauma, injection drug use, concurrent infection, and malnutrition. The most significant risk factor in our cases was poorly controlled type 2 diabetes mellitus. Poorly controlled diabetes is known to cause impaired clearance of pathogens, predisposing patients to abscess formation. Both patients also delayed presenting to the hospital due to concerns surrounding the coronavirus disease of 2019 (COVID-19) pandemic. We describe the use of a deltoid-pectoral approach to access the subscapular abscess allowing surgical drainage. The supraspinatus abscess was drained by direct incision. We advocate utilising common and familiar approaches with or without arthroscopy where possible. These cases highlight the importance of early imaging in patients presenting with the physiological signs of infection and idiopathic shoulder pain.

Comparison of the accuracy of telehealth examination versus clinical examination in the detection of shoulder pathology.

HYPOTHESIS/BACKGROUND: In 2017, the American Orthopaedic Association advocated for the increased use of telehealth as an assessment and treatment platform, and demand has significantly increased during the coronavirus disease 2019 pandemic. Diagnostic effectiveness (also called overall diagnostic accuracy) and reliability of a telehealth clinical examination vs. a traditional shoulder clinical examination (SCE) has not been established. Our objective is to compare the diagnostic effectiveness of a telehealth shoulder examination against an SCE for rotator cuff tear (RCT), using magnetic resonance imaging (MRI) as a reference standard; secondary objectives included assessing agreement between test platforms and validity of individualized tests. We hypothesize that tests provided in a telehealth platform would not have inferior diagnostic effectiveness to an SCE. METHODS: The study is a case-based, case-control design. Two clinicians selected movement, strength, and special tests for the SCE that are associated with the diagnosis of RCT and identified similar tests to replicate for a simulated telehealth-based examination (STE). Consecutive patients with no prior shoulder surgery or advanced imaging underwent both the SCE and STE in the same visit using 2 separate assessors. We randomized the order of the SCE or STE. A blinded reader assessed an MRI, to be used as a reference standard. We calculated diagnostic effectiveness, which provides values from 0% to 100% as well as agreement statistics (Kappa) between tests by an assessment platform, and sensitivity, specificity, and likelihood ratios for individual tests in both SCE and STE. We compared the diagnostic effectiveness (overall) of the SCE and STE with a Mann-Whitney U test. RESULTS: We included 62 consecutive patients with shoulder pain, aged 40 or older; 50 (81%) received an MRI as a reference standard. The diagnostic effectiveness of stand-alone tests was poor regardless of the group, with the exception of a few tests with high specificity. None had greater than 70% accuracy. There was no significant difference between the overall diagnostic effectiveness of the STE and SCE (P = .98). Overall agreement between the STE tests and the SCE tests ranged from poor to moderate (Kappa, 0.07-0.87). CONCLUSION: This study identified initial feasibility and noninferiority of the physician-guided, patient-performed STE when compared with an SCE in the detection of RCTs. Although these results are promising, larger studies are needed for further validation of an STE assessment platform.